Even before the COVID-19 pandemic, youth mental health was in decline. New results from the 2021 Youth Risk Behavior Survey (YRBS),¹ the first administered since the start of the COVID-19 pandemic, confirm what many had suspected: that youth mental health has declined again and the rate of decline even accelerated somewhat. Reflecting these concerns, the US surgeon general in 2021 released a public advisory warning of alarming increases in mental health challenges among youth and calling for a widespread response. While mirroring these national trends, new local data reveal even steeper increases in feelings of sadness among Boston Public School (BPS) students, especially among female; lesbian, gay, and bisexual (LGB); Black; and Latino students.

The YRBS is the nation’s largest public health survey designed by the Centers for Disease Control and Prevention (CDC) to monitor youth health behaviors and experiences that affect long-term health and social well-being related to violence and safety, mental health, sexual activity, diet, physical activity, alcohol, tobacco, and drug use. BPS administers the survey every two years to a sample of middle and high school students. As a large urban district, Boston has received funding from the CDC since 1993 to conduct the YRBS. Not all districts choose to administer the YRBS, which is why we aren’t able to compare Boston with other Massachusetts districts. State-level 2021 estimates, which are separately collected from a sample of schools from across the state, will be publicly available sometime in spring 2023. 

By some measures, Boston Public School students are doing fairly well. Substance use among BPS high schoolers has largely trended downward since the first YRBS survey was administered in 1993 and this trend continued in 2021. The proportion of students who drink alcohol has dropped from 40 percent in 1993 to 16 percent in 2021. Additionally, as of 2021, Black, Latino, and Asian high schoolers all had statistically significant lower rates of drinking alcohol and binge drinking than White students. Marijuana use steadily increased since 1993 but declined between 2019 and 2021, even though recreational marijuana is now legal for adults in Massachusetts. Heroin use has remained relatively constant since 1999,² but decreased at a statistically significant rate between 2019 and 2021 from 3 percent to 0.5 percent. On another measure, since 2005³ the rate of high schoolers who have been pregnant or gotten someone pregnant has steadily decreased and did so at a statistically significant rate between 2019 and 2021, from 6 percent to 2 percent.

Unfortunately, indicators of mental health from the YRBS are more unequivocally disturbing. On the YRBS a question about feelings of sadness and hopelessness serves as a proxy measure for depressive symptoms.⁴ Nationally, the rates of sadness are the highest reported in over two decades and the same is true for BPS students. In fact, the proportion of students reporting feelings of sadness increased at an even steeper rate for BPS students than for their peers nationally. Between 2019 and 2021, reports of feeling sad or hopeless increased by 9 percent among BPS high school students, while nationally this rate increased by 5 percent. Sadness among BPS high schoolers began increasing in 2015, and then made a statistically significant jump between 2019 and 2021. Among middle schoolers, reports of feeling sad or hopeless also increased by 9 percent.⁵

Some students are acting on those feelings of sadness by attempting self-harm. The rate of BPS high schoolers who reported doing something to hurt themself without wanting to die⁶ also increased at a statistically significant rate between 2019 (15 percent) and 2021 (19 percent). Self-harm can be a precursor to suicidality. However, since 1993, we’ve seen considerable decreases in reports among BPS high schoolers⁷ of seriously considering suicide (8 percent decrease), making a plan about how to attempt suicide (6 percent decrease), and actually attempting suicide (7 percent decrease). 

Middle school results are more concerning. Middle schoolers are reporting higher rates of suicidality than high schoolers and the rate of middle schoolers considering suicide is increasing at an alarming rate. In 2021, 28 percent of middle schoolers seriously considered suicide compared to 15 percent of high schoolers. Among middle schoolers this rate jumped from 23 percent in 2019. Thankfully, attempted suicides have actually decreased slightly between 2019 and 2021 among students in both middle school (11 percent to 10 percent) and high school (9 percent to 7 percent).

Bullying may be contributing to poor mental health among students, especially middle schoolers. Concerningly, rates of bullying are much higher among middle school students than high school students, with 37 percent of middle schoolers reporting ever being bullied on school property and 27 percent reporting ever being electronically bullied. Bullying among middle schoolers also seems to be shifting to online platforms, as bullying on school property dropped slightly from 40 percent but electronic bullying increased from 21 percent in 2019. High schoolers who said they were bullied on school property decreased from 11 percent in 2019 to 6 percent in 2021; however, electronic bullying remained constant at 9 percent.

While most demographic groups report increasing mental health challenges, females,⁸ LGB students,⁹ Black students, and Latino students were more likely than their counterparts to report negative experiences, particularly on indicators of sadness and sexual violence. 

Females and LGB youth are experiencing statistically significant higher rates of sadness and hopelessness than their male and straight counterparts, respectively.   

LGB youth and females are also faring worse on several other mental health and violence indicators—they were much more likely to report having done something to purposefully hurt themself, seriously considered suicide, made a plan about how to attempt suicide, or actually attempted suicide. LGB students seriously considered suicide at three times the rate of straight students and actually attempted suicide at nearly six times the rate of straight students. Female students seriously considered suicide and attempted suicide at rates roughly double that of male students.

Both groups reported being bullied and experiencing sexual violence at higher rates than their peers as well, which could have played a role in declines in mental health. Twenty-two percent of LGB students experienced sexual violence, compared to 5 percent of straight students. Fourteen percent of female students experienced sexual violence, compared to 5 percent of male students.

Racial gaps are not quite as large, but they appear to have grown a bit, especially for 2021¹⁰: 48 percent of Latino youth and 44 percent of Black youth reported feeling sad compared to 38 percent of White students and 33 percent of Asian students. Notably, Latino students have consistently reported feeling sad at higher rates as compared to all other races, which could be related to barriers limiting access to mental health services that affirm their cultural identity.

Black and Latino students also attempted suicide at higher rates than White and Asian students. Eight percent of Latino students and 7 percent of Black students have attempted suicide compared to 4 percent of White students and 2 percent of Asian students.

The 2021 survey was the first to include a measure of school connectedness with the question: “Do you agree or disagree that you feel close to people at your school?”. School connectedness is an important factor for protecting and improving many health outcomes, including mental health. When teens feel like they belong and are valued, they are more likely to be able to cope with adversity, anxiety, and depression.

Looking at the BPS 2021 results, we see that nearly half of high school students report not feeling close to people at their school. Notably, the same student demographic groups who reported feeling sad or hopeless at higher rates were less likely to report feeling connected to people at their school. LGB, female, Black, and Latino students reported not feeling close to people at their schools at statistically significant higher rates. It is likely that experiences of racism and other forms of prejudice and discrimination play a role in making these students feel less connected to their peers, further contributing to poor mental health.

What might be driving trends?

Mental health is complex, but while more research is needed, there are theories explaining these trends. While not an exhaustive list, below are a few leading theories about why youth mental health has been on the decline:

The COVID-19 Pandemic

Teen mental health was already on the decline, but the COVID-19 pandemic only made it worse. During the pandemic, quarantine, social distancing, and school closures were necessary to contain the disease. However, those measures also separated youth from their friends, teachers, and community networks, leaving them feeling lonely and less connected to people at their school. Remote learning during the pandemic may have also affected school connectedness and teen mental health, along with a prioritization of academic rigor over social-emotional well-being. The fear, uncertainty, and frustration around the disease and its restrictions touched youth and the adults around them, seeping into all the other factors listed here.

Smartphones and Social Media

Many point to smartphones and social media as factors leading to poor adolescent mental health outcomes prior to the COVID-19 pandemic. Social media is a major driver of poor mental health for girls especially. Constant comparison to unachievable standards presented to teens on social media takes a toll on mental health, making teens feel insufficient. Social media also has a tendency to give more attention to bad news, making everything seem dismal, and can also lead teens to substitute real-world relationships with digital ones that are less emotionally satisfying. Social media has been around for many years now, but the more recent ubiquity of smartphones makes it possible for teens to access the internet at all hours of the day and night and, has intensified the negative impacts of social media on their mental health.

Sleep Deprivation

It may sound inconsequential, but lack of sleep likely contributed to the recent trend of increased sadness. Sleep is an important factor in overall health and sleep deprivation can have significant consequences for youth mental health, physical health, academic success, and safety. It is recommended that teens get eight or more hours of sleep per night, but most teens don’t. The national YRBS shows that the rate of teens not getting a full eight hours of sleep on an average school night jumped 5 percent, a statistically significant rate, between 2013 (68 percent) and 2015 (73 percent). Since 2015 this rate has steadily increased. In 2021, 85 percent of BPS high school students didn’t get eight or more hours of sleep. With early school start times, hours of homework in the evening, and social media to catch up on, teens are getting less sleep and it’s likely taking a toll on their mental health. 

The World Is Stressful Place

Teens are aware of the world around them and it affects their mental health. For example, mass shootings have drastically increased in the United States over the past seven years, occurring at schools, grocery stores, churches, and other places where teens and their families live their lives on a daily basis. In the grand scheme of things, mass shootings are rare, but exposure to them through news and social media can chip away at a teen’s sense of safety and lead to elevated levels of anxiety and stress. There has also been more awareness of police violence against Black people, particularly since the killing of George Floyd in 2020. Research shows that these killings specifically have a heavy effect on mental health in Black communities, including among teens. Political polarization is another example of the impact of world events on teen mental health, with more Americans reporting the future of our nation is a significant source of stress than in previous years.

The confluence of stressors for young people in recent years has created a tidal wave of mental health concerns. The teen years are notoriously stressful even in the best of times, especially for those who feel marginalized, but these trends suggest that we cannot write off the current surge of negative mental health status among our youth as a mere variation of teen angst. And yet while these numbers are alarming, there’s hope that greater awareness of what constitutes compromised mental health in youth lets us recognize problems early and identify pathways to alleviate them.

---

1. Reports national trends for high school students only.

2. 1999 is the first year that data are available on heroin use.

3. 2005 is the farthest back rates of pregnancy are publicly available.

4. Exact question is “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?”

5. 2021 national middle school data is not yet publicly available, so not comparable.

6. An optional question that BPS adds to the high school survey only, so not comparable to middle school and national results.

7. Data for middle schoolers only date back to 2013.

8. Gender identity results are only disaggregated by female and male because the YRBS question about gender identity (sex) only offers female or male as response options. On the 2021 survey BPS added a separate question to assess transgender identity (“some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?”) but BPS preliminary data tables do not provide analysis of behaviors disaggregated by transgender identity.

9. Here we are referring to youth who identify as lesbian, gay, or bisexual. The “t” representing transgender identity that is often included with this acronym is omitted because results disaggregated by transgender identity are not yet available.

10. 2021 results for American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Multiracial students are not included here because they are not available on BPS’ preliminary data tables.