Mental Health Rx

A global study of 80,000 youths showed depression and anxiety symptoms have doubled since the beginning of the pandemic, with one in four youths experiencing depression symptoms, and one in five experiencing anxiety symptoms, according to The ‘New Normal’ and Life Beyond COVID-19, a report by the Evidence-Based Policy Institute distributed by the Baker Center for Children and Families.

Nationally, more than 25 percent of high school students reported worsened emotional and cognitive health during the pandemic, the report said, and many parents of younger children (ages 5 to 12) reported their children were displaying more symptoms of depression, anxiety, and psychological stress.

Now, HMS has a plan to develop education and training programs aimed at making mental health care more widely available to children and adolescents, an initiative supported by a $5.5 million, three-year grant from the Manton Foundation, a charitable philanthropy.

“The pandemic exposed the vulnerability of our young people to the mental health crisis,” said Edward Hundert, the Daniel D. Federman, M.D. Professor in Residence of Global Health and Social Medicine and Medical Education and dean for medical education at HMS, who helped spearhead the new Harvard enterprise.

Risk factors

Within the medical community, the understanding that there never seem to be enough psychiatrists, psychologists, or other mental health care professionals to meet the demand — whether for adults or children — has long been common knowledge.

Part of the difficulty in providing enough care for children and adolescents however, according to Patel, is the lack of mental health professionals in school settings who have the necessary training to help, and also because young people are often reluctant to reach out to mental health professionals. The pandemic, he said, has exacerbated the situation.

“Around the world, in every single country, every single study has shown that the youth of those countries have been disproportionately affected,” said Patel. “But it is important to acknowledge that the crisis was there before the pandemic. What the pandemic has really done is uncover a mental health crisis that already existed, because it got a lot worse.”

An expert in the field of global mental health, Patel co-leads the HMS Mental Health for All Lab and the GlobalMentalHealth @Harvard initiative.

To understand the current surge in mental health needs among children and adolescents, he said, it’s necessary to look at the increase in risk factors driving the escalation as well as the concurrent decline in protective factors that have occurred over the past 20 years.

He cited the potential impact of interpersonal violence, including cyberbullying, as risk factors that have been amplified by a simultaneous decline in authentic “social connectedness.”

“The idea — especially for young people — that we're all connected to each other through these invisible social bonds is very important for our identity as a member of a social group,” Patel said. “I don’t think one has to look very far to see that those bonds have been really grievously eroded in our communities in the U.S. in the past two decades.”

Add to that a growing anxiety among young people about threats over which they feel they have no control, such as climate change. Patel noted that climate change concerns are causing eco-anxiety among many youths who are worried that “the world's climate is irreparably damaged, and no one seems to have the resolve to do anything about it.”

Three-pronged approach

The new initiative aims to expand mental health care for children and adolescents through the creation of education and training programs that will be disseminated through online learning tools developed and implemented by the HMS Office for External Education.

“COVID has brought out and widened existing cracks in our society. Social justice, mental health, the digital divide, economic disparities, those things are all having implications on health and wellness throughout the world. We’re trying our best to fill those gaps with information and education,” said David Roberts, HMS dean for external education. “Our part is really to create content for clinicians and for the lay public on these key topics.”

The HMS plan involves developing a wider range of mental health care access points by providing educational assistance to middle- and high-school counselors and community health workers; by providing additional training to health care providers, such as pediatricians and OB-GYNs; and by more thoroughly integrating mental health into the HMS MD curriculum.

“We hope the training modules we develop will be used all over the country and throughout the world,” said Hundert.

Part of the difficulty with getting care to those who need it is the traditional division between mental and physical health care, said Todd Griswold, HMS assistant professor of psychiatry at Cambridge Health Alliance, who will be working with others at HMS to develop an enhanced curriculum for medical students.

“I’m hoping that the pandemic has opened people’s eyes so that they’ll see that psychiatry is not separate from the rest of clinical medicine. It has been considered that for way too long in education and in clinical work,” Griswold said.

The approach to the new curriculum will, in part, be inspired by the collaborative care model for depression, an approach whose goal is to provide access to mental health support and treatment across a range of primary care settings.

“When people have depression and see their primary care provider, the primary care providers will have been trained, and will see depression care as part of their work. And if a patient’s case is complicated, they will have mental health providers and psychiatrists to whom they can refer the patient. So, in this model, non-psychiatrists can see basic mental health care as part of their general day-to-day work,” Griswold said.

To incorporate this approach into future practice, the new HMS curriculum will be integrated into MD students’ preclerkship courses, which occur before their clinical rotations begin, and then be supported and reinforced within specific clerkship rotations, such as primary care, pediatrics, OB-GYN, and psychiatry. There will also be an emphasis on strengthening child and adolescent psychiatry training within the psychiatry clerkship.

Specific materials, such as videos, interactive online course modules, and case-based discussions will be created, and clerkship directors will be surveyed to determine how best to support a wider variety of physicians in clinical settings. This would include, for example, learning from pediatric clerkship site directors what kind of mental health care most pediatricians would like to be better equipped to provide, so that HMS can better train students to respond to those needs when they begin to practice.

“The more complex thing is to integrate the learning into students’ clinical experiences when they’re rotating and seeing patients, and that usually involves faculty development. So, the clinical teachers — say the primary care doctors or pediatricians they’re working with — may need a little bit of faculty development,” Griswold said.

Griswold said both the pandemic and a new generation of students have spurred a demand for fresh educational approaches.

“Students are quite attuned to the integration of mind and body in people’s overall physical and mental health,” said Griswold. “Of course, we won’t be able to completely remedy the mind-body split in medical education, but I think we can make a significant difference.”

In the schools

While Griswold focuses on enhanced training for future doctors, Patel will work with leading U.S. and international adolescent mental health treatment experts to train school counselors and other providers in key evidence-based intervention principles. This will allow them to better support middle- and high-school students, the age range in which Patel said the majority of mental disorders first emerge.

“The way mental health care systems have been structured is to deal with diagnosed mental disorders in adults,” Patel said. “That means by the time you see patients in those services, the majority have had mental health difficulties going back five or 10 years. So, the whole prospect of early intervention, which is to catch the illness in its earliest stages, is squandered, leading to years of suffering and, ultimately, worse outcomes for the individual in the long term. No other branch of medicine does that.”

HMS will design a digital skills-based curriculum inspired by an initiative called EMPOWER, which enables community-based frontline providers to learn, master, and deliver brief psychosocial treatments. It also provides a suite of competency assessments and tools for supervision by peers once interventions have been mastered.

Courses will be developed in concert with school counselor professional groups and other target audiences. The courses will be thoroughly tested, and training certifications will be developed, all with the goal of helping school counselors move to a more evidence-based practice. The program will also be available to other providers who deliver care to adolescents, such as community health workers and nurses.

“We know that mental health problems lie on a spectrum, and what we have historically done is treated mental health problems in a binary way: either you have a problem or you don't. You only receive care if you get a diagnosis, and that can only be given by a certain kind of professional. That paradigm is, for me, one of the single biggest reasons why we have a crisis of care in America today,” Patel said.

The new approach, Patel said, embraces a dimensional model of mental health problems, “recognizing that you don’t need a diagnosis to receive care and that the care you could receive can be delivered wherever you are, in the settings that you are living or working in, by people who are close to you and who you connect with,” Patel said.

The ultimate goal is to provide care that will give young people the skills they need to cope with different kinds of emotional distress and the motivation to deal with their difficulties in a purposeful way, said Patel.

“This is not going to solve all the various aspects of crisis for youth mental health,” said Patel. “What it will do is help mitigate the impact of those mental health problems by enabling young people to recover from their emotional distress and prevent the escalation into full-blown crises.”