One in eight: Young people and mental health
The growth in mental health problems in young people is a serious cause for concern. Pharmacists have an important role to play in tackling the issue
After reading this feature you should be able to:
• Describe the prevalence and impact of mental health conditions on children and young people in England
• Recognise the challenges of childhood obesity and the steps that can be taken to stem the tide
• Understand the practical strategies that pharmacy can use to support and safeguard the mental and physical health of young people
According to a 2017 NHS report into the mental health of children and young people in England, over 12 per cent of five to 19-year-olds – or around one in eight – are currently dealing with at least one mental health disorder. This equates to one in every eight young people having a recognised mental health issue, the commonest of which are emotional disorders.
The report also revealed that the prevalence of mental health disorders appears to be growing – fast.
Emotional disorders in particular are becoming commoner in five to 15-year-olds – up from 3.9 per cent in 2004 to 5.8 per cent in 2017. This category of mental health problems encompasses anxiety disorders characterised by fear and worry, depressive disorders associated with sadness, loss of interest and energy, and low self-esteem, as well as more severe conditions such as mania and bipolar disorder.
Rates of all other types of mental health disorder, such as behavioural, hyperactivity and other less common disorders, remained steady. Among young people, mental health disorders were also shown to increase with age, rising from rates of just over 5 per cent in two-four year-olds to around 17 per cent in 17-19 year-olds.1
“The growth in emotional disorders in children between 2004 and 2017 is a serious cause for concern,” says Mark Rowland, chief executive of the Mental Health Foundation. “The findings in new categories such as the prevalence of mental disorders in two to four year-olds as well as 17-19 year-olds show new areas of risk and evidence of distress, which are important to understand and to track.
“Today’s prevalence figures show what many have been saying for some time: some groups in society are more likely to be affected by mental health disorders. Those most at risk are children from low-income households, children whose parents have poor mental health or are in receipt of a disability payment, and 14-19 year-olds who identify as LGBTQ.”2
• It is estimated that one in eight young people between five and 19 years of age are currently dealing with a mental health disorder
• There has been a 10-fold increase in the national incidence of obesity among children and adolescents since 1975
• Pharmacy has a pivotal role to play in promoting mental and physical well-being among its younger customers
Safeguarding and supporting mental health
In May 2018, the Royal Pharmaceutical Society hosted a roundtable to discuss the potential role that pharmacy can play in supporting patients with mental health problems.3 Several of the key recommendations from this report provide valuable tools to facilitate supporting young people’s mental health.
Indeed, the RPS concluded that the community pharmacy setting offers some of the greatest untapped potential for using the skills of pharmacists and their teams in aiding people of all ages with their mental health. Important steps that pharmacy can take to adopt a more active role in safeguarding the mental health of young people include:
Acting as advocates for young people with mental health problems
The pharmacy is an accessible, comfortable and familiar setting for people of all ages, making pharmacy staff perfectly positioned to take on the role of confidant or adviser for young customers with mental health issues, particularly emotional disorders such as anxiety or depression.
Identifying mental health problems early
Pharmacists and their teams need to be aware of common trigger points for emotional disorders in young people such as bullying, abuse, family problems, social deprivation, low self-esteem and sexuality. If suspected, these should prompt simple but engaging questions such as: ‘How does this make you feel?’. Pharmacists should also be alert to potential mental health problems when talking to any young patient with a newly diagnosed or longer-term medical condition.
Suicide is always an important risk to be aware of in young people, with recent data from the Office for National Statistics showing that suicide rates among 15-19 year-old girls are growing at record rates. In 2017, the incidence of suicide among 15-19 year-olds stood at 3.5 and 7.6 per 100,000 members of the population for males and females, respectively.4
Providing ongoing medication monitoring
Children prescribed pharmacotherapy for attention deficit hyperactivity disorder (ADHD), for example, require regular monitoring of key metrics such as blood pressure and pulse. Pharmacies provide a convenient and accessible location to carry out this physical screening, which young people may prefer to the more clinical setting of their GP surgery.
Promoting adherence and optimal use of medicines
Adherence levels can be particularly poor in patients taking medicines for mental health conditions and pharmacists can play a key role in promoting better compliance by targeting adolescents in charge of their own medication directly or the parents of younger children. Pharmacy also has an important responsibility to help reduce the adverse events and potential harm from medications used to treat mental health conditions.
Linking up with mental health initiatives and campaigns
A key national programme relevant to young people’s mental health that pharmacy is well-placed to support is STOMP, which stands for ‘Stopping over-medication of people’ with a learning disability, autism or both.
Signposting to other sources of support
With mental health currently high on the public health agenda, a huge raft of supportive services are now available for a broad range of mental health disorders. Mental Health UK and Mind are good places to start.
Promoting physical health
Pharmacy teams can work collaboratively with young people to support not only their mental health, but also physical well-being. Giving children with mental health problems the tools they need to safeguard their physical health over the long-term may be a key step towards closing the 15-20-year mortality gap that currently exists in people with severe mental illness. However, healthy living advice is equally important for all young people – particularly given today’s sedentary, online lifestyles and ready access to high calorie foods.
Research indicates that there has been a 10-fold increase in the number of children and adolescents with obesity since 1975, highlighting the urgent need for early and proactive intervention to tackle one of the biggest health threats currently facing the UK.5
As Dr Max Davie, officer for health promotion for the Royal College of Paediatrics and Child Health (RCPCH) points out, “twenty per cent of children are already obese by the time they leave primary school and this is totally unacceptable. Access and funding of high quality weight management services are urgently needed now if we are to ensure no child slips through the net and all children, no matter where they live, are given the same opportunity to good health.”6
By 2020, the RCPCH estimates that half of all children in the UK will be overweight or obese. This in turn makes them much more likely to become obese adults and carries significant health risks such as type 2 diabetes and cancer, as well as impacting negatively on self-esteem and body image.5
Practical advice and education from pharmacists for young people should centre on diet and physical activity. Key steps for success include:
• Keeping meals and snacks to age-appropriate portion sizes and featuring nutritious foods and drinks
Young people should aim to eat the recommended five portions of fruit and vegetables per day and intake of sugary or high-fat foods should be discouraged or kept to a minimum. Consider signposting to Change4Life, which provides practical tips on diet and exercise and simple everyday steps to keep children physically healthy
• Increasing activity levels
Children require at least 60 minutes of physical activity per day. For young people, choosing an activity or sport they enjoy is key to establishing long-term patterns of regular physical exercise. Group activities and team sports also offer the additional mental health benefit of socialising, while exercise such as yoga or tai chi can help promote relaxation and overall well-being
• Cut down on screen time and get more sleep
Limiting time spent on inactive, sedentary activities such as playing on electronic devices or watching television boosts overall activity levels and also improves sleep (which is independently linked to obesity risk). Children should be limited to a maximum of two hours of screen time per day.
Whenever possible, advice on healthy living for young people should extend to and include parents, who are the major role models and drivers of good health habits in their children. Recent research by NHS Digital has confirmed the link between obese parents and obese children.
Children with obese parents are three times more likely to be obese themselves compared to their peers with healthy weight parents. Notably, around half of parents of obese children believe their child is of the correct weight.7
Sensitive health complaints in young people
Acne is a common condition among adolescents, usually occurring around puberty and bringing with it embarrassment and a negative impact on selfesteem and body confidence.8 Pharmacy teams can recommend OTC acne treatments and also provide important self-care advice for young sufferers.
Acne products come in a wide range of formulations, typically containing active ingredients such as the anti-inflammatory nicotinamide, benzoyl peroxide (which combats the acne-causing Propionibacterium acnes bacteria on the skin and also removes dead cells), salicylic acid (which encourages skin cell shedding) and topical antiseptics/antimicrobials.
Customers should be advised to use the products as directed for maximum benefit, applying to the entire area of affected skin and not just to individual spots. Treatments may need to be used for one to two months before full improvement is seen. Customers should be warned that benzoyl peroxide has a bleaching effect and can trigger skin irritation and redness, so use may need to be increased gradually over time. Picking or squeezing spots should be discouraged as this can aggravate the problem and increase the risk of permanent scarring.
Make-up can help boost confidence and disguise spots but acne sufferers should always be advised to choose products that are oil-free and noncomedogenic. It is important to remove make-up and cleanse skin daily using a mild soap or gentle cleanser, avoiding very hot water, strong detergents, rough scrubbing pads or astringents.
For young people with more severe acne, pharmacy staff can reassure them that effective therapies are available including topical retinoids, topical or oral antibiotics, combined oral contraceptives, the hormone treatment co-cyprindiol and isotretinoin.
Suggest they make an appointment with their GP to discuss treatment options and remind them the pharmacy team is always on hand to provide ongoing advice and ensure they derive maximum benefit, and minimal harm, from any medication prescribed. This is particularly critical for any young customers on isotretinoin, which is associated with mood changes and other potentially serious adverse events.
Often dismissed as a trivial and minor problem, dandruff is unsightly and unpleasant for sufferers and may cause embarrassment and dent confidence – particularly among aesthetically-sensitive younger adults who are prone to developing this scalp complaint. Fortunately, dandruff responds well to shampoos containing antifungal ingredients, such as ciclopirox and ketoconazole, which target overgrowth of the tiny causative yeast malassezia on the scalp surface.
Other active ingredients in dandruff shampoos, such as salicyclic acid, selenium sulphide, zinc pyrithione and coal tar, are also effective and work to slough away the build-up of dead skin cells on the scalp surface. To help reduce dandruff, sufferers should massage their scalp gently during hair washing, brush hair regularly to encourage shedding of skin cells and follow a healthy, balanced diet (as nutritional deficiencies in B vitamins and essential fatty acids have been linked to dandruff).
Body odour (bromhidrosis) is generated by the apocrine glands, which produce sweat that is broken down by bacteria on the skin. Apocrine glands are concentrated in the armpits and develop during puberty. Like many of the other health complaints that commonly afflict young people, body odour can produce feelings of embarrassment and shame, causing significant distress to sufferers.
Self-care advice aimed at eliminating excess skin bacteria is key to managing body odour. Advise affected customers to bath or shower (at least once daily), wash armpits thoroughly using an antibacterial soap and keep the area clean-shaven, wear natural fibres that allow sweat to evaporate, ensure clothes are always clean, and limit the consumption of foods linked to body odour such as curry, garlic and red meats.
Pharmacy staff should recommend roll-on antiperspirants containing aluminum chloride, which are most effective in combating body odour, in favour of deodorants that only serve to mask the smell of sweat.
For customers with intractable body odour and/or excessive sweating, suggest they consult their GP to discuss next-step treatment strategies such as higher-dose aluminum chloride products, surgery, liposuction to draw out sweat glands and botox injections into the armpits.
This affects between 50-90 per cent of menstruating women and has a significant impact on quality of life and well-being on young females, as well as leading to absenteeism from school.9 For OTC period pain relief, NSAIDs (ibuprofen or naproxen) are preferred to paracetamol due to their greater efficacy and prostaglandin-targeting mode of action. NSAIDs can also be used in combination with paracetamol if required.
Non-pharmacological pain relief options include heat and transcutaneous electronic nerve stimulation (TENS) set to a high frequency. Stopping smoking, taking gentle exercise, massage and relaxation techniques are all potentially beneficial self-care measures.
Any young person with severe or persistent pelvic pain should be encouraged to consult their GP to rule out other potential underlying causes such as endometriosis, fibroids or pelvic inflammatory disease, as well as to discuss prescription treatment options (e.g. mefenamic acid).
The combined oral contraceptive pill can be a good option for teenagers, helping to ease period pains by thinning the uterine lining and reducing prostaglandin release, but should always be accompanied by comprehensive advice on sexually transmitted infection prevention.
The arrival of body hair is a key harbinger of adolescence and brings with it many choices about hair removal. For younger girls, shaving or hair removal creams may be preferred to more painful and long-lasting approaches like waxing or epilation. It is also important to tailor product recommendations to the specific area of the body from which hair is to be removed, considering key issues such as skin sensitivity.
For boys, adopting a good shaving technique to remove hair from the face can help to prevent potential problems such as nicks, cuts, razor burn and ingrown hairs. Recommend shaving after a shower or bath when the hair is softer and pores open.
A shave gel or foam can be applied to aid razor glide and light gentle strokes should be taken in the direction of the grain that feels most comfortable. Shaving creams, gels or lotions applied after shaving can help to protect the skin and relieve irritation.