Ian G Manion, PhD, CPsych1,2,3, Simon Davidson, MB, BCH, FRCPC1,2, Sharon Clark, BA4, Christina Norris, MA1, Sarah Brandon, MA1
As in the rest of society, mental illness or euphemisms thereof remain a source of great stigma to adolescents. The stigma is so great among youth that the knowledge base and management of mental illness and emotional difficulties across the health-illness spectrum is significantly impeded. As well, Canadian youth are at a disturbingly high risk for mental illness and mental health problems (1). Furthermore, previous research has revealed that death by suicide remains the second most common killer of youth in Canada, and adolescence is the only age group in which suicide is on the rise. It appears that, despite the methodology used, about 1 out of 5 Canadian children or adolescents has a significant mental health problem or psychiatric disorder (2). This finding is substantial and significant. We must use the limited resources we have in the best possible way to understand what is going on with our youth, why they are at risk, and how we can try to address the needs of youth with psychiatric disorders.
An increasing awareness of the importance of these issues led to the development and implementation of the Canadian Youth Mental Health and Illness Survey (CYMHIS) as the Canadian Psychiatric Association (CPA) focused on youth to kick off the Mental Illness Awareness Week of October 1993. The CPA's CYMHIS was designed to provide a broad-brush profile of the opinions, awareness, and behaviour of Canadian youth toward mental illness and mental health issues. (For the purposes of this study, participants are considered mainstream if the focus group was conducted at a school [rural or urban] and nonmainstream if the youth were not attending regular school and/or were recruited because of their association with services for youth [often services for youth in special circumstances].) The survey showed that mainstream Canadian youth are at a disturbingly high risk for mental health problems. It also revealed that youth are largely dissatisfied with existing mental health services and that they are most comfortable interacting among themselves.
Overall, females reported more significant difficulties in most areas compared with males, who reported being more likely to keep such difficulties to themselves. The frequency of difficulties and the level of concern raised by adolescents increased with age and grade level. Fifty-one percent of the sample reported significant feelings of stress, on a daily to monthly basis, with this rate increasing to 66% among youth in grade 13. Similarly, 33% of the sample reported significant feelings of depression. Nineteen percent of those interviewed revealed having suicidal thoughts with 22% of these having purposely tried to kill themselves. Roughly one-third of the adolescents indicated that they keep mental health problems to themselves rather than talking to someone else. Almost two-thirds (63%) of respondents indicated that embarrassment, fear, peer pressure, and/or stigma are the major barriers to adolescents seeking help for mental health problems. Detailed results from this survey have been presented elsewhere (3).
The above findings were the impetus for the development of a regional youth mental health promotion and mental illness prevention program. Youth Net/Réseau Ado (YN/RA) is a bilingual program for youth, by youth, which strives to promote awareness and increase communication among youth regarding mental health and illness issues, as well as to help youth develop connections with a safety net of youth-friendly professionals. The following is a summary of the information that youth have provided through this program to date.
Through the medium of focus groups, YN/RA provides a forum for open discussion on mental health and illness. The goals are to destigmatize mental illness while promoting good mental health; facilitate early identification of mental health concerns and connection to services; and respect what youth are telling us in order to make the present mental health services more youth-appropriate by advocating on their behalf.
YN/RA has endeavoured to include all youth and to be attentive to the opinions and attitudes of both mainstream and nonmainstream youth. This has been done using both quantitative (a questionnaire) and qualitative (focus groups) methods. These tools allow for an in-depth understanding of the youth's perspective regarding issues about mental health and illness. Throughout this process, youth learn more about such issues and can engage in more open, confidential, and less stigmatizing discussions on how best to help themselves and others.
The items for the questionnaire were developed by Davidson and Manion (3) and/or adapted from other sources (4,5) and included 15 self-report questions relating to self-esteem, feelings of depression and stress, and suicide ideation. All questions were reviewed for youth-appropriate language and modified accordingly. The focus groups were 1.5-hour semistructured discussion groups, each having roughly 6 to 15 youth participants. Two trained young-adult facilitators attended each group and recorded the youths' opinions and attitudes regarding mental health and illness.
From September 1995 to May 1996, 1091 youth participated in YN/RA focus groups. Fifty-four percent of the groups were held in English and 46% in French. Participants included 630 young women and 461 young men. Eighty-four percent of the groups were held with youth in mainstream school programs, and 16% were held with youth in nonmainstream programs (for example, street youth, gay and lesbian youth, adolescent mothers, and youth in alternative education programs).
Nonmainstream youth reported significantly more physical health (60.6% versus 46.3%) and mental health (50.8% versus 39.6%) concerns relative to mainstream youth. Females reported significantly more physical health (57.0% versus 37.1%) and mental health (49.3% versus 30.6%) concerns than males. Overall, a large number of youth reported significant levels of stress (74.3% of nonmainstream youth and 64.0% of mainstream youth) and depressive feelings (52.4% of nonmainstream and 41.2% of mainstream youth). Gender seemed to affect levels of stress and depression, with more females reporting significant feelings of stress (75.0% versus 53.0%) and depression (49.1% versus 35.1%) than males.
The youth also reported on their suicidal thoughts and behaviours. Among mainstream youth, 30.1% indicated having had suicidal thoughts at some time in their lives, with 12.7% having had such thoughts within the previous 3 months and 9.4% having previously attempted suicide. In contrast, 51.7% of nonmainstream youth reported having past suicidal thoughts, 24.9% reported having had such thoughts recently, and 32.9% had made a suicide attempt. Overall, females reported significantly more lifetime suicidal ideation (39.2% versus 26.2%), recent suicidal ideation (17.5% versus 10.2%), and suicidal behaviour (16.5% versus 8.6%) than males. In spite of these high rates of suicidal ideation and attempts, 42.6% of mainstream youth and 34.5% of nonmainstream youth had never disclosed these thoughts or feelings to anyone.
With respect to coping, nonmainstream youth were more likely to report trying to cope on their own than were mainstream youth (43.8% versus 33.4%). If youth approached anyone for help about their mental health concerns, they were most likely to talk to friends (53.0% nonmainstream and 73.0% mainstream). A minimal number of both nonmainstream (5.6%) and mainstream (2.1%) youth indicated that they would talk to a professional about such concerns.
Qualitative findings from the focus group discussions revealed that only a minority of youth (20%) defined mental health in a positive manner. The positive definitions included emphasis on effective coping strategies, positive mental states, and high self-esteem. The majority of youth defined mental health in either very negative (32%) or neutral (48%) terms.
The following mental disorders were most frequently discussed in focus groups: depression (30%), schizophrenia (26%), and eating disorders (11.3%). There were no positive definitions given for mental illness. Ninety percent of the comments relating to mental illness were negative, with the other 10% being more neutral. Youth identified the following issues (stressors) as being important to them: parents (90.6%), drugs and alcohol (90.6%), peer issues (86.8%), suicide (86.8%), money (80.2%), and depression (70%). Youth were asked who they would turn to for help in coping with such stressors. The top source of support identified by youth was friends (86%), with family (50%) mentioned as a distant second. Youth reported that they would not turn to the following sources for support: psychologists and/or psychiatrists (43%) and guidance counsellors (26%).
Overall, the information collected through the YN/RA focus groups to date suggests an even higher level of distress being reported by youth than what was seen in the 1993 CYMHIS (3). Sampling and methodological differences may well account for this disparity. The focus group methodology allowed for the establishment of a trusting, nonjudgemental environment in which youth may have felt more at ease in reporting mental health concerns. As well, the YN/RA sample included a mix of both mainstream and nonmainstream youth, with the latter experiencing more pronounced levels of distress. Mental health professionals need to be ever aware of the heterogeneity of youth in terms of their mental health concerns and the different, sometimes creative, approaches required to meet their varied needs.
The high proportion of youth who reported having thought of suicide or having purposely attempted to kill themselves was particularly disturbing. There are many youth who, when faced with a mental health concern, will cope adaptively or maladaptively by keeping problems to themselves. Clearly, youth consider their friends as the most important resource for them when they need help in coping. Youth expressed a high level of dissatisfaction with traditional models of service delivery. At the same time, however, there appeared to be a limited framework for youth in their understanding of mental health and illness.
The suicide-specific classification of Emile Durkheim (6) has been used by YN/RA as a theoretical foundation for the understanding and remediation of the array of mental health and service delivery problems previously described. Durkheim proposed 3 basic types of suicide, 2 of which seem to add understanding to the reciprocal interplay of problems youth have with our society and society has with our youth. "Egoistic" suicide occurs when the person has too few ties with the community. "Anomic" suicide occurs when the accustomed relationship between the person and his or her society is suddenly shattered (possibly through an experience of loss). It seems quite plausible that our youth's isolation from or loss of their sense of belonging to their community may manifest symptomatically through the previously described array of specific problems in social structure, relationships, attitudes, and mental health, as well as the prevalence of mental illness.
YN/RA has been developed as an innovative way of combining both macroscopic and microscopic approaches to mental health intervention with youth. At a macroscopic level, youth are connecting with youth (which decreases their sense of isolation) in an open discussion on mental health and illness. YN/RA also encourages youth to empower themselves by creating their own mental health promotion and mental illness prevention initiatives. Such initiatives might include youth-focused support groups (for example, depression, self-esteem, and relationship issues), a mental health board game, question and answer boxes, or newsletters (for example, YOUTH FAX, FAX ADO). YN/RA is available to facilitate the implementation of such youth-generated programs and offers facilitator training to youth so that they can organize their own focus groups. YN/RA is also supporting the translation of traditional and formal mental health and illness information into youth-friendly language or "youth speak." At a microscopic level, YN/RA links youth in most acute need with professionals and more traditional mental health services through a youth-friendly and community-based program. We are trying to educate youth about mental health and illness while we educate professionals on the flexibility and sensitivity required to serve all youth better.
YN/RA continues to offer focus groups throughout Eastern Ontario and Western Quebec. Youth have provided very positive feedback on the YN/RA philosophy and programs. More formalized evaluation of the impact of this program at both an individual and a community level is being developed. As well, plans to replicate the YN/RA model through satellites in 10 different communities across the country are underway. We truly believe that, as stated so well in The Health of Canada's Children: a CICH Profile, "It is our responsibility to work with youth to find ways to maintain, enhance and improve their health (including mental health). Not only do our approaches have to move with the times and the changing society, but also with the attitudes and perceived needs of and by our youth" (1, p 86). YN/RA seeks to provide the opportunity for youth to voice their concerns and to encourage and respect the role that youth will play in the evolution of mental health services.
Portions of this project were undertaken in collaboration with the Canadian Psychiatric Association in conjunction with Mental Illness Awareness Week 1993 and with support from the Children's Hospital of Eastern Ontario Foundation.
1Department of Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, Ontario.
2Department of Psychiatry, University of Ottawa, Ottawa, Ontario.
3School of Psychology, University of Ottawa, Ottawa, Ontario.
4Department of Psychology, Acadia University, Sackville, Nova Scotia.
Please address correspondence to Ian Manion or Simon Davidson, Department of Psychiatry, Childrenn's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa ON, K1H 8L1.
This article has been peer reviewed.