Adolescent and Young Adult Mental Health is Better in States that Mandate More School Mental Health Policies

Stephanie Spera and Shannon Monnat
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Key findings:

  • States with more mandated mental health policies in public schools have significantly lower adolescent suicide and substance abuse rates.
  • States that mandate school-based mental health centers, professional development in suicide prevention, and social-emotional curriculums have significantly lower adolescent suicide and substance abuse rates.
  • Mandated anti-bullying and family engagement policies are also associated with significantly lower adolescent suicide rates.

In the United States, one in five adolescents ages 15 to 24 experience serious mental health disorders, and one in eight have been diagnosed with depression.1 Substance abuse is the leading cause of death among youth, followed by suicide.2 Nearly two-fifths of students with a diagnosed mental illness drop out of school each year.1 These outcomes have widespread societal implications, including lower educational attainment, increased risk of poverty, higher health care costs and incarceration rates, and pressure on already-strained health care systems.

According to the National Alliance on Mental Illness, of the nearly 50 percent of youth in the U.S. who do not receive the mental health services they need, 29 percent attribute it to being denied coverage by their insurance.1 Other barriers include affordability, lack of local resources, lack of mental health professionals trained to provide appropriate care, and confidentiality concerns among minors in unsafe home situations seeking care. This makes schools an important venue for the provision of mental health services. After all, children spend more of their awake hours in school than in any other setting.

The purpose of this study was to determine whether adolescent and young adult mental health outcomes are better in states that mandate the implementation of mental health services in public schools, and if so, which specific policies are associated with better adolescent and young adult outcomes.

How Does Adolescent and Young Adult Mental Well-being Vary Across the U.S.?
Figure 1 shows how mental well-being among individuals ages 15 to 24 varies across the U.S. This well-being index includes state-level rates for suicide, substance abuse, and major depressive disorder (MDD) among adolescents ages 15 to 24 between from 2013-2017. The best performing states are Georgia, Alabama, and Pennsylvania. The worst performing states are Alaska, Wyoming, and Colorado.

Figure 1: Adolescent and Young Adult Wellbeing Varies across the U.S.
Figure 1: Adolescent and Young Adult Wellbeing Varies across the U.S.
Data Source: U.S. Centers for Disease Control and Prevention (2013-2017)
Figure 2: Variation in the Number of Mental Health Policies Mandated by State
Figure 2: Variation in the Number of Mental Health Policies Mandated by State
Data Source: National Association of State Boards of Education (2019)

How do School-Mandated Mental Health Policies Vary across States?
Figure 2 shows how state-mandated school mental health policies vary across the U.S. We examined ten specific policies that were in place as of 2018: school-based mental health centers; family engagement programs; primary and secondary school counseling; professional development in suicide prevention, trauma, and mental health; early identification and referral services for mental health needs; anti-bullying policies; tiered behavioral interventions; and the use of a social-emotional curriculum.4 The states with the most policies were Georgia, Utah, and Illinois. The states with the fewest policies were Arizona, South Dakota, and Alaska.

What is the Relationship between State-Mandated School Mental Health Policies and Adolescent and Young Adult Mental Well-being?
Figure 3 overlays state school mental health policies onto the adolescent and young adult well-being scores. States that perform poorly on both measures (few policies, low well-being) include Idaho, Montana, Wyoming, Colorado, Alaska, and South Dakota. States that perform best on both measures (many policies, high well-being) include Alabama, Georgia, Tennessee, and Missouri. Two states – Illinois and Virginia – perform well on mandated policies but have low well-being scores. Studying these states may help to identify state-mandated programs that are ineffective or not adequately implemented and provide suggestions for improvement. Finally, there are five states that perform well on adolescent and young adult mental well-being despite having few state-mandated mental health policies: New Mexico, North Dakota, Nebraska, Kentucky, and Florida. It may be that schools in these states have implemented some of these mental health policies, even without a state mandate. Alternatively, schools in these states may have other policies and programs that are beneficial to adolescent mental health. Future research in these states should examine why adolescent mental health is better in these places, despite the lack of state-mandated school mental health policies.

Figure 3: Relationship between Youth Wellbeing and Mandated Mental Health Policies
Figure 3: Relationship between Youth Wellbeing and Mandated Mental Health Policies
Data Source: U.S. Centers for Disease Control and Prevention (2013-2017); National Association of State Boards of Education (2019)

Which Specific State Policies Matter for Adolescent and Young Adult Mental Health?
States that mandate more mental health policies in public schools overall have significantly lower adolescent and young adult suicide and substance abuse rates. However, a handful of specific policies appear to be driving these trends. State-mandated school-based mental health centers, social emotional curricula, and school professional development in suicide prevention are all associated with significantly lower adolescent and young adult suicide and substance abuse rates (p<0.10) (see Figure 4). States with mandated school family engagement programs and anti-bulling programs also have significantly lower adolescent and young adult suicide rates than their peer states without these mandated programs (see Figure 5).

Figure 4. Adolescent and Young Adult Suicide Rates are Lower in States with Specific Mandated School Mental Health Policies
Figure 4. Adolescent and Young Adult Suicide Rates are Lower in States with Specific Mandated School Mental Health Policies
Data Sources: U.S. Centers for Disease Control and Prevention (2013-2017)
Note: Analyses control for state poverty rate, educational attainment, percent white, and percent living in an urban area. Differences are statistically significant (p<0.10) for school-based mental health centers, professional development in suicide prevention, social emotional curricula, family engagement programs, and anti-bullying programs.
Figure 5. Adolescent and Young Adult Substance Abuse Rates are Lower in States with Specific Mandated School Mental Health Policies
Figure 5. Adolescent and Young Adult Substance Abuse Rates are Lower in States with Specific Mandated School Mental Health Policies
Data Sources: U.S. Centers for Disease Control and Prevention (2013-2017)
Note: Analyses control for state poverty rate, educational attainment, percent white, and percent living in an urban area. Differences are statistically significant (p<0.05) for school-based mental health centers, professional development in suicide prevention, and social emotional curricula.

What Does This Mean for Policy?
Children spend more of their awake hours in school than in any other setting. This makes schools an essential setting for promoting adolescent mental health. Ultimately, the quality and availability of mental health programs both in and out of schools is essential for youth mental wellbeing. Providing mental health services in public schools is an important step toward ensuring that this vulnerable population is reached during a critical stage of development.

Data
Data on school-based mental health policies came from the National Association of School Boards of Education (NASBE), which identified ten state-level mental health policies and reported whether states mandate, recommend, or do not require implementation. Data on mental health outcomes for individuals ages 15-24 came from U.S. Centers for Disease Control and Prevention data from 2013-2017. 5 Analyses controlled for several state-level variables (poverty rate, percent of the population age 25+ with a bachelor’s degree or more, percent living in urban areas, and percent white).6

Endnotes

  1. National Alliance on Mental Illness (2018). Mental Health by the Numbers. Retrieved from: https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
  2. Centers for Disease Control and Prevention (2019). CDC Wonder. Retrieved from: http://wonder.cdc.gov
  3. WHO (2014). “Mental health: a state of well-being.” Website. Accessed Feb. 21, 2019. https://www.who.int/features/factfiles/mental_health/en/
  4. National Association of State Boards of Education (2019). State Health Policy Database. Retrieved from: http://statepolicies.nasbe.org/health
  5. Centers for Disease Control and Prevention (2017). CDC Wonder. Retrieved from: http://wonder.cdc.gov
  6. United States Census (2018). Quick Facts (States). Retrieved from: http://www.census.gov/quickfacts/fact/table/US/PST045218

Acknowledgements
The authors thank Alexandra Punch for her feedback on previous versions of this brief.

About the Author
Stephanie Spera is a Graduate Fellow Alumna with the Lerner Center for Public Health Promotion and is a graduate of the Masters of Public Administration and International Relations program in the Maxwell School of Citizenship of Public Affairs at Syracuse University (smspera@syr.edu).  Shannon Monnat is the Lerner Chair for Public Health Promotion, Associate Professor of Sociology, and Co-Director of the Policy, Place, and Population Health Lab in the Maxwell School at Syracuse University. (smmonnat@syr.edu).