Mental Health Trajectory Worsening in Canadian Youth

Does the increasing prevalence of depressive symptoms in adolescents portend a potential future mental health crisis in adults? Canadian researchers are sounding the alarm that early diagnosis and interventions are essential, with much of the burden falling squarely on the shoulders of general practitioners (GPs).
“There’s a temptation to assume that experiencing depression in childhood isn’t associated with depression symptoms in young adulthood, but that would be a mistake,” Marilyn N. Ahun, PhD, co-author of a new study and a public health researcher at McGill University’s Faculty of Medicine and Health Sciences in Montréal, Quebec, Canada, told Medscape Medical News.
“Experiencing depressive symptoms during adolescence negatively impacts perceptions of ourselves and our relationships with others, which can lead to a vicious cycle that increases as we grow up,” she explained.
Ahun and her co-authors explored data collected until June 30, 2019, in the ongoing Québec Longitudinal Study of Child Development. Their goal was to assess the relationship between depressive symptoms in childhood and depression symptoms and psychosocial outcomes at age 20 years.
The researchers categorized participants as being in early (ages, 1.5-6 years) or middle (ages, 7-12 years) childhood or adolescence (ages, 13-17 years). Subclinical depressive symptoms included unhappiness, sadness, lack of self-esteem, lack of energy or feeling tired, lack of interest in things or activities that were previously enjoyable, trouble concentrating, and feeling like a failure. They were reported by parents for the early childhood cohort, by teachers for the middle childhood cohort, and by the adolescent participants.
The results, published online on August 8, 2024, in JAMA Network Open, highlighted that in the final analytic sample (which ranged from 1118 to 1254 of a sample of 2120 participants across outcomes, due to dropouts), depressive symptoms in adolescents were associated with an increased level of depressive symptoms at age 20 years (β, 1.08, P < .001) and perceived stress at age 21 years (β, 3.63, P < .001).
An unrelated longitudinal study, which was published on August 14, 2024, in JAMA Network Open, found an increasing prevalence of depressive symptoms in adolescence and young adulthood since 1990. The participants were 36,552 American 12th graders.
Among females, who represented 50.5% (18,597) of the overall cohort, 19.1% of participants born between 1997 and 2001 had high depressive symptoms at age 18 years. This percentage was higher than in any prior cohort. The prevalence of depressive symptoms among females at ages 21-22 years also was higher than in any prior cohort. In addition, 13.4% of males had high depressive symptoms at age 18 years, which was higher than in any prior cohort. Prevalence increased to 15.6% by age 21 years.
“We’re seeing that depressive symptoms are increasing in young adulthood, with more mental health problems than young adults had in previous generations. That signals a youth mental health crisis that is quickly going to become an adult mental health crisis,” said lead author Katherine Keyes, PhD, professor of epidemiology at Columbia University in New York City.
Old News, New Impact
The relationship between depression or depressive symptoms in adolescence and depressive symptoms in adulthood is not a novel discovery. Over 40 or so years, the Oregon Youth Study has made similar connections. But considering this connection within the context of the COVID-19 pandemic is novel.
Marshall Korenblum, MD, associate professor of psychiatry at the University of Toronto and former psychiatrist-in-chief at the Hincks-Dellcrest Centre for Children and Families in Toronto, Ontario, Canada, pointed out that the pandemic had the “greatest impact on kids who were in grade 12 during the peak because they missed all the rituals and rites of passage usually associated with graduation. When you look at their social skills, emotional self-regulation, they’re behind, they’re less mature. It’s as if they’re about 2 or 3 years younger than their chronological age,” he said. Korenblum was not involved in either study.
“There was a lack of normalization and natural evaluation that happens within the school setting,” added Evangelia Amirali, MD, associate professor of the Department of Psychiatry at Université de Montréal and president of the Canadian Academy of Child and Adolescent Psychiatry (CACAP). “We’re seeing a lot of depressive symptoms that resulted from academic failure. Because a lot of these adolescents gave up on school and were not in normal classrooms…their problems have not been identified.”
Keyes said that their data showed that although mental health problems began increasing before the pandemic, they accelerated, rather than leveling off or decreasing.
“The kids who experienced increased financial stress during the pandemic and food and housing insecurity are the ones who had accelerated mental health problems in our data,” she added. “What remains to be seen is the long-term impact of their mental health and really traumatic experiences that occurred between 2020 and 2022.”
Intervention Is Critical
Mental health experts emphasize that there is a window of opportunity in which timely intervention can change the current trajectory in Canadian youth.
“We have reason to believe that influences, both positive and negative, can physically change the brain,” said Korenblum. “The good news is that because the brain remains plastic up to at least age 25 years and perhaps beyond, those changes aren’t permanent and can be reversed if there are positive influences in the environment and culture,” he said.
The challenge lies in the increasing dearth of child psychiatrists across Canada, which places identification and treatment on the shoulders of the nation’s GPs, many of whom never received the needed training. Part of the answer lies in a shared care model (ie, pairing a group of GPs and pediatricians with a psychiatrist who can be consulted as needed), said Korenblum. “Let’s expand the expertise, improve the training of GPs and pediatricians. They can handle the mild to moderate cases and leave the more severe ones to the child psychiatrists,” he said, adding that nurse practitioners and social workers can also pitch in.
CACAP will offer two courses next year to train child and adolescent psychiatrists and GPs and pediatricians to address competencies in youth mental health, said Amirali. “The idea is to ensure that our colleagues are comfortable with initiating psychological treatment,” she said.
In the interim, Korenblum and Amirali suggested that GPs and pediatricians take advantage of office visits to ask parents and caregivers about changes in their child’s behavior that might indicate some of the key signs of subclinical depression (eg, irritability, sleep issues, changes in eating habits, less pleasure, or less social or sports engagement), being mindful that the adults might also be in a similar state. “We need to expand our reach to include parents,” said Korenblum. “Let’s also upskill the parents because if teens are supported by the parents, their mental health is going to improve.”
Ahun’s study was supported by the Fonds de recherche du Québec-Santé, the Fonds de recherche du Québec-Société et culture, the Social Sciences and Humanities Research Council of Canada, and the Canadian Institutes of Health Research. Keye’s study was supported by grants from the National Institute on Drug Abuse. Ahun, Keyes, and Korenblum reported no relevant financial relationships.
Liz Scherer is an independent health and medical journalist based in the United States.
 
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