COMMENTARY

Identifying Mental Illness Early Through Routine Mental Health Screening

John H. Genrich, MD; Leslie C. McGuire, MSW

Disclosures

November 02, 2009

In This Article

Undetected Mental Illnesses in Adolescence

According to the US Surgeon General, 11% (4.5 million) of US youth between the ages of 10 and 19 years suffer from a serious mental illness that causes significant impairment in their day-to-day lives at home, in school, and with peers.[14] Recent research revealed that 50% of all lifetime mental disorders start by age 14.[15] The most common mental disorders during the adolescent years are anxiety and depression. When left untreated, mental illness can lead to drug and alcohol abuse, violence, school failure, involvement in the criminal justice system, the loss of critical developmental years, and suicide.[2]

Depression

Among adolescents who were 12-17 years old during 2004-2006, 8.5% suffered an episode of major depression and were about twice as likely to increase their overall risk factors by using alcohol or an illicit drug as youth who had not experienced a major depressive episode during the past year.[1] The rate of those who experience major depression increases as teens get older, with 11.5% of 16- and 17-year-olds suffering an episode in a 1-year span of time[1] (Figure 1). Of those who experienced a major depressive episode, only 38.9% received treatment of any kind.[16]

Figure 1.

Percentages of youth aged 12-17 who experienced a past-year major depressive episode (MDE), by age, 2004-2006.

Anxiety

It is estimated that 13% of 9- to 17-year-olds suffer from an anxiety disorder, an issue that, like other internalizing disorders, often goes undetected in regular adolescent health visits.[14] Anxiety disorders are highly correlated with attempted and completed adolescent suicides, with 27% of adolescents who commit suicide suffering from an anxiety disorder at their time of death.[17]

The most common types of anxiety disorders are phobias, social anxiety, and separation anxiety. Youth who suffer from anxiety are often quiet and compliant, making it even more difficult to detect symptoms. Risk factors for serious anxiety disorders should be monitored so that early interventions can help to prevent dire consequences.[18]

Suicide

Suicide is the third leading cause of death for 11- to 18-year-olds in the United States, and almost as many teens die by suicide each year as those who die from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined.[19] In addition to the thousands of youth who die by suicide, millions more think about and attempt suicide. According to the US Centers for Disease Control and Prevention, 15% of US high school students reported thinking seriously about killing themselves and 7% reported a prior suicide attempt.[20]

Approximately 90% of adolescent suicide victims have a psychiatric disorder, with 63% exhibiting psychiatric symptoms identifiable by screening for at least a year before their death.[17] Rates of mood disorders (Figure 2), such as depression, can be as high as 68% in adolescents who commit suicide, and up to 28% may be suffering from anxiety disorders. Substance abuse is also common, particularly among adolescent male suicide victims.[17]

Figure 2.

Underlying mental disorders contributing to adolescent suicide.

Disability

Mental illness is the second leading cause of disability and premature mortality in the United States.[21] Up to 10% of youth experience serious impairment that leaves them unable to function in school, at home, or with peers.[14] These illnesses are a leading cause of school dropout, substance abuse, unemployment, incarceration, poor physical health, and shortened life expectancy in later life.[2]

Approximately 50% of students age 14 and older who suffer from mental illness drop out of high school; this is the highest dropout rate of any disability group.[22] Junior high and high school students with mental illness fail more courses, earn lower grade point averages, miss more days of school, and are retained at grade level more often than students with other disabilities.[23]

Additionally, it is estimated that up to 50% of the mentally ill population also has a substance abuse problem, with the incidence of abuse greater among adolescent boys and those aged 18-44 years, highlighting the need for early intervention.[24]

Furthermore, mental illness, when undetected, can affect employment status throughout the lifetime. One study showed a 90% unemployment rate among adults with serious mental illness, the highest rate of unemployment of any group of people with disabilities.[25]

Many youth with unidentified and untreated mental illness also end up in jails and prisons. Sixty-five percent of boys and 75% of girls in juvenile detention suffer from mental illness.[26]

When youth go untreated for mental illness, they also experience poorer physical health, use more healthcare services, and incur higher healthcare costs in their adult years than others in the same age group.[27] Youth who are experiencing emotional and behavioral problems, or with higher levels of psychosocial distress, are also likely to be more frequent visitors to their primary care providers.[28,29]

Missed Opportunities

Today only 1 in 5 adolescents between the ages of 12 and 17 years who has a mental health disorder receives treatment.[14] There is also a lengthy gap between onset and treatment. Although symptoms of mental illness are typically present for 2-4 years before the onset of a full-blown disorder, most mental illnesses are not diagnosed for an average of 10 years after the first symptoms appear.[14] Missing early symptoms can result in disorders that create a lifetime of disability or tragically result in suicide.

Adolescent mental illness is especially underidentified in primary care settings. Studies have shown that PCPs identify internalizing disorders, such as depression and anxiety, at rates much lower than the prevalence for mood and anxiety disorders in adolescents; internalizing disorders were identified in less than 1 in 5 cases, and as many as 2 in 3 depressed youth are not identified by their PCPs and do not receive any kind of care.[30]

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