Collective Mode: How Could Psychology Respond to Increases in Common Mental Health Concerns Among Secondary School Students in 2020s Aotearoa New Zealand? A Critical Realist Exploration

Background: Since around 2010, significant increases in common mental health concerns, such as anxiety and depression, have been reported among adolescents in various countries, placing considerable strain on mental health services. While anecdotal evidence suggests a similar trend in Aotearoa New Zealand (Aotearoa), comprehensive data has been lacking. In this rapidly changing environment, it is crucial to develop timely responses that consider the unique Aotearoa context, including upholding commitments made in Te Tiriti o Waitangi. Psychologists, as key players within a broader ecosystem, must explore new approaches to address these challenges effectively.

Aims: I aimed to consider how psychology could respond to apparent increases in common mental health concerns among secondary school students in 2020s Aotearoa. This involved empirically investigating the nature, extent, and consequences of the purported increases; identifying patterns of need from a population perspective; describing adolescents’ use of mental health and wellbeing supports; and exploring adolescents’ and service providers’ priorities in addressing the need.

Methods: As part of the Youth19 Rangatahi Smart Survey team (the most recent wave of the Youth2000 survey series), I shaped key survey questions and contributed to ethics and survey implementation. We surveyed 7721 Aotearoa secondary school students (13–18 years) in 2019, providing data for four of the five studies presented here. I adopted a critical realist theoretical framework and mixed-methods approach. Studies 1–4 used Youth19 data to: describe need in 2019, and changes between the 2012 and 2019 Youth2000 surveys (Study 1); derive clusters of students based on their responses to mental health and wellbeing variables and identify predictors of cluster membership (Study 2); describe students’ use of supports for mental health according to derived cluster (Study 3); and analyse responses from students in the most severe clusters to an open-ended question regarding what could make things better (Study 4). I conducted Study 5 outside the Youth19 umbrella. I present thematic analysis of interviews with eight experienced psychologists and other service providers regarding the effects of perceived levels of need on services and potential future directions. I then integrated results across studies in a concluding discussion.

Results: I found that symptoms of common mental health concerns were high among Aotearoa secondary school students in 2019 and had increased markedly between 2012 and 2019, overall and especially among females, rangatahi Māori, Pacific students, and those living with higher socioeconomic deprivation, increasing inequity. For example, clinically significant depressive symptoms assessed using the Reynolds Adolescent Depression Scale (Short Form) increased from 17% among females in 2012 to 29% in 2019 (Study 1). Mental health need clustered into distinct profiles, with 40% of Youth19 participants reporting minimal symptoms and good wellbeing, 28% reporting signs of elevated anxiety, 9% reporting elevated but subclinical depressive and anxiety symptoms, 16% reporting above cut-off depressive and anxiety symptoms and high suicide ideation, and 6% reporting high symptoms across indicators and 100% prevalence of suicide attempt (Study 2). Fewer than a third (29%) of students with high need reported that they had accessed formal supports such as counsellors or health professionals in the past year, although many (82%) had talked with peers or family members (Study 3). In response to an open-ended question about what would help young people who were having a hard time or feeling bad, distressed students emphasised the need for young people to feel loved, accepted, and connected, as a foundation for talking and sharing the load with others and developing their own coping skills. They asked for more nurturing, less harmful environments and systems, including updated mental health services, and noted the importance of thinking and talking about mental health in helpful ways (Study 4). Psychologists and other service providers in the youth mental health sector reported that they have been hugely affected by increased demand, with services overloaded and clinicians facing burn out, further compounding service overwhelm. They highlighted the need for collaboration, new approaches and, crucially, a substantial workforce boost (Study 5).

Implications: This thesis provides converging findings from population survey and clinical perspectives that there are major increases in demand for addressing mental health and wellbeing concerns among adolescents, and suggests that current responses are inadequate, to the detriment of young people, whānau (extended family), and providers. I propose that multi-factor solutions are needed, by which psychology, along with other disciplines: - Contributes to understanding needs and opportunities (e.g., via research and evaluation of needs and initiatives) - Considers ways to support and retain new and existing psychology staff in pressured services - Considers ways to meet increased demand while upholding competency and ethical practice (e.g., increased training and service provision focused on group therapy, brief interventions, utilising broader workforces, or other resources such as digital tools) - Contributes to, or at least does not block, the expansion of the talking therapy or mental health and wellbeing workforce (e.g., via training more people, training people more quickly, providing supervision, and support for new roles) - Contributes to, or at least does not block, community efforts to support adolescents (e.g., supporting whānau, school staff, and community to respond to adolescents’ needs) - Contributes to or supports prevention and health promotion efforts (e.g., via data and information sharing, advocacy, and contributing regarding helpful ways of communicating about mental health with adolescents and others).

All actions should respond to the needs of taiohi Māori (young Māori), given commitments made in Te Tiriti o Waitangi. The needs of Pacific students, and students living with greater economic deprivation, should also be prioritised, among those of other underserved groups. Developing clinicians and approaches that increase equity is essential.

While none of these ideas are new to psychology and other disciplines, this research emphasises the urgency for psychology to be part of systems that contribute to population wellbeing as well as addressing individual needs. While I have listed a variety of actions, none are the responsibility of any one psychologist or group alone. Some are actions for psychology as an academic discipline, or groups such as researchers, the New Zealand Psychologists Board, training institutions, and others. I consider a range of theories and models to guide and structure collective thinking.

Conclusions: Reports of common mental health concerns among Aotearoa adolescents appear to be high, increasing, and uneven, consistent with international trends. Current responses are a poor fit, and bravery and fresh thinking are required, while ensuring to uphold competent and ethical practice. We can learn from international approaches, and responses for Aotearoa must be grounded in Te Tiriti o Waitangi, with youth, Māori, and underserved groups at the centre. Psychology has an important role to play as part of the complex system supporting mental health and wellbeing among adolescents in Aotearoa. There is a clear need for a substantial workforce boost, as well as attention to connection, integration, and working relationally across disciplines, communities, and government to achieve positive collective impact for young people and whānau.