Section 4 - Mental Health
Problem: There is some evidence of an increase in mental health problems among young people, especially young women. Poor mental health can impact on education and employment, which in turn may have long-term impacts on future prospects and increase poverty risks.
Assessment of a wide range of mental health indicators for both children and young people (aged 17 and under (2013) and adults (2012) in Scotland concluded that, over the past decade, mental health outcomes have been generally stable with some promising improvements, particularly for children and young people. 
However, analysis of recent data for young adults for the evidence review has highlighted some issues. Mean wellbeing scores were slightly lower for young adults than older age groups and the proportion of young adults who self-reported to have ever self-harmed was much higher than for older age groups. Moreover, the analysis suggests there may have been increases in the proportions of young adults self-reporting two or more symptoms of depression and anxiety. 
In particular, some concerns were raised regarding the mental wellbeing of young women. Young women reported lower levels of life satisfaction and wellbeing than young men. They were also more likely to exhibit signs of a possible psychiatric disorder and self-report higher levels of self-harm compared to young men and older age groups.  The evidence indicates that these higher level of mental health issues among young women is manifesting earlier in adolescence. Analysis of data for adolescents found that, while overall mental health and wellbeing scores have remained fairly constant over time, 15 year old girls report much poorer mental health and wellbeing than other groups, particularly for emotional problems. 
Here's what young people said:
"Mental health issues have risen due to social media - it makes everyone depressed."
"Today's young people look at Facebook and think that everyone's life is great and theirs is not; so this can lead to mental health issues, depression and anxiety."
"There is a mental health epidemic amongst young people and no one is really listening or paying attention."
"You get a diagnosis and then they leave you for months. They don't do that to cancer suffers."
"The stigma around mental health is not going to go away anytime soon."
This is often not about medically diagnosed mental illnesses, necessarily. It's more about how we tackle increasing levels of stress and anxiety. For example, in terms of exam stress, 80% of 15 year old girls in Scotland feel pressured by school work - significantly higher than the European average. Girls also experience stress about body image. While 30% of girls in Scotland have a BMI outside of the healthy range, 55% of fifteen year olds consider themselves fat.  In addition, while social media use has been shown to have some positive effects, it has also been linked with increased rates of anxiety, depression and poor sleep in young people.  There is also a tension to be managed between the focus on raising educational attainment and the increased pressure this can put on young people. This may in a diagnostic sense be relatively low-grade, but all the same it can have serious effects on wellbeing. Half of adult mental health problems start before the age of 14 and 75% start before the age of 24.  Early identification and early intervention are essential in ensuring that young people can achieve their potential and avoid poverty in later life.
In adults and adolescents, poorer mental health outcomes have found to be associated with greater socioeconomic disadvantage.  As in virtually all other types of health outcomes, mental health has a social class gradient, with the poorest more likely to have problems. There is lack of data specifically on socio-economic disadvantage and mental health in young adults. As with all adults, young adults in the most deprived areas generally had poorer physical health outcomes in several areas and reported lower levels of wellbeing compared to those in the least deprived areas. 
Groups with a high risk of mental health issues include those with experiences of Adverse Childhood Experiences (' ACEs').  In particular, care leavers have been found to experience poorer mental health than non-care leavers. This is not surprising, as some degree of childhood trauma is strongly associated with coming into care. But it does indicate that the care system is failing to respond effectively to this early disadvantage. In terms of young people who are carers, there appear to be wellbeing benefits for those caring for up to 4 hours per week, but unpaid caring for longer hours is a significant predictor of poor mental wellbeing and the presence of possible psychiatric disorder. Young carers (aged under 25) are more likely to report a mental health condition than those who are not carers.  Young mothers experience poorer mental health and are at a higher risk of post natal depression in the first three years after giving birth than do older mothers. Young mothers also have higher than average feelings of isolation and low self-esteem than older mothers.
I have grouped my two recommendations on mental health together, as they are essentially two sides of the same coin.
Recommendation 17 - Take action to embed positive mental health approaches, based on quality evidence, in key settings where young people engage
Recommendation 18 - The Scottish Government should fund applied research on school and classroom practices that encourage wellbeing and mental health
Schools, colleges, universities, workplaces and other settings where young people spend much of their time could usefully develop a stronger focus on the determinants of mental health and on helping young people before they reach the point of needing treatment. For example, the Royal College of Paediatrics and Child Health ( RCPCH) has recommended that the professional bodies representing all those working with children and young people in health, social care, education, criminal justice and community settings should equip their members with the necessary tools to identity mental health issues through the promotion of resources such as the MindEd portal. 
For these reasons, I support the focus in the Scottish Government's recently published Mental Health Strategy 2017-2027 on prevention and early intervention in relation to young people.  In particular, I welcome the actions on: reviewing counselling and guidance services in schools, to ensure they are delivering for children and young people; rolling out improved mental health training for those who support young people in educational settings; commissioning the development of a matrix of evidence-based interventions to improve the mental health and wellbeing of children and young people; and supporting the development of 'Think Positive', to ensure consistent support for students across Scotland. My recommendations in this section are intended to amplify these actions on creating mental health promoting environments and better understanding how to improve young people's mental health.
While the family environment and peer relationships are clearly central to young people's mental health, school has been flagged as a particularly important place in which more emphasis on preventative mental health approaches is needed. Teachers themselves feel under pressure, and perhaps we expect too much of schools. But a preventative approach should reduce rather than increase pressure on students and teachers. Some school cultures make children and young people feel terrible. Much has already been done on issues such as bullying in relation to race, gender and sexual orientation. But many young people described feelings of worthlessness related to their sense of low academic ability. They felt teachers spent more time and effort with the children who were clearly on their way to higher education. While the young people I spoke to cannot be considered a representative sample, or indeed a majority experience for young people, it was deeply depressing to hear how hurt some felt because of their school experience, including at primary school.
Healthy schools programmes of various kinds are in operation, but traditionally much of the focus has been on healthy eating and exercise. There is a real need for more focus on mental health promoting schools and colleges. It's very positive that the Curriculum for Excellence includes wellbeing. But the demonstrable commitment that tackles all those things that make children feel bad at school is less clear. There is a critical issue in the secondary phase. Primary schools in Scotland do very well on wellbeing measures in comparison with other countries, but there is considerable fall off in secondary schools. Clearly, narrowing the gap is extraordinarily important for social justice; however, when it results in putting undue pressure on young people it can be damaging. Schools need to work at narrowing the gap and building social and emotional skills as mutually reinforcing. The earlier section of this paper on employment issues stressed the need to pay more time, attention, and resources to those young people who clearly have a lot to offer, but are not bound for traditional academic success.
The Mental Health Strategy highlights the particular needs of some groups of young people, including young carers, those with disabilities, and those from a minority ethnic background. It highlights that mental health and wellbeing should be considered within relevant frameworks and processes (e.g. the Framework for supporting disabled children, and young carer statements). I welcome the focus on the needs of these groups, and embedding mental health and wellbeing considerations within relevant processes for supporting these young people. But I still believe more research is needed to ensure school environments are generally health promoting rather than risking poor mental health.
Email: Andrew Fraser, firstname.lastname@example.org
Phone: 0300 244 4000 – Central Enquiry Unit
The Scottish Government
St Andrew's House