Young Adult Mental Health Beyond the COVID-19 Era: Can Enlightened Policy Promote Long-Term Change?

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The adolescent and young adult mental health crises suggest the need for urgent reform. Seven priorities can achieve long-needed, systemic change: enhance mental health tracking, accessibility, collaboration, prevention, community focus, and equity.

Key Points

Introduction

The COVID-19 pandemic has been a watershed event in history, leading to severe social and economic dislocations, chronic uncertainty, social isolation, and disruptions of daily routines, particularly for young people and their families (Gruber et al., 2021; Lee et al., 2020; Liu et al., 2020). Immediate effects of the pandemic on multiple indicators of mental health and well-being were pronounced, with sharply higher rates of anxiety and depression across all age groups. As the pandemic waned, most adults’ worst fears abated and, by and large, anxiety and depression returned to baseline levels (Aknin et al., 2022). Yet for young adults, especially adolescents and emerging adults, negative effects have persisted, exacerbating a mental health crisis that was already of unprecedented scope (Office of the Surgeon General, 2021). That is, high rates of distress, mental disorders, and self-harm (including suicidality) preceded and have continued to escalate beyond the initial pandemic “spikes” in clinical distress and symptoms for young people (De France et al., 2022). Young adults from marginalized backgrounds have been especially affected, including those of Asian ethnicity–who have been targeted as having “caused” the pandemic–and for people of color in the United States, who have disproportionately died of COVID-19 and had serious mental health problems (DHHS, 2022). Finally, the confluence of the pandemic with increased awareness of systemic racism has revealed mental health needs among chronically under-addressed populations (Lee et al. 2022; Ramprasad et al., 2022).

The status quo regarding the provision of mental health services for young adults is not likely to be salvaged by incremental steps such as bolstering the existing mental healthcare system's infrastructure, training more practitioners, or gradually increasing the use of technology to provide mental health services virtually (Sohn, 2022). Only a wholesale policy transformation of mental health sciences and dissemination can address crises of this scale and scope. Although discussion is relevant to public health in general, a focus on young adults, which encompasses adolescence through emerging adulthood (late teens and early 20s; Arnett, 2007), will have the greatest long-term effect, particularly with enactment of preventive procedures and dissemination of evidence-based interventions.

COVID-19 Impacts on Young Adult Mental Health

Psychological distress and mental health problems have been rising in young adults over the past several decades. Although space does not permit a complete review of relevant findings, it should be noted that the average age onset for depression has decreased significantly in the past generation (Hinshaw & Kranz, 2009). Although delinquency and criminality appear to have decreased overall, rates of self-harm (including both non-suicidal self-injury and attempted suicide) have clearly risen and are a leading cause of death among adolescents (Mortier et al., 2018; Shain et al., 2016). Crucially, although adult rates of depression and anxiety have largely returned to pre-pandemic baseline, parallel rates for young adults have continued to rise (Barendse et al., 2021; De France et al., 2022). Moreover, the declines in academic achievement during the pandemic, largely a function of the need for remote instruction or home schooling, have also placed huge stress on parents and caregivers who must juggle their own work and their offspring's education (Brown et al., 2020).

These difficulties have not been dispersed equitably. Spikes in serious mental health concerns have risen particularly for disenfranchised adolescents from underrepresented racial and ethnic backgrounds (Barendse et al., 2021). Hopelessness has increased as well, particularly given increasing recognition, particularly among young adults, of the worldwide crisis regarding climate change (Crockett et al., 2023; Obradovich & Minor, 2022). Although many young adults have demonstrated resilience—and this is needed more than ever given the global challenges lying ahead—efforts to ameliorate pessimism and mental health risks in youth and young adults remain critical at this time of high vulnerability, in both individual development and current economic and climate-related situations (English & Brindis, 2022).

Priorities for Looking Ahead: Youth Mental Health Policy Transformation

A clear priority concerns the nature of normative versus maladaptive responses to stressors. When challenges transcend coping strategies, high levels of allostatic load—the experience of chronic stress without an adaptive response—can become maladaptive (Ellis & Del Gludice, 2014; Juster et al., 2016). Particularly for young adults, executive functions and self-regulation are still maturing and, if delayed, may take years to mature. Especially regarding the long time needed to attain financial independence and navigate the major societal demands for performance, vulnerability is high during the protracted period spanning adolescence through emerging adulthood (Sisk & Gee, 2022; Wood et al., 2021). Implications for mental health-related issues reverberate across families, secondary and postsecondary educational systems, social and mental health service agencies, and broader societal initiatives and policies. Without a coordinated plan, any solutions are likely to be temporary and piecemeal.

Accordingly, seven priorities aim to achieve long-needed and systemic changes in both practice and policy for young adult mental health sciences, with implications for basic and applied science globally (Figure 1). These priorities derive from experiences during the pandemic that revealed the need for transdisciplinary, population-wide changes to address the ongoing mental health crisis, which remains particularly acute and persistent among young adults. Proposing each priority aims to promote dialogue among mental health and allied health care professionals, policy makers, corporate and educational stakeholders, and the public at large. Integrated progress across these priorities can act together to revolutionize mental healthcare, reducing population-wide mental health burden and raising the standards of mental health care, especially for young adults facing disparities in notable ways that can improve their long-term mental health trajectory.

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Figure 1.

Seven mental health priorities to transform young adult mental health following COVID-19.

Frequent mental health tracking and access. The COVID-19 crisis has shown the importance of tracking percentages of the population, including its subgroups that are developing impairing conditions; this information can help identify populations at risk, uncover disparities in access to care across groups, and locate where additional resources are needed. Parallel efforts for tracking mental health symptoms in the population are now possible, as many reliable and valid brief screening measures are widely available (Cella et al., 2010). Furthermore, emerging technology can help individuals regularly track their own changes in mental health symptoms. Most notably, portable electronic devices can now monitor various metrics related to mental health outcomes. These metrics include changes in speech patterns, heart rate, and blood pressure, and even interpersonal interactions and app usage (Ahmari et al., 2015). Because young adults are “digital natives,” this group is most likely to benefit from implementing this type of tracking. However, without investment of significant resources, the potential of these methods may not be realized among disadvantaged populations. Therefore, also essential are mental health check-ups among at-risk populations (e.g., high schools with high absenteeism; communities with high unemployment rates, crime, and violence; individuals with high levels of impulsivity or depression at early ages in adolescence and emerging adulthood).

Given that (a) per year, fewer than half of U.S. adults with mental illness received mental health services (with a far lower percentage receiving evidence-based care) (Kazdin, 2019), (b) among racial/ethnic minorities this proportion is far lower—around one-fifth (Asian) to one-third (Hispanic) (Substance Abuse and Mental Health Services Administration, 2018), and (c) the last comprehensive Surgeon General's report on culture, race, and ethnicity factors in mental health occurred almost 20 years ago (Office of the Surgeon General, 2021), it is time to turn scientific attention and to direct public policy toward developing new ways to screen for and prevent mental health problems and symptoms early on in young adults’ lives. In fact, the dominant model of mental healthcare delivery is ironically “a key barrier” to widespread use of mental health services (Kazdin, 2019, p. 455) .

Alongside tracking, increased access to available evidence-based treatments is crucial. Many in need of mental health care cannot access treatment, due to resources needed to pay or copay, to cover transportation or childcare; lack of nearby health care providers; or inability to take off work for weekly 50-minute appointments. These issues disproportionately affect young adults of color and low-income populations. However, COVID-19 necessitated a rapid shift to telehealth and online treatment sessions, including not only standard treatments, such as mindfulness-based cognitive therapy, but also electronically delivered single-session therapies as treatment supplements (Dimidjian et al., 2014; Morgan et al., 2017). These efficient treatment modalities have the potential to increase access to mental health treatment dramatically (Naslund et al., 2015; Whitfield et al., 2022).

Social norms interventions. Many individuals, particularly young adults, are guided by the unwritten norms of their own group even as perceptions of those cultural and social norms are sometimes inaccurate. In such cases, perceivers mistakenly believe that the attitudes and behavioral practices of peers and other community members differ from their own. More specifically, they tend to overestimate patterns of health negative behavior and underestimate the extent of healthy behavioral tendencies. Such erroneous perceptions, termed “pluralistic ignorance” or “false consensus” (Berkowitz, 2005) can and do yield seriously negative consequences, as young people adapt their own behavior to mimic such misperceptions. Thus, social norms interventions are motivated improve mental and physical health by correcting such misplaced perceptions. (For a classic set of examples related to perceptions of problematic drinking, and smoking among teens and college students, see Berkowitz (2005); for theoretical and empirical background, see Miller & Prentice (2016) and Cislaghi & Heise (2018).)

At a population level, messaging can change normative misperceptions and reduce rates of alcohol and tobacco consumption (Berkowitz, 2005). By the same logic, altering perceptions of social norms related to mental health has untapped potential for motivating individuals—especially peer-oriented younger adults—to engage in preventive efforts or indicated treatments. For example, professional sports teams which are often predominated by young adults and can serve as role models to a larger network of young adults more generally, are beginning to prescribe not only regular physical examinations but also “check-ups from the neck-up” to evaluate mood, anxiety, stress management on a regular and expected basis (Hickman, 2002). When such evaluations come to be viewed as normative, the potential stigma and shame surrounding mental health should wane consistent with the expectation that understanding one's emotional and mental well-being is a sign of strength rather than weakness.

Engage communities. To further broaden impact, a key initiative is to deliver mental health interventions via masters-level providers and peer individuals in the community to young adults. As long as adequate training is provided (Shahmalak et al., 2019), it is possible to increase the pool of effective providers to address mental health needs of young adults identifying as racial/ethnic minorities, from low-income families or communities, along with other groups of young adults suffering from poor access to health care. Because of high current need, it is imperative that mental health scientists and professionals consider how treatment can be provided through collaborative, community-based partnerships that are geared toward the developmental needs of young adults. For example, given the known positive effects of social support on protecting against mental distress and fostering the ability to recover after experiencing distress, peer delivered or peer support interventions (e.g., including peers from high schools and colleges or the community) that take place in pairs or groups can occur over both telephone and internet, within families or smaller social communities. These approaches can reduce symptoms of depression and other severe forms of mental illness generally (Fuhr et al., 2014) and in university and nonstudent young adults (Richard et al., 2022), but they have yet to be used widely in practice for young adults.

Collaborate across disciplines and stakeholders. To broaden adoption of easy-to-use techniques among young adults, mental health scientists should go outside standard clinical and mental health sciences to find new ways to support behavioral change and promote well-being. For example, insights from such fields as cognitive sciences and behavioral economics can help develop straightforward approaches, such as using simple daily practices and behavioral choices (e.g., following a program to develop better sleep-related behaviors to increase wellness for adolescents and to foster the ability to bounce back after setbacks, such as academic failures or relationship stressors for young adults). Many of these are freely available online. Developing more cross-disciplinary collaboration will require structural support and funding opportunities, changes within colleges and universities to encourage collaborative work, and new research approaches to increase scientific communication both across and within different fields of study pertinent to the developmental sciences and optimizing mental health trajectories for young adults (e.g., developmental neuroscience, education policy, sociology, and public health).

Focus on prevention. More than 80% of people, including young adults, who have mental disorders live in low- and middle-income countries (LMICs), in which the mental health workforce (e.g., clinical psychologists, psychiatrists, mental health counselors, clinical social workers, psychiatric nurses, marriage and family therapists) is utterly inadequate even for basic treatment of mental health symptoms (Rathod et al., 2017). Moreover, even in high-income countries, such as the United States, which has many times the mental health workforce of LMICs, an illness-oriented treatment system is clearly not able to address population-wide mental health needs, and the financial resources needed to treat mental disorders are lacking. In resource-rich urban areas, even for people or families with resources, waiting lists are huge (National Institutes of Health, 2021). These issues are often exacerbated among young adults with limited ability to seek and attain adequate mental health treatment independent of their family and school infrastructures.

In other healthcare disciplines, widespread prevention methods are common, and are saving millions of dollars in immediate care needs annually (Fisher et al., 2003). For example, school health care programs for youth and young adults emphasize the importance of basic hygiene, good nutrition, and physical activity. Similarly, psychological scientists have long shown that low-cost behavioral practices, such as exercise (Stathopoulou et al., 2006) and sleep hygiene (Morin & Ware, 1996), work well to reduce mental health problems, including among adolescents (Adrian et al., 2014). Simple prevention approaches aimed at improving emotion regulation are also useful for youth and young adults (Trosper et al., 2009)—for example, avoiding mental traps, such as all-or-none thinking, drawing overly broad conclusions from one experience, thinking that every small problem is a catastrophe—or practicing mindfulness, which involves awareness of negative emotions and preventing their escalation for young adults ( Greeson et al., 2014).

To achieve widespread effects, programs that teach these practices need to be adopted by key institutions. For example, schools are critical nodes for reaching youth; whereas workplaces are critical nodes for reaching adults. Indeed, the most successful methods to change behavior, such as those that were used to reduce smoking, have had strong backing as public health initiatives(e.g., Surgeon General's warning about the dangers of smoking printed on every pack of cigarettes).

Preventative methods are most powerful among youth. For instance, in elementary schools worldwide, dental hygienists ask young children to brush their teeth and then chew a disclosing tablet. As unbrushed teeth turn pink, children directly learn a healthcare behavior that offers a lifetime of prevention against cavities and tooth decay. Foundational skills to increase physical fitness, healthful dietary habits, and protection from sexually transmitted infections also are common in primary and secondary school settings. In contrast, programs to prevent or reduce mental health problems are extremely rare, yet they could prevent a variety of mental health problems (Hoying et al., 2016). For instance, brief, but repeated, lessons to promote social problem-solving can be effective in reducing bullying and other disruptive behavior (Davidson et al., 2007), alcohol and other substance misuse (Alarcó-Rosales et al., 2021; Arzin et al., 2001), and even suicide rates (Sobanski et al., 2021). Mental exercises that promote helpful ways of thinking about situations (e.g., avoiding all-or-none-thinking) could prevent many young adults from experiencing crippling depression and anxiety, as well as other mental health symptoms. Such programs can not only reduce the pain and suffering of young people, but also reduce multiple collateral harms, including absences, lower school and work performance, lower participation in beneficial school activities (clubs and sports), and the severity of physical health problems (Clayborne et al., 2019; Colasanto et al., 2020; Wickersham et al., 2021).

Approaches directed towards adult populations, will also, in turn benefit youth as well. Given the economic impact of mental health impairment, workplaces should invest in promoting mental wellness strategies for all employees. Such preventive strategies have the promise of raising productivity and lowering costs, including reducing use of costly medical care. For this reason, employers and health insurers share interest in covering mental health wellness checks. Like discounts on insurance premiums offered to nonsmokers, similar insurance and other financial incentives could be offered for behaviors known to improve emotional well-being. Employees also could offer on-site training and facilities to promote emotional and behavioral, as well as physical, health. Finally, sick leave should be supported for coping with stress, disruption to daily routines, exacerbation of mental health symptoms, and to support family members with mental health symptoms.

Progress along dimensional descriptions, not categorical pronouncements. Mental health symptoms are not all-or-none phenomena, but reflect dimensions of severity from health to mild, moderate, and severe psychopathology (Kotov et al., 2021). Further, mental health problems impair multiple aspects of daily life. Finally, some studies suggest that more severe one's mental health problems, the more they can negatively affect one's daily functioning (Markon, 2010). What this means for public health is that “every little bit helps.” Thus, for example, reducing mental health symptoms from moderate to mild by changing such behaviors as better sleep habits, more regular physical activity (including simply walking more frequently) and a more healthful diet, will be associated with better functioning in one's daily life. Moreover, widespread understanding that mental health problems reflect dimensions of severity has the potential to reduce stigma, which is particularly critical for addressing the youth mental health crisis. That is, it is possible to normalize the idea that many people have periods of feeling more worried or disheartened and other periods of feeling more optimistic and energetic. Understanding, for example, that the so-called mental disorder major depression is a more serious version of feeling disheartened reduces its stigma because it means that people who experience a major depressive episode are not different in any fundamental way.

Address inequities. Systemic racism in the United States has created political, economic, and educational inequality that is strongly related to mental health disparities. Compounding these issues, mental health research has been predominantly conducted by White, heterosexual, middle-to-upper class scholars, mostly with White, heterosexual, middle-to-upper class participants, and then evaluated mostly by White, heterosexual, middle-to-upper class editors and reviewers. As a result, uncertain applicability of many research findings to people of color and other marginalized groups limits developing practice guidelines effective across the whole population. Thus, all mental health disciplines require more research that is less biased by White-heterosexual-middle-to-upper class (Buchanan et al., 2021; Roberts et al., 2020).

To address disparities in mental health will also require addressing how systemic racism has created conditions that are associated with greater risk for psychological symptoms. Indeed, the effects of systematic disparities in mental health on young people may be particularly deleterious. Changing problematic policies could have substantial benefits for mental health and could rely on psychological research. For instance, policies requiring equitable educational funding across school districts could be guided by science, using known associations of various educational practices that knowledge and skills increase with effort and practice (vs. are limited by a fixed level of “intelligence”), with depression, anxiety, suicide, alcohol and other substance use, and other mental and behavioral health problems.

Conclusion

The COVID-19 crisis and racism pandemic have forced change across systems, some of which were long in need of reform for young adults experiencing profound mental health challenges compared to other age groups. The ideas presented here to address mental health care for young adults more fully are not new, yet they have faced considerable resistance both within and outside the mental health field. Those in mental health care disciplines must relinquish established, yet outdated traditions for young people. To address both population mental health and the unfolding mental health crisis among younger people fully requires inviting new areas of expertise into psychology's ranks, reform practices to allow for new models develop innovative approaches and demonstrate flexibility in traditional beliefs about mental health care. Perhaps most importantly, mental health professionals need to work with and across many separate mental health disciplines, gracefully intersect and interact with the community and educational systems young adults are embedded within, and bridge existing ideological rifts.

Those in disciplines other than mental health fields should consider emotional and behavioral wellness as an urgent global priority for young adults. The far-reaching impacts that would come from a serious, systemic commitment to mental health among young people and their futures ahead have yet to be realized. Yet addressing each of the priorities herein could change that. The initiatives discussed here will require policy changes, fiscal support, and transdisciplinary collaboration. Plus perhaps most importantly, ongoing data collection to guide successful progress and document the efficacy of each change to ensure that the future of mental health care is evidence based. The future of young adults and the mental health sciences and for their current and future lives whose well-being depends upon them, is in the field's hands.