Tackling South Africa’s teen mental health crisis

October commemorates Mental Health Awareness Month. In acknowledgement of this there is a recognition that South African teens are facing a mental health crisis. Research by the Alan J Flisher Centre for Public Mental Health (CPMH) reveals alarming levels of depression and anxiety among adolescents in the Western Cape. Over 50% of 15- to 18-year-old adolescents experience elevated levels of depression symptoms, while more than 30% of adolescents aged between 10 and 14 are impacted.

Tackling this burden in a low-income setting is a challenge, but PhD candidates Mirriam Mkhize and Chesney Ward-Smith, both Sue Struengmann Fellows and based within the CPMH, have successfully tested interventions for depression and anxiety in low-income schools. This work offers a much-needed lifeline for these vulnerable age groups.

"What we are teaching here are social and emotional skills that these adolescents can use throughout their lives to manage and cope with stressful situations in a productive and healthy way."

EASE: Intervention for early adolescent years

As part of her PhD research Mkhize adapted and tested a World Health Organization (WHO) intervention called Early Adolescent Skills for Emotions (EASE) in the Western Cape. Unlike most mental health interventions EASE was specifically developed for use in low-and-middle-income countries and is targeted at adolescents aged 10 to 14 years along with their caregivers.

The programme comprises seven sessions for adolescents and three for caregivers. It teaches emotional regulation, behavioural activation as well as problem-solving strategies to reduce depression and anxiety.

Each session builds on the previous one, starting with understanding feelings and managing the physical responses caused by stress. Later sessions focus on strengthening behavioural activation skills such as identifying enjoyable and meaningful activities, as well as problem-solving skills to improve coping strategies for dealing with practical life challenges.

“What we are teaching here are social and emotional skills that these adolescents can use throughout their lives to manage and cope with stressful situations in a productive and healthy way,” said Mkhize.

Caregiver involvement is critical for this age group, as caregivers have an impact on their children’s emotional wellbeing. The caregiver sessions cover mental health education and strategies for self-care and stress management.

The intervention was tested in four Cape Town schools in group sessions with a total of 79 adolescents and 33 caregivers.

The adolescent #FeelThinkMove (#FTM) Programme

"We teach teens how to manage difficult feelings through practical, proven strategies, such as learning to strike a balance between the things you must do and the things you love to do."

The #FTM programme is a group-based emotion regulation intervention for older teens at risk of depression and anxiety. It was first designed for high-income countries but was later co-adapted by Ward-Smith and local teens to better suit the needs of 15 to 18-year-olds from low-income settings in South Africa. The programme was tested with 85 local adolescents in four Cape Town schools.

#FTM is unique in that it incorporates physical activity into every session, which is well-known for its positive effects on anxiety, stress and depression. The programme also takes an experiential approach to learning through role plays, skits and games, making it fun and engaging for teens.

The programme takes place over 10 sessions and is made up of five modules. #FTM integrates several evidence-based psychological strategies, such as cognitive behavioural therapy, mindfulness, and acceptance and commitment therapy, to help adolescents develop emotion-coping strategies to deal with life’s stressors.

“The intervention starts with teaching the teens how to relax their breathing and bodies,” said Ward-Smith. “Because you cannot function at your best if your body is in fight or flight mode.”

The sessions guide participants through a journey of learning to understand and accept difficult emotions and respond to them in productive and adaptive ways – using specific strategies.

“We teach teens how to manage difficult feelings through practical, proven strategies, such as learning to strike a balance between the things you must do and the things you love to do, engaging in healthy distractions, problem solving and learning how to shift how they think about things,” she said.

A resounding success

Both interventions proved to be highly feasible and acceptable as well as therapeutically promising. Participants who had previously reported anxiety and depression symptoms showed significant improvements in their mental health at follow-up assessments. They also reported higher self-esteem and stronger resilience to life’s pressures in the weeks and months after the interventions.

In their feedback after the interventions many of the adolescent participants noted the skills taught would be of value to all young people:

“[T]hey [the skills] are like an amazing addition. If a school had to incorporate these lessons, most students would actually have a coping mechanism in case they're [under] serious stress and need to think [through their options] without making the wrong decision. So, in general, I think these skills are very helpful,” wrote one male participant in the 15-to-18-year group.

In the younger group the feedback was equally positive from both adolescents and caregivers. One caregiver noted that learning how to treat her child, how to talk to him rather than screaming at him or spanking, was very valuable.

While one adolescent in the group noted: “I learned how to calm myself down and control [my] anger. So, I was using the skills when I was alone.”

Non-governmental organisations have begun to implement both these CPMH interventions, including Community Keepers, who seek to build a culture of well-being in schools, and Students for a Better Future who thrive and access extraordinary futures.

A rewarding age group

For Mkhize and Ward-Smith collaborating with teens to enhance their mental health has been rewarding.

“Intervening to address anxiety and depression at an early age can have an incredible impact,” said Mkhize, whose intervention targeted the 10- to 14-year-old adolescent category. With mental health conditions often emerging by age 14, early intervention is crucial.

Adolescents, particularly from low-income settings, are often not treated for mental health conditions, despite mid-adolescence being the peak age of onset for these conditions. Group interventions like EASE and #FTM offer powerful opportunities to build a strong mental health foundation.

Ward-Smith added: “Adolescents are at a stage where even small interventions can make a big difference. Once they lower their defences and start to trust, there's significant potential for positive change.”