Elsevier

The Lancet

Volume 369, Issue 9569, 14–20 April 2007, Pages 1302-1313
The Lancet

Series
Mental health of young people: a global public-health challenge

https://doi.org/10.1016/S0140-6736(07)60368-7Get rights and content

Summary

Mental disorders account for a large proportion of the disease burden in young people in all societies. Most mental disorders begin during youth (12–24 years of age), although they are often first detected later in life. Poor mental health is strongly related to other health and development concerns in young people, notably lower educational achievements, substance abuse, violence, and poor reproductive and sexual health. The effectiveness of some interventions for some mental disorders in this age-group have been established, although more research is urgently needed to improve the range of affordable and feasible interventions, since most mental-health needs in young people are unmet, even in high-income countries. Key challenges to addressing mental-health needs include the shortage of mental-health professionals, the fairly low capacity and motivation of non-specialist health workers to provide quality mental-health services to young people, and the stigma associated with mental disorder. We propose a population-based, youth focused model, explicitly integrating mental health with other youth health and welfare expertise. Addressing young people's mental-health needs is crucial if they are to fulfil their potential and contribute fully to the development of their communities.

Introduction

I would there were no age between ten and three-and-twenty, or that youth would sleep out the rest; for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing, fighting.

William Shakespeare, The Winter's Tale

In this paper, we focus on the mental-health needs of young people aged 12–24 years. Adolescence is a fluid concept: the traditional age-bound definition of this phase of life (10–19 years)1 is greatly influenced by social, environmental, and cultural factors. Puberty is considered by many as signifying the onset of adolescence and this is often associated, in girls, with menarche; as the age of menarche fell, particularly in the early part of the last century in developed countries,2 the onset of adolescence also seemed to take place at a younger age. In many cultures, for example in the Hmong culture of southeast Asia, the age of 12 or 13 years denotes the end of childhood and the simultaneous onset of adulthood.3 In Bangladesh, a child who goes to school and has no economic or social responsibilities will be regarded as a child up to the age of puberty. However, boys or girls who are employed will no longer be regarded as children, even if they start work aged 6 years.4 In other societies, adolescence has been used to define the phase of sexual maturity before marriage: thus, once a girl or boy is married, she or he becomes an adult. The duration of adolescence has also increased substantially into early adulthood.5 Although puberty might be considered a biological marker of the onset of adolescence, no set of clear biological markers is available to indicate its end.

Surprisingly, despite the hundreds of societies in which a stage corresponding to adolescence has been identified,6 many investigators have questioned whether the notion of adolescence is valid.7, 8 The consensus, which we support, is to consider the health and developmental needs for two age-groups separately: children and young people. Young people are those who are aged between 12 and 24 years.8 Developmentally, they are emerging adults,7 sexually mature, in the final stages of their educational career or in the early stages of their employment career, and embarking on several socially accepted adult pursuits including finding and keeping a job, romantic relationships, and, in some cultures, using alcohol and tobacco. The confluence of these experiences helps contextualise the mental-health needs of young people.

Youth is the stage at which most mental disorders, often detected for the first time in later life, begin. Young people have a high rate of self-harm, and suicide is a leading cause of death in young people. A strong relation exists between poor mental health and many other health and development concerns for young people, notably with educational achievements, substance use and abuse, violence, and reproductive and sexual health. The risk factors for mental disorders are well established, and substantial progress has been made in developing effective interventions for such problems. Yet, most mental-health-service needs are unmet, even in wealthier societies, and the rate of unmet need is nearly 100% in many developing countries.9 Furthermore, there is a dearth of interventions to prevent mental disorders and promote mental health. We propose a youth-focused model for development of services and integration of mental health with other youth health and welfare concerns; such a model explicitly acknowledges the persistence of risk factors, and psychiatric disorders that often begin during childhood and adolescence, into adulthood.

Section snippets

Burden of mental disorders in young people

Many investigators reporting prevalence rates of mental disorders in young people include children or older adults in their samples. Furthermore, the prevalence rates have not been stratified to enable the rates applicable to young people to be ascertained. To summarise the data for our age-group of interest is therefore difficult. We tried to identify a set of community epidemiological studies undertaken since 1995 that included a substantial sample of young people aged 12–24 years, and used

Risk factors

Good evidence is available in support of a multifactorial cause for mental disorders in young people (table 2). Poverty and social disadvantage are strongly associated with mental disorder.39, 40, 41 Evidence for the pathways suggests that this association is complex and bidirectional: growing up in a poor household increases the risk of exposure to adversities such as scarcity of food, poor nutrition, violence, inadequate education, and living in a neighbourhood characterised by absence of

Public-health significance

The suffering, functional impairment, exposure to stigma and discrimination, and enhanced risk of premature death that is associated with mental disorders in young people has obvious public-health significance. This significance is amplified, since mental disorders in young people tend to persist into adulthood.28 Conversely, mental disorders in adults often began in youth or childhood, as shown by the National Comorbidity Survey Replication75 in the USA, which was the first study to examine

Health-system responses

Treatments for mental disorders in young people have improved substantially during the past two decades with safer and more effective drugs, more practical forms of psychosocial interventions, and reforms in service-delivery models. Several meta-analyses96, 97, 98 have shown support for individual, group, and family psychotherapies, particularly those with a behavioural or cognitive-behavioural orientation, for a range of mental health and behavioural disorders. In terms of evidence for

Implications for policy and practice

Although mental and substance use disorders represent the major health problems affecting young people and youth is the period of life during which most mental disorders emerge, provision of mental-health services is weakest during adolescence and youth.133 Taking a population-health perspective, we advocate a continuum of response with a series of levels, from the community through to specialist services.134 Self-limiting disorders and milder yet potentially serious disorders in an early stage

Youth mental health matters in all countries

It is ironic that, although substantial investment has been made in mental-health promotion and interventions for young people in many developed countries, no equivalent acknowledgement of mental health needs of young people exists in developing countries. The priorities for young people seem to be different in rich and poor countries. We disagree with this dualism. Young people in every society have mental health needs; it is imperative that youth mental health is actively supported and

Search strategy and selection criteria

We searched two online databases: MEDLINE (1996 to current) and PSYCINFO (1995 to current). The search words covered any aspects of the epidemiology, risk factors or treatment of mental health or illness record for children, adolescents or young people. An example of the search history for epidemiology was to use the following search tree: Epidemiol* or statistic* or inciden*; AND adolesc* or child* or young; AND mental*; AND health or illness or disorder. Only publications in English language

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