April 8, 2022

By Tom Insel, MD, and Matthew Hirschtritt, MD, MPH

Good morning, Research Roundup readers. This week, we bring you some sobering data from the CDC on the extent of mental health and substance use disorders among our youth and the degree to which it has worsened through the pandemic. We also examine some fascinating data on how subtle changes in the language people use in online text therapy sessions can signal improvement and act as a way to evaluate the impact of the therapy. Finally, we look at the double burden faced by people who experience both medical and mental health conditions at the same time.

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The Kids Are Not Alright

Photo: Shutterstock

Four reports, posted simultaneously last week by CDC researchers, paint a dark picture of youth mental health during the pandemic. Researchers analyzed data from the Adolescent Behaviors and Experiences Survey, an online survey distributed to 9th to 12th graders in the spring of 2021 to collect information about health-related behaviors while high schoolers were attending classes virtually. About 7,700 teens responded and they are largely representative of public and private high school students in the U.S.

Among the reports’ findings:

Mental health

  • Over one-third (37.1%) reported having poor mental health during the pandemic.
  • In the year before the survey (during the initial stages of the pandemic), 44.2% had persistent depressive symptoms, 19.9% considered suicide and 9.0% attempted suicide.
  • Teens who felt connected to others at school reported substantially better mental health and less suicidality.
  • LGBTQ teens consistently reported worse mental health, higher rates of suicidality, and less connection to others at school.

Substance use

  • Nearly one-third (31.6%) reported current use of any substance – including tobacco, alcohol, cannabis, or opioids. One-fifth (19.5%) were currently using alcohol.
  • Of those who vaped (15.4% of respondents), about one-third did so daily. Of those who used alcohol, over one-fifth drank at least six times a month.
  • Among teen who reported using alcohol or drugs, about one-third (29.6%) said they were using more during the pandemic.
  • Teens who attended school virtually were less likely to use substances than teens who continued to attend in-person or hybrid (virtual and in-person) classes.


  • Over one-third (35.6%) of teens of all races reported experiencing racism; rates were highest among Asian (63.9%), Black (55.2%), and multiracial students (54.5%).
  • Poor mental health during the pandemic was reported by 24% of teens who’d never experienced racism and 38% of teens who had. Teens who had experienced racism were also more likely to have concentration or memory problems and to feel isolated from others at school.

Disrupted home and school life

  • Over half (55%) said they’d experienced emotional abuse from their caregiver at home – and this rate skyrocketed to about 75% among LGBTQ teens.

Is there a silver lining here? Perhaps. Increased awareness of the plight of youth during the pandemic has lead to bipartisan support for bills like the Improving Mental Health Access for Students Act, the Youth Mental Health Services Act of 2021, and the STAND UP Act. But for any intervention to be successful, it must proactively address the needs of minority and marginalized youth – especially non-white and LGBTQ youth, who face multiple societal stressors that long predate this pandemic.

Here are links to each of the four reports that posted online on April 1:

Use of Tobacco Products, Alcohol, and Other Substances Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021.

Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021.

Perceived Racism and Demographic, Mental Health, and Behavioral Characteristics Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021.

Disruptions to School and Home Life Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021.

– Matthew Hirschtritt

Linguistic Distance: The Psychological Journey From “Me” to “Thee”

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Sigmund Freud famously wrote about the narcissism inherent in melancholia, the disorder we today call major depressive disorder. With access to modern linguistic tools, he could have seen that a subtle feature of depression is the shift in pronouns from “we” and “they” to “I” and “me.” This shift to first person singular ­– which Freud may have labeled narcissism ­– is a consistent finding in studies of the writing or speech patterns of people with depression.

A new study looks at a variant of this pronoun finding by examining the role of linguistic distance in virtual psychotherapy sessions. Linguistic distance describes the ability of people to put emotional or psychological distance between themselves and things that they have experienced – to take a step back and view a situation that is difficult or challenging as separate from themselves.

Laboratory studies have shown that when people increase linguistic distance, they also tend to experience a reduction in negative emotions (like despair and worry); this in turn can help them to better regulate their emotions. For instance, shifting from “I feel hopeless because I am a failure,” to “Others who in the past saw themselves as failures also felt hopeless,” provides not only linguistic distance from the negative emotion of hopelessness, it may help individuals to manage this emotion.

Does linguistic distance reveal anything about the process of psychotherapy? Erik Nook of Harvard University and colleagues reviewed some 1.2 million text messages from over 6,000 clients participating in online text therapy with Talkspace. Over the course of therapy, “internalizing” symptoms – depression, anxiety, rumination – decreased as emotional distance increased. Measure of linguistic distance correlated with symptom severity and treatment outcome. While the effects were small – and the results don’t demonstrate that the increased linguistic distance itself was the mechanism for an easing of symptoms – the findings do suggest that changes in the language people employ as they talk about challenges or emotional issues may offer a useful way to monitor the impact of psychotherapy.

While previous research had shown that using language to distance oneself from negative events or feelings is important for effective emotional regulation, this is the first demonstration that changing language – specifically increasing linguistic distance – is associated with improvement in psychotherapy. The language effect does not depend on diagnosis, therapy, or therapist.

As the authors note, “These results support a theoretical model in which linguistic distance reflects healthy emotion regulation, making linguistic distance a tool for measuring mental health and treatment progress.” We need more objective tools for understanding mental health and mental health treatment. So much of mental health treatment is about communication. We have the tools for analyzing language objectively. It’s time to use them to help people with mental illness.

Linguistic measures of psychological distance track symptom levels and treatment outcomes in a large set of psychotherapy transcripts  Proceedings of the National Academy of Sciences, March 22, 2022

-Tom Insel

The Double Whammy: When Mental Illness and Medical Conditions Both Strike

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The average life expectancy of people with a medical condition like type 2 diabetes or heart disease is significantly shorter than for healthy people. Likewise, people with mental illness may die seven to 10 years earlier than those without a mental illness. But what happens when people have both? Previous research compiled by the Robert Wood Johnson Foundation has shown that 68% of people with a mental illness also have a medical condition, and 29% of people with a medical condition also have a mental illness.

As you might imagine, death rates are higher and life expectancy is shorter for these doubly afflicted people. Natalie Momen and colleagues at Aarhus University in Denmark examined comprehensive health data from nearly six million Danes born between 1900 and 2015. They then compared anticipated life expectancies for people with and without these conditions (the mortality rate ratio) and calculated years of life lost among four groups:

  •People with specific mental and non-psychiatric medical conditions

  •People with mental conditions only

  •People with medical conditions only

  •People with neither mental nor general medical conditions.

They found that people with both a mental and medical condition were about six times more likely to die during the observation period than those with neither. The dually affected also died earlier than those with only one condition. For example, people with a mood disorder and a medical condition were nearly twice as likely to die and those with an eating disorder and a medical condition were more than three times as likely to die as adults of similar ages and backgrounds with only a medical condition. Adding a cancer diagnosis on top of a mental health condition increased the risk of premature death four-fold.  

On average, people with both types of conditions died about 11 years earlier than people with neither. The addition of a mental disorder to a medical condition led to more than five years of lost life and the addition of a medical condition to a mental condition led to more than four years of lost life.

Bottom line: You don’t want any of these conditions, of course, but if you develop a second condition, you want to know as soon as possible. Patients with mental illnesses should be routinely screened for medical conditions and offered appropriate treatments. This work supports a growing movement toward the integration of mental health care and medical care in the US.

Mortality Associated With Mental Disorders and Comorbid General Medical Conditions. JAMA Psychiatry, March 30, 2022.

– Matthew Hirschtritt

If you or anyone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255. And if you’re a veteran, press 1.

Tom Insel, MD, is a psychiatrist, neuroscientist, and former director of the National Institute of Mental Health (NIMH). He is a donor to MindSite News and chair of its Editorial Advisory Board. Dr. Insel’s financial conflict of interest statement, which includes equity and advisory roles in several early-stage mental health technology companies, can be found here.

Matthew Hirschtritt, MD, MPH, is a clinical psychiatrist with the Permanente Medical Group, Inc., a mental health services researcher with the Division of Research, Kaiser Permanente Northern California, and assistant program director of the Kaiser Permanente Oakland Adult Psychiatry Training Program. His current research focuses on identification and treatment of patients with first-episode psychosis, as well as implementation of a telehealth-based mental health evaluation and referral program.

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