The Declining Mental Health of Millennials: Is Depression the New Normal?

It is a familiar sight to see a group of teens bent over phones or gaming devices, checking in, tagging each other, posting pictures and commenting, and waiting impatiently for all their cyber friends to ‘like’ their work, or re-tweet their location, or post an accompanying video.

Teenagers today are some of the most enthusiastic users of social media sites like Facebook, and as an age group their Internet use is near universal—a full 95 percent of teens are now online.

This trend has provoked anxiety, raising a range of concerns, from sex predators to promoting a sedentary lifestyle. Less noticed has been the effects of heavy media use on mental health.

But just as teen internet use has risen in recent years, teen depression and psychopathology has risen five-fold since the early part of the 20th century.

This relationship has recently been of concern to psychologists and psychiatric epidemiologists. Dr. Jean Twenge, a professor of psychology at San Diego State University, has been one of the most outspoken in her field on linking these two trends.

As she says in her recent book, The Narcissism Epidemic: Living in the Age of Entitlement, rising rates of depression are partly the result of a culture that promotes the narcissism pulsing through social media usage.

Americans—especially teenagers—now rely so much on external and immediate gratification, social status and image, and the superficial gain they get from social media that they are forgoing values that contribute to a sound internal life—like strong communities built more on shared goals than on individual success, and the pursuit of activities that provide internal satisfaction, Dr. Twenge says.

Eight percent of 12-17 year-olds in the United States experienced at least one major depressive disorder in the past year. While some have argued that this is simply the result of greater recognition and diagnosis of the illness than in the past, Dr. Twenge and others say it owes to the rise in materialism and narcissism in what she has termed “Generation Me.”

Teens who have grown up in today’s social media environment know no other reality than the one in which anyone in their ‘network’ has a lens into their life and the chance to judge every act of it. 80 percent of teens active online participate in social networking sites, according to a Pew Research Center study from 2011. For this reason, they get the message that “extrinsic” values like how people perceive—virtually or in reality—is of greater importance than “intrinsic” values like their personal goals and the development of a unique self.

Dr. Twenge has elaborated on this in her blog at Psychology Today, saying that culturally, we have lost rites of passage that demarcate adulthood, emphasize individual fame for fame’s sake as opposed to real accomplishment, over-indulge our children from early developmental stages, and support and even laud self-promotion at the expense of others.

Additionally, Dr. Twenge and colleagues have indicated in their research that this generation of teens and young adults are less civic-minded, care less about social and political issues, are less interested in working towards solutions to environmental concerns, and have less empathy or interest in social justice.

Dr. Twenge’s theory is backed up by parallel psychological research, which has suggested that feeling one’s fate is shaped by external forces rather than one’s own efforts—what is known as ‘locus of control’—is more likely to cause depression and anxiety than feeling an internal drive and control over one’s future.

“Externality,” a measure of one’s perception of the influence of external forces over one’s life versus the influence of internal motivation and action, can be used to determine to what extent someone takes responsibility for their own actions and how accurately one identifies how their own behavior leads to certain outcomes.

High externality also indicates little conviction in one’s ability to behave in a specific way, something known as self-efficacy.

This could mean that those who focus on more materialistic and superficial lavishing of attention are in part doing so because they lack the self-esteem and efficacy to think that they can achieve something more significant and tangible.

This is in line with Dr. Twenge’s hypotheses. She argues that narcissism and the rising but inaccurate levels of self-evaluation can ultimately lead to deeper disappointment in one’s self and depression from alienation caused by increased self-involvement.

There has been a marked increase since 1960 in the number of people who feel this way—that external elements control their lives and future, according to a 2004 epidemiological study that Dr. Twenge and her colleagues conducted.

These feelings are associated not only with depression but also ineffective stress management, feelings of helplessness, and decreased self-control. They are also associated with higher levels of cynicism and self-serving bias.

Two studies of Dr. Twenge’s are illustrative of the fact that this rise in teen depression is indeed both significant and new.

One is a recent meta-analysis she and other researchers conducted, which explored self-reported feelings of depression and sadness in college and high school students from the 1930s to the present.

Even though self-reporting is often questioned, studies have shown that self-reported feelings of depression and compromised mental health tend to be accurate in children and adolescents—perhaps even more so than in adults— and even complement diagnostic criterion for mental illness.

Five times as many teens and young adults now score above cutoffs meeting psychopathology criteria as they did in the earlier through mid 20th century, according to Dr. Twenge’s analysis.

Population level results indicate the underlying shift has societal causes and is not merely the result of genetic predisposition to mental illness or an individual’s circumstances.

The second study took a closer look at teen depression in the past twenty years. Dr. Twenge noted that while major depressive disorder and suicide appear to have slightly receded since the early 1990s—likely a result of an increase in anti-depressant medications—current prevalence remains higher today than before the 1990s and psychosomatic complaints have continued to increase, such as feelings of being overwhelmed and anxious.

Other research has found a relationship between external motivators and neurological patterns.

One study revealed that teens suffering from depression had diminished responses to rewarding stimuli, such as genuine assurance of a job well done, a friendly affirmation from a friend, or small monetary compensations for the actual completion of tasks. Follow-up research showed that 20 year-olds who experienced depression as teens still have muted reward responses, indicating that help needs to be offered as early as possible.

Teen depression of course can have significant consequences, such as the increased likelihood of substance use and abuse, social withdrawal, strained relationships with family and friends, and in the worst cases, suicide.

To be sure, Twenge’s findings are controversial, and some continue to insist that there is no increase in depression or psychopathology in teens. But, in the opinion of Dr. Twenge, to prevent further increases in these depression statistics, teens need to move from constant self-promotion to feeling gratification from real achievement, and to reward feelings deriving from accomplishment as opposed to blindly seeking praise and compliment.

In today’s ubiquitous social media environment, that may be difficult to do, and the results slow to come.

Originally Published at The 2×2 Project November 7, 2012

The Top Five Myths About the Affordable Care Act

Originally published at The 2×2 Project, October 2012

It’s almost impossible not to be confused by the Affordable Care Act, even though it’s one of the most significant laws to be passed in the last fifty years.

If the content slicing and dicing wasn’t enough, there were the disingenuous characterizations of the law from its opponents, and the flagrant mistakes that some of our leading news organizations made in reporting the Supreme Court’s decision to uphold the law in June. A few misunderstandings that are particularly egregious keep arising in public health discussions about the ACA.

Let’s clear them up, shall we?

Myth #1: The ACA is a Sign of Impending Socialism

It’s true that the ACA is the biggest social welfare legislation since Medicare. It’s also true that socialized medicine has existed here for decades, with little opposition and even much support.

The crux of the socialist argument seems to hover around the issue of government control over an industry that would supposedly better function under a free market framework and limited restrictions. But it should be obvious that this is the framework we’ve operated under for decades, and that is has left millions without care. And true socialized medicine presumes that Americans are contributing to a government-administered healthcare delivery system. But that’s just not the case with the ACA.

Myth #2: The Government is Taxing You for Healthcare

Taxes have long been the poster child for government control. But the way this supposed “taxing” functions in the context of the ACA is tricky. Normally taxes are levied against all citizens, gleaned from earnings or tagged on to spending—like an income tax or sales tax you learned about in Econ 101.

While some justices used Congress’s taxing authority to render the law constitutional, the penalty fee—the “tax” in question—only applies to those who choose not to buy insurance, so outside of legal circles, calling it a “tax” seems a bit disingenuous to the true character if the penalty.

What’s more, whereas taxes are intended to pay for public goods that the government provides to everyone, the penalty under the individual mandate is intended to charge those individuals who don’t choose to buy insurance for the cost that society incurs as a result of their decisions—emergency room fees should they get hurt, for example.

Myth #3: It’s Going to Plunge Us Into More Debt and Cost Us Trillions

The claim that the entire bill will increase the deficit isn’t quite accurate. In fact, the Congressional Budget Office projects the ACA will save us money and cut the deficit by about a trillion dollars during its second decade of implementation.

In fact, as explained above, the ACA prevents average Americans from paying the healthcare costs of others: As is, those of us with insurance pay for care for the uninsured when they show up to the ER at our local hospitals requiring care—premiums go up, procedures are more costly, and physicians have to charge more. The ACA helps end that by requiring people buy insurance—or pay that penalty.

Myth #4: The Government is Eliminating My Choices

Opponents argue that under the ACA, the government will decide who lives and dies, and where Americans need to buy insurance. In fact, choice is built into the ACA with health insurance exchanges. These allow people to choose the providers and plans they want, something it turns out most people support and many states have begun to implement. By giving you the ability to select your physician, the ACA reallocates to you the power previously held by insurance companies to tell you which doctors you could see.

Additionally, with the expansion—and elimination in some cases— of spending limits, you’re no longer forced to choose what essential medical tests or care to pursue based on arbitrarily low spending limits imposed by insurers. Previously, these annual limits were in the tens of thousands. Now, the annual limit can be no less than $2 million, and lifetime limits are illegal for nearly all plans. This means you’re far less likely to run out of coverage if you develop a costly illness. It also means you don’t have to limit options if you and your physician choose additional forms of care or treatment that may improve your condition.

Myth #5: Obama is Raiding Medicare

In the last decade, payments from Medicare to private plans have increased dramatically—in fact, figures show that Medicare actually overpaid by 14-20 percent, and the costs of this overpayment fell on our seniors via increased premiums. Worse, there’s no evidence that these higher payouts to insurance companies improved care, probably because insurance companies—not seniors or providers—controlled allocation of that money.

The ACA has made Medicare more efficient by cutting some of that overpayment. This saves Medicare millions, but more importantly, improves care for beneficiaries in ways that a raid would not: Cuts will help close the prescription drug gap, reducing seniors’ costs. It also gives them preventive care free of any co-pays. Because of these changes, increases in payments to hospitals and providers is predicted to slow, hopefully slowing the growth of premiums and copayments that seniors have to pay. Most importantly, saving Medicare money ensures its longevity long into the future.

Returning to the Blogosphere

Hello readers! It’s been a while – three and a half years, it seems. In that span of time, I’ve moved on from my role at Stanford, worked for a couple years in HIV research management and capacity building at UCSF and in Kampala, Uganda, and then as an implementation director for a 13-country HIV surveillance project funded by the CDC. After a few years splitting time between SF, NYC, and East and Southern Africa, I’m back at UCSF at the AIDS Research Institute, where I’m directing strategic communications and partnerships for the HIV enterprise at UCSF and our affiliated institutions.

It’s been a good run – but I’m also working on documenting articles I’ve written across media sources in the last few years. Some I’e shared the beginnings of, and others I’ve yet to really promote. So in order to keep everything somewhat centralized, I’ll be publishing those pieces freshly on the blog over the next couple weeks. In order to prevent you all from being inundated by email updates, I’ll initially publish them privately and then make them public – so be sure to check back in the next few weeks. And more original content will be coming again soon. I hope you’ll all keep enjoying the reads, and as always, I welcome your feedback.