Adolescent substance use is on the decline (but so is mental health)

Behavioral health refers to mental health and substance use, which can frequently co-occur. This is what makes the results of the most recently published Youth Risk Behavioral Survey (YRBS) so intriguing, yet disturbing as well. Reported substance use among high school students has been steadily decreasing while rates of hopelessness and suicidal ideation are on the rise. What can explain this, and what can be done about it?

First, the good news.

The proportion of high school students reporting current alcohol use has been steadily decreasing from approximately half of students in the 1990s to fewer than one in four students (22.7 percent) in 2021. Current marijuana use has also declined from about a quarter of students in the late 1990s to 15.8 percent in 2021.

Even tobacco use in the form of cigarettes has been on the decline since the late 1990s, well before electronic vapor products became available in 2007. High school students reporting having tried a cigarette fell from 70 percent in the 1990s to 17.8 percent in 2021. Vapor products eventually overtook cigarette use in 2014 as the most commonly used nicotine product among youth, though this has recently declined as well.

Now, the bad news.

From 1999 to 2015, the number of students reporting feelings of sadness or hopelessness did not significantly change and never exceeded 30 percent in any of the YRBS biannual results. This started to change in 2017 when the percentage increased to 31.5 percent, 36.7 percent in 2019, and 42.3 percent in 2021. The 2023 YRBS results will not be available until 2025, but early indications suggest the situation is not improving.

Other indicators of mental health in the YRBS have had similar trends. In 2021, 22.2 percent of students reported seriously considering a suicide attempt, 17.6 percent reported making a suicide attempt plan, and 10.2 percent indicated actually attempting suicide. All these rates have significantly increased since 2009.

When removing male responses, the situation turns dire. In 2021, more than half of females (56.6 percent) reported feelings of sadness or hopelessness, 30 percent seriously considered a suicide attempt, nearly a quarter (23.6 percent) made a suicide attempt plan, and 13.3 percent actually attempted suicide.

What can be done to help?

In October 2023, children represented nearly half of Medicaid and Children’s Health Insurance Program (CHIP) enrollees across the United States. According to a MACPAC report, nearly one in four adolescents ages 12-17 covered by Medicaid or CHIP received mental health services, which is similar to those with private insurance coverage.

The health care system cannot address this crisis by itself. There is a perfect storm of factors contributing to this mental health emergency, particularly among teen girls. These include social challenges that linger from the pandemic and missed opportunities to connect with peers, social media’s impact on self-esteem and reduced face-to-face contact, and feeling that the future will not necessarily be brighter.

Improving mental health treatment affordability and accessibility is critical. It is also important to reduce the stigma associated with seeking professional help, including cultural stigma, which can be perceived differently across gender, culture, and ethnicity. Positive steps can be taken at the community level by integrating mental health care with primary care, as well as implementing school-based programs that address behavioral health.

Like most challenges, the most effective outcomes occur when solutions are identified and implemented early and often. When one adolescent considers, plans or attempts suicide, that is one too many. A multi-faceted effort across schools, communities, health systems, insurers and the government is needed to address the mental health needs of adolescents and prevent needless tragedies.

Steve Delaronde is a senior manager of product, population and payment solutions at 3M Health Information Systems.