Increasing Data and Understanding of Adolescent Mental Health Worldwide: UNICEF’s Measurement of Mental Health Among Adolescents at the Population Level Initiative

Abstract

The 2030 Sustainable Development agenda, officially adopted by 193 countries in 2015, is the first global monitoring framework that features mental health, an area critical to development that has previously been neglected and not attracted much-needed investment. Target 3.4 aims at reducing by 2030 premature mortality from noncommunicable diseases by one third, through prevention, treatment, and promotion of mental health and well-being. A specific related indicator is the suicide mortality rate. Globally, mental health conditions are among the leading causes of disability and death for adolescents aged 10–19 [[1]World Health OrganizationGlobal health estimates for 2019. World Health Organization, Geneva, Switzerland2020https://www.who.int/data/global-health-estimatesDate accessed: November 30, 2020Google Scholar]. The majority of mental disorders begin in adolescence [[2]Thapar A. Collishaw S. Pine D.S. AK T. Depression in adolescence.Lancet. 2012; 379: 1056-1067Abstract Full Text Full Text PDF PubMed Scopus (1422) Google Scholar]; therefore, addressing mental health problems during the adolescent period can have positive lifelong impacts. Addressing adolescent mental health starts with good data on the prevalence of mental health conditions as well as risk and protective factors. These data are essential for informing the design and implementation of appropriate policies and programs and allocation of resources to support adolescents. Yet, data on adolescent mental health remain sparse, especially in low- and middle-income countries (LMICs) where available data coverage represents about 2% of the adolescents living in these settings [[3]Erskine H.E. Baxter A.J. Patton G. et al.The global coverage of prevalence data for mental disorders in children and adolescents.Epidemiol Psychiatr Sci. 2017; 26: 395-402Crossref PubMed Scopus (212) Google Scholar]. This is especially striking because nearly 90% of the world’s 1.2 billion adolescents live in LMICs [[4]United Nations Population DivisionWorld population prospects [Internet].https://population.un.org/wpp/Download/Standard/Interpolated/Date: 2019Google Scholar]. The challenges inherent to measuring mental health are exacerbated in LMICs, as lack of investment has led to lack of resources and standardized validated tools for measuring mental health in these settings. Understanding the global burden of adolescent mental ill health is even more pressing as the world responds to the COVID-19 pandemic. Massive school closures have meant the loss of social support networks and peer contacts for millions of adolescents. Lockdown measures to reduce the spread of the virus are also associated with increased risk of exposure to domestic violence and online exploitation or bullying, which can exacerbate or trigger mental health conditions [[5]Cowie H. Myers C.A. The impact of the COVID-19 pandemic on the mental health and well-being of children and young people.Child Soc. 2021; 35: 62-74Crossref PubMed Scopus (89) Google Scholar]. Adolescents who were already out of school before the onset of the pandemic have faced increased economic insecurity and fewer job opportunities [[6]International Labour OrganizationYouth & COVID-19: Impacts on jobs, education, rights and mental well-being.https://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_753026.pdfDate: 2020Date accessed: February 10, 2021Google Scholar]. At the same time, adolescents’ access to mental health services and support have been disrupted in many countries [[7]Fegert J.M. Vitiello B. Plener P.L. Clemens V. Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.Child Adolescent Psychiatry Mental Health. 2020; 14: 1-11Crossref PubMed Scopus (1041) Google Scholar]. To address the global lack of data on adolescent mental health, United Nations Children’s Fund (UNICEF), in collaboration with the World Health Organization and other key institutional and academic partners, is leading the development of a suite of tools for Measurement of Mental Health Among Adolescents at the Population Level (MMAP) [[8]UNICEFMeasurement of mental health among adolescents at the population level (MMAP) 2020 [updated December 2020].https://data.unicef.org/topic/child-health/mental-health/mmap/Date accessed: December 1, 2020Google Scholar]. The principal goal of the MMAP is to enable monitoring of adolescent mental health conditions across countries through a rigorous approach. The MMAP validation process has encompassed assessing scales such as the Revised Children’s Anxiety and Depression Scale [[9]Chorpita B.F. Yim L. Moffitt C. et al.Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale.Behav Res Ther. 2000; 38: 835-855Crossref PubMed Scopus (1226) Google Scholar] and tools from the Patient Health Questionnaire set [[10]Kroenke K. Wu J. Yu Z. et al.Patient health Questionnaire anxiety and depression scale: Initial validation in three clinical trials.Psychosomatic Med. 2016; 78: 716-727Crossref PubMed Scopus (225) Google Scholar]. Brief item sets on functioning, suicidality, mental health care, and connectedness have been developed and tested by UNICEF based on common approaches to population-level measurement in these domains. In addition, the MMAP toolkit will include a vignette-based tool for proactive case detection of mental health symptoms called the Community Case Detection Tool that enables community gatekeepers to promote in detection and helpseeking of adolescents who may benefit from care or support [[11]Jordans M.J. Kohrt B.A. Luitel N.P. et al.Proactive community case-finding to facilitate treatment seeking for mental disorders, Nepal.Bull World Health Organ. 2017; 95: 531Crossref PubMed Scopus (35) Google Scholar,[13]World Health Organization WHOHelping Adolescents thrive - guidelines on mental health promotive and preventive interventions for adolescents. World Health Organization WHO, 2020https://www.who.int/mental_health/maternal-child/guidelines_promotive_interventions/en/Date accessed: February 10, 2021Google Scholar] (Of note, any copyrighted tools are subject to terms of usage as established by their developers or copyright holders. For RCADS: https://www.childfirst.ucla.edu/resources/, for PHQ: https://www.phqscreeners.com/, for CCDT https://www.warchildholland.org/intervention-ccdt/). The MMAP methodological approach to tool development involves a series of steps (Figure 1) and includes clinical validation of measures of depression, anxiety, functional limitations due to mental health problems, and suicidality. Cross-cultural applicability and adaptation to local realities, including integration of adolescents’ voices and diverse experiences, have been formative in the development of the MMAP toolkit and guidelines for its use. Another key step in the MMAP process has involved engagement of country partners, such as national and regional governments, local health authorities, and academic institutions, who are key to its adoption and sustained use across settings. An initial MMAP clinical validation was concluded in Belize in 2020. Similar validation efforts are proceeding in settings in sub-Saharan Africa and Asia during 2021. The MMAP initiative will result in a set of metrics and tools that will enable the following:•Collection of comparable data on adolescent mental health through representative national surveys. These data can be used for global monitoring, prioritization of policies and programs, and allocation of resources for adolescent mental health.•Collection of equity-sensitive data that can be stratified to ensure measurement of the most vulnerable populations.•Monitoring and evaluation of adolescent mental health programs implemented at local and national levels, and among special population groups including adolescents on the move, pregnant or parenting adolescents.•Assessment of risk and protective factors for adolescents’ mental health. The MMAP toolkit will also be included as a monitoring resource for the UNICEF and WHO jointly developed Helping Adolescents Thrive program for promotion of mental health and prevention of mental health conditions [[12]van den Broek Myrthe et al.Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.J Adolesc Health. 2021; (In this issue)https://doi.org/10.1016/j.jadohealth.2021.03.011Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. The MMAP project brings the world one step closer to increased availability of valid and reliable data on adolescent mental health for LMICs where most of the world’s young people live.