Are Public Schools Causing an Epidemic of Mental Illness?

Behavioral health has become a public health crisis. No other public health crises are as widespread or contribute as much to the burden of illness in the U.S. as do behavioral health disorders. By 2020, mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability.

Separately, an article at ManagedHealthCareExecutive.com notes that “Anxiety and Depression” is the most costly of mental health issues to treat ($87 billion in the U.S. in 2013 alone). “Substance Abuse and Addiction” is the third most costly (the second most costly category, “Alzheimers and Dementia” is not relevant to the young).

Around the world, we are gradually winning public health battle after public health battle. The CDC list of “Ten Great Public Health Achievements, 2001–2010” includes significant improvements globally with respect to infant mortality, vaccine-preventable diseases, access to safe water & sanitation, malaria, HIV, tuberculosis, tropical diseases, tobacco, road safety, and response to pandemics.

Meanwhile, developed nations are leading the world with respect to a new generation of public health crises relating to physical health (chronic diseases, such as heart disease and diabetes) and behavioral health (mental illness & substance abuse). As noted above, by 2020, “mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability.”

The perspective of the public health establishment is that the behavioral health crisis must be met with increased funding for “public behavioral health services.” From their perspective, we need massive new investments in treatment centers, counselors, therapists, psychologists and psychiatrists, community interventions, etc.

The Hippocratic Oath exhorted doctors to “first do no harm.” In order to scale back the accelerating public health crisis stemming from mental health and substance abuse issues, I propose that public health officials first reflect on the role of government-managed secondary education in causing our epidemic of mental illness and substance abuse.

Stated so bluntly, my thesis is controversial. But it is not controversial that lifelong substance abuse (see here, here, and here) and mental illness typically start in adolescence. As the National Institute of Mental Health notes, “Mental disorders are really the chronic diseases of the young.” The appropriateness of focusing on adolescent years is not controversial.

There are those who regard behavioral health as strictly a matter of genetics. We now know this is not accurate (See the footnote below, added June 2019, for an analysis of 600,000 person sample by geneticists that conclusively refutes the earlier belief in a “depression gene.” Slate Star Codex summarizes, “This isn’t a research paper. This is a massacre.”)

Meanwhile, The Center for Disease Control has firmly stated the role of “school connectedness” in preventing adolescent dysfunction:

School connectedness was found to be the strongest protective factor for both boys and girls to decrease substance use, school absenteeism, early sexual initiation, violence, and risk of unintentional injury (e.g., drinking and driving, not wearing seat belts). In this same study, school connectedness was second in importance, after family connectedness, as a protective factor against emotional distress, disordered eating, and suicidal ideation and attempts.

Figure from Improving the Odds: The Untapped Power of Schools to Improve the Health of Teens, p. 4.

The data above is taken from a study of 36,000 teens.

Researchers are only now discovering just how deeply these connections go. For instance, a 2007 article in the Journal of Adolescent Health discovered a direct connection between early teen experiences and mental health. They surveyed a cohort of almost 3,000 teens at grade 8, grade 10, and one year after graduation:

Overall, young people’s experiences of early secondary school and their relationships at school continue to predict their moods, their substance use in later years, and their likelihood of completing secondary school. Students with good school and good social connectedness are less likely to experience subsequent mental health issues and be involved in health risk behaviors, and are more likely to have good educational outcomes.

In a world in which an estimated one-third of teens are on prescription medication, and almost half of those are on psychiatric drugs (ADHD, anti-depressants, antipsychotics, and anti-anxiety), it is important for more parents to realize that school may be a causal factor with respect to their child’s depression.

Another cohort study of 2,000 teens states bluntly in its report titled: “School Connectedness Is an Underemphasized Parameter in Adolescent Mental Health.” It explicitly suggests that a lack of school connectedness is a causal factor in mental health issues.

School connectedness also predicted depressive symptoms 1 year later for both boys and girls, anxiety symptoms for girls, and general functioning for boys, even after controlling for prior symptoms. . . . Results suggest a stronger than previously reported association with school connectedness and adolescent depressive symptoms in particular and a predictive link from school connectedness to future mental health problems.

Pharmaceutical companies invest significant marketing dollars into persuading parents and health care practitioners that depression is a biochemical disorder to be corrected by pharmaceuticals. But what if a significant portion of adolescent dysfunction and mental illness is actively caused by a child’s feeling of disconnection from the school community?

A recent dissertation on schools and depression summarizes the scale of the issue:

Depression is a debilitating condition that is increasingly recognized among youth, especially adolescents. Nearly a third of adolescents experience a depressive episode by age 19 and an increasing number of youth experience depressed mood, subsyndromal symptoms, and minor depression. The prevalence of depression is particularly high among female, racial minority and sexual minority youth. . . . major depression and subthreshold depressive symptoms often first appear during the adolescent years. Rates of depression steadily increase from ages 12 to 15. Based on retrospective studies of depressed adults and prospective studies of youth, major depression is most likely to emerge during the mid-adolescent years (ages 13–15). Prospective studies that follow the same children over time reveal a dramatic increase in the prevalence of major depressive episodes after age 11 and again after age 15, with a flattening of rates in young adulthood.

Moreover, the importance of school connectedness extends to suicide as well:

The protective associations of higher school connectedness for suicidality in adolescents after accounting for the presence of depressive symptoms suggests that enhancing school connectedness may be a useful universal strategy for preventing suicidal behaviours in adolescents.

There is growing mainstream recognition that “school connectedness” is a significant risk factor for adolescent dysfunction, including substance abuse, mental illness, and suicide. Certainly “family connectedness” is also important. But as Judith Rich Harris showed twenty years ago, for adolescents peers are much more important influence on behavior than are parents. In prominent surveys, “School connectedness” includes

• I feel close to people at this school.
• I am happy to be at this school.
• I feel like I am part of this school.
• The teachers at this school treat students fairly.
• I feel safe in my school.

Clearly, relationships to peers and educators are key variables here. Guess what? Human relationships are important to adolescents.

Meanwhile, a Gallup poll finds that only 44 percent of high school students feel engaged at school. Beyond a “smoking gun,” this is an obvious catastrophe. For decades pop culture has been celebrating teen loathing of school: Alice Cooper, “School’s Out,” Pink Floyd, “Another Brick in the Wall,” or as Rolling Stone describes Mogwai’s “I Love You, I’m Going to Blow Up Your School,”

And what better way to show that special someone how much you care? For seven minutes the Scottish noise-rock monks of Mogwai ride a slow fuse from somber restraint to explosive chaos, adding their own unique contribution to rock’s rich canon of school-as-murderous-hellhole songs — from Hüsker Dü’s “Guns At My School” to the Dead Milkman’s “Violent School” to the Boomtown Rats’ school-shooting lament “I Don’t Like Mondays.”

Sometimes I wonder what planet public health researchers live on. Haven’t they noticed that school is hell?

Here we find the key problem: Academic research is generated by individuals who underwent a self-selection process. Those who found school tolerable are more likely to continue formal education. Some eventually become degreed experts with the authority to dictate to others what education should look like. Meanwhile, most who find school a living hell leave and never look back.

Although I was a straight-A student who got into Harvard, to this day I regard my secondary school years as the most boring and cruel years of my life. I was completely sympathetic then and now to those who hate school — many of whom self-medicated to address the boredom and cruelty (often thereby starting on the path to substance abuse) and/or were horribly depressed.

What if the institution of school itself is only appropriate for a fraction of our population? Perhaps that 44 % who are engaged according to Gallup? What if school was actively harmful to most of the rest? Not just, “That was a bummer” harmful, but contributing to lifelong substance abuse and mental illness harmful?

In Mind, Modernity, and Madness, Liah Greenfeld argues that reforming education is the only real solution we have to address the mental health epidemic. While she acknowledges there are genetic and familial factors that may predispose one to mental illness, the fact that rates of mental illness increase as nations transition from traditional cultures to modern cultures, and continue to increase with prosperity, is evidence that a cultural variable is essential to explain the growing prevalence of mental illness. Because some believe that the increased prevalence of mental illness may be a reporting artifact, note the increased prevalence of teen suicide in the modern world: rates in the U.S. are up about 3x since 1950. An astute student of Durkheim, she recommends greater urgency in addressing the growing anomie in the modern world that has resulted in higher rates of suicide, substance abuse, and mental illness.

What does “school connectedness” and “identity formation” have to do with public schools “causing” mental illness? By and large, there is little evidence that private schools are much better. Indeed, while Catholic students at Catholic schools are at a lower risk of suicide than the population as a whole, non-Catholic students at Catholic schools faced a 2–4 x higher risk of suicide. Private religious schools might actually be more dangerous if there is a mismatch.

Is it possible to create better schools, or should we simply accept that a growing percentage of our population will be depressed, try to counsel alienated teens from suicide and substance abuse, and accept the associated health care costs anticipated by the public health establishment?

I’ve spent most of my life creating small private and charter schools where teens who were previously miserable become happy and well. I’ve worked with dozens of teens who had been depressed, suicidal, and medicated with various pharmaceuticals become happy and well without “medication.” Let’s hear from a teen who was suicidal but is no longer thanks to a change in the school environment,

I walk through the hallways of the public middle school on my way to the bathroom. I stop in the center of hallway staring ahead at the overwhelming endless hallway, no one in sight. clenching my fists I look around panicky around the solid brick white wall. No sign of anyone or anything living anywhere. I scratch my fingernails hard on the plastered wall. not making a dent. I do this several times until the tips of my fingers look like the tops of roses. I then start hitting my head then slamming my body against the wall still hitting my head trying to get out . . .

A backpack of melancholy weighs down on my shoulders so I free the questions inside with my thoughts: Why did I have to be depressed?, Why couldn’t I learn like everyone else?, Why did I have to be scared? . . . I figured something was wrong with me. Just an idiot with issues, too stupid to learn and too ungrateful to be happy. All I could ever do was make my parents and the people around me worry. I was angry at myself, I was angry that I couldn’t learn or be happy. If all I could do was make my parents worried I was just a waste of time to them. I didn’t deserve to live I wanted to hurt myself. . . .

I stayed up all night in bed fearing the next day of school. I eventually did start talking to the school counselor about my problems. At first I would come in calmly and just talk to her. Then I started coming in every single day crying and more depressed than the day before. Sometimes I just came in asking to call my mom. I never told anyone that I wanted to commit suicide. Until the day I told my mom.

I fiddle with lock and push open the steel door to the inside of my small house. Immediately I drop my school bag near the the front door. Mom is still at work. Slowly walking to the kitchen I stare at the sharp kitchen knife tucked into the knife block. Slowly still walking toward it I carefully take out the knife and feel the blade across my finger. I endeavor to conceive how much it would hurt if I were to stab it into my chest. I pose the knife back in its place. i’m too afraid too and cowardly of the pain. I think of less brutal ways but all thoughts fail. . . .

There is nothing abstract about these issues for me. Sure we could add more counselors and medication. But simply changing schools, from a one-size-fits-all public school to one at which she was allowed to learn at her own pace in her own way, in a warm, supportive peer culture, eliminated the misery.

But our system creates unreasonable obstacles to the creation of such schools. Because of my experience creating small, personalized schools, I am intimately familiar with the obstacles to creating them. For instance, my current school, The Socratic Experience, offers both an accredited high school option and an unaccredited high school option — because I want the flexibility to do what is right by a child (even if that means more of a self-directed option than accreditation allows). Even in the world of private schools, mainstream accreditation agencies tend to force mainstream expectations on schools.

Because I know it is possible to create schools that integrate emotional well-being with academic performance if it was not so challenging to create such schools the demand would be great for them. If parents could choose schools at which their children were happy and well, they would do so. Indeed, in light of the high stakes associated with school connectedness, as recognized as the CDC, I go ballistic when I read about education researchers insulting the judgment of parents who choose to leave public schools, such as this summary of a famous 2006 paper by Judy Jackson May:

“Many parents base their school choice decision on factors that have nothing to do with the quality of education” (May, 2006, p. 28). In her study, parents reflected on positive feelings, which translated into smaller class sizes, teacher familiarity, one-on-one attention, and a sense of belonging. May refers to this construct as “the perception gap” — the positive expressions parents charter schools that are consistent more with their feelings rather than with achievement results, but are ultimately defined as “academic satisfaction.”

She calls parents’ decision to put their children in a school with “ smaller class sizes, teacher familiarity, one-on-one attention, and a sense of belonging” a “perception gap”? I perceive I don’t want my child to kill herself, and you call that a “perception gap” that has “nothing to do with the quality of education”?

I used to be optimistic about the charter school movement. Indeed, I co-created a charter school in rural New Mexico that was ranked the 36th best public high school in the U.S. (and ranked the best public high school in NM by K12.Niche.com in 2016). But federal control restricts charter school autonomy too much to address our public health crisis. In order to create fundamentally new kinds of schools, educators need freedom from all existing curricular constraints, licensing constraints, and testing constraints. As long as opportunities for “innovation” in education are constrained by the same constraints faced by public schools, innovators only have small parameters within which to innovate.

In order to develop robustly healthy personal identities in a world of anomie and constant change, adolescents will need to be embedded in new subcultures which have not yet been developed. Thus rather than new technology, new pedagogies, new evaluations, and so forth, the educational project of the future is the creation of new, deliberately developed teen subcultures that will support lifelong happiness and well-being.

Thus it is not so much that public schools per se are causing mental illness. But their existence and dominance are preventing the evolution of a better system much as the existence and dominance of the Soviet Union prevented the evolution of an innovative technology sector. We need an innovative humanities sector to address the behavioral health crisis coming our way. It must be based on radical freedom to create new systems of education and new subcultures of well-being.

What will they look like? We don’t know. But if you’d like to explore ten school designs that are “eye-poppingly liberating to the pedagogical imagination” (in the words of the poet Fred Turner), please do so. And improve upon them. And allow them. Let’s get started now.

Footnote on genetics and depression, added June 2019:

A recent paper acknowledges that depression is moderately heritable,

“Major depressive disorder (hereafter referred to as“depression”) is moderately heritable (twin-based heritability,∼37%”

But this same paper goes on to show that previous research claiming that there was a “depression gene” was simply false. Scott Alexander of Slate Star Codex suitably summarizes this paper and why it conclusively refutes all of the previous studies claiming that a “depression gene” exists ( 5-HTTLPR, referred to below, is the serotonin transporter gene often regarded as the depression gene),

“While psychiatrists have been playing around with samples of a few hundred people (the initial study “discovering” 5-HTTLPR used n = 1024), geneticists have been building up the infrastructure to analyze samples of hundreds of thousands of people using standardized techniques. Border et al focus this infrastructure on 5-HTTLPR and its fellow depression genes, scanning a sample of 600,000+ people and using techniques twenty years more advanced than most of the studies above had access to. They claim to be able to simultaneously test almost every hypothesis ever made about 5-HTTLPR, including “main effects of polymorphisms and genes, interaction effects on both the additive and multiplicative scales and, in G3E analyses, considering multiple indices of environmental exposure (e.g., traumatic events in childhood or adulthood)”. What they find is…nothing. Neither 5-HTTLPR nor any of seventeen other comparable “depression genes” had any effect on depression.

I love this paper because it is ruthless. The authors know exactly what they are doing, and they are clearly enjoying every second of it. They explain that given what we now know about polygenicity, the highest-effect-size depression genes require samples of about 34,000 people to detect, and so any study with fewer than 34,000 people that says anything about specific genes is almost definitely a false positive; they go on to show that the median sample size for previous studies in this area was 345. They show off the power of their methodology by demonstrating that negative life events cause depression at p = 0.000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001, because it’s pretty easy to get a low p-value in a sample of 600,000 people if an effect is real. In contrast, the gene-interaction effect of 5-HTTLPR has a p-value of .919, and the main effect from the gene itself doesn’t even consistently point in the right direction. Using what they call “exceedingly liberal significance thresholds” which are 10,000 times easier to meet than the usual standards in genetics, they are unable to find any effect. This isn’t a research paper. This is a massacre.”

Depression is not simply genetic or biochemical. If you happen to be one of those readers who had been convinced by that line of research, adjust your priors. The environment matters.