Review Article, Int J Ment Health Psychiatry Vol: 6 Issue: 3
Social Determinants of Mental Health in Adolescents and Young Adults in Western Nations – A Literature ReviewJalla R*, Baral D and Pithadia D
Medical College of Georgia at Augusta University, United States
*Corresponding Author : Jalla R
United States Tel: 6786727988
E-Mail: [email protected]
Received date: June 19, 2020; Accepted date: June 23, 2020; Published date: July 3, 2020
Citation: Jalla R, Baral D, Pithadia D (2020) Social Determinants of Mental Health in Adolescents and Young Adults in Western Nations – A Literature Review. Int J Ment Health Psychiatry 6:3. doi: 10.37532/ijmhp.2020.6(3).181
Social determinants, such as culture, socioeconomic status, sex/gender, lifestyle and environment, and social media, heavily influence adolescent and young adult mental health in the United States and Europe. Racial and cultural minority groups are more likely to suffer from mental illness. African and Native Americans have expressed the most discrimination amongst minority groups in the United States, which may contribute to the increased prevalence of mental illness in these groups. College-aged Asian Americans have high rates of suicidality although they are less likely to receive a mental health diagnosis compared to Caucasian counterparts. Outside of race, low socioeconomic status is associated with poor coping skills and poor mental health. Sex/gender expression shows a discrepancy in suicidality, as girls attempt suicide more often, while boys are more likely to successfully complete suicide. This may be due to increased prevalence of internalizing mental disorders in females and externalizing mental disorders in males. Gender minorities have increased depression and anxiety, and a significant percentage report mistreatment by healthcare officials. Data regarding the effects of social media and mental health is varied, and no strong association has been demonstrated between social media use and mental health. Environmental outcomes such as noise pollution and disparity of healthcare workers have been shown to have a negative impact on mental health.
Keywords: Mental Health Disparities; Adolescent Mental Health; Social mental health; Minority Mental Health; Marginalized Mental Health
Over the past decade, mental health has been in the spotlight in the media with regards to its impact on overall health. Adolescents in particular are a special population with regards to mental health as they are still developing mentally and emotionally. This paper is a review of prominent social determinants that may help to better understand the mental health disparities present among particular groups. The disadvantaged groups discussed in this paper include ethnic/racial minorities, sexual and gender minorities, and the socioeconomically disadvantaged. Additionally, this paper addresses common challenges faced by most adolescents, such as navigating social media or other environmental factors.
With globalization and the expansion of immigration, especially in Western nations, comes an association of different cultures and racial/ ethnic backgrounds. Several studies have detailed the psychological tendencies of specific racial and ethnic groups in countries with nonhomogenous populations. A study conducted to assess suicidality amongst US college students demonstrated that Asian and multi-racial students exhibited significantly higher rates of suicidal ideation and attempts compared to their Caucasian peers. This is despite having lower rates of mental health diagnoses than Caucasians. On the other hand, African Americans and Hispanics exhibited significantly lower rates of self-injury and suicidal ideation relative to Caucasians but no significant difference in suicide attempts . Such discrepancies found amongst similarly aged individuals requires further studies of how various groups perceive and act on mental disorders.
A 2018 study comparing the mental health status of US children with immigrant parents to that of children of non-immigrant parents found similar disruption and depressive behavior scores in children of European American and non-immigrant parents. Within Asian and Latino groups, children of immigrants had higher depression scores than non-immigrants. Furthermore, Asian American/ Pacific Islander children with two immigrant parents had higher depression scores compared to children of similar ethnic background with a single immigrant parent. Parents tend to use parental methods rooted in their native culture, so parent-adolescent conflict, familial dysfunction, and poor mental health are more likely in children who assimilate to American culture at a faster rate than their parents . This suggests that children of immigrants whose culture differs greatly from the culture of the US suffer more from mental disorders.
Delving more into how mental health varies in accordance to different social factors in specific ethnic/racial groups, a study conducted by Lo and Cheng determined that overall discrimination experiences impaired mental health in African Americans the most, out of Latinos, Asians, and Blacks. The same study showed that marriage contributed to better mental health in Asian individuals, but not in African Americans. Furthermore, higher education levels contributed to improved mental health in Latino individuals but not in African Americans. The study surmised that a possession of factors valued by a particular ethnic group led to improved mental health of individuals within that group.
Discrimination, while not isolated to a particular group, is more likely to be experienced by certain ethnic groups in the United States. For example, 35% of African Americans and Native Americans, 25% of Latinos, 22% of Asians, and 18% of whites reported that they had an experience of being unfairly not being hired for a job. Similarly, 34% of American Indians, 23% of blacks, 19% of Hispanics, and 11% of Asians and non-Hispanic whites reported that they experienced everyday discrimination almost every day or at least once a week. It is internationally observed that discrimination is associated with symptoms of depression/anxiety and psychological stress .
There are large racial differences in life expectancy, and this can have an impact on mental health in loved ones. Compared to whites, black Americans are exposed to more deaths of friends and relatives from early childhood through late life and to more losses earlier in life. This elevated rate of bereavement and loss of social ties is a unique stressor that adversely affects levels of supportive social ties and mental (and physical health) across the life span. Similar outcomes have been seen as a result of institutional racism favoring whites over Hispanics and blacks within the criminal justice system.
Socioeconomic Status Impacts on Mental Health
The correlation between socioeconomic status and mental health outcomes have been long established and is even stronger than the association between mental disorders and education level or social class. Some models that have been established to describe the relationship, including the critical period model, accumulation of risks hypothesis, and the social mobility hypothesis.
The critical period model states that experiences early in life influence health outcomes later in life. This is a fairly rigid model since it says any alleviating factors that happen after a ‘critical period’ cannot change the outcome of the events that occurred during the critical period early in life. If the events during this critical period are negatively impacting, then the mental health outcome later in life will also be poor regardless of the events that occur after the critical period. This model was one of the early hypotheses and is mainly regarded as outdated.
The social mobility hypothesis states that if a person moves up in socioeconomic status during life, the effects or benefits of being in a higher socioeconomic class will compensate or even overcome the risks the person faced when younger in a lower socioeconomic class leading to a modification in their mental health outcomes. This hypothesis takes into consideration that women and children are at a higher risk for mental disorders since it is traditionally more challenging for them to move up the socioeconomic ladder.
The accumulation of risk hypothesis states that the overall collection of risk throughout one’s life causes common mental health conditions, such as depression and anxiety. This means the more disadvantages or risk factors a person faces throughout his lifetime, the higher the chance of developing a common psychiatric condition. Within this hypothesis, there are two sub-models: additive and interactive. The additive model states that both childhood risks and adult risks are independent of each other and hold the same value with regards to developing a mental health disorder. The interactive model states that childhood risks and adulthood risks are synergistic and influence each other on how impactful they are with regards to impact on developing a common mental health condition.
A study from Morrissey and Kinderman supports the accumulation theory overall. The main outcome was that the duration and persistence of financial difficulty had a greater impact on mental health outcomes than the specific timings of these hardships. This effectively contradicted the critical period model .
Other studies have shown similar correlations. Elovainio et al stated that the recurrent depressive episodes during adolescence is a risk factor for depressive episodes later in life. There seems to be a longlasting negative association between living in a socioeconomically disadvantaged area during childhood and adolescence and mental health regardless of other family related risks, which is partially due to adversity later in life from socioeconomic disadvantage .
De France and Evans stated that there is an indirect correlation between socioeconomic status and mental health outcomes. Lower socioeconomic status was associated with worse coping with mental and emotional stressors, which led to worse mental health outcomes. One poor coping mechanism on which he elaborated is disengagement: the internalization of emotions such as anxiety and depression. Disengagement is also associated with poor mental health outcomes. Higher socioeconomic status was found to have protective effects on people who experienced disengagement, while a lower status negatively impacted those who experienced disengagement, which demonstrates how socioeconomic status can modulate employment of coping mechanisms (disengagement vs externalizing emotions) .
Sex/Gender Impact on Mental Health
Various sex/gender differences exist to uniquely impact an adolescent’s mental health. Adolescence is a critical time period for not only physical, but also psychological growth; therefore, an individual’s social environment during this time period can have lasting effects on mental health. Per most studies looking at cis-gender individuals, females are more prone to internalizing mental disorders and thus are more susceptible to depression and anxiety disorders. On the other hand, males are more prone to externalizing mental disorders. This is evidenced by the higher rates of ODD and substance abuse disorders seen in males. The World Health Organization (WHO) notes that gender bias is prevalent among healthcare providers; for example, physicians are more likely to diagnose depression in women compared to men even when both score similarly on standardized depression tests. This may be due to stereotyping of women as more susceptible to emotional problems and men as more susceptible to alcohol abuse. This stereotyping could further cement a self-fulfilling prophecy, making it more difficult for men to open up about depression and women to open up about alcoholism, seeing as documented evidence per WHO notes men are reluctant to open up about their depression compared to women, and women are less likely to speak about their alcoholism compared to men.
Per the CDC, as of 2019, suicide is the second leading cause of death among adolescents in the United States. Females are more likely to attempt suicide, whereas males are more likely to successfully complete suicide. Males attempt suicide through more lethal methods, such as hanging or firearms. Females are more likely to attempt suicide by selfpoisoning, although self-poisoning is a prevalent suicidal measure amongst both sexes. Males who self-poison are twice as likely to die compared to females who self-poison . This suggests that males are more likely to ingest higher doses of poisonous substances, on theme with males’ tendency to externalize their mental disorders and hence be more destructive in their suicidal attempts compared to females. A research study comparing physical and mental health outcomes of sexual minority African American males with sexual minority African American females showed that the males (ie: gay, bisexual) are more susceptible to poor mental health outcomes compared to females (ie: lesbian, bisexual) . This may be associated with lower rate of help seeking behaviors in males overall in conjunction to less socially supportive friend groups. Additionally, males are more likely to engage helpin environments where physical harm is encouraged , further contributing to externalizing destructive behavior.
While males are at higher risk for completing suicide compared to females, females not only have an increased risk of suicide attempt, but also have increased mental health disorders overall. This increased rate of disorders may be a combination of increased reporting by females compared to men in conjunction to additional stressors experienced by adolescent females. Women are significantly more likely to experience dating violence compared to men. They furthermore have increased rates of eating disorders and have the added stress of possible pregnancy and abortion related stressors.
Aside from the social factors contributing to differences in mental health expression in cis-gender males and cis-gender females, there are more social factors contributing to the mental health of transgender or gender non-conforming individuals. Transgender and non-binary youth are much more susceptible to symptoms of anxiety and depression in comparison to their cis-gender counterparts. The Meyer minority stress theory details several factors that contribute to the high prevalence mental health disorders among transgender and nonbinary individuals. These factors include general stressors applicable to most individuals, such as work and school stress, combined with increased discrimination associated with minority gender identity combined with internalized stigma as a product of the increased discrimination. Furthermore, gender minority groups are much less likely to have a supportive social system, which further contributes to stress and self-destructive/externally destructive behaviors.
Gender minority teens are more likely to report disrespectful behaviors from their healthcare providers in comparison to their cisgender counterparts. Regardless of whether they were respected or not, gender minority individuals with depressive/suicidal thoughts were more likely to have had to educate their providers on their identity. In a 2019 study exploring correlations between healthcare providers and transgender/non-binary youth, one-third of participants stated that they experienced disrespect from a provider after the provider learned their gender identity. This is particularly problematic because these teens are facing discrimination from outlets that are intended to provide them with support. However, given the increased self prejudice experienced by these individuals, as highlighted in the minority stress theory model, it has been questioned whether mental health status impacts these individuals’ ability to find an affirming provider .
A major protective factor against suicide in sexual and gender minorities is a supportive school system. LGBT youth in the 19 states and the District of Columbia with anti-bullying laws specific for sexual and gender minorities have reported fewer experiences of harassment compared to students in states without the anti-bullying laws in place. LGBT inclusive curriculums are also associated with more psychologically healthy youth. Positive parental relationships should also be emphasized, as LGBT youth who fear rejection from their families are at increased risk for depressive symptoms, anxiety, and suicide attempts .
Lifestyle and Environment
There are various other social factors that determine mental health outcomes in adolescents. Poverty, conflict among adults in their lives, abuse, quality of psychotherapy or counseling available, stigma around mental health concerns, noise pollution, severity of hopelessness, suicidal ideation, and physical activity or lack thereof are all factors in an adolescent’s life that can affect both short-term and long-term mental health outcomes.
Lifestyle can have a significant impact on mental health. There seems to be an association between psychological well-being and physical activity levels since a sedentary lifestyle was associated with lower psychological well-being. A study by Rodriguez-Ayllon states that there was a “small but significant overall effect of physical activity on mental health in children and adolescents aged 6-18 years.” The study also claimed that an adolescent’s mental health can be improved by encouraging more physical activity in one’s lifestyle and decreasing sedentary behavior. These changes may even be protective against mental health issues . Certain behaviors such as hopelessness, suicidal ideation, and exposure to sexual abuse are also associated with repetitive self-harm. Self-harming behaviors can also be provoked by mood or personality disorders .
The environment that adolescents surround themselves with or grow up in can also play a role in mental health outcomes. Factors such as poverty, conflict, or abuse can have detrimental effects on mental health. Chronic psychiatric conditions developed during adolescence can harm mental during adulthood . There have also been studies about the effects of excess noise in living environments on overall health. A meta-analysis found that noise pollution may impede development of proper coping mechanisms for emotional issues in adolescents. Traffic noise also increased the odds for hyperactivity and inattention. However, the associations between transportation noise and emotional or behavior problems among children were inconclusive .
Access to proper therapists and other mental health experts also impacts the mental well-being of adolescents. Children and adolescents with anxiety, depression, or conduct disorders can benefit significantly from psychotherapy . In addition, the general shortage of mental healthcare professionals specializing in adolescent health prevent many adolescents from receiving care from specialists. A study by Feiss et al. demonstrated that despite the efficacy of schoolbased programs involving counselors in alleviating anxiety and depression in adolescents, the outcomes are not typically long-term. The stigma surrounding mental health in a community can also have a significant impact on whether teens seek professional help or even realize that they may need help; hence, programs aimed at reducing this stigma may prove beneficial. Another barrier to receiving mental health care is poor technological infrastructure. Mental healthcare providers may expand their services throughout underserved areas by offering cognitive behavioral therapy (CBT) services utilizing telehealth. However, many underserved areas lack the technological capacity to establish such services [17,18].
Within the past decade, social media has developed a prominent role in society. Use of social media has significant effects on mental health outcomes in adolescents, who tend to be particularly impressionable to messages portrayed by social media content.
O’Reilly et al. found that social media is considered a threat to adolescent mental health by provoking mood and anxiety disorders, being a platform for cyberbullying, and inducing social media addiction. In addition to these direct effects on mental health, social media can impact develop of coping mechanisms by adolescents. The development of poor coping mechanisms by receding to social media for comfort during emotionally distressing times may lead to poor mental health outcomes and even addiction. However, some state that the risk of social media has been over exaggerated, citing that social media may bring out preexisting risk factors that adolescents have inherently or due to other environmental triggers, rather than creating mental health disturbances. Another statement supporting the exaggerated risks of social media, which is frankly oversimplified, is that adults seem to make social media a scapegoat for the undesirable adolescent mental health outcomes rather than attributing these outcomes to other cultural, personal, or social factors .
Data analyzing correlations between Facebook use and mental health outcomes in adolescents are weak. One study by Marino et al. found a positive correlation between psychological distress, such as depression and anxiety, and problematic Facebook use, defined as “problematic behavior characterized by either addictive-like symptoms and/or scarce self-regulation related to Facebook use reflecting in social and personal problems, ” among adolescents and adults. Nonetheless, the positive correlation found in the study between psychological distress and problematic Facebook use and the negative correlation between well-being and problematic Facebook use were fairly weak, with R values being 0.34 and -0.22 respectively. The directionality of this correlation was also not reported. Adolescents with pre-existing anxiety or depression may also resort to using Facebook to modulate their emotions as well without receiving appropriate benefit . Another study discusses a 2016 US survey that found a significant association between increased depression and social media use, but again the direction of association was not identified. The study also makes a qualifying statement that there are many contradicting and inconclusive studies on this topic in general .
Based upon this literature review, there are five broad categories of social factors that affect mental health in adolescents: ethnicity, socioeconomic status, gender and sexuality, lifestyle and environment, and social media influence. Various correlations were found in these studies; however, there is still inconclusive evidence about certain topics, warranting further studies. One limitation of the literature available on this topic is that the majority of studies took place in Europe (especially the UK) or China. Additionally, the majority of studies focused on the impact of physical ailments or diseases rather than specific social determinants of mental health. More studies should be performed to tease out specific correlations and directionality of these correlations to have a better understanding on the social determinants of mental health of adolescents. The availability of this information may facilitate improvement of mental health outcomes.
According to the data available, it is clear that disparities present in minority and marginalized communities are correlated with worse mental health outcomes in these populations. Elimination of these disparities may warrant major changes in societal structure. Nonetheless, education regarding these social factors may help to mitigate these disparities. Studies have demonstrated that healthcare workers frequently contribute to discrimination of particular groups, and thus, counterintuitively may have a negative impact on the mental health of these individuals. Healthcare providers should not only be educated on disadvantages faced by ethnic/racial and gender minorities, socioeconomic disparities, and the impact of sexual identity and orientation on mental health outcomes, but should also be educated on how to recognize and appropriately manage these certain groups. Unfair treatment of particular groups may be an important contributing factor to the increased rates of mental illness in minority groups.
Adjusting school curriculums to raise awareness of the disparities faced by certain groups may also have positive impacts on the mental health of adolescents. Since adolescents spend much of their lives in school, having a welcoming environment that acknowledges their difficulties can be largely beneficial. For example, schools commonly teach students about the inequalities faced by African Americans during the era of segregation, but they can further emphasize that discrimination continues exists towards this group. Mental health education in schools may also be more widely implemented. Validating adolescents’ emotional struggles in a learning environment may help to minimize the severity of internalizing and externalizing mental disorders. This may be especially beneficial for adolescents who feel that their thoughts are not adequately addressed in their home environments.
The general social environment can also have a remarkable impact on adolescents’ mental health. Although a strong correlation has not been observed between social media use and mental health, responsible use of social media can be taught to students to help alleviate the negative impacts of social media on mental health. Other aspects of the environment, such as noise pollution, sedentary lifestyle, and access to mental healthcare or healthcare professionals in general should be more closely analyzed. Further research is warranted to better understand and address these factors.
- Liu CH, et al. (2019) The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use. Depress Anxiety 36: 8-17.
- Kim J, et al. (2018) Comparing Mental Health of US Children of Immigrants and Non-Immigrants in 4 Racial/ Ethnic Groups. J Sch Health 88: 167-175.
- Williams DR, (2018) Stress and the Mental Health of Populations of Color: Advancing Our Understanding of Race-related Stressors. J Health Soc Behav 59: 466-485.
- Morrissey K, Kinderman P (2020) The impact of childhood socioeconomic status on depression and anxiety in adult life: Testing the accumulation, critical period and social mobility hypotheses. SSM Popul Health 11: 100576.
- Elovainio M, et al. (2020) The contribution of neighborhood socioeconomic disadvantage on depressive symptoms over the adult lifetime: a 32-year prospective cohort study. Am J Epidemiol.
- De France K, Evans GW (2020) Expanding context in the role of emotion regulation in mental health: How socioeconomic status (SES) and developmental stage matter. Emotion.
- Miranda-Mendizabal A, et al. (2019) Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. Int J Public Health 64: 265-283.
- Pérez AE, et al. (2018) Sexual and behavioral health disparities among African American sexual minority men and women. Ethn Health 1-12.
- Rice SM, Purcell R, McGorry PD, (2018) Adolescent and Young Adult Male Mental Health: Transforming System Failures Into Proactive Models of Engagement. J Adolesc Health 62: S9-s17.
- Kattari SK, et al. (2020) Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults. SSM Popul Health 10: 100525.
- Colvin S, Egan JE, Coulter RWS (2019) School Climate & Sexual and Gender Minority Adolescent Mental Health. J Youth Adolesc 48: 1938-1951.
- Rodriguez-Ayllon M, et al. (2019) Role of Physical Activity and Sedentary Behavior in the Mental Health of Preschoolers, Children and Adolescents: A Systematic Review and Meta-Analysis. Sports Med 49: 1383-1410.
- Witt K, et al. (2019) Population attributable risk of factors associated with the repetition of self-harm behaviour in young people presenting to clinical services: a systematic review and meta-analysis. Eur Child Adolesc Psychiatry 28: 5-18.
- Skeen S, et al. (2019) Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis. Pediatrics 144.
- Schubert M, et al. (2019) Behavioral and Emotional Disorders and Transportation Noise among Children and Adolescents: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health 16.
- Bergman H, et al. (2018) Client feedback in psychological therapy for children and adolescents with mental health problems. Cochrane Database Syst Rev 8: Cd011729.
- Grist R, et al. (2019) Technology Delivered Interventions for Depression and Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis. Clin Child Fam Psychol Rev 22: 147-171.
- Feiss R, et al. (2019) A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents. J Youth Adolesc 48: 1668-1685.
- O'Reilly M, et al. (2018) Is social media bad for mental health and wellbeing? Exploring the perspectives of adolescents. Clin Child Psychol Psychiatry 23: 601-613.
- Marino C, et al. (2018) The associations between problematic Facebook use, psychological distress and well-being among adolescents and young adults: A systematic review and meta-analysis. J Affect Disord 226: 274-281.
- Schønning V, Aarø LE, Skogen JC (2020) Central themes, core concepts and knowledge gaps concerning social media use, and mental health and well-being among adolescents: a protocol of a scoping review of published literature. BMJ Open 10: e031105.