Getting to the bottom of the teen mental health crisis

The stakes are high when it comes to tackling the unprecedented mental health issues facing today’s teens. In this episode of The McKinsey Podcast, global editorial director Lucia Rahilly speaks with McKinsey partner and coleader of the McKinsey Health Institute Erica Coe and the founding president and medical director of the Child Mind Institute, Harold Koplewicz, about what the struggle means for society at large.

Then, Maggie Smith, author of You Could Make This Place Beautiful (Atria/One Signal Publishers, April 2023), shares how grief can be transformative, in an interview excerpt from our Author Talks series.

This transcript has been edited for clarity and length.

The McKinsey Podcast is cohosted by Roberta Fusaro and Lucia Rahilly.

A mental health imperative

Lucia Rahilly: We hear much about the crisis of mental health among teenagers. Harold, would you give us a sense of what you’re seeing in your work leading the Child Mind Institute?

Harold Koplewicz: The youth mental health crisis is very real, but it’s also a global crisis. Worldwide, at least 200 million children and teenagers struggle with a mental health disorder. And in the US, around 17.1 million young people have a mental health disorder by the age of 18.

Girls, in particular, are really in crisis. According to the CDC [US Centers for Disease Control and Prevention] report from earlier this year, almost 60 percent of US teen girls said they felt persistently sad or hopeless. And one in three seriously had contemplated attempting suicide in 2021. That’s almost a 60 percent increase from the decade before.

Lucia Rahilly: How much of this diminished mental health do you attribute to the pandemic?

Harold Koplewicz: The most chilling fact is that the numbers of teen suicides jumped from 2007 to 2018.

And that’s before the pandemic. I think the only thing we can see that changed in society at that time was social media. We should seriously consider US Surgeon General Vivek Murthy’s advisory that social media could be very dangerous for certain teenagers, and particularly ones who have a mental health disorder.

The social media mire

Lucia Rahilly: Erica, you and some colleagues at the McKinsey Health Institute recently authored an article on the impact of social media on Gen Z, in particular. Many parents fret about social media usage among their kids, citing FOMO [fear of missing out], body image, and other challenges. What did you learn from conducting this research?

Erica Coe: It was eye-opening. It was a global survey across 26 countries with over 40,000 respondents. We were able to not only get a close look at Gen Z perceptions and behaviors but also at how they compare to other generations. Gen Z reported a perceived mental health that was much poorer than any other generation.

When it comes to social media and tech, we know that they are not going away. Therefore, an important aspect of the survey is how are people using social media and tech? What is leading to the positive impacts versus the negative impacts? While a third of respondents reported a positive impact on their body image, almost as many reported a negative impact on their body image.

Interestingly, those in Generation Z were much more likely to experience negative effects from social media interaction, to interact in very passive versus active ways, compared to older generations.

Lucia Rahilly: Erica, say a bit more about passive versus active and what that means.

Erica Coe: There have been a number of studies that have shown that passive interactions, like scrolling through Instagram posts or seeing all the experiences others are having, could be linked to declines in subjective well-being over time.

If you are using social media in active ways, it might not only be DMing [direct messaging] people, but also using it for professional connections, and to develop social circles.

Compare that to passive interactions, where you’re seeing how many likes something can get. Even giving something a thumbs up still falls into the passive bucket, because you’re not actually interacting with others in a different way.

Stuck on screens

Lucia Rahilly: Harold, what does your research say about the amount of time teens are spending on screens?

Harold Koplewicz: We looked at problematic internet usage throughout the pandemic, which was defined as internet use habits that negatively impact quality of life. Our survey suggested that screen usage went up and stayed up in the first years of the pandemic. Between the baseline assessment in 2019 and our survey in May 2020, the majority of kids went from spending less than an hour a day gaming to spending one to three hours or more. And prepandemic, less than 20 percent of kids used streaming video for four hours a day or more, but by May 2020 (remember, we were shut down by then) we found that number had doubled, with 40 percent spending four or more hours a day watching video online.

Lucia Rahilly: That’s such a significant jump. Anything more to say about the research on tech usage among teens?

Harold Koplewicz: Well, there was a clear increase in social media use by both kids and adults during the pandemic. And following the pandemic, if parents were overusing the internet, their children were likely to be overusing it too. Later, in February 2021, we found that these shifts persisted.

We know that the more hours parents spend on the internet has a definite effect on kids. As many as 50 percent of adults were watching digital media for four or more hours a day, along with 40 percent of their children. That is a worrisome amount of time, because the more hours you spend on the internet or social media, the less hours you sleep. There is more sleep deprivation, there’s less exercise, and there’s less real live interactions. And we certainly need all three of those for healthy brain development.

After 24, you’re no longer considered an adolescent, but adolescence and childhood are crucial periods for brain development. So problematic internet usage can have a very severe effect presently and in the future.

Lucia Rahilly: Erica, did you want to add anything there?

Erica Coe: When we did our global survey across 26 countries, close to three-quarters of Gen Z respondents felt they spent too much time online. Often, there’s an acknowledgement that it’s probably not the best thing, but it’s hard for them to get away from it.

Harold Koplewicz: There’s an addictive quality here that has a different effect on an adult brain than on a teenager’s brain. It’s widely known that algorithms are built to keep people on the platforms as long as possible. Therefore, sometimes it’s directly harmful. But the content on these platforms is based on very user-specific data—for instance, someone worried about their weight or someone thinking about exercise and dieting. This can be very divisive content for a teenage girl or for a teenage boy in a way that is particularly different. The adolescent brain is much more vulnerable.

A pandemic is tough enough

Lucia Rahilly: What are some of the other significant factors that are contributing to challenging mental health among today’s teens?

Harold Koplewicz: COVID-19 took a bad situation and made it exponentially worse. Think about worrying about your grandparents dying, or losing a caregiver. Recovering from this trauma could take over a decade. If 30 percent of the approximately 17 million kids who have a mental health disorder get treatment, that means there’s always about 70 percent for multiple reasons who are not getting any intervention.

I think those are the kids who have been most affected by COVID-19, by the loss of two years of school and social interactions, and by worries about the future, their health, and their parents’ health. Somehow, we believe our educational system is so good that kids will just recover from missing two years of school. I don’t understand how a third grader who’s mastering reading and doesn’t get back to school until fifth grade can catch up without some real remediation. That’s pretty obvious. However, I think it becomes less obvious but more chilling to think about what happens to those anxious kids who now have to go back and get back into social interactions. So I think the rates of depression and anxiety and loneliness are going to continue to rise unless we start thinking about a whole different way of approaching this problem.

Raising mental health awareness

Erica Coe: To add on that, there’s so much value in early intervention and really focusing on prevention and promotion. It’s useful to remember that not only is there value in addressing the immediate need right now among youth, but this can change the trajectory of somebody’s life.

It may not just relieve a mental disorder or burden. There’s so much co-occurrence of chronic health conditions on the physical side. You can change all of that if you teach some of these skills early on and identify problems early.

Basically, giving people an increased mental health literacy of what’s normal, what isn’t, and how to pick up on the signs that intervention may be necessary. That way, so much disease burden can be avoided later in life.

Harold Koplewicz: We also have to help parents become smarter. Most parents know that you’re supposed to walk at one, have your first words by two, and be toilet trained by three. But I’m not sure we teach parents when your kids are supposed to interact with friends, when they’re supposed to sleep through the night, or what are baseline kinds of appetite and energy levels. I think that kind of information and education could be very helpful, almost like a mosquito net to malaria; what are the prevention models we should be looking at?

Lucia Rahilly: Parents talk a lot about safety and about striking that balance between safety and independence. Our generation had much more freedom than many kids today. We were mobile and out in the world. Any counsel for parents on agency and teen mental health?

Harold Koplewicz: It doesn’t take much for a parent to feel worried or guilty about something their kid is experiencing. To give them some freedom, we have to sometimes fight our need to protect them. We need to recognize when they’re able to walk to school on their own or when they can ride on a bus, with the understanding that guardrails have to be up.

I think COVID-19 made that worse for parents, so we have to retrain ourselves to say, “This is in the past.” How do we as parents put our cell phones away, have cell-free time, and have conversations at dinner that last at least ten minutes? How do we get our kids back outside, playing sports with their friends, with some amount of monitoring? They need to experiment and experience even distress and failure so they can become more resilient, healthy, and independent.

Bring out the role models

Erica Coe: Peer influence can be strong early on, so how do we harness that? In recent discussions we’ve had with youth leaders, we often clearly hear that youth want to be able to help their friends, but they don’t always feel equipped. How do we enable them and really invest in a peer support model for youth? Equipping them with that agency could unlock a lot of potential.

Harold Koplewicz: Peer support has really changed. Young people aren’t as quiet about whether they go to therapy, take medicine, or if they’re having difficulty. They share that information. Knowing how their peers have overcome struggles can be very helpful for teenagers.

At the Child Mind Institute, we’ve invested in public awareness campaigns since 2017. Most recently, we did the You Got This campaign. And I am amazed at the power of athletes like Kevin Love or Brandon Marshall. They’re the epitome of physical health, so when they talk about their anxiety or their depression, teenage boys really respond to that and draw inspiration in dealing with their own mental health problems.

Lucia Rahilly: Harold, you mentioned gender as a strong factor in susceptibility to mental health issues. How does that come into play in terms of treatment? Are there approaches that work particularly well for girls and young women?

Harold Koplewicz: Girls are much more available. They talk about things. They seem to have less shame and less embarrassment about their struggles. Frankly, we’ve always had an easier time getting female actors and athletes to participate in these programs.

So in May 2017, it was Emma Stone talking about her anxiety. It was life-changing for girls to see an impressive, creative person—who on screen looks completely carefree—say that they’ve struggled in life and that therapy worked and made things easier.

I think one of the reasons we see higher numbers of anxiety and depression in girls postpuberty is that there is a hormonal difference. We see many more boys who are disruptive in prepubertal times. But we know that girls wait a shorter period of time to get help. When they’re in pain, they are more likely to tell a friend, and they’re more likely to seek help. I think boys tend to be more vulnerable to looking weak. That’s one of the reasons athletes seem to have so much more power as influencers than we previously imagined in the mental health sphere.

Demographic perception varies

Lucia Rahilly: Are there geographic, class, or cultural variations even within the United States in the way that treatment and approaches affect these kids?

Harold Koplewicz: Take SSRIs, for instance—selective serotonin reuptake inhibitors. In the 1980s, Prozac was released. And it turned out that it was also good for obsessive compulsive disorder, and it may have been good for other anxiety disorders. And it starts getting released at a rate that’s quite amazing.

Remarkable suicide rates among teenagers drop across the country. But African Americans really hesitate on any kind of treatment that even smells like it is research or experimental. But if you looked at zip codes, it was very clear that there were less suicides and attempted suicides in areas where pediatricians were prescribing these meds.

But then there was a backlash. There were deaths caused by violent events like shootings, that people attributed to SSRI use, but they couldn’t prove it. In fact, several times when they did autopsies on these kids who had been prescribed SSRIs, it was found that they never took the medicine. So it’s hard to blame the medicine. Nevertheless, there were hearings in Congress, and a black box was put on all SSRIs indicating that they could cause suicidality. I don’t know what that really means. It was a new word. It could mean slapping yourself in the face.

Inevitably, pediatricians stopped prescribing SSRIs. The suicide rate generally went back up, but if you looked at the data by zip code, you could see that it just remained the same in African American neighborhoods.

So we need to think about what kind of education, what kind of campaigns we’re doing for the African American community and for the Hispanic American community so that we can raise awareness and decrease stigma.

There are workforce problems too. It’s very hard to get a male therapist of color. There are very few. We just started a pilot program recently called the Youth Mental Health Academy. In California, we’re going to find 2,500 bright high school kids in 11th or 12th grade who are interested in mental health. They’ll get paid internships and hands-on experience with research and clinical care. This is with the hope that we can expose them to the possibility of becoming a child mental health professional in the future.

Talking about it

Lucia Rahilly: Mental health is so much more in the public discourse than it was when I was growing up.

Harold Koplewicz: When I was a kid, you wouldn’t tell someone you had a reading tutor, but today people are much more open and willing to talk about it. So I’m optimistic. I think the COVID-19 pandemic, while awful, had two silver linings.

One is that everyone started to be concerned about their children’s mental health, even if they didn’t have a disorder. So it became part of the national conversation. The second is the concept of telehealth jumping in popularity and usage because of the isolation we had.

Lucia Rahilly: Erica, you’ve done a lot of work on stigma. Have you seen any demonstrable change in the workplace?

Erica Coe: One thing we are seeing is pressure on employers. About three-fourths of Gen Z around the world said that the availability of mental health resources—whether that be access to therapy or mental well-being programs—is one of the key things when they’re selecting an employer. This is different than it has been for other generations.

Harold Koplewicz: Just think about the fact that mental health disorders do not have parity in insurance with physical disorders. One of the reasons for that is that employees don’t demand it. There was so much stigma. “Why do you want coverage for depression?” The fact that new employees are actually questioning what the mental health coverage is only means that hopefully sooner than later we will see more parity.

I think childhood cancer is serious, and we should support the work on it, but it pales in comparison to the scale of the mental health crisis.

Evolving the mental health system

Lucia Rahilly: As we’re looking ahead to this next-gen workforce, are there any particular challenges you see as today’s teens begin to grow into professionals and enter the job market?

Harold Koplewicz: We have an educational system, but do we have a system that’s going to treat mental health symptoms and mental health disorders with the same kind of respect, scientific rigor, and funding that led to the advances we’ve made in cancer or diabetes or seizure disorders?

There are costs to not investing in such a system. Kids who have a mental health disorder are more likely to have academic failure, to drop out of school, to use illicit drugs, or to have interactions with the juvenile justice system. They’re also more likely to have physical complaints later on and utilize more physical-health services than the kids who don’t have these disorders.

If there are greater numbers of kids who are symptomatic than before, I think it necessitates a reevaluation of how we’re going to take care of these kids and take preventative measures. More importantly, when symptoms strike, we need to do early intervention.

Erica Coe: I would 100 percent agree. These things only go so far if services are inaccessible. So much of it has to be around evolving the mental health system as part of the overall health system. Getting rid of the lack of parity will be at the root of a lot of improvement. There’s an interesting question around digital mental health solutions in general. Obviously, there’s been a proliferation, so sometimes it’s hard to figure out what is helpful and what isn’t.

One thing that stood out in our survey was a very interesting contradiction. About 22 percent of Gen Z respondents reported using digital mental health tools. Yet for those who did use them, 80 percent reported them as effective but often didn’t stick with them. So there’s a real question of how we engage Gen Z users to really utilize the power of digital innovation.

Harold Koplewicz: We have a grant to look at the next generation of digital therapeutics. It sounds great, but does everything really work? Evidence-based psychotherapy or psychopharmacology, particularly with young people, is very challenging. To pretend that we can just switch a program and say, “Now we’re going to do it on a screen,” I think really minimizes the fact that we have to have different techniques. That’s going to require study.

I could tell you anecdotally that the Child Mind Institute still does around 50 percent of our sessions online. But we find that 30 minutes is about the maximum we can keep a young person on a screen versus 45 minutes or an hour when we would see them in person. So that means you have to pace yourself differently.

You might need a few more sessions. You might need to engage parents in between. You might have to use coaches or emails to keep them engaged in a way that you might not if you were doing it the old-fashioned way in person. But I think the fact that 20 percent of them are using it but 80 percent are finding it helpful means that we’re on the right path. We just need to make sure that path is smoother and more effective.

Erica Coe: One other point, returning to passive-versus-active social media use: we know that the Gen Z respondents were the least likely of all age cohorts to report actually actively posting and, instead, report higher hours of passive social media. But imagine some pop-up on your phone that gives you a reminder of how much your time has been passive versus active. In the same way we teach what are healthy foods, and what they should be doing for physical exercise, we need to equip them with more information to make smart decisions.

Harold Koplewicz: That’s a terrific idea, because it’s using data and coming up with an intervention. When I was in training, patients smoked and doctors smoked. Now people don’t smoke in schools, in buildings, or on an airplane. They don’t even smoke in the airport. So you could change that behavior. And remember, it’s much easier to teach someone who has a young brain, 24 or younger, new habits than old people.

Erica Coe: I know within Utah, there’s been great uptake of the SafeUT app, which the Huntsman Mental Health Institute has been behind. It is a resource for youth to be able to reach out and get information they need if they have a friend they’re worried about.

Harold Koplewicz: You have different groups, new family foundations, making very big investments in mental health, because it’s real, it’s common, it’s treatable. Everyone who’s listening to this podcast knows and loves one of these kids. If you’re lucky enough that it’s not your children, then it’s your niece or nephew, it’s your best friend’s child, or it’s your child’s best friend. So when it reaches these numbers, we have to step back and figure out what’s going on. If we just continue to deny it, that denial could levy a tremendous amount of future costs, whether deaths or suicide attempts or a productivity deficiency among a large percentage of our population.

Lucia Rahilly: Erica and Harold, thanks so much for joining us today.

Harold Koplewicz: My pleasure. I’m so delighted you’re highlighting this topic.

Erica Coe: Yes. Many thanks.

Roberta Fusaro: Mental health is top of mind for so many of us, including Maggie Smith, author of You Could Make This Place Beautiful.

Maggie Smith: This book is really written out of the upheaval of my divorce, but also other big life changes. I think one of the unkind stories we tend to tell ourselves is, “OK, what is my life now? Life is over as I know it. How did I get here?” The answer to that really needs to be, “OK, this is how I got here, but also now where am I going?” I think making peace with the past helps us live more with the possibilities of the present and the possibilities of the future.

There’s a sort of narrative that we need to forgive people who we perceive as having done us wrong. I agree with that, and yet I think there is a difference between really forgiving someone and just being able to get to a place of greater peace and acceptance with what has happened. Part of that is also owning your own stuff. By that I mean all relationships, all systems, whether it’s a working relationship or a family or a marriage, all of those relationships and systems are co-created.

We also have to own our part in creating that environment. We have to forgive ourselves and accept that what’s done is done. Figure out how can we learn from it, and then move forward with some greater wisdom to make some different decisions today and in the future.

Now what do I have to do to gather myself, stand in my own power, remember who I am, and reach out to my community. I think those are all things we have to do. My thinking is that change is the only constant. We’re all human beings, and we’re all dealing with that in various ways in our lives.

I think all literature is sort of self-help and instructive in one way, shape, or form. At least for me, books make me feel less alone, even if the experience of the writer is not my experience. When I read I feel let into their lives, and I see how they coped, how they grieved, what their experience was like. In doing so, I feel seen.

So for this book, if I’m thinking about processing difficult events and rumination and memory, all of that happens in a sort of nonlinear way. It happens usually in pieces. Memory is associative, not linear. When we see something, it reminds us of something else, which then pings and reminds us of something else, etcetera. That tends to look a little bit more like a collage than like a time line. So the structure of the book was really meant to not only tell the story but to give the reader a sense of what the experience felt like for most of us.

Spoiler alert, I did not actually exit this book having all the answers. We never really get access to all the answers.