Anxiety and depression in 14 - 24 year-olds

The Wellcome Trust has kindly funded (grant number 223553/Z/21/Z) an initial study of the health impact of UBI entitled ‘Assessing the prospective impacts of Universal Basic Income on anxiety and depression among 14-24-year-olds’. The project will commence on in August 2021, with final report due at the end of August 2022.

This first phase examines the Wellcome Trust Mental Health Priority area of anxiety and depression among 14-24 year olds. This cohort may be the most vulnerable of all young people since WWII. Their mental health has been affected by the Global Financial Crisis, a decade of austerity and now the COVID-19 Pandemic. Our model of impact suggests that Universal Basic Income can mitigate those health conditions by reducing poverty, mitigating stress associated with inequality and changing behaviour to promote longer-term interests.

While UBI has been promoted for various reasons across the political spectrum, debate on the topic has reached a relative impasse in the absence of representative, accurately measured trials in industrialised countries. However, a health case that highlights potential impact on a vulnerable group is novel and has the potential to shift debate, particularly at a time of pandemic. Given that the UK Government is committed to a prevention agenda, this project provides valuable evidence on the public health impact by which to advance debate.

Our multidisciplinary team will be working with the Royal Society of Arts (RSA) and Compass to engage with young people from Bradford via the ActEarly project and a range of disability rights bodies to design UBI schemes. These schemes will then be used to predict impact on anxiety and depression. Our findings will be communicated to key policy makers through our end of project report, which will be published by the RSA, who have a track record of driving forward debate on UBI. Vitally, the project will also, for the first time, establish universal research protocols for accurate measurement of health impact during trails of UBI.

This will lead to a series of publications, reports and a set of research materials that can be used to examine further health impacts of cash transfer schemes.

Background

There is emerging evidence that young people aged 14-24 face particular mental health challenges. The Global Burden of Disease Study (2019) estimated that, in the UK, 6.61% 15- to 19-year-olds and 6.18% 20- to 24-year-olds (6.18%) had anxiety disorders, compared with 5.08% of those aged 25+. Indeed, this cohort is not just disproportionately affected in relation to other age groups, it is disproportionately affected in comparison to previous cohorts. Pitchforth et al.’s (2019) analysis of 36 national cross-sectional surveys of 140,830 4- to 24-year-olds from 1995-2014, found that long-standing mental health conditions increased in England from 0.8% to 4.8%. Although there was no consistent increase in reported psychological distress among children and young people over that period, there were signs of worsening trends among the 16-24 age group between 2011 and 2014 after previously positive ones. Using data from the Avon Longitudinal Study of Parents and Children (born 1991–92) and Millennium Cohort Study (born 2000–02), Patalay and Gage (2019) found that 14-year-olds in 2015 were significantly more likely than those in 2005 to experience depressive symptoms (14.8% vs 9%) and self-harm (14.4% vs 11.8%). Indeed, the study reported a 60% increase in the rate of severe depressive symptoms. This, along with a rise in reported BMI and reduction in sleep duration, is despite rates of health-damaging behaviours, such as cigarette, alcohol and cannabis use, generally being lower than among previous cohorts.

These data on mental health are supported by research that conceptualises mental health as being larger than healthcare (Smith & Wolpert 2020, 5). Using data from two waves of the Longitudinal Study of Young People in England, Lessof et al. (2016) found that Year 10s (14- to 15-year olds) in 2014 were markedly more ‘work focused’ than their counterparts in 2005 and that their mental wellbeing – particularly that of girls – had worsened, with feelings of control over their own destinies reduced. Indeed, the PISA 2018 results (OECD 2019) found that UK 15-year-olds had the second lowest life satisfaction out of 30, above only Turkey, and had reported the greatest drop in life satisfaction between 2015 and 2018. It also found that UK 15-year-olds had some of the lowest levels of agreement among the 73 countries and regions surveyed with the following statements: ‘my life has clear meaning or purpose’ (57%); ‘I have discovered a satisfactory meaning in life’ (52%); ‘I have a clear sense of what gives meaning to my life’ (58%).

These trends are particularly concerning as Kessler et al. (2005), using data from the 2001-03 National Comorbidity Survey Replication in the US, found that half of all lifetime cases of mental health conditions begin by age 14, and three quarters by 24. As McGorry et al. (2007, S5) state, mental health conditions at this young age are associated with ‘enduring disability, including school failure, impaired or unstable employment, and poor family and social functioning, leading to spirals of dysfunction and disadvantage that are difficult to reverse.’

Many of the studies above neither examine the underlying factors behind worsening trends in mental health nor suggest means of addressing ill-health in non-healthcare settings.

Justificaction

Understanding the factors behind this crisis is essential to effective public policy development, particularly at a time of austerity, pandemic and unemployment. The Black Report (1980) and Whitehall II Study of Civil Servants (Marmot & Steptoe 2008) have served to establish the influence of social determinants on health, asserting that poverty and inequality strongly influence health outcomes. A person’s health is heavily influenced by their social and economic environment: income influences housing and access to health care; predictability of income influences the extent to which individuals invest in long-term interests, and experience of inequality influences level of stress. These factors influence health-affecting behaviour, including with regard to diet and drug use (see Johnson, Johnson, Nettle & Pickett 2021).

This project examines the effect of cash transfers on social determinants of mental health among 14- to 24-year-olds in order to evaluate Universal Basic Income as an upstream intervention. This work is extremely time-sensitive since COVID-19 has imposed a mental health crisis on young people that, we argue, will only be exacerbated in coming years and can only be resolved through emergency upstream interventions to provide people with stable, predictable incomes (Johnson, Johnson, Webber & Nettle 2020). The research aims to provide the first comprehensive examination of UBI’s potential to advance Wellcome’s key active ingredients for prevention of problems and intervention once anxiety and depression have arisen (Wolpert 2020). This supports Wellcome’s understanding of mental health as larger than healthcare (Smith & Wolpert 2020, 5) and complements the UK Government’s ‘prevention agenda’ to challenge conceptualization of the NHS as the ‘National Hospital Service’ (see Department of Health and Social Care & Hancock, 2018) in favour of evidence-based measures to avoid illness.

Recently, The Lancet Public Health (2020) has called for examination of upstream interventions, the BMJ has called for a trial of UBI on health grounds (Painter 2016), both Labour (Labour Party 2019) and the SNP made commitments to UBI trials (Crerar 2020) and the Spanish Government has introduced a UBI-like (Ng 2020a) Minimum Income Guarantee (Ng 2020b) in response to COVID-19. However, while Gibson, Hearty and Craig (2018) have scoped some existing evidence on the impact of cash transfers, there have been no trials of UBI designed for health impact and no trials that have measured health impact comprehensively. As such, given that all data, while indicative, stem from ad hoc measurement, there is an urgent need for further examination.

This project seeks to: 1) extract data from the literature to create a ‘risk’ factor for anxiety and depression among 14- to 24-year-olds; 2) deploy the RSA’s Citizen Engagement Workshops and focus groups with disabled people to advance designs for a ‘transitional UBI’ for 14- to 18-year-olds and an overall scheme aimed specifically at mental health impact (measured by anxiety and depression), while also examining how to account for additional needs; 3) use the ‘risk’ factor from O1 to model the impact of the cash transfer schemes from O2) for 14- to 24-year-olds on anxiety and depression 4) design research protocols to measure impacts in different schemes using Pickett’s forthcoming cash transfer pilot for 18- to 20-year-olds as part of ActEarly in Bradford and the RSA/Scottish Government’s prospective trial in Dunfermline as practical cases around which to develop materials.

The research will be conducted around our existing model of impact. This builds upon the Black Report (1980) and Whitehall II (Marmot & Steptoe 2008) to outline three overlapping pathways to health impact: improved satisfaction of need via poverty reduction (Johnson, Degerman & Geyer 2019); reduced stress by mitigation of inequality (Johnson & Johnson 2018), and behavioural change associated with reduction in extrinsic mortality cues (Pepper & Nettle 2017).

We have produced a series of scoping papers that establish a cluster of design (Johnson, Johnson, Nettle & Pickett 2021), measurement (Johnson, Johnson & Webber 2020), costing (Johnson, et al. 2021), ethics (Johnson & Johnson 2021) and political framing (Nettle, et al. 2021) questions that need to be addressed in order for the policy to be evaluated and the case for a trial developed. This project examines the first two: design and measurement. This is particularly important in this instance as mental health has often been seen solely as a ‘healthcare’ issue, with the determinants misunderstood or overlooked. We need to understand these, using our model, in order to be able effectively to design policy, not just to intervene, but to prevent, the crisis that is developing.

Urgency and time sensitivity

This work is urgent. We have argued that we are in the midst of an unprecedented crisis of mental health that will exacerbate exponentially in the absence of a coherent upstream intervention that affects the determinants of health (Johnson, Johnson, Webber & Nettle 2020). Put simply, this 14- to 24-year-old cohort may be the most vulnerable of all such cohorts since WWII. They have been subject to the Global Financial Crisis of 2007/2008, subsequent deep austerity policies, a global pandemic and a general chipping away at a sense of opportunity. Just in terms of those in employment, according to research commissioned by Business in the Community (2019, p.9), 26% of 18- to 29-year-olds said that they struggle to make ends meet financially, compared with 21% of respondents overall. ‘73% of 18-29s reported having experienced symptoms of poor mental health due to work compared to 49% of those aged 65+’ (Business in the Community 2019, p.31). Meanwhile, a US study of 1,500 respondents by Mind Share Partners (2019), found that 75% of Gen Z respondents (aged 16-22 in this study) had left roles for mental health reasons, both voluntarily and involuntarily, compared to 50% of Millennials (aged 23-38) and 34% of respondents overall. Meanwhile, Gen Z, Millennials, and Gen X (39-54) respondents were 4, 3.5 and 2 times more likely to have been diagnosed with a mental health condition compared to baby boomers (55-73).

These issues have been exacerbated by the economic crisis in the wake of the COVID-19 Pandemic. Analysis undertaken by the TUC (2020b) in June 2020, using data from the ONS Business Impact of COVID-19 Survey, indicates that young people (aged 25 and under) are overrepresented in industries that are at particular risk of job losses due to the coronavirus pandemic. For example, they represented 37% of workers in the accommodation and food industry as well as a quarter of the arts, entertainment and recreation industry, despite accounting for just 13% of employees overall. Businesses in these sectors have been particularly likely to have temporarily paused or cancelled trading, furloughed their workforce or seen their normal turnover decrease by more than 50%.

These risks have now begun to be played out, as the TUC (2020a) found that 59,000 workers aged 16-24 experienced redundancy between July and September 2020, compared to 56,000 across all of 2019. Employment among young people is down 8% to 3.5m (60%) between December 2019 to February 2020 and July to September 2020, lower than any other point on record. This means that there are now more than 600,000 (14.6%) young people officially unemployed, with the rate at 25% in London. Meanwhile, weekly median pay fell by 10% among those aged 18-21 between April 2019 and April 2020, a five times greater fall than that of any other age group. This comes at a time during which the percentage of young people aged 21-24 living with parents has increased from 42% in 2006 (the same as 10 years previously) to 50% in 2019 (Office for National Statistics 2019), delaying independent living and the autonomy that brings (see Nussbaum 1999).

Patton et al. (2016, p.10) suggest that an important driver of health and wellbeing during and after adolescence is the promotion of a balanced and healthy independence through ‘autonomy-enhancing paternalism’. Social and economic changes that have resulted in young people relying on parents for longer for both financial support and accommodation may mean that the potential for this health-promoting autonomy is reduced.

While Patton, et al, (2016, 37) found that intervention in adolescence could help to avoid early experiences of mental health conditions continuing or recurring in adulthood, the inability of purely reactive, clinical ‘healthcare’ interventions to address mental health conditions has been highlighted by Stockings et al.’s (2016) meta-analysis. This found that the efficacy of such interventions in relation to both depression and anxiety among children and adolescents aged 5–18 was only short-term in nature, while suggesting that repeated exposures should be considered. There is, however, clearly a need to develop alternative interventions that have a long-lasting, consistent impact on young people’s mental health. Indeed, with graduate opportunities now declining, people’s wellbeing within the cohort is reduced and their ability to transition into adulthood is diminished as a consequence.

The effect of diminished opportunity for income is compounded by inequality. In broader economic terms, the UK has the sixth highest income inequality among OECD nations with recent available data (OECD 2020a). Indeed, Pickett and Wilkinson (2015), have highlighted the significant correlations between income inequality and worse child mental health outcomes.

We suggest that these issues can only be addressed by a policy that reduces poverty, reduces inequality and promotes predictability. These are social determinants that, in a world of increasing automation and job insecurity, can only be provided by a state-led upstream intervention. UBI offers significant promise.

Gibson, Hearty and Craig’s (2020) systematic review of cash transfer programmes found that in some studies there were modest to strong positive effects on health outcomes including child mental health, with suggestions that underlying mechanisms could include ‘reduced stress, improved parenting quality, and reduced financial strain’.

The project is the first to combine Citizen Engagement-based participatory action qualitative research on design and implementation of the policy with microsimulation modelling. The former will be deployed by Matthew Johnson, who has a record of leading international, collaborative Participatory Action Research (e.g. Johnson 2021), Elliott Johnson, who has a record of leading participatory research with disabled people and disability rights organisations (e.g. Johnson & Spring 2018) and the RSA, which has conducted Citizen Engagement work on UBI in Fife (Painter, Cooke, Burbidge and Ahmed 2019). This collaborative research will be conducted, in the midst of this crisis, with young people to draw upon their lived experience and will develop a series of UBI schemes to address the specific sources of their anxiety and depression. It is essential that this research be conducted now in order to present policy makers with an evidence base for assessment of schemes that citizens actually endorse. The research protocol for this work is available here. This assessment will take place within the model of economic microsimulation that we have developed for this purpose.

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