Anxiety and depression is spiking among young people. No one knows why.

State and local governments across the country are scrambling to find new strategies to slow an epidemic of kids’ mental illness that exploded during the pandemic.

But there’s a problem: No one knows what’s causing the spike. Even after the isolation and fear Covid wrought dissipated, levels of anxiety and depression remain sky high.

Governments are forging ahead anyway, conducting a nationwide experiment in whatever ideas seem promising. That could ultimately help determine what works and save a generation. But some who treat children worry the lack of evidence to support many of the approaches threatens to waste time and money — or could even make matters worse.

Across interviews with nearly 30 policymakers, care providers and advocates over six months, as well as responses to a POLITICO survey of 1,400 health professionals, the desperation driving the experimentation is palpable.

“There is no way we can treat our way out of this,” Dr. Ashwin Vasan, commissioner of New York City’s health department, said. “A lot of things are being tried, and not all of it will pan out.”

That fact shouldn’t stop U.S. leaders from acting, he said.

“If we don't act now,” he said, “these are young people that are going to deal with mental health problems the rest of their lives.”

So many patients in mental crisis, often not old enough to drive, are going to the ER that it’s slowing care for everyone. Health systems have created new facilities to handle the load. And many kids aren’t receiving care at all. More than one in five high school students seriously considered suicide in 2021, according to the Centers for Disease Control and Prevention.

And the health system is at times buckling under the load. Of the nearly 1,400 health providers who responded to POLITICO’s questions about the state of treating mental health care, 56 percent were dissatisfied or very dissatisfied with their ability to treat kids.

Initiatives like free online therapy for all teens in a region, new K-12 curricula on handling stress, investing in institutions that cultivate community, adding suicide hotline numbers to student IDs and taking social media companies to court are among the straws being grasped in states and cities.

That’s out of a recognition that the traditional policy solutions to treat mental illness, including training more doctors and therapists and reducing barriers to care, aren’t going to work — the case load would overwhelm even a well-funded health system, care providers and policymakers agree.

That has left local, state and federal authorities to try new ideas to figure out what’s driving the problem.

Theories are plentiful. Depending on the researcher, doctor, therapist, lawmaker or business leader who’s talking, the epidemic level of children and teens’ mental illness is caused by loneliness, social media, the opioid-fueled destruction of families, social isolation from smartphones, climate change’s existential threat, political rancor, overactive parenting, phone-induced sleep deprivation, long Covid, the decline of churches and other social institutions, bad diets or environmental toxins.

Definitive answers, and therefore proven solutions, are few.

Understanding the causes of the crisis is “one of the million-dollar questions,” said Dr. Sunny Patel, senior adviser for Children, Youth and Families at the federal government’s Substance Abuse and Mental Health Services Administration — echoing a host of other policy and health leaders who were interviewed for this article.

“We've moved beyond the navel-gazing around identifying what the issues are,” Patel said. “This is an acute-on-chronic crisis.”

But the rush has some who treat children worried about wasting effort on unproven theories that won’t pan out or, worse, may exacerbate the problem.

“We shouldn’t let our practice get ahead of the evidence,” Dr. Darby Saxbe, clinical psychologist and professor of psychology at the University of Southern California, said — adding she worries the scattershot of new ideas could be “more like a Band-Aid and less like something that's really going to be meaningful.”

Thinking outside the clinic

Since 2020, over 100 state laws have been passed to address the depression, anxiety and suicide rates that policymakers feared would be exacerbated by the pandemic.

Seemingly nothing is off the table: printing crisis hotlines on student IDs, offering mental health days, teaching mindfulness in class, loosening telehealth restrictions, funding new kinds of mental health clinics. In some cases, states have appointed boards to get a handle on what’s happening and suggest or implement initiatives to change it.

Local governments are getting involved, too. New York City, for example, released an ambitious mental health agenda that included a $12 million investment in tele-therapy, as well as community suicide prevention programs and new initiatives for hospitals treating mental health patients.

“This is, in a lot of ways, kind of new,” Vasan said of the “whole-population approach” that the city has taken, instead of its earlier strategy, which focused on access to care for those suffering most.

Some state governments have looked to open health services for mental illness in schools, bringing in funding, staff and rules for how students can be treated in the place they’re spending much of their time.

Health policymakers are in some instances pushing schools to be a major new site of care for mental health concerns, with the aim of improving accessibility where it was lacking in the traditional system. Those efforts are growing even as educators and parents are sounding the alarm about the growth of chronic absenteeism among students post-pandemic — and as researchers consider the connection between missing class and mental illness.

“Schools are akin to what primary care functions for adults,” said Patel, noting the education system was “a major place of investment” for the administration.

And school-based programs to infuse more meaning and connection or teach strategies for resilience and emotional well-being are among the strategies to get a handle on the crisis.

Schools have implemented curricula to keep students from developing severe anxiety or depression — sometimes teaching mindfulness skills or drawing on cognitive behavioral therapy.

“We also have a real opportunity to extend mental health literacy for all and equitable access for all,” said Dr. Zainab Okolo, senior vice president of policy, advocacy and government relations at the The Jed Foundation, an organization that works toward the emotional well-being of young people.

But it’s not just schools. The internet — as much as it is often blamed for causing the crisis — is becoming another new site of care for kids.

New York City, for example, has been enacting a slate of policies as part of its mental health plan, including free virtual therapy for every teen under 18 in the city.

Talkspace, the company partnering with the city, has worked toward similar partnerships across the country, with its executives saying the ability to scale a solution could make it appealing to nearly all jurisdictions.

“The only barrier is getting people to know about it,” said Dr. Jon Cohen, the CEO of Talkspace.

Lawmakers find the solution appealing, too, keeping the telehealth rules that were loosened through the pandemic through the end of the year. The new, less regulated system could be here to stay, with some lawmakers looking to make the post-pandemic approach permanent.

And some want to go further, especially to allow therapists to practice across state lines, even if they aren’t licensed in each state in which they have patients.

Former Ohio Gov. John Kasich, who described the current interstate licensure requirements as “stupid,” is working with the Bipartisan Policy Center’s new mental health and substance use task force on that issue “aggressively.”

“At least if you have a therapist and you move that you get to keep your therapist — that might be the start of this thing,” he said.

But some experts are skeptical of the number of new initiatives and the speed with which they’re being embraced.

Some research suggests, for instance, that some of the mental health curriculum in school hasn’t helped — and in some cases, hurt — student outcomes. And government auditors who assessed one state’s curriculum change, granted anonymity to discuss the inner workings of their review, said schools were implementing the policy differently — adding that it’s unclear whether mental health is improving.

It’s not just for school curriculum: Government leaders behind many of the programs acknowledge they don’t have enough data to identify the causes of the crisis.

Concerns about online-based solutions also exist. Some clinicians who spoke with POLITICO shared an uneasiness about the total embrace of online mental health products, saying the in-person connection can be an important part of mental health care. But the bustling market of tech solutions seems to be only growing.

“It is really hard to suss out which of these tools and new little bobbles is really delivering clinically meaningful benefit,” said Julia Harris, who works on the Bipartisan Policy Center’s initiative.

Others don’t doubt the evidence supporting the new initiatives as much as they fear a scattershot approach won’t have much impact.

“There is a tendency to try to do everything,” Kasich said. “If you do everything, it's kind of like you're not going to do anything.”

Even so, many state and local governments feel they can’t wait amid the onslaught of despair in the next generation.

A trove of large, peer reviewed studies — which could validate or disprove the new approaches they’re in the midst of implementing — will take too long to develop, leaders argue. Some say relatively early research, which is quickly growing, or commonsense reasoning is enough to back the programs.

Vasan is among them: “I don't think we can afford to wait.”

Senators and school sports

In the basement of a Senate building last month, congressional staffers shuffled into their seats with boxed lunches and listened to researchers and advocates discuss what they believe to be driving the mental health downturn across the country.

Declining engagement with community, sports, art and nature likely play big roles, they said, a point echoed by policymakers at the event.

Sens. Alex Padilla (D-Calif.) and Thom Tillis (R-N.C.), co-chairs of the Senate Mental Health Caucus, joined the meeting, touting their bipartisan approach as a good sign for action on the issue.

“There’s no daylight between us in this space,” Tillis said.

He and Padilla seemed to agree with the researchers, acknowledging the need for new venues to get at the problem.

School-based programs are part of their approach, with the caucus leaders introducing legislation to make mental health grants more accessible for schools. Administration officials are laying what they believe to be the groundwork for an expanded mental health care system, from schools to clinics. Federal leaders across the government are looking to boost the mental health workforce to handle the high caseload, especially in places with shortages.

But leaders also see the mental health crisis as something that has as much to do with shifts in American society as it does with a health care system treating patients.

“We have to make sure that the amenities exist,” Tillis said of medical care, “but we all have a role to play in changing a culture.”

The new culture being imagined by Tillis and others includes more connection and community to not only treat mental health issues but keep them from developing in the first place.

That new, more comprehensive view of the crisis presents larger challenges for government solutions — demanding more than just cash for therapists and psychiatrists.

That has lawmakers concerned not only about how effective they can be in reversing the trends of millions of kids but also about how their own kids may fit into those statistics.

“I have colleagues who are very concerned about their children,” said Rep. Annie Kuster (D-N.H.), leader of the House’s youth mental health task force. “Everyone is involved.”

Kuster’s proposed solutions are also more expansive in another way: Tackling climate change — a point echoed by the Biden administration — and tamping down the political rancor could help put kids at ease about their future.

There may be a hint of guilt among some lawmakers for their roles — if not personally, then as part of an institution — in creating an America that many see as more cruel, less hopeful and ripe for despair.

Some clinicians have suggested depressed or anxious thoughts are natural, perhaps reasonable, responses to the existential threats future generations face. Others point to the need to reframe the conversation with an emphasis on the progress humanity has made up to this point.

Regardless of the framing going forward, young people feel uneasy about their future, said Jorge Alvarez, a youth mental health advocate who has taken young people’s perspectives to federal officials.

“The combination of climate change and the anxiety of just existing … [I’m] like, holy shit, things are not okay around me.”

A could-be renaissance for mental health care

“Overwhelmed” is a word that was regularly used by doctors, nurses, psychologists, psychiatrists and health system executives describing the state of mental health care in interviews and the survey data. Pediatricians who have little specialized training in behavioral health are inundated with patients with mental health concerns. And health system leaders are calling for a “moonshot” effort to treat mental illness.

It’s pushing the health system to look within for answers — some undergoing a renaissance in how they handle mental illness in young people.

“The overwhelming majority of what I do as a clinical pediatrician is address behavioral health needs,” said Dr. Benjamin Hoffman, president of the American Academy of Pediatrics. “If I identify a need, I cannot find a therapist for them.”

Because primary care clinicians have become the de facto front line of mental health care, a new approach has grown to use doctors as an extension of psychologists and psychiatrists. Generalists can be trained to triage and treat common concerns, sometimes consulting with or referring patients to specialists when needed.

This “integrated care” model often involves a brief but intense training — sometimes over a weekend — to get clinicians more specialized skills about how to handle behavioral health concerns.

“Not every kid needs to see a clinical psychologist,” said Dr. Lisa Hunter Romanelli, herself a clinical psychologist and CEO of the REACH institute, which promotes integrated models. “There are things that a pediatrician can help the child with.”

That sort of approach is taking hold, largely driven by demand for services.

“They all know me on a first-name basis because I’m on the phone with them so frequently,” Hoffman said of the behavioral health specialists he talks with.

Congress has taken an interest, with a bill that would further incorporate behavioral health in primary care advancing through the Senate Finance Committee late last year.

But integrating care isn’t the only approach: Some health systems, overrun with patients with depression and anxiety, are creating new facilities and systems to handle them separately. There are two benefits to separate systems, leaders believe: creating care environments that are better fitted to the needs of patients with mental illness and shielding an already stretched health system from additional strain.

Emergency facilities for just patients with urgent mental health needs have opened across the country, with hopes of reducing emergency room backlogs that, at times, have rivaled Covid surges, according to hospital leaders.

And the need goes beyond emergency services.

“There needs to be a lot more outpatient care,” said Michael Dowling, president and CEO of Northwell Health, one of the largest mental health care providers in New York. “I’m trying to raise money to build an adolescent mental health facility to deal just with adolescents and mental illness.”

That facility would provide both in- and outpatient care, he said, adding Northwell has tried to work more with the schools to get upstream of demand.

But providers, despite the changes they’re making, aren’t happy with the larger system they’re in.

“The reimbursement is a huge impediment because most of it is paid for by Medicaid,” said Dowling. “The more you do, the more money you lose. … From a business point of view, it's a loser, but it's something that we have to do.”

Concerns about pay, workloads and stress also undercut efforts to build up the mental health care system, especially to fill the gap in clinicians projected to be needed in the coming years.

“We don’t make it easy or attractive for providers to do the kind of work that we need them to do,” said Dr. Laura Erickson-Schroth, a psychiatrist and chief medical officer at The Jed Foundation.

But for Erickson-Schroth, the solution is both: Providers need new support, and policymakers need to look beyond the health care system.

“You have to start with taking a comprehensive approach,” she said. “If you don’t, I like to say, you’re playing whack-a-mole.”

Going to war online

State and federal lawmakers have also taken on big tech companies, hoping to limit access or better regulate kids’ use of their products.

Social media use has become a direct target of many policymakers, with most states suing Meta, owner of Facebook and Instagram, for its alleged role in fueling the crisis. Federal lawmakers have joined in, grilling leaders of the companies about their products’ effects on kids.

Some states are taking restrictions into their own hands, requiring parents to approve the creation of accounts for kids.

Though experts don’t agree on a single driver of the crisis or how to combat it, social media is consistently brought up by policymakers and researchers alike.

Those working with kids also note its importance in creating the current climate. Among the 1,400 clinicians surveyed by POLITICO, over a quarter said social media was “the biggest driver” of the mental health crisis.

Research connecting cell phone and social media use to the mental health epidemic continues to grow, and policymakers — like parents — are wondering how to loosen tech’s grip on the next generation.

The exact mechanisms by which social media seems to harm kids is more of a mystery. Clinicians notice children comparing themselves to their peers more when using the platforms, feeling they aren’t measuring up.

Huge sums of time are spent on the platforms — often instead of time with friends or time asleep, both crucial for mental well-being. And while some groups are taking community-building efforts online, hoping to use social media as a tool to encourage deeper connection, clinicians see mobile technology as often detrimental to kids.

With systems not always developed to process or cope with the information they’re taking in, mental health professionals say, kids are taking in more content, often by themselves, than perhaps any previous generation.

“It’s staggering,” said Erickson-Schroth. “That's really driving young people's distress — and it's causing them to have real fears about the future and the world that's being left to them.”

Youth advocates agree.

“I'll open up my feed and one video is someone dancing and then the next one is a global catastrophe,” said Alvarez. “It’s very dystopian at times.”

A deeper problem

But technology use may just be a growing symptom of a deeper problem.

Loneliness and isolation are plaguing children and teens, policymakers and researchers argue, a line of thinking that has come front and center in the surgeon general’s campaign to promote community.

Social isolation was among the top responses from clinicians surveyed by POLITICO when asked what is behind the mental illness epidemic.

“Digital devices maybe aren't inherently bad,” Saxbe said. “But I think the way that they pull us away from our connections with other people can be really bad.”

Some clinicians, even a few pill-wielding psychiatrists who largely focus on molecular changes in the brain, are now looking to society and culture to get at some of the root issues at play.

In their view, kids are suffering from a deficiency in connection — to each other, to nature, to religion, to community, to sources of meaning and fulfillment. Instead, they say, children and teens are being given cheap alternatives that corrode the foundations of well-being.

“You sort of get driven to think: Well, what we need here in order to move things in a better direction is some sort of cultural transformation — societal transformation,” said Dr. Benjamin Maxwell, chief of Child and Adolescent Psychiatry at Rady Children's Hospital-San Diego.

Maxwell, usually thinking about treating children in a formal health facility, envisions a more radical, all-encompassing solution for the crisis: "Where communities come back together, the human values that have been taught to kids for generations upon generations are being reinstilled into the next generation … to get people back to these things that we all know are important and we all know are missing from our lives.”

But that’s a tall order for a health system that has traditionally been seen as the solution to mental illness.

“They certainly didn't teach me in medical school how to create social or cultural transformation,” Maxwell said.

Policymakers are similarly perplexed by how to reverse a decade of cultural changes.

But there are efforts to begin building an alternative, policymakers said.

Fostering supportive, social environments for children and teens has become a goal for federal, state and local leaders — from the surgeon general to school leaders in Blaine, Idaho, where parents, teachers and community leaders work together to create and execute plans to make communities more supportive for kids with mental health concerns.

“We’ve got to think in terms of a team approach,” said Dr. Nerissa Bauer, a developmental-behavioral pediatrician who works with the American Academy of Pediatrics on its mental and emotional development policy.

She sees a future in which doctors, students, parents and communities at large create environments conducive to mental well-being.

“I want to broaden that conversation about treatment,” she said, looking beyond not just the people involved in caring for kids but also what exactly is considered care. “It’s everything else.”

Until then, Kuster suggests, kids may just need hope to get through this time.

“Hope is very powerful because it implies that your personal decisions can make a difference — and that your future can look bright even if this moment of despair feels very real,” she said. “That's partly what the ‘health’ in mental health is all about, is giving people a purpose and a reason to keep going.”