TL;DR The interactive combination of (1) increased healthcare coverage, healthcare utilization, and mental health screenings, (2) expanded protections for behavioral healthcare, (3) reduced stigma of mental health, and (4) changing coding practices and diagnostic criteria explain a large portion of the observed increase in adolescent mental health problems in the U.S.
What kind of data is available for 2005-2006 range? That was the first depression / suicidality moral panic re: the Internet that I remember. That may have been a total media invention though.
Good question, I'm not as familiar with that particular panic. But it suggests that panics about new tech only really catch on when there are concomitant changes in observed trends in well-being.
Here's an observational take. I've taught at the same high school for the past twenty years. The student population is largely upper middle class, and well insured. The onset of the ACA had little to no impact on my students. The trend I first noticed, back in 2016 or so, was an increase in students missing school for anxiety. I still remember the first student I had who had missed multiple days of school. When I asked her what was wrong, she explained she was too anxious to come to school. This was unusual. In the past when students had missed school for illness, they'd come back the next day still with a runny nose or on crutches. Now this is a regular occurrence. I regularly hear from students, mostly girls, that their panic attacks and depression are what are keeping them home. Some of these students have missed over 50% of my class this year. It's dire.
Thanks for writing this. Very much appreciate your pushback.
There is a lot here to address. First, to note, I am going to need time to really look through the arguments that you make, and want to do it full justice. These are just some initial questions and thoughts:
1. I certainly don't doubt that the changes had some impact, but the degree to which you are attributing is definitely more than my sense of what the data reflects. There are a number of points in my post that weren't addressed here (including why self-harm hospitalization rates went down for other age groups, while only going up for adolescents; and some other points). Also, see Jean's recent post on this topic: https://www.generationtechblog.com/p/is-the-adolescent-mental-health-crisis. She'll be opening up the post on Tuesday (so no more paywall).
2. If there was more screening and *more treatment* for depression after 2011, shouldn't that drive depression rates down, not up? (especially over longer periods of time). Treatment should work, so if more teens were getting treated, there should be less depression. If "Behavioral health services are more available, more accessible, and more affordable." Would this imply that behavioral health services are making teen mental health worse instead of better? Do you disagree?
3. You say: "More check-ups, more screenings, and more protections for behavioral health conditions leads to lots of kids screening positive for depression and getting diagnosed—helping to explain the rise in self-reported depression since 2011." I am not sure how this applies to the NSDUH because it is not asking about diagnoses. It's using the DSM symptoms of depression, including symptoms that some of people (perhaps especially teens) don't know are linked to depression (like insomnia, weight loss/gain, and fatigue).
Also, with the NSDUH, mental health got worse across all socioeconomic groups -- the rise is similar across all income brackets. If insurance/screening was the driving force for mental health increases, I would expect that the uptick should have been concentrated by income.
4. There is also data from many other sources showing worsening trends in the U.S.: We find that there is less life satisfaction, less happiness, and lower expectations for the future, along with more kids reporting feelings of meaninglessness and uselessness. (All of which Monitoring the Future data is showing). All are correlated with depression but aren't exactly the same thing. Is this just a coincidence with the increase of screening?
5. I have a lot to say about the international data, and this is something I am currently working on. I think that you are underplaying the theory we are putting forth, which *is not uni-causal*. The loss of the play-based childhood is essential; and the "play-based childhood" I think is often misunderstood and simplified to only apply to play itself (which is a reasonable.. as the name does not fully encompass what I see it entailing). it applies to a broader social ecosystem, something I'm starting to call a "community-based childhood." (this includes mentorship, guidance, trusted adults, rites of passage, etc.). This is central to Chapter 4 of the book. New technologies (and other social forces) have long been pulling individuals away from local place-based relationships, real world communities and groups, which drive reduction in local social trust and unsupervised play. This leaves physically isolated kids in an isolating online world without a community of real world support around them. All of this is part of the story. And there is a lot of cultural variation in the tightness and enmeshment of real world communities, and relationships with technology.
[This is how I am thinking about the issue. I don't want to speak for Jon]
What kind of data is available for 2005-2006 range? That was the first depression / suicidality moral panic re: the Internet that I remember. That may have been a total media invention though.
Good question, I'm not as familiar with that particular panic. But it suggests that panics about new tech only really catch on when there are concomitant changes in observed trends in well-being.
Here's an observational take. I've taught at the same high school for the past twenty years. The student population is largely upper middle class, and well insured. The onset of the ACA had little to no impact on my students. The trend I first noticed, back in 2016 or so, was an increase in students missing school for anxiety. I still remember the first student I had who had missed multiple days of school. When I asked her what was wrong, she explained she was too anxious to come to school. This was unusual. In the past when students had missed school for illness, they'd come back the next day still with a runny nose or on crutches. Now this is a regular occurrence. I regularly hear from students, mostly girls, that their panic attacks and depression are what are keeping them home. Some of these students have missed over 50% of my class this year. It's dire.
Hey Craig,
Thanks for writing this. Very much appreciate your pushback.
There is a lot here to address. First, to note, I am going to need time to really look through the arguments that you make, and want to do it full justice. These are just some initial questions and thoughts:
1. I certainly don't doubt that the changes had some impact, but the degree to which you are attributing is definitely more than my sense of what the data reflects. There are a number of points in my post that weren't addressed here (including why self-harm hospitalization rates went down for other age groups, while only going up for adolescents; and some other points). Also, see Jean's recent post on this topic: https://www.generationtechblog.com/p/is-the-adolescent-mental-health-crisis. She'll be opening up the post on Tuesday (so no more paywall).
2. If there was more screening and *more treatment* for depression after 2011, shouldn't that drive depression rates down, not up? (especially over longer periods of time). Treatment should work, so if more teens were getting treated, there should be less depression. If "Behavioral health services are more available, more accessible, and more affordable." Would this imply that behavioral health services are making teen mental health worse instead of better? Do you disagree?
3. You say: "More check-ups, more screenings, and more protections for behavioral health conditions leads to lots of kids screening positive for depression and getting diagnosed—helping to explain the rise in self-reported depression since 2011." I am not sure how this applies to the NSDUH because it is not asking about diagnoses. It's using the DSM symptoms of depression, including symptoms that some of people (perhaps especially teens) don't know are linked to depression (like insomnia, weight loss/gain, and fatigue).
Also, with the NSDUH, mental health got worse across all socioeconomic groups -- the rise is similar across all income brackets. If insurance/screening was the driving force for mental health increases, I would expect that the uptick should have been concentrated by income.
4. There is also data from many other sources showing worsening trends in the U.S.: We find that there is less life satisfaction, less happiness, and lower expectations for the future, along with more kids reporting feelings of meaninglessness and uselessness. (All of which Monitoring the Future data is showing). All are correlated with depression but aren't exactly the same thing. Is this just a coincidence with the increase of screening?
5. I have a lot to say about the international data, and this is something I am currently working on. I think that you are underplaying the theory we are putting forth, which *is not uni-causal*. The loss of the play-based childhood is essential; and the "play-based childhood" I think is often misunderstood and simplified to only apply to play itself (which is a reasonable.. as the name does not fully encompass what I see it entailing). it applies to a broader social ecosystem, something I'm starting to call a "community-based childhood." (this includes mentorship, guidance, trusted adults, rites of passage, etc.). This is central to Chapter 4 of the book. New technologies (and other social forces) have long been pulling individuals away from local place-based relationships, real world communities and groups, which drive reduction in local social trust and unsupervised play. This leaves physically isolated kids in an isolating online world without a community of real world support around them. All of this is part of the story. And there is a lot of cultural variation in the tightness and enmeshment of real world communities, and relationships with technology.
[This is how I am thinking about the issue. I don't want to speak for Jon]
6. Also see this study by David Blanchflower, on some new international data https://www.nber.org/system/files/working_papers/w32337/w32337.pdf
For my response to Zach's thoughtful comments/questions see this post: https://open.substack.com/pub/craigsewall/p/responding-to-comments-regarding?r=1jg7sp&utm_campaign=post&utm_medium=web