ISSN 2691-7475 Health Policy Brief January 2021 Nearly 1 in 3 Adolescents in California Reports Serious Psychological Distress Blanche Wright, D. Imelda Padilla-Frausto, Hin Wing Tse, Ann Crawford-Roberts, Firooz Kabir, and Safa Salem ‘‘ One in 2 adolescents is affected by a mental health ’’ problem. SUMMARY: National estimates show that 1 of every 2 adolescents ages 12 to 17 is affected by a mental health disorder. This brief uses data from the 2019 California Health Interview Survey (CHIS) to identify adolescents who are most vulnerable to moderate and serious psychological distress, both measures of mental health status. Results indicate that in 2019, nonconforming, and multiracial; among adolescents who had poor health, poor nutrition, and sedentary behavior; and among adolescents who engaged in binge drinking and marijuana, hashish, and e-cigarette/ cigarette use. To ensure the best mental health outcomes for approximately 1 in 3 adolescents in California, or adolescents, families, communities, and society, 29.3 %, reported symptoms that meet the criteria the structural, political, and systemic issues for serious psychological distress (SPD), while 1 in that create socioeconomic inequities must be 7 adolescents, or 15.7%, reported symptoms of addressed, and there must be increased access moderate psychological distress (MPD). to and improvement of mental health services. Policy recommendations for federal, state, and Guided by the World Health Organization’s local policymakers and stakeholders include conceptual framework on the structural reducing socioeconomic inequities, establishing determinants of health inequities, analysis of universal service access in schools, increasing CHIS data shows high rates of SPD among mental health literacy among caregivers, and adolescents who were female, gender- adopting integrated care models. A ccording to the World Health Organization (WHO), mental health problems are among the leading identifying correlates of mental health problems, including health and health behaviors, can inform key areas for prevention causes of illness and disability for children and intervention.5 and adolescents ages 10–19.1 Approximately 1 in 2 adolescents is affected by a mental Using 2019 California Health Interview health disorder, and almost half of all mental Survey (CHIS) data, this policy brief examines illnesses first manifest before individuals serious and moderate psychological distress are 14 years of age.2,3 If not treated early among adolescents. Descriptive analyses and and properly, adolescent mental health policy recommendations are guided by the problems can impair a youth’s academic and WHO’s conceptual framework on the social social functioning and have long-lasting determinants of health inequities (SDHI). negative consequences in adulthood.4 As The WHO’s framework of SDHI shows how a such, it is imperative to identify important society’s social and political context produces socioeconomic determinants of adolescent a set of economic and social conditions in mental health problems. In addition, which populations are positioned in a social 2 UCLA CENTER FOR HEALTH POLICY RESEARCH Adolescent Mental Health in California DEFINITIONS In 2019, nearly 1 in 3 adolescents (29.3%) reported having serious psychological distress Serious Psychological Distress (SPD) (SPD) in the past year. An additional 1 Based on the number and frequency of in 7 adolescents (15.7%) reported having symptoms reported in the past year, an moderate psychological distress (MPD) estimate of adolescents with serious, in the past year. Older adolescents, ages diagnosable mental health disorders 15–17, were 1.5 times more likely to report that warrant mental health treatment SPD (35.9%) than younger adolescents, within a population.7 ages 12–14 (22.9%). Reports of MPD were similar in both age groups (15% Moderate Psychological Distress (MPD) and 16.3%, respectively). Beyond age, Based on the number and frequency of adolescents in various socioeconomic contexts symptoms reported in the past year, an disproportionally reported psychological estimate of adolescents with moderate distress. mental distress—i.e., distress that is clinically relevant and warrants early Structural Determinants of Mental Health mental health intervention—within a Inequities population.8 The structural determinants of mental health inequities highlight socioeconomic ‘‘ injustices and the differential vulnerability some populations have for poor mental health Nearly two- hierarchy by factors such as income, education, outcomes. This section examines economic status indicators, which include family poverty thirds of occupation, gender, race and ethnicity, and citizenship status. The sociopolitical context level and insurance status, and social status adolescents and the resulting socioeconomic status of indicators, which include gender, gender in families individuals, combined, are considered the identity, race and ethnicity, and citizenship status. with incomes structural determinants of health inequities. This framework further posits that SDHI below the FPL operate through intermediate determinants of Economic Status Indicators reported MPD health, such as behavioral health factors, that Reports of psychological distress varied ’’ can either improve or exacerbate mental health by economic status. Nearly two-thirds of or SPD. outcomes.6 adolescents in families with incomes below the federal poverty level (FPL) reported moderate This policy brief examines family poverty to serious psychological distress, with 27.4% level, insurance type, gender, gender identity, reporting MPD and an additional 30.6% race and ethnicity, and citizenship status as reporting SPD (Exhibit 1). Adolescents from proxies for the structural determinants of families with incomes of 200%–299% FPL mental health inequities, and health status, were 1.5 times more likely to report SPD nutrition, physical activity, use of social media, (37.5%) than their counterparts with family binge drinking, marijuana use, and cigarette incomes of 100%–199% FPL (22.9%). Nearly use as intermediate behavioral determinants. one-third of adolescents with private health UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Structural Determinants (Economic Status Indicators) of Mental Health Inequities, Exhibit 1 Adolescents Ages 12–17, California, 2019 0%–99% FPL 30.6% 27.4% Income, by FPL 100%–199% FPL 22.9%* 15.8% 200%–299% FPL 37.5% 14.6%† 300% FPL and above 29.9% 12.6% Private 31.9% 14.5% Insurance Uninsured/Medicaid 25.2% 17.7% 0% 10% 20% 30% 40% 50% 60% 70% Serious Psychological Distress Moderate Psychological Distress Source: 2019 California Health Interview Survey *Statistically significant difference between groups at p <.05. For FPL, all groups were compared to 200%–299% FPL. †Unstable estimate insurance and one-quarter of those with public or no health insurance reported SPD. Social Status Indicators Reports of MPD and SPD varied by social status. As shown in Exhibit 2, adolescent females were 1.5 times more likely to report Intermediary Determinants of Mental Health According to the WHO framework, structural determinants of mental health inequities operate through a set of intermediate determinants, such as health and behavioral factors, that can either improve ‘‘ Approximately 2 in 5 adolescents who self-identified as multiracial SPD (36.6%) than their male counterparts (22.4%). Nearly 2 in 5 adolescents who identified as gender-nonconforming reported or exacerbate mental health outcomes. The following section examines SPD and MPD by health status, nutrition, physical activity, reported SPD. ’’ SPD (36.4%), and nearly 1 in 6 reported and social media use as health behaviors, and MPD (15.7%). Approximately 2 in 5 binge drinking, use of marijuana, hashish, adolescents who self-identified as multiracial e-cigarettes, and cigarettes as risky health reported SPD (42.9%). Non-Latinx white behaviors. adolescents were more likely to report SPD (36.6%) when compared to Latinx (27.1%) Health Status and Health Behaviors and non-Latinx Asian (20.9%) adolescents. Reports of SPD were higher among Adolescents from diverse racial and ethnic adolescents with poor health and poor health backgrounds reported MPD at similar rates. behaviors. As shown in Exhibit 3, 1 in 2 Foreign-born adolescents were more likely adolescents who reported their health as than U.S.-born adolescents to report SPD fair or poor reported SPD (49.9%). These (37.7% vs. 28.8%). individuals were three times more likely to report SPD than adolescents in excellent 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2 Structural Determinants (Social Status Indicators) of Mental Health Inequities, Adolescents Ages 12–17, California, 2019 Female 36.6%* 17.1% Gender Male 22.4% 14.3% Gender-nonconforming 36.4%* 15.7% Gender Identity Gender-conforming 27.7% 15.7% Multiracial (NL) 42.9% 16.4%† Race and Ethnicity White (NL) 36.6% 12.8% Latinx 27.1%* 16.3% Asian (NL) 20.9%* 19.4%† African American (NL) 13.9%† 18.9%† Citizenship Foreign-born resident 37.7%* 20.1%† U.S.-born resident 28.8% 15.4% 0% 10% 20% 30% 40% 50% 60% 70% Serious Psychological Distress Moderate Psychological Distress Source: 2019 California Health Interview Survey *Statistically significant difference between groups at p <.05. Note: For race and ethnicity, all groups were compared to †Unstable estimate non-Latinx (NL) white. ‘‘ Reports of SPD were higher among adolescents who engaged in risky health (16.0%). Adolescents who ate less than five servings of fruits and vegetables daily were 1.5 times more likely to report SPD (32.2%) than adolescents who ate five or more servings a day (21.2%). Adolescents who were sedentary for five or more hours on a typical weekend were nearly twice as likely Risky Health Behaviors Reports of SPD were higher among adolescents who engaged in risky health behaviors. Adolescents who had ever tried marijuana or hashish were nearly twice as likely to report SPD (47.6%) as adolescents who had not (26.0%) (Exhibit 4). ’’ health behaviors. to report SPD (34.6%) as adolescents who were sedentary less than three hours (19.0%). Reports of MPD were nearly twice as high Adolescents who had ever smoked cigarettes or e-cigarettes were nearly twice as likely to report SPD (45.1%) as adolescents who among adolescents who were sedentary for had not smoked (26.0%). Additionally, five hours or more (17.7%) compared to approximately 2 in 5 adolescents who had adolescents who were sedentary from three to engaged in binge drinking in the past month less than five hours. Adolescents who reported reported SPD (41.3%). they used their computer or mobile device for social media almost constantly were twice as Conclusions and Recommendations likely to report SPD (39.1%) as adolescents In 2019, more than 45% of adolescents in who were on social media less than a few California experienced moderate to serious times a day (18.7%). psychological distress, and rates varied by UCLA CENTER FOR HEALTH POLICY RESEARCH 5 Intermediary Health Status and Health Behaviors, Adolescents Ages 12–17, California, 2019 Exhibit 3 Fair or poor 49.9%* 20.7%† Health Status Good 39.4%* 21.1% Very good 28.8%* 18.4% Excellent 16.0% 5.1%† Less than 5 servings 32.2%* 17.2% Nutrition of fruits and vegetables 5+ servings 21.2% 11.4% Typical Weekend 5 or more hours 34.6% 17.7% Sedentary on 3 to less than 5 hours 25.6% 9.9%* Less than 3 hours 19.0%* 17.2% Almost constantly 39.1% 16.4% Social Media Use Many times a day 27.9%* 15.4% A few times a day 29.8% 14.6% Less than a few times a day 18.7%* 17.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% Serious Psychological Distress Moderate Psychological Distress Source: 2019 California Health Interview Survey *Statistically significant difference between groups at p <.05. Notes: For health status, all groups are compared to those who †Unstable estimate reported “excellent health.” For sedentary, all groups are compared to those who reported “five or more hours.” For social media use, all groups are compared to those who reported “almost constantly.” determinants of mental health inequities. The proportion of California adolescents experiencing psychological distress is comparable to national estimates.3 In alignment with WHO, current findings underscore the need for socioeconomic equality, universal prevention of adolescent behavior, excessive use of social media, and use of marijuana, hashish, e-cigarettes, and cigarettes are important intermediate determinants that may exacerbate psychological distress. To safeguard the psychological and emotional ‘‘ Poverty, gender, gender identity, and being multiracial or an immigrant mental illness, and universally delivered well-being of adolescents, the following are key recommendations are offered to federal, state, psychosocial interventions that have been shown to be effective in improving adolescent and local policymakers and stakeholders who structural mental health.5,9 These data highlight work with adolescents and their families. determinants that poverty, gender, gender identity, and •Reduce socioeconomic inequities. To of adolescent being multiracial or an immigrant are key structural determinants of adolescent ensure the best mental health outcomes for psychological psychological distress. The data also show that poor health, poor nutrition, sedentary adolescents, the structural, political, and systemic issues that create socioeconomic ’’ distress. 6 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4 Intermediary Risky Health Behaviors, Adolescents Ages 12–17, California, 2019 Engaged in Binge Drinking in the Past Month Yes 41.3% 14.8%† No 28.3% 15.7% Marijuana or Yes 47.6%* 18.5% Ever Tried Hashish No 26.0% 15.0% Ever Smoked Cigarettes or E-Cigarettes Yes 45.1%* 18.0% No 26.0% 15.2% 0% 10% 20% 30% 40% 50% 60% 70% Serious Psychological Distress Moderate Psychological Distress Source: 2019 California Health Interview Survey †Unstable estimate ‘‘ *Statistically significant difference between groups at p <.05. Policymakers inequities must be addressed. Federal, school districts to establish universal state, and local policymakers can work prevention programming (i.e., screening, and stakeholders with disadvantaged and marginalized intervention delivery) that addresses must take communities to critically evaluate adolescent physical health, mental health, specific steps to current policies with an equity-based lens. Communities such as racial, ethnic, and substance use. Federal, state, and local agencies can help promote school-based safeguard the immigrant, and LGTBQ can help to inform mental health workforce development psychological the development and implementation of with incentives such as implementing and emotional equity-based policies in areas such as (but not limited to) economic security, education, loan repayment programs. Workforce development can include hiring more well-being of the labor market, housing, health care, and school psychologists and training teachers adolescents. ’’ social welfare and protection. Advocacy efforts to reduce socioeconomic inequities via expansion of government benefits and in mental health screening and classroom- based interventions. employment-related actions (e.g., increasing •Continue telehealth service-delivery the minimum wage) require stakeholder model. The rapid adoption of telehealth support for implementation, as reducing during COVID-19 proved to be valuable inequities directly benefits the well-being for improving treatment engagement, of youth.10 with increases in session attendance.11 As such, telehealth delivery can be retained in •Establish universal access to health primary and specialty mental health care and mental health services in schools. settings and schools, with continued efforts Organizations that provide evidence-based to ensure technology access for adolescents mental health care, especially those that facing socioeconomic inequities. are federally funded, could partner with UCLA CENTER FOR HEALTH POLICY RESEARCH 7 •Increase parent mental health literacy. Implementation of these policy Public health, schools, and health care recommendations can help mitigate adolescent organizations can increase outreach mental health problems by investing in actions initiatives (e.g., media campaigns) to that reduce socioeconomic inequities, raise educate parents on signs of distress and awareness about adolescent mental health, effective treatments, since they are key and increase access to and improve treatment gatekeepers for access to care for youth.12 for adolescents. To ensure the best mental Tailored and increased educational and health outcomes for adolescents, families, service outreach for parents of multiracial, communities, and society as a whole, the female, gender-nonconforming, and structural, political, and systemic issues that immigrant adolescents is warranted. create socioeconomic inequities for some Readily available translated information populations and not others must be addressed is critically important for non–English in conjunction with increasing access to and speaking immigrant families. Health care improving mental health services. organizations can help every family access services by ensuring that a mental health Data Source and Methods care navigator is available, as understanding This policy brief presents data from the 2019 California Health Interview Survey (CHIS), conducted insurance benefits and obtaining effective by the UCLA Center for Health Policy Research. We care may be challenging. used data collected in interviews with adolescents sampled from every county in the state. Beginning •Adopt integrated care models. The strong in 2019, following the successful implementation link between psychological distress and of two field experiments to test a new sample design poor physical health and health behaviors and data collection methodology, CHIS transitioned warrants a more rapid adoption of integrated to a mixed-mode survey (web and telephone) using a care models to help address the holistic random sample of California addresses. Households with eligible adolescents (ages 12 to 17) were invited needs of adolescents. Federal, state, and to have one randomly selected adolescent complete local funding is needed to develop the the survey online or by telephone, with a parent’s infrastructure for large-scale adoption, permission. A total of 847 adolescents completed the such as establishing a universal electronic interviews, a number nearly double that in 2018 (432 The California Health adolescents). Interviews were conducted in English, Interview Survey (CHIS) health record to streamline coordination Spanish, Chinese (both Mandarin and Cantonese), covers a wide array of in treatment plans between primary care health-related topics, Vietnamese, Korean, and Tagalog. providers (e.g., doctors, nurse practitioners) including health insurance and mental health professionals. Federal, CHIS is designed with complex survey methods, coverage, health status state, and local support is needed to broaden requiring analysts to use complex survey weights and behaviors, and access Medicaid insurance reimbursement for same- in order to provide accurate variance estimates and to health care. It is based statistical testing. All analyses presented in this on interviews conducted day primary care and mental health services. brief include replicate weights to provide corrected continuously throughout Additionally, screening for mental health the year with respondents confidence interval estimates and statistical tests. and substance use needs to be routinely from more than 20,000 implemented in health care visits. For analyses in this brief, serious psychological California households. distress (SPD) in the past year was measured using •Increase mental health training for a cutoff score of 13 to 24 on the Kessler–6 (K6), a CHIS is a collaboration those in law enforcement. Members of validated measure designed to estimate the prevalence among the UCLA Center of diagnosable mental disorders within a population.7 for Health Policy Research, law enforcement need training to ensure Moderate psychological distress (MPD) in the past California Department of that adolescents engaging in substance use Public Health, California year was measured using a K6 score of 9 through are linked to appropriate mental health 12­— a conservative cutoff on the lower score, as Department of Health Care services. Cross-system coordination with one validation study found a cutoff of 5 or 6 to be a Services, and the Public providers of mental health care is needed, clinically relevant level.8 Health Institute. For more including further investment in mobile information about CHIS, please visit chis.ucla.edu. teams to support law enforcement during acute crisis situations involving adolescents. UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 Author Information Endnotes Blanche Wright, MA, C.Phil, is a doctoral 1 World Health Organization. Adolescent Mental Health. September 5, 2020. Accessed December 14, candidate in the UCLA clinical psychology 2020. https://www.who.int/news-room/fact-sheets/detail/ program, a National Institute of Mental Health adolescent-mental-health The UCLA Center for Health Policy Research NRSA Fellow, and a Robert Wood Johnson 2 Kessler RC, Berglund P, Demler O, Jin R, Foundation Health Policy Research Scholar. Merikangas KR, Walters EE. 2005. Lifetime is part of the Prevalence and Age-of-Onset Distributions of DSM- UCLA Fielding School of Public Health. D. Imelda Padilla-Frausto, PhD, MPH, is iv Disorders in the National Comorbidity Survey a research scientist at the UCLA Center for Replication. Archives of General Psychiatry 62(6):593. Health Policy Research. Hin Wing Tse is https://doi.org/10.1001/archpsyc.62.6.593 3 Merikangas KR, He J, Burstein M, et al. 2010. a CHIS researcher and data dissemination Lifetime Prevalence of Mental Disorders in U.S. coordinator at the UCLA Center for Health Adolescents: Results From the National Comorbidity Policy Research. Ann Crawford-Roberts, MD, Survey Replication—Adolescent Supplement (NCS-A). Journal of the American Academy of MPH, is a resident physician at UCLA Resnick Child & Adolescent Psychiatry 49(10):980-989. Neuropsychiatric Hospital and the Semel https://doi.org/10.1016/j.jaac.2010.05.017 The analyses, interpretations, conclusions, and views expressed in this policy brief are Institute for Neuroscience and Human Behavior, 4 Clayborne ZM, Varin M, Colman I. 2019. Systematic those of the authors and do not necessarily and an APA/APAF leadership fellow. Firooz Review and Meta-analysis: Adolescent Depression represent the UCLA Center for Health Policy and Long-Term Psychosocial Outcomes. Journal Kabir is a master’s student at the UCLA Fielding of the American Academy of Child & Adolescent Research, the Regents of the University of California, or collaborating School of Public Health. Safa Salem is a UCLA Psychiatry 58(1):72-79. https://doi.org/10.1016/j. organizations or funders. CDC Public Health Scholar alum and a Harvard jaac.2018.07.896 graduate in history and science. 5 Skeen S, Laurenzi CA, Gordon SL, et al. 2019. PB2021-1 Adolescent Mental Health Program Components and Copyright © 2021 by the Regents of the Behavior Risk Reduction: A Meta-analysis. Pediatrics University of California. All Rights Reserved. Funder Information 144(2). https://doi.org/10.1542/peds.2018-3488 Editor-in-Chief: Ninez A. Ponce, PhD This policy brief was funded by the California 6 Solar O, Irwin A. 2010. A Conceptual Framework for Action on the Social Determinants of Health. Social Department of Health Care Services – Community Determinants of Health Discussion Paper 2 (Policy Services Division. The content is solely the and Practice). Geneva, Switzerland: World Health Phone: 310-794-0909 responsibility of the authors and does not Organization. Fax: 310-794-2686 7 Kessler RC, Green JG, Gruber MJ, et al. 2010. necessarily represent the official views of the funder. Screening for Serious Mental Illness in the General Email: chpr@ucla.edu healthpolicy.ucla.edu Population With the K6 Screening Scale: Results Acknowledgments From the WHO World Mental Health (WMH) Survey Initiative. International Journal of Methods in The authors truly appreciate Tiffany Lopes, Psychiatric Research 19(S1):4-22. https://onlinelibrary. Venetia Lai, Elaiza Torralba, Celeste Peralta, wiley.com/doi/abs/10.1002/mpr.310 Donna Beilock, and Mary Nadler for all 8 Prochaska JJ, Sung H, Max W, Shi Y, Ong M. 2012. Validity Study of the K6 Scale as a Measure of their support in copyediting, designing, and Moderate Mental Distress Based on Mental Health disseminating this policy brief. In addition, Treatment Need and Utilization. International Journal the authors would like to thank the California of Methods in Psychiatric Research 21(2):88-97. https://doi.org/10.1002/mpr.1349 Department of Health Care Services – 9 World Health Organization. 2020. Guidelines on Community Services Division, Susan Babey of Mental Health Promotive and Preventive Interventions the UCLA Center for Health Policy Research, for Adolescents. Geneva, Switzerland: World Health and Dr. Bonnie T. Zima of the UCLA Center for Organization. Health Services and Society for their thoughtful 10 Perrin JM, Duncan G, Diaz A, Kelleher K. 2020. Principles and Policies to Strengthen Child and thorough reviews. and Adolescent Health and Well-Being. Health Affairs 39(10):1677-1683. https://doi.org/10.1377/ hlthaff.2020.00709 Suggested Citation 11 Martinelli K, Cohen Y, Kimball H, Sheldon-Dean H. Wright B, Padilla-Frausto DI, Crawford-Roberts 2020. Children’s Mental Health Reported: Telehealth in A, Tse HW, Kabir F, Salem S. 2021. Nearly an Increasingly Virtual World. New York, N.Y.: Child Mind Institute. 1 in 3 Adolescents in California Reports Serious 12 Hurley D, Swann C, Allen MS, Ferguson HL, Vella Psychological Distress. Los Angeles, Calif.: UCLA SA. 2020. A Systematic Review of Parent and Center for Health Policy Research. Caregiver Mental Health Literacy. Community Mental Health Journal 56(1):2-21. https://doi.org/10.1007/ Read this publication online s10597-019-00454-0