Why some researchers are concerned about mental health campaigns

Some research on the effectiveness of mental health campaigns has come back with mixed results.

One study, called the My Resilience in Adolescence (MYRIAD) trial, involved 28,000 teenagers over the course of eight years. Half of those teenagers were trained by teachers to direct their attention to the present moment in 10 lessons of 30 to 50 minutes each.

The researchers found there was "no support for our hypothesis" that mindfulness training would improve students' mental health and concluded that students at the highest risk for mental health problems did worse after receiving the training.

The researchers suggested that the training programs were ineffective because they "bring awareness to upsetting thoughts," encouraging students to sit with their more difficult feelings but not providing solutions, especially to societal issues like racism or poverty. The researchers also found the students didn't enjoy the classes and didn't practice at home.

It's also possible the mindfulness training could lead to "co-rumination" — the long, unresolved group discussion that brings up problems without finding any solutions.

By the end of the eight-year trial, "mindfulness is already embedded in a lot of schools, and there are already organizations making money from selling this program to schools," said Lucy Foulkes, a research psychologist at the University of Oxford, who assisted on the study. "And it's very difficult to get the scientific message out there."

Separately, Jack Andrews, another research psychologist at Oxford, led an evaluation of Climate Schools, an intervention in Australia based on the principles of cognitive behavioral therapy where students watched cartoon characters navigate mental health concerns and then answered questions about practices to improve mental health.

Andrews found that students who took the course reported higher levels of depression and anxiety symptoms six months and 12 months later.

Some research has also suggested that it's not necessarily helpful to be able to label mental health symptoms.

Isaac Ahuvia, a doctoral candidate at Stony Brook University, studied 1,423 college students and found that 22% "self-labeled" as having depression, telling the researchers "I am depressed" or "I have depression." However, 39% of the students met the diagnostic criteria for depression.

Ahuvia also found that students who self-labeled felt like they had less control over their depression and were more likely to catastrophize and less likely to put their difficulties in perspective during times of distress compared to peers who had similar symptoms.

Jessica Schleider, co-author of the study and an associate professor of medical social sciences at Northwestern University, said this wasn't surprising to her. People who self-label "appear to be viewing depression as a biological inevitability," she said. "People who don't view emotions as malleable, view them as set and stuck and uncontrollable, tend to cope less well because they don't see a point in trying."

Last year, Foulkes and Andrews suggested in a paper that mental health awareness campaigns were contributing to "prevalence inflation," in which the reporting of mild or transient symptoms are being interpreted as mental health disorders.

"It's creating this message that teenagers are vulnerable, they're likely to have problems, and the solution is to outsource them to a professional," Foulkes said.

Until there is high-quality research that clarifies what the negative effects of mental health campaigns are, Foulkes and Andrews argued that schools should proceed with caution.

"It's not that we need to go back to square one, but it's that we need to press pause and reroute potentially," Foulkes said. "It's possible that something very well-intended has overshot a bit and needs to be brought back in."

Other experts push back

The view that mental health awareness programs need to be scaled back is a minority review among specialists, and many experts agree the more urgent issue is a lack of access to treatment, Barry reports. Roughly 60% of young Americans with severe depression do not receive treatment, according to Mental Health America.

Schleider disagreed with the idea that students are overdiagnosing themselves and added that awareness campaigns are bound to help some students and not others. Ultimately, Schleider said, the priority for public health should be reaching the young people in the greatest distress.

"The urgency of the mental health crisis is so clear," she said. "In the partnerships that I have, the emphasis is on the kids truly struggling right now who have nothing — we need to help them — more so than a possible risk for a subset of kids who aren’t really struggling."

It's possible that experts need to look beyond the "universal, school-assembly-style approach" and instead move towards targeted, light-tough interventions, which research has found can be effective at decreasing anxiety and conduct disorders, Schleider said.

"There is a risk of throwing the baby out with the bathwater," Schleider said. "The response can't be 'Forget all of it.' It should be 'What about this intervention was unhelpful?'"

Other researchers agreed, noting that studies have found students benefit from social and emotional learning courses on average, Barry reports.

One meta-analysis of 252 classroom programs in 53 countries, published last year, found that students who participated in the programs performed better academically, displayed better social skills, and showed lower levels of emotional distress or behavioral problems.

"We clearly have not figured out how to do them yet, but I can't imagine any population-based intervention that the field got right the first time," said Andrew Gerber, the president and medical director of Silver Hill Hospital.

"Really, if you think about almost everything we do in schools, we don't have great evidence for it working," he added. "That doesn’t mean we don't do it. It just means that we're constantly thinking about ways to improve it."

Jessica Gold, chief wellness officer for the University of Tennessee system, said the college students she's seeing are noticeably different than they have been in the past, more comfortable speaking about their emotions, and more comfortable with being vulnerable. However, students do often overuse diagnostic terms and believe they can question a psychiatrist's judgment.

"It's sort of a double-edged sword," Gold said. "We want people to talk about this more, but we don't want that to lead to overdiagnosis or incorrect diagnosis or overtreatment. We want it to lead to normalizing of having feelings." (Barry, New York Times, 5/6)

Advisory Board resources on mental health

To learn more about addressing mental health, Advisory Board offers several resources:

This case study looks at how GRAND Mental Health developed an innovative crisis care model that was able to reduce psychiatric inpatient hospitalizations by 93%.

This cheat sheet provides a resource for organizations to learn how to improve care for anxiety disorders and depression in women.

This expert insight explains why incorporating behavioral health into your value-based care strategy might not be as big of a lift as you may think.

This research provides organizations with tactics to advance long-term, equitable change in behavioral health.

This expert insight identifies three nonnegotiable steps that need to be taken in order to improve behavioral healthcare and correct the foundational flaws baked into the system.