Friday, December 9, 2022

Transcript: The State of Youth Mental Health

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MS. WINFIELD CUNNINGHAM: Hello, and welcome to Washington Post Live. I’m Paige Winfield Cunningham, deputy newsletter editor here at The Post, and today we’re here to talk about something that has taken an immense toll on children and teenagers in the last two years, and that is the pandemic and the toll on their mental health and well‑being. And today I’m delighted to be joined by two guests to discuss this.

My first guest is Zeinab Hijazi, the senior mental health technical advisor at UNICEF. Zeinab, welcome to Washington Post Live.

DR. HIJAZI: Thank you, Paige. Thank you for having me.

MS. WINFIELD CUNNINGHAM: A quick note to our audience before we start. We would love to hear your questions. So please tweet us using the handle @PostLive, and I will try to incorporate those during our conversation.

Zeinab, let’s start off with some statistics. I’ve heard that seven‑‑one in seven kids under 19 years old experiences some kind of mental health disorder around the world. Do those figures sound correct to you?

DR. HIJAZI: Yes, absolutely, Paige. You know, mental health and these statistics really are an important indication of mental health being this global issue, but of course, it remains stigmatized and underfunded in almost every country, rich or poor. And poor mental health in childhood and adolescence prevents children from fulfilling their rights and reaching their true potential.

But, you know, you mentioned the statistics, and even before the pandemic, far too many children were burdened under the weight of unaddressed mental health issues, with the latest available data estimating other statistics that are important to note, including that one in four children live with a parent who has a mental health condition, and that really half of all mental health conditions start by age 14 and three‑quarters by age 25. But most cases, while treatable, go undetected and untreated, and this puts an emphasis on the importance of acting early and prioritizing child mental health.

MS. WINFIELD CUNNINGHAM: I know one question that always comes up in my mind when I think about this issue is, you know, by many measures, the world is a better place than it’s ever been before on almost every measure. Is it the case that mental health for kids is worsening, or is it more that we now have the resources to be aware that to track it and to try to counter it? What’s your take on that?

DR. HIJAZI: It’s a really good question. I mean, of course, throughout the pandemic, there were very frequent warnings that we may be facing a wave of mental health problems. I think we saw in many headlines the word “tsunami,” and numerous studies and surveys have appeared during the pandemic that seem to bear out these concerns. And, of course, combined, they paint a picture that children and young people are reporting feelings of being anxious, of being depressed, of being overwhelmed, and parents reporting changes in children’s behavior, including difficulty concentrating, restlessness, and irritability and more.

But we need to be a little cautious here. You know, the pandemic has produced a flood‑‑call it a “tsunami”‑‑of research studies of variable quality. For those researching the field, the challenge is not finding evidence but rather assessing how much of this evidence is really useful, and this, sadly, is not a new problem. You know, even before the pandemic, it was very clear that evidence and knowledge around children’s mental health was sadly lacking.

Data on mental health conditions, including anxiety, depression, and self‑harm, are available for less than 7 percent of the world’s children and adolescents, and most of these children and adolescents live in high‑income countries. So, in other words, when it comes to understanding the mental health of most children in most of the world’s countries, we just don’t know nearly enough.

MS. WINFIELD CUNNINGHAM: Yeah, that’s a great point.

Let’s drill down into some of the specific causes of these mental health difficulties, and of course, you mentioned the pandemic when you’re sort of looking at how a variety of countries handled the pandemic. What did you observe in terms of how, you know, what opportunities children were given to, say, go to school, to have social interaction, and then what toll that did take on kids as those things changed and were rolled back?

DR. HIJAZI: Yeah. You know, no generation has experienced a childhood quite like this one. In cities, towns, and villages around the world, the lives of children and young people were repeatedly put on hold for over a year, and many are still impacted to this day. And so, what the COVID‑19 did was it, you know, triggered shocks on multiple fronts that intensified certain vulnerabilities for children such as, you know, increased exposure to violence, neglect, and deprivation; disrupted access to education, as you just said; and social isolation. So, alone or in combination for many children, these likely led to negative educational outcomes and increased stress levels.

Parents and caregivers, of course, were also affected and needed help as they provided the necessary environment and support for children’s continued learning and to cope during the crisis. So, yes, less visible but no less worrying for many is the impact of the pandemic on children, including their mental health, and this is not surprising, you know, given that children’s mental health and wellbeing is affected by how well they are supported by their schools and their peers and even more broadly by the economic and political structures in our societies and, yes, by events like disaster, war, community violence, and major health emergencies like the pandemic, which impacted all of these areas that are usually protective factors for children’s mental health.

MS. WINFIELD CUNNINGHAM: I want to pull in an audience question here from Gael in North Carolina who asks, is the risk of isolation to prevent COVID worth the mental health consequences of depression, and how do you assess the risk/reward ratio? And I find this an interesting question because, of course, this has sort of sparked a furious debate in the U.S. as people have looked at the school closures and sort of in retrospect, you know, realized that maybe this has a greater toll than it needed to have no kids. What is your take on all that?

DR. HIJAZI: You know, this is a‑‑I guess it requires a two‑fold response. The first is, you know, from a public health perspective, and, you know, the measures that were put into place were necessary to protect children at the physical level. But certainly, you know, UNICEF and partners, we worked very hard to ensure that children remained connected, that the peer‑to‑peer interaction was supported through different channels.

You know, we talk a lot about social media and platforms that are‑‑you know, certainly, pose a risk to young people but that also provide new possibilities for increased youth and peer‑led opportunities for promoting mental health among young people and also strengthening interaction. So, it’s hard to respond to whether or not it was worth it because, also, I think there are measures that have been put into place to also ensure that the peer‑to‑peer and social interaction and connectedness was maintained through different channels within families and within schools and within communities as well.

MS. WINFIELD CUNNINGHAM: Let’s talk about social media for a minute, and this is also just a fascinating debate because, as you say, it can facilitate connectedness, but, of course, we’ve also heard a lot about how different social media platforms are especially harming girls in the way that they are being used. Do you see social media as a net positive or a net negative when you think about teenagers in particular and how they’re using these platforms?

DR. HIJAZI: I mean, it’s no doubt that technology has transformed the way children and young people interact with each other and how they interact with the world, with profound impact on behavior, day‑to‑day activities, and all with positive as well as negative implications on mental health.

You know, new possibilities for improving the availability, reach, and quality of mental health care and services are a reality because of social media and these types of technological platforms, but we’ve also noted, of course, that social media has led to increased frequencies of anger words or varied negative emotions and related patterns of language use associated with social media users’ likelihood of self‑reported mental health problems.

So, yeah, I mean, we cannot deny that the use of online platforms and popular social media present risks for users, especially young users and girls, including worsening of mental health symptoms through prolonged screentime use, exposure to hurtful content, and hostile interactions with others, threats to privacy as well as negative consequences of everyday life due to stigma, impact on personal relationships, and unintended consequences of disclosing personal health or mental health information online.

But really, the big question is if digital technologies such as social media and other online platforms are here to stay, what are the ways to ensure safe use of these technologies, and how do we minimize the risks that impact mental health?

MS. WINFIELD CUNNINGHAM: Yeah. That’s an interesting question because I could see people seeing it, viewing it as, you know, maybe technology helps to correct these problems, but maybe technology is leading to some of these problems in the first place.

I wanted to zoom back quickly to something you mentioned at the outset, and that is when you’re sort of surveying countries for where we see the biggest problems with youth, mental health, is there a difference between, way, wealthier countries and poorer countries in terms of children that are reporting mental health problems?

DR. HIJAZI: Yeah. Of course, when children are exposed to humanitarian crises, of course, you know, we are going to be seeing increased levels of distress in low‑ and middle‑income countries that are not necessarily impacted by humanitarian crises. Usually, the infrastructure that is available to support these children is just not there. So, yes, we see a difference in a sense where in developed countries and high‑income countries, there is an infrastructure available to provide the care and services, but this is not a rule. You know, we’re seeing in Europe and in Ukraine and the neighboring countries that sometimes high‑income or developed countries who have not experienced emergencies before are less equipped to respond to the emerging mental health needs.

So, we’re active, for example, at the moment in that emergency, but luckily enough, in those developed contexts, there are active partners, and the government has the resources to roll out care and services for families and communities.

MS. WINFIELD CUNNINGHAM: Are there factors kind of that cross country lines that are sort of consistently true in terms of risk factors? Like, in other words, if you’re trying to perhaps identify a child that might be at a higher risk for mental health difficulties, what might some of those factors be?

DR. HIJAZI: You know, I think to answer that question, I think it’s important to understand that children’s mental health and wellbeing is linked to their environment. So, in other words, child development and well‑being are embedded in a child’s own contacts and experiences, with risk and protective factors tied to relationships with caregivers, friends, and family, supports in schools and communities, sociocultural influences, as well as broader political and economic factors.

So, you know, if you have a child who is being displaced because of a certain humanitarian crisis, but they are still with their family, their parents are supported and are able to provide nurturing care for the child and the child is able to resume some sense of normalcy in school, it’s very likely that that child will continue to do well.

In a developed context, in a poor setting, where a child might be experiencing neglect or abuse within the home and they don’t have a nurturing relationship within the home and they’re not receiving the support that they need in school, that child is likely not to do well. So, across lines, across settings, it is the child’s world and circles of support that surround them that really are the key indicators for how well that child is doing and an indicator for their mental health status.

MS. WINFIELD CUNNINGHAM: It’s hard to think of a region of the country where children may be struggling more than in Ukraine, which I know you already alluded to. We know they’ve been under attack for months, unfortunately. Can you talk to us a little bit about what you’re doing in that region to support the needs of Ukraine’s young people?

DR. HIJAZI: Yes. So, you know, in Ukraine, we, of course‑‑there’s‑‑we had to respond to the immediate needs, you know, in any emergency, we go in. We are‑‑immediately carry out a rapid needs assessment to better understand what are the experiences of children and families, what are the support systems that exist that we could leverage in our response, who are the partners that are active on the ground. You know, we are far beyond this medicalized, solely health approach that requires mental health services be delivered through the health sector. We’ve now‑‑we are now able to advocate and implement an approach that supports mental health services through education, through health services, and through social services and child protection.

And in the Ukraine response, specifically, we are, you know, establishing a network of Blue Dot support hubs in coordination with other partners and United Nations agencies, and essentially, these hubs are located within neighboring countries where displaced families are received. They provide child and family friendly spaces, information and advice desks, legal aid, identification, referral of children at risk, and basic mental health and psychosocial support services. So, anyone who is on the front line providing any type of service should receive basic training in mental health, mental health care as well as psychological first aid.

And, of course, that’s the immediate response. Now we’re moving into a medium‑term response, and we’re working very closely with the government and other partners to strengthen systems for care. Protection and education for children is critical, and also, we’re really investing in capacity building of social workers and education personnel who are working directly with children, so really meeting children where they are in an environment where there is likely going to be a lot of stigma and discrimination around seeking services directly, should those families and children need it.

MS. WINFIELD CUNNINGHAM: Well, we’re almost out of time, but for the last minute or so, I’d love to hear from you whether you’ve seen any success stories. Are there any countries that seem to be really ahead of the curve in terms of trying to provider these mental health supports?

DR. HIJAZI: Yeah. You know, it’s interesting. You know, usually, when we talk about emergencies, we talk about emergencies as an opportunity for making a change, for bringing awareness to mental health, and really investing in support and building care systems for young children and families.

And I touched a little bit on stigma and discrimination, and maybe it’s a good opportunity to maybe talk a little bit about an experience that we had in Kazakhstan. Kazakhstan, about a decade ago, had one of the highest adolescent suicide mortality rates in the world, and suicide was the leading cause of death among adolescents, ages 15 to 19. And since 2012, UNICEF has collaborated with the government of Kazakhstan to develop and implement adolescent mental health and suicide prevention program, and this program is a school‑based response that aims to strengthen the national education and health system’s ability to respond to adolescents’ mental health and psychosocial needs, and it does this by improving early identification and referral of those at risk.

Fast forward to 2018. We’ve scaled up the implementation to over 1,500 schools across five regions, and an evaluation very recently found that adolescents were identified at risk experienced a significant decrease in suicidal ideation, depression and anxiety, and stress after receiving treatment. So, this is a really successful example of where, you know, we’re able to mobilize resources, understand the problems that are experienced at the country level, and respond and scale up an effective and promising approach to address mental health issues and decrease risk and improve access to services and roll that out at the national level and importantly really focus in on the data piece. It is because of the data available in Kazakhstan that we were able to identify a problem, and it is through data that we’re able to understand better that what we are doing works, and we’re seeing a decrease in mental health issues as well as building and contributing to the evidence that could be applied in other countries and other settings.

MS. WINFIELD CUNNINGHAM: Well, unfortunately, we’re out of time, so we’ll have to leave it there. But, Zeinab Hijazi, thank you so much for joining us today. It’s been a great conversation.

DR. HIJAZI: Thank you, Paige.

MS. WINFIELD CUNNINGHAM: Well, I’ll be back in just a few minutes with my next guest, U.S. Surgeon General Vivek Murthy. Please stay with us.

MS. KOCH: Hi. I’m Kathleen Koch. Young people around the world have been experiencing higher levels of anxiety, stress, and grief in recent years. It started before the pandemic. Of course, the pandemic only made things worse by limiting social interaction and reducing access to education.

To help us understand how we can respond with meaningful solutions, I would like to welcome Heidi Kar. She is principal advisor for Mental Health, Trauma, and Violence Initiatives at Education Development Center. Welcome, Heidi.

DR. KAR: Thanks, Kathleen. Pleasure to be here.

MS. KOCH: Heidi, the global youth mental health crisis presents such an enormous set of challenges. What are the barriers would you say to addressing the crisis, and where should we start?

DR. KAR: Well, Kathleen, I’d say we need to think holistically across a continuum of mental health needs. So we need to think about how do we interweave promotion of mental health, prevention of mental health issues, treatment of mental health disorders, of course, but also recovery from mental health issues because we know most people do recover from mental health challenges, and understand how we link those different pieces across the continuum and what the different entry points are.

You know, a lot of conversations seem to focus lately on how do we increase the number of mental health clinicians and how do we scale up acute treatment in health systems, but the truth is we’re never going to have enough clinicians to meet our demand. And in many places, health systems are not accessible to the majority of people, especially outside of the U.S. So we need solutions that don’t require mental health professionals if we’re going to really achieve large‑level change.

There are three pillars that guide a lot of our work in mental health at the Education Development Center. One is that interventions are scalable, right, so that we’re designing interventions that can be administered to large groups of youth at the same time. The second is that they’re multipronged. So we can bring mental health interventions into many different settings in our communities, homes, schools, workplaces; and finally, that they’re horizontal, which means that we are addressing co‑occurring issues, not kind of continually creating an intervention for one thing at a time. It’s just not a way to address the staggering need that’s out there.

EDC is actually working to create solutions and adhere to these three pillars. We are in the middle of designing a mental health curriculum that can be administered by non‑clinicians, that can be administered in a variety of settings, and that addresses many of these co‑occurring issues together.

MS. KOCH: Heidi, what do you think will happen if we don’t confront this challenge facing children around the world? What are the implications would you say?

DR. KAR: Well, we already know the ways that poor mental health kind of affects the whole aspect of individuals’ lives. We know that pretty well, but we often fail to recognize what mentally unhealthy groups of people or communities fail to get out of life if people are not mentally well.

On the community level, we know that mental unwellness leads to increase in conflict, for example, both interpersonal but also group‑based. The ability of individuals in groups to think flexibly, which is, you know, thinking about there are many different solutions to every problem is a core mental health skill, and that ability to think flexibly has a huge part to play in group violence, like violent extremism, but also in domestic violence.

We know that mentally healthy people are also more able to contribute to their economies. They’re more able to be creative, to take risks. They’re more effective in their jobs, which means the economic health of a culture greatly depends on the mental health of its people, and so the mental health of a community or society, Kathleen, really underscores its ability to grow, to innovate, and as such, we really have to get better at understanding the repercussions of not investing in mental health.

MS. KOCH: So fascinating. If you could leave our audience with one call to action, what would it be, and what would you say are the most urgent next steps that should have been taken yesterday to help young people struggling with mental health issues?

DR. KAR: Great question. I would say we need community‑led, culturally humble, and innovative solutions to meet this need. Of course, they need to be based on our evidence that we know in terms of what works, but they need to be adapted. No matter what area of work you might be involved with or lead, we need to be incorporating a mental health lens into that sector, every sector, working with youth or working with people who care for youth, because we know that, you know, the environments youth grow up in, learn and live in have so much to do with their own mental health. So whether we are talking about a workplace, employers can strengthen the mental health of their workforces in comprehensive ways, more than just sending individual people to clinicians.

Health systems can focus on culture change and policy adaptation to support their beneficiaries but also their staff. We know that if staff are healthy in health systems, they deliver better care.

And, finally, in our education systems, we need to focus, of course, on social‑emotional learning instruction, but we need to go deeper, and we need to teach mental health skills to youth in systematic innovative ways.

So, in other words, I think I’m calling for a clear understanding that every sector has a role to play, and it’s beyond time for all hands on deck.

MS. KOCH: Heidi Kar, principal advisor for Mental Health, Trauma, and Violence Initiatives at Education Development Center, thank you so much.

MS. KOCH: All right. And now I’ll hand it back over to The Washington Post.

MS. WINFIELD CUNNINGHAM: Hello, and welcome back. For those just joining, I am Paige Winfield Cunningham, deputy newsletter editor here at The Washington Post, and I’m pleased to welcome my next guest, who is someone I’ve spoken to a number of times on here before, and that is U.S. Surgeon General Vivek Murthy, here to talk us through the mental health of young Americans.

Dr. Murthy, welcome back to Washington Post Live.

DR. MURTHY: Thanks so much, Paige. It’s good to be with you again.

MS. WINFIELD CUNNINGHAM: So, before we get started, a quick note again to our audience, we’d love to hear your questions. Tweet us using the handle @PostLive, and we’ll incorporate those.

Dr. Murthy, of course, lots to talk about in terms of youth mental health, but I want to quickly throw a couple of questions at you about monkeypox because I know that that is top of mind for a lot of people in this moment and certainly dominating headlines.

And, at the moment, the U.S. has the most known cases in the world. It’s spreading particularly rapidly in New York City, and of course, the administration has sort of been under fire for its response. I’d love to hear from you. What should the government be doing more of to try to get this outbreak under control?

DR. MURTHY: Well, Paige, I’m glad you asked. I know that people have been hearing about monkeypox, and they may be worried about it. So here are some of the key things that people need to know, and here is some of what our government is doing and plans to do more of.

Monkeypox is an illness that we are very concerned about and are mobilizing our resources to try to address. This is a virus that has symptoms that includes swollen lymph nodes, symptoms that can mimic a flu or a cold, but also, it has a characteristic painful rash that many people that have had monkeypox have experienced.

And what’s important to know is that it’s spread primarily through skin‑to‑skin contact. That can occur during sexual activity, as has been discussed a lot in the press, but it could also happen through other forms of close physical contact. So it’s important to know about. As important as monkeypox is, this is not spreading with the level of contagiousness that we saw with COVID, which is a different route of spread and a different illness altogether.

The key, though, with monkeypox is to also recognize that treatments and vaccines and tests, these are three critical aspects of the response, and what the administration has been doing has been mobilizing either the vaccine portion of the response, getting more than a million doses of vaccine committed and working on more on the way. Testing is now available in commercial labs as well as state public health labs, and we also have treatments that have been sent out to jurisdictions across the country.

But this is‑‑as much as has been done, there’s more that has to be done in all of these areas, and that’s why you’re seeing across the administration from the CDC, the FDA, to other parts of Health and Human Services, there’s a lot of work ongoing to speak to communities, especially those where the virus is spreading the fastest, which are among the community of men who have sex with men. That’s why many of our messages of vaccines and other testing have been targeted to that community.

So we’ll continue to work on this, and people should be aware of what this is and how it spreads so you also know how to keep yourself safe.

MS. WINFIELD CUNNINGHAM: I know my colleagues have been working on a story about what the CDC recommendations will look like and, as you note, that this is chiefly spreading among gay men, and I know the agency has been hesitant to recommend limiting sexual partners among this population for different reasons. In your opinion, would that be a helpful recommendation at this moment in time?

DR. MURTHY: Well, I think people should be aware of all the different pathways to which they can reduce risk, and if you are somebody who has, let’s say, a number of‑‑many sexual partners and may have many new sexual partners, you should know that that does increase your level of risk. And, certainly, you know, thinking about how to reduce your exposure during a time like this when the virus is spreading and we’re still working to make vaccines more accessible, that’s an important consideration that we want people to be aware of.

It’s also important that people know, again, the other aspects of how this is spread, through skin‑to‑skin contacts. We want people to know that vaccines are available now in many parts of the country. Hundreds of thousands of doses have been shipped out, with many more on the way, and it’s also important that people know testing is available too. So we want to make sure people have all the tools necessary so that they can protect themselves against this virus.

MS. WINFIELD CUNNINGHAM: And on that question of vaccines, of course, I know there’s a limited supply, and the administration has talked about splitting doses to try to get that supply to go further. But, in response, the manufacturer has threatened to cancel all future vaccine orders from the U.S. if that happens. So it seems to be quite a conflict here, but what’s your own take on that? Is it a good idea to try splitting vaccine doses?

DR. MURTHY: Well, this is a recommendation that was not made lightly by the FDA and by HHS more broadly. They carefully looked at this. They have some data from a prior study that indicates this strategy would, in fact, be effective, and it was on that basis that they made a recommendation to split the doses. And, specifically, so people know what we’re talking about is the notion of taking a single dose, splitting it into five, and administering it through a slightly different way, something called “intradermally,” which is into the layers of the skin, and this is a strategy that we believe will not only allow for more vaccine doses to be available but would also still have a robust response in terms of protecting people from monkeypox. So I think it is a reasonable strategy to pursue, especially under the circumstances.

Now, it doesn’t mean that the FDA is not going to continue studying this and looking at the data to make sure that people continue to have the protection they need from the vaccine, but this is a very reasonable strategy to take at this point in the monkeypox outbreak.

MS. WINFIELD CUNNINGHAM: Okay. Well, let’s go on to talking about youth mental health because so much to address there, and I know that you have given the assessment that what we’re currently in is something of a youth mental health pandemic, even as we come out of the COVID pandemic. Can you unpack for us some of the challenges you’re seeing at the moment when you look at what young Americans are facing in terms of their mental health?

DR. MURTHY: Yeah. I’m deeply worried, Paige, about the mental health of young people in America right now, but we are in the midst of a crisis, and we have been for many years, even though it hasn’t always made the headlines or been top of mine for people.

But what COVID did is it really pulled back the curtain on just how severe the mental health epidemic is in the United States, particularly among youth, and there are three numbers, Paige, that always stick in my head. One is the number 11. That’s the number of years it takes on average for a child to receive treatment after developing symptoms. The second number is 57. That’s the percentage increase in the suicide rate that we had among kids in the decade prior to the pandemic, and this got worse for a number of kids during the pandemic. And the other number that I remember is 42 percent. That’s the percentage of high school students‑‑sorry‑‑44 percent. That’s the percentage of high school students who say they feel persistently sad or hopeless.

And think about it. When you think of high school, it’s a time where your life is opening up for you, but nearly half of high school kids are feeling despondent about themselves and about the future. So these to me stick in my head because they give me a snapshot of where we are, and it’s echoed by the conversations that I have with young people all across the country who routinely tell me that they are struggling with anxiety or depression, many of whom also tell me that their experience on social media often leaves them feeling worse about themselves and about their friendships.

And, finally, I think it’s important to not lose sight of the experience of parents here as well, and I say this as a dad myself. I have two small kids who are four and five, and my interest in this topic of youth mental health is partly motivated by them. When I think about their future, I want to make sure that they are well, but when I talk to parents across the country, they are struggling right now. They are dealing with their own anxieties and worries, whether it’s about COVID, economic worries, et cetera, but they’re also worried about their kids. And I’ll tell you that one of the worst feelings that you can have as a parent is to see your kid struggling and to not be able to get them the help that they need, and that is a situation that many parents are in.

With all of that said, though, Paige, the good news is we can do something about this. It does not have to be this way, and we, in fact, know much of what we have to do. We know we’ve got to expand access to treatment, and we know how to do that. We know that we’ve got to increase the workforce of people who can provide and deliver mental health care, and we know we have got to invest in prevention and prevention programs especially that are school based that we know work. And, finally, we’ve got to shift our culture around mental health as well to one that is not so imposing of this terrible stigma on mental health; it doesn’t make people feel ashamed to ask for help. These are things we can do. We’ve already started to do. We’ve got to accelerate because there are millions of children who are struggling right now, and they can’t wait any longer.

MS. WINFIELD CUNNINGHAM: It strikes me that when we talk about youth mental health, you know, there’s perhaps two aspects to this, and as you note, very troubling statistics in terms of suicides going up, serious mental illnesses sort of thing. But then there’s another aspect to it that I’d like to ask you about, and that is, you know, we’ve removed stigma of talking about mental health and mental illnesses. But one thing that I often hear among my friends who are parents‑‑and I’m a parent myself, although my kids are not on social media yet, thankfully, but that in some cases, it’s almost become trendy for young people to say that they have a mental health condition, to, you know, say they have multiple personality disorder or something else. And, of course, we know that teenagers are highly susceptible to suggestion and social contagion.

So, without diminishing, of course, the seriousness of real cases of mental illness, I wonder if there is another component to this of perhaps social media contagion. Is that anything that you’ve thought about or heard discussed?

DR. MURTHY: Sure. It’s certainly something I have thought about and I’ve heard others ask about this and wonder, you know, is there‑‑is there a contagion here around people sort of wanting, in fact, to admit that they have a mental health problem, but while I do hear those concerns, my sense is that that is not where the vast majority of people are. I still find that there are young people all across our country who are ashamed to admit that they are struggling, and even if they do admit they’re struggling, they feel a sense of shame around actually asking for help and getting continued help.

There are so many children I encounter who are bullied that don’t feel comfortable admitting that because they feel that that says something about them, that they’re weak, that they’re not worthy, that they can’t defend themselves, and so there is still a heavy burden of stigma and shame that people carry around the country.

I think to guard against what you’re raising, we need to make sure we’re talking about mental health in the right way. We know that everyone struggles at some point in their life, whether they’re public about it or not, whether it’s short‑lived or long‑lived. Everyone struggles at some point. We have to be open and honest about that, but we also have to be clear that we don’t want people to struggle. It’s not a state that we desire for anyone, but what we do want to do is to meet those moments of struggle with compassion, with help, and with support. That’s how we’ll ultimately help this crisis get better.

MS. WINFIELD CUNNINGHAM: You’ve said that the challenges that today’s young people face are unprecedented and uniquely hard to navigate. What are some of those things?

DR. MURTHY: You know, I think, Paige, so often about like my own experience growing up, and, you know, this topic is personal to me because I also struggled with my mental health as a young person. I struggled with loneliness, you know, as a kid, and then later times as an adult, I struggled and wondered if I, you know, was experiencing depression at various points during my childhood, didn’t always know how to talk about it, rarely told anyone, including my parents about it, even though they loved me unconditionally and were very supportive. So it is‑‑it’s certainly a very personal sort of matter to me as well.

But when I think about the broader crisis, Paige, I think there are a couple of things that we have to keep in mind. One is that young people today are growing up in an environment where they are digital natives. They’re surrounded by social media.

Years ago, if I did something, you know, embarrassing in class, 25, 30 people knew about it. Now, you know, a child does something that may be embarrassing and hundreds or thousands of people may learn about it online. Bullying, which is not new‑‑it’s been happening for generations‑‑can now take place offline and online.

But you also look at the experience that social media creates for one’s own self‑esteem, and that’s also deeply concerning to me. And what social media does for many young people is it accelerates the culture of comparison that already exists in society. People have been comparing themselves to each other for, you know, hundreds, if not thousands of years. But social media makes that a moment‑to‑moment experience. It happens numerous times throughout the day, and all of this leads to an experience of technology that can be really hurtful to people in terms of their relationship and their sense of self at a time where kids are still developing in terms of their identity.

But, finally, Paige, let’s keep this in mind as well. It’s not only technology that’s profoundly different for kids. Young people growing up today are surrounded by crises that they really look at as existential, profound crises that affect how they think about whether the future is truly bright or not, that’s a crisis of climate change, of racism, of violence, and yes, you know, these challenges have existed for years. But they’re hearing about them. They’re seeing about them 24/7 now on the news, on social media, and through other venues. And so, when I meet young people today, I often ask them, “Do you think the future is brighter than the past?” Many of them wonder. They’re not quite sure because of these crises. These are all challenges, and the media environment, in particular, especially the social media environment, these are features of growing up today that are quite different from the experience that I and prior generations had.

That’s why I think we have to be mindful of how unique the challenges are that the current generation is facing and recognizing that the numbers are not lying to us. These suicide rates that we’re dealing with, the rates of hopelessness, the rates of loneliness, which are sky‑high among young adults and adolescents, we have to take this seriously because our kids are suffering. And they’re telling us that through their stories and through the numbers.

MS. WINFIELD CUNNINGHAM: I want to pull in an audience question here, which I think fits well with what we’re talking about, and this question is from Lisa in Maryland. And Lisa asks, I have followed the Surgeon General’s profound work on the loneliness epidemic in America. I worry greatly that our children who are exposed to virtual learning and play around every corner will and are suffering from, quote, “alone together syndrome.” Please discuss the relationship between screen time and mental health, as you see it.

So, Dr. Murthy, would you elaborate a little bit more on that? I know there are some positive things about technology but also a lot of negatives. So can you talk more about that?

DR. MURTHY: Well, Lisa, I love this question because this is a question that I grapple with as a parent too, right, and I think parents all across America are trying to figure out, which is how much screen time is okay for my kids, what kind of screen time is enough, and if I’m totally exhausted and I give my kid, you know, a device for a short period of time so I can just have a moment to relax, does that make me a bad parent? The answer to that last question, by the way, is no. It does not make you a bad parent. It’s something I find myself having to do from time to time, but this is a universal struggle for all of us as parents.

But there are a few things, I think, we can use as guidelines. Number one is just to recognize that screen time and I’ll say more broadly the use of technology, whether it’s utilizing social media, to watch videos online, to engage in other forms of entertainment or learning, technology is not bad in and of itself. It’s a took that can be used to help or to hurt ourselves, and there are some cases where kids can find ways to use tech that are helpful. Some kids have used technology to learn, to connect with other friends, to find communities and moments where they have felt like they didn’t belong or there is no one else who share their interests or their identity, and that is very, very powerful.

And as parents, what we have to be aware of are a couple things. One is how much time are our kids actually spending on social media, and what is their actual experience with social media and technology more broadly? Are they getting bullied online? Is their experience leading them to feel worse about themselves and their friendships? We can only understand this if we actually start a conversation with our kids on their use of technology, screen time, and social media, in particular.

The second thing, though, is to look at what the impact of their screen time may have on the rest of their life. Is it crowding out their time with family and friends? Is it reducing the amount of time that they actually spend going out and playing? Is it compromising their ability to do their work for school? If the answer is yes in any of those categories, that may tell us that we need to change something about how much our kids are using technology.

And, finally, keep this in mind. All of us, both our kids and ourselves, we need sacred spaces in our life that are free of technology. You might decide that that’s the dinner table and that you’re going to have meals as places where there is no tech, no phones. It’s just all of you talking. There might be other times right before your child goes to bed or when they first get up in the morning that they’re free from technology, but we all need these.

This last piece I’ll mention is probably the toughest one for many of us as parents, myself included, which is that we also have to be good role models here, and the truth is that we all struggle with our own use of technology, right? I’ve had conversations with friends where I’ve been catching up with them, and somehow, I find that my hand is reaching into my pocket and taking out my phone, and I’m refreshing my In Box or checking the scores on or doing something else that I don’t really need to be doing online, and then I’ll realize, oh, my gosh, what am I doing? I don’t need to be doing this. We do this unconsciously. It doesn’t make us bad people. These devices are often designed in ways to pull us in, but I think when kids, in particular, we have to be conscious about modeling the right behavior for them. It doesn’t mean we have to be perfect, but it means that if we’re going to draw boundaries around‑‑ask our kids to draw boundaries around where they use technology, then we’ve got to do the same. If we’re going to prioritize our time with people and make sure we’re fully present and not distracted by our phones and we want our kids to do that, we’ve got to do that as well.

So all this to say that this is a challenge how to manage technology with your kids, and I’m certainly right there with you as a parent. But these are a few tips that may help you along that journey.

MS. WINFIELD CUNNINGHAM: Well, on that note, let’s imagine for one moment that you wake up tomorrow, someone hands you a magic wand, and you are able to eliminate social media for all kids under, say, age 18. Would you do it?

DR. MURTHY: Well, that’s a really good question. I certainly think that kids start using social media at way too young an age right now. Even though the legal limit is 13 on many of these platforms, I routinely have parents who talk to me about their kids who are 10, 11, and 12 who are utilizing multiple platforms and have often multiple counts on individual platforms.

So I certainly think the age needs to be higher. If it was left up to me, I think that I certainly wouldn’t want kids using social media in middle school, and I’d also be quite concerned about them using it in high school, certainly not early in high school. So I do think the age at which kids use it should be higher.

But here’s the other thing I’d say for parents. If you’re interested in your kid waiting to be older until they use social media, I recognize that’s not always easy because if they’re the only one who’s not on social media and all of their friends are, that can be really difficult, right? It can make them feel like they’re left out, they’re not part of the conversations that everyone else is part of, which is why these kind of movements that I’m starting to see among parent groups, to make a pact with one another, that among a group of parents, that they’re going to make sure that none of their kids actually use social media until an older age. Maybe that’s 15. Maybe it’s 16. Maybe it’s 17. These pacts are actually much more effective than an individual parent trying to make the decision because then at least your child looks around and they have peers who are similarly not using social media at that age.

So bottom line is I certainly would be in favor of our kids waiting longer until they use social media. I think it starts way too early right now, and that should change.

MS. WINFIELD CUNNINGHAM: I like that advice. Us parents need to band together.

Let’s talk about schools for a moment because students are preparing to return to school and to college campuses. For some college students, this is their third year of college life with pandemic‑related restrictions, although certainly less than in the last two years. What’s your advice to these young people as they start the new school year?

DR. MURTHY: Well, let me just say young people today, whether you’re in college or whether you’re in grade school, they’ve just been through so much during this pandemic. Their life has been turned upside‑down. They haven’t been able to interact and spend in‑person time with their classmates nearly as much as pre‑pandemic, and in their learning as well, both their academic learning as well as their social learning has been just profoundly interrupted. And I think we will be seeing the impacts of this for some time, which is why it’s so important again for us to focus on our kids, to think about how to make their educational experience more robust, to get them back to school safely, but also to recognize the mental health impact of the pandemic from the last few years.

For young people who are going back to college, here are a few things that I would say. Number one is just to recognize that the last few years has taken a toll on all of us, and if you feel like you’re struggling, like you’re having some anxiety around or reengaging with other people socially or you’re worried about being behind academically, just please know that you’re not alone. There’s nothing to be ashamed about, about struggling in a moment especially like this.

The second thing to remember is that it’s really important to ask for help when you need it. Help is there for a reason. It’s there because it can help you over a difficult moment, over a hump, and all of us have those difficult moments.

You know, when I first got to college, I struggled mightily, let me tell you. I just did not want to be there. I didn’t know how to reengage and build a community. I really, really struggled, and the one regret I have is I never asked for help. So that’s something I don’t want people to feel any compunction or shame over, and there is help available. Many universities have counselors that are set up to provide care especially for moments like this.

We also, though, want everyone to know we have now the 988 number available. Everyone is familiar with 911. 988 is a number you can dial, simple, easy to remember, for mental health emergencies, and you’ll find a trained counselor who’s there and willing to help you and to support you.

And, finally, one last thing that’s important, I think, for young people to know as they return to college, which is don’t forget how incredibly powerful your relationships are to help buffer the stresses and mental health struggles that you may experience in the months ahead.

One of the things that I learned over the years as a doctor, as a surgeon general in the past, but also just as a human being, as somebody who struggled with loneliness myself, was that our relationships are healing. They’re natural buffers to stress, and so it’s in moments like this when we’re feeling stress, when we’re going through transitions that it’s especially important to reach out to the people that we love, the people who care for us.

That might be our friends on campus. It might also be our parents and our friends from back home. I know things get busy when you go back to school, but stay in touch with the people you love. That could just be five minutes a day, you know, calling home or calling a friend and saying, “Hey, I’m just thinking about you. I want to see how you are.” But those connections, those are like lifelines, and they help sustain us during the difficult moments we have in our journeys.

MS. WINFIELD CUNNINGHAM: Well, we’re running short on time, but I do want to fit in a quick question on the 988 number that you referenced, and we know this new mental health crisis hotline was launched earlier this summer. But we’ve heard reports that these call centers may be understaffed. Is that something that you’re watching? Are you concerned about that, especially the people who are in serious distress are perhaps calling and maybe there’s nobody to pick up the phone?

DR. MURTHY: Well, Paige, I’m glad you asked because, you know, we certainly are following very closely what’s happening with the 988 service. The good news is it’s being utilized more. The number of calls has increased. You can text as well to 988, and people are utilizing that function. And we are seeing that, yes, in some parts of the country, there are longer wait times than we want, and we are certainly working on this as well.

In fact, the administration has pumped in millions of dollars, hundreds of millions of dollars, in fact, into strengthening the 988 system because it has been underfunded for years, and this is a place also where localities, states and local communities, also have an important responsibility here to help build up that local system so there is more capacity, so we reduce wait times.

And while, yes, it took about five decades for the 911 system to really build up and get to the capacity it has today, we can’t wait that long, you know, for 988, and that’s why we’re pulling out the stops, getting more funding in there, and working with states and localities to make sure we increase capacity.

But just, you know, I want to say, though, just more broadly, as we think about mental health, in fact, I’ll leave you with one sort of key message is this. It’s that this is a make‑or‑break moment for our youth mental health in our country. We cannot afford to continue down the path that we’re on right now. Too many of our kids are suffering. Too many of our children are losing their lives. Too many parents are suffering as well as they watch their kids go through these incredibly difficult struggles.

But the good news is we know how to turn this around, and now is the time for us to summon the will and the determination to do so. I want to be able to look back in a few years as I think about my own children and many children I’ve met across the country and know that we seized this moment to make the investments that we needed to make, to have the conversations in our communities that we needed to have, to step up and talk to our children and open up a conversation on mental health, recognizing that conversation we have with them as a parent‑‑that conversation, they might tell them it’s okay to talk about these struggles. That could be a conversation that makes a huge difference in their life and that might ultimately save their life.

But, as much as the policy changes are important to expand access to treatment and invest in prevention, we won’t solve this problem if we also don’t build a culture in America that supports youth mental health, and that has to be a culture that’s centered around compassion, around kindness, and around belonging. There are too many children who are walking around today who feel that they don’t belong, who feel that they don’t matter, who feel nobody cares about them in the world, and even though whether‑‑even if you don’t have a policy lever, even if you’re not a legislator, even if you’re not a doctor or a mental health expert, you can make a difference in someone’s life by reaching out to them, by checking on them, by letting them know that you care.

And so that is a step all of us can take today, and I would encourage you to do so because together I do believe we can solve this young mental health crisis, and I will certainly use every day that I have as Surgeon General and beyond that to make sure that we are advancing this cause around youth mental health and getting our kids the help that they need.

MS. WINFIELD CUNNINGHAM: Well, we’ll have to leave it there, but thank you so much for joining us today, Vivek Murthy, and a wonderful conversation, as always, with you.

DR. MURTHY: Thanks so much, Paige. It’s always good to talk to you as well. Take care.

MS. WINFIELD CUNNINGHAM: Please come back and join us again sometime.

And thanks to all of our viewers for watching this afternoon. To check out what interviews we have coming up, please head to to register and find out more about our upcoming programs.

I’m Paige Winfield Cunningham, and thanks again for joining us today.

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