Disrupted transitions

Entering the labour force from education marks one of the most significant transitions that takes place during a young person’s life, and this transition has become more complex in recent decades (Arnett Reference Arnett2000). During recent periods of economic recession, young people have much higher rates of unemployment (Bell and Blanchflower, Reference Bell and Blanchflower2011). The effects of periods of unemployment in youth have disproportionate and long-lasting effects on income and health beyond the period of economic recession as well as risks of concurrent and future insecure employment (Kahn, Reference Kahn2010; Cockx, Reference Cockx2016). Currently, a majority of young people (51%) between the ages 15–24 within the labour force (i.e. those available for work and not in education) are unemployed in Ireland (CSO, 2020). This represents almost 2.5 times the unemployment rate in adults and almost 2.5 times the peak unemployment rate in the same age reference category during the most recent economic recession (CSO, 2020). Analysis from the Economic and Social Research Institute predicts Ireland to experience a severe economic recession in the coming year (McQuinn et al. Reference McQuinn, O’ Toole, Allen-Coghlan and Coffey2020). In periods of recession, more highly educated youths have moderate long-lasting reductions in income for at least a period of 10 years, whilst losses are restored for lower educated youths more quickly (Cockx, Reference Cockx2016). Graduating from university during a recession has particular long-lasting and large impacts on earning potential (Kahn, Reference Kahn2010). During periods of recession, high educational level may not be a protective for young people’s mental health and may be a risk factor for poor mental health outcomes specifically when youth are engaged in insecure working arrangements or are unemployed. One recent study from Italy suggests that young highly educated women are at most increased risk of poorer mental health due to economic insecurity during periods of recession (Fiori et al. Reference Fiori, Rinesi, Spizzichino and Di Giorgio2016). Economic inactivity (i.e. not being in employment education or training) increases risks of suicidal thoughts and behaviours in young people beyond the effects of prior mental health vulnerability (Power et al. Reference Power, Clarke, Kelleher, Coughlan, Lynch and Connor2015). The mental health effects of unemployment in youth persist to midlife with those exposed to unemployment in youth having increased rates of common mental health symptoms like anxiety and depression on long-term follow-up (Virtanen et al. Reference Virtanen, Hammarström and Janlert2016).

Youth is also a point of cognitive, social and emotional transitions. Young people, particularly adolescents, have different cognitive approaches to making social decisions in comparison to adults (Blakemore & Choudhury, Reference Blakemore and Choudhury2006). Social connectedness and social identity have more prominence in youth and high rates of reported loneliness are reported in young people (Matthews et al. Reference Matthews, Danese, Caspi, Fisher, Goldman-Mellor and Kepa2019). Loneliness in young adults is associated with a number of negative health behaviours and indicators of poor mental health independent of other risk factors (Matthews et al. Reference Matthews, Danese, Caspi, Fisher, Goldman-Mellor and Kepa2019). In this context, young people may be more affected by the negative psychosocial consequences of ‘lockdown’ and social distancing than adults. Young people may also find it more difficult to cope with the current crisis as their coping skills are not equivalent to that of a fully-fledged adult as coping is a developmentally acquired skill (Fields & Prinz, Reference Fields and Prinz1997).

An acute on chronic public health crisis

Investing in early intervention in mental health has potential to reduce population level chronic disease morbidity. Early intervention programmes in psychosis show reductions in mortality and improvements in significant and pragmatic indicators of psychosocial functioning (McGorry, Reference McGorry2015; Pollard et al. Reference Pollard, Ferrara and Lin2020). Despite these innovations, new service models for psychosis are only selectively available to a small proportion of the population depending on geographical area. Early intervention for other specific serious mental disorders is in earlier phases of development (Chanen et al. Reference Chanen, Sharp and Hoffman2017; Vieta et al. Reference Vieta, Salagre, Grande, Carvalho, Fernandes and Berk2018). Early intervention services for adolescents and young people at primary care level (such as Jigsaw in Ireland and Headspace in Australia) are also being rolled out in line with international best practice (Hetrick et al. Reference Hetrick, Bailey, Smith, Malla, Mathias and Singh2017; McGorry et al. Reference McGorry, Bates and Birchwood2013). Despite new and evolving evidence in youth mental health, resource allocation for young people’s mental health remains insufficient. A recent survey of Child and Adolescent Mental Health Services consultants showed high levels of burnout (McNicholas et al. Reference McNicholas, Sharma, Oconnor and Barrett2020). Known precipitants to this are insufficient staffing, incomplete coverage and long waiting lists (McNicholas, Reference McNicholas2018). Incomplete coverage is a specific issue for primary care services such as Jigsaw. In this current pandemic crisis, educational, health and social care services have had to curtail the level of service offered to young people and their families. This COVID-19 pandemic presents an ‘acute on chronic crisis’ for services for young people where demand on services is likely to increase but supply of services is further constrained and inconsistent.

Ensuring the material needs and physical health of communities is the immediate priority in any public health emergency, conflict situation or natural disaster. The mental health needs of young people can be overlooked in a public health crisis (Danese et al. Reference Danese, Smith, Chitsabesan and Dubicka2020). There are worries for a ‘final wave’ of the effects of the virus in terms of the negative mental health and social consequences borne by young people whom have little control over their environmental circumstances. There are many potential adverse consequences for young people who have lost access to structured school and college and work environments. There are broad physical and mental health implications for all young people. Negative physical health consequences such as poorer sleep, poorer diet, increased sedentary behaviour and loss of cardiometabolic fitness are more common and these are likely to relate to poorer mental health during COVID (Wang et al. Reference Wang, Zhang, Zhao, Zhang and Jiang2020). However, the mental health consequences may be more significant and long lasting. Early survey reports from China highlight the negative mental health consequences of exposure to the pandemic in young people, reporting increased rates of anxiety, poorer sleep and irritability (Jiao et al. Reference Jiao, Wang, Liu, Fang, Jiao, Pettoello-Mantovani and Somekh2020).

The mental health impacts of any disaster are unevenly distributed. Those with lower social capital and those in vulnerable positions are most at risk. One example is young people in temporary accommodation or direct provision. These groups of individuals and their family members face an already higher burden of mental health risk as well as direct increased risks of COVID infection due to unsuitable accommodation (Rosenthal et al. Reference Rosenthal, Ucci, Heys, Hayward and Lakhanpaul2020). Reports of increased rates of exposure to domestic violence are concern for vulnerable young people also (Gunnell et al. Reference Gunnell, Appleby, Arensman, Hawton, John and Kapur2020; Chandan et al. Reference Chandan, Taylor, Bradbury-Jones, Nirantharakumar, Kane and Bandyopadhyay2020). Public institutions buffer the effect, length and severity of childhood adversity and trauma. This is through a multitude of mechanisms such as providing free school meals, providing a physically safe environment for part of the day through school participation, support through voluntary services and mandated child welfare/protection reporting. Access to a supportive adult is a protective factor for a young person’s mental health and some will have lost this protective factor during this crisis through loss of supports outside the family home (Dooley et al. Reference Dooley, Fitzgerald and Giollabhui2015). In this context, prioritizing equity in reopening services is important. Services, such as school placements, should be provided for the most vulnerable young people first.

Early research efforts from the YoungMinds organisation in the UK highlight the predominance of concerns around the psychological and social consequences of the pandemic response, particularly on young people (YoungMinds, 2020; Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020). In this recent UK survey, 83% of young people with mental health needs believed that COVID-19 had an adverse impact on their mental health, with specific concerns around loss of social contact and structured activities. In this survey, young people with varying types of mental health conditions, such as obsessive compulsive disorder, anxiety disorders and anorexia nervosa specifically noted that the crisis had worsened their pre-existing conditions. One in four young people whom had been accessing mental health supports prior to the pandemic reported that they no longer had access because of the crisis (YoungMinds, 2020).

Research priorities

The effects of mandated self-isolation in terms of morbidity and mortality of young people most at risk of negative health consequences of the pandemic should be a primary focus of research. Existing cohort studies should be leveraged to investigate the changes in health status in youth during the time of COVID (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020). The World Health Organisation recommends that the mental health needs of young people should be included within coordinated statutory disaster response mechanisms through at minimum the dissemination of psychoeducational and self-help resources for young people to promote universal advice on maintaining positive health behaviours (World Health Organisation, 2020). Simple guidance on addressing young people’s concerns with age appropriate emotion-focused language is highly likely to be significantly effective (Dalton et al. Reference Dalton, Rapa and Stein2020). Guidance for caregivers on the positive impact of maintaining their own well-being is also important. Young people’s mental health is strongly influenced by the well-being of their caregivers. Evidence-based digital platforms, such as interventions targeting disruptive behaviour in children, may benefit in being rolled out at this time. They are effective in reducing target symptoms and secondary care utilisation after 2-year follow-up (McGrath et al. Reference McGrath, Sourander, Lingley-Pottie, Ristkari, Cunningham and Huttunen2013; Reference Sourander, McGrath, Ristkari, Cunningham, Huttunen and Hinkka-Yli-SalomäkiSourander et al. 2018).

Opportunities for change

Opportunities for positive change exist at many levels, for some individual young people, for families, for health and social care professionals and researchers, for communities and for specific sectors. Many young people will have unique opportunities to spend more time with their families and a small minority (8%) in the YoungMinds survey reported this (YoungMinds, 2020). For caregivers working from home or temporarily furloughed, current remote working arrangements could offer opportunities for longer-term flexible working conditions that are common in many Nordic countries and appear to have a well-being dividend for young people and their families (Caan & Jenkins Reference Caan and Jenkins2008). The current crisis may also be an opportunity to investigate the effects of community cohesion on prosocial behaviours, psychopathology and suicidality in young people (Oosterhoff et al. Reference Oosterhoff, Palmer, Wilson and Shook2020).

Opportunities exist for health care professionals to change work practices to rapidly scale up effective digital and digital-hybrid interventions. Whilst digital interfaces in mental health can be effective, clinician resistance is cited as hindering widespread uptake (Wind et al. Reference Wind, Rijkeboer, Andersson and Riper2020). Telepsychiatry is broadly acceptable to a large majority of young people with severe mental disorders such as psychosis, with some caveats around potentially increased dropout from treatment (Lal et al. Reference Lal, Abdel-Baki, Sujanani, Bourbeau, Sahed and Whitehead2020). Digital platform development is specifically important for youth as young people are digital natives who look online first for information related to their mental health. Emerging platforms offer partially guided adaptations of standard therapies (such as cognitive behavioural therapy) through video games (Chapman et al. Reference Chapman, Loades, O’Reilly, Coyle, Patterson and Salkovskis2016). These are scalable, effective and youth-friendly alternatives to traditional therapies. Emerging digital services offer a democratisation of access to emerging and specialist therapies, for example, in depression and psychosis in young people (Rice et al. Reference Rice, Gleeson, Davey, Hetrick, Parker and Lederman2018; McEnery et al. Reference McEnery, Lim, Knowles, Rice, Gleeson and Howell2019). Digital services have many practical advantages, as access to services is contingent on geography, particularly in Ireland. One positive outcome of the pandemic is that clinicians and patients have had the opportunity to use digital or tele-platforms where previously this option would not have been available to them. Digital platforms have potential to improve quality of care particularly in non-urban areas where there may be no or insufficient access to services locally. Digital services may also reduce costs associated with obtaining mental health care for young people and their caregivers.

In conclusion, we have discussed why the COVID-19 pandemic will disproportionately affect young people both in the short- and long-term, and why the harms of the pandemic at a population level are inequitably distributed. The COVID-19 pandemic will however be a catalyst to rethink the delivery of services and to provide more accessible, equitable and efficient services in the future.