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Developing Solid Measures for Mental Health Will Improve the Health and Well-Being of Young People Throughout the World

      With this issue of the Journal of Adolescent Health, we are fortunate to bring our readers a supplement that focuses exclusively on mental health, one of the most critical health issues for adolescents, young adults, and their families. Developing a better understanding of the mental health needs of adolescents and young adults through data will help us advance evidence-based prevention and treatment programs. The momentum that we discussed in our introductory editorial launching this supplement in 2021 [
      • Carvajal L.
      • Requejo J.H.
      • Irwin C.E.
      The measurement of mental health problems among adolescents and young adults throughout the world.
      ] is stated explicitly by Kabiru and Blum in their editorial accompanying this supplement: “The inclusion of the goal specific to mental health in the United Nations Sustainable Development Goals is an important inflection point because it marks the first time that mental health is acknowledged by the global community as a cornerstone for national development” [
      • Kabiru C.
      • Blum R.W.
      Strengthening the measurement of adolescents’ mental health at the population level.
      ].
      It is often stated that what gets measured gets done! This guiding principle is the foundation for this supplement, where 17 original articles, commentaries, and protocols for measurement point us to a better understanding of how to improve the health and wellbeing of adolescents through gathering population specific data [
      • Erskine H.E.
      • Enright M.E.
      • Blondell S.J.
      • et al.
      Core principles of international research: Lessons from the national adolescent mental health surveys.
      ,
      • Guthold R.
      • Carvajal L.
      • Adebayo E.
      • et al.
      The importance of mental health measurement to improve global adolescent health.
      ,
      • Hayes J.
      • Carvajal L.
      • Hijazi Z.
      • et al.
      You can’t manage what you do not measure - Why adolescent mental health monitoring matters.
      ,
      • Verhulst S.
      • Vidal Bustamante C.M.
      • Carvajal L.
      • et al.
      Toward a demand-driven, collaborative data agenda for adolescent mental health.
      ,
      • Azzopardi P.
      • Hijazi Z.
      • Wulan N.
      • et al.
      Bringing a wider lens to adolescent mental health: Aligning measurement frameworks with multisectoral actions.
      ,
      • Carvajal-Velez L.
      • Requejo J.H.
      • Ahs J.W.
      • et al.
      Increasing data and understanding of adolescent mental health worldwide: UNICEF’s measurement of mental health among adolescents at the population level initiative.
      ,
      • Carvajal L.
      • Ahs J.W.
      • Requejo J.H.
      • et al.
      Measurement of mental health among adolescents at the population level: A multicountry protocol for adaptation and validation of mental health measures.
      ,
      • Carvajal L.
      • Ottman K.
      • Ahs J.W.
      • et al.
      Translation and adaptation of the revised children’s anxiety and depression scale: A qualitative study in Belize.
      ,
      • Carvajal L.
      • Ahs J.W.
      • Lundin A.
      • et al.
      Validation of the Kriol and Belizean english adaptation of the revised children’s anxiety and depression scale for use with adolescents in Belize.
      ,
      • Marlow M.
      • Skeen S.
      • Grieve C.
      • et al.
      Detecting depression and anxiety among adolescents in South Africa: Validity of the patient health questionnaire-9 and generalized anxiety disorder-7.
      ,
      • Tele A.
      • Carvajal-Velez L.
      • Ahs J.W.
      • et al.
      Validation of the English and Swahili Adaptation of the PHQ-9 for Use Among Adolescents in Kenya.
      ,
      • Erskine H.E.
      • Blondell S.J.
      • Enright M.E.
      • et al.
      Measuring the prevalence of mental disorders in adolescents in Kenya, Indonesia, and Vietnam: Study protocol for the national adolescent mental health surveys.
      ,
      • De Castro F.
      • Cappa C.
      • Madans J.
      Anxiety and depression symptoms among adolescents in 26 low- and middle-income countries: Prevalence and association with functional difficulties.
      ,
      • van den Broek M.
      • Hegazi L.
      • Ghazal N.
      • et al.
      Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.
      ,
      • Pavarini G.
      • Booysen C.
      • Jain T.
      • et al.
      Agents of change for mental health: A survey of young people’s aspirations for participation across five low- and middle-income countries.
      ,
      • El Omrani O.
      • Carmen V.A.
      • Bionat J.F.
      • et al.
      COVID-19, mental Health, and young people’s engagement.
      ,
      • van der Westhuizen C.
      • Carvajal-Velez L.
      • de Carvalho Eriksson C.
      • et al.
      Implications for mental health promotion and prevention interventions: Findings from adolescent focus group discussions in Belize, Kazakhstan, and South Africa.
      ]. With this information, policies and programs can be targeted to improving the health and wellbeing of young people.
      Three commentaries lead the supplement and identify reasons for the limited availability of data on adolescent mental health [
      • Erskine H.E.
      • Enright M.E.
      • Blondell S.J.
      • et al.
      Core principles of international research: Lessons from the national adolescent mental health surveys.
      ,
      • Guthold R.
      • Carvajal L.
      • Adebayo E.
      • et al.
      The importance of mental health measurement to improve global adolescent health.
      ,
      • Hayes J.
      • Carvajal L.
      • Hijazi Z.
      • et al.
      You can’t manage what you do not measure - Why adolescent mental health monitoring matters.
      ]. These include the lack of age-specific tools with standardized measures that reflect the rapid biological and psychosocial changes of the second decade of life; the lack of coordination among agencies, organizations, and regions of the world; the lack of monitoring surveys focused on youth; and the lack of resources for research on mental health. Erskine et al. go on to describe the launching of a new survey that builds on the unique characteristics of adolescents in low-income and middle-income countries (LMICs), the National Mental Health Surveys [
      • Guthold R.
      • Carvajal L.
      • Adebayo E.
      • et al.
      The importance of mental health measurement to improve global adolescent health.
      ].
      As a first step to ensuring relevant data on adolescent mental health, Verhulst et al. [
      • Verhulst S.
      • Vidal Bustamante C.M.
      • Carvajal L.
      • et al.
      Toward a demand-driven, collaborative data agenda for adolescent mental health.
      ] propose a list of research priorities based on a highly collaborative, multisectoral consultative approach. These priorities align with the conceptual framework of Azzopardi et al., which situates adolescent mental health in a broader socioecological environment [
      • Azzopardi P.
      • Hijazi Z.
      • Wulan N.
      • et al.
      Bringing a wider lens to adolescent mental health: Aligning measurement frameworks with multisectoral actions.
      ]. Azzopardi's framework includes addressing the structural determinants of adolescent mental health, prevention of mental health in the immediate social context of where young people live, accessible responsive healthcare to address mental health problems and disorders, and improved strategies for embedding adolescent mental health in normative settings.
      In an effort to launch new mental health measures and approaches to LMICs, the supplement provides new and adapted existing measures for identifying and measuring a broad range of mental health conditions. Carvajal-Velez, Requejo et al. describes the Measurement of Mental Health among Adolescents at the Population Level (MMAP) initiative that is developing tools for use at the population and clinical levels [
      • Carvajal-Velez L.
      • Requejo J.H.
      • Ahs J.W.
      • et al.
      Increasing data and understanding of adolescent mental health worldwide: UNICEF’s measurement of mental health among adolescents at the population level initiative.
      ]. Building on this initial work, Carvajal-Velez, Ahs et al. expands the protocol with cultural adaptation and clinical validation of the MMAP tools in four LMICs [
      • Carvajal L.
      • Ahs J.W.
      • Requejo J.H.
      • et al.
      Measurement of mental health among adolescents at the population level: A multicountry protocol for adaptation and validation of mental health measures.
      ]. Four unique articles on the MMAP initiative, including Carvajal, Ottman, et al., Carvajal, Ahs et al., Marlow et al., and Tele et al., report on the transcultural translation, adaptation, and validation of well-established measures such as the Revised Children's Anxiety and Depression Scale, the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7–item (GAD-7) scale [
      • Carvajal L.
      • Ottman K.
      • Ahs J.W.
      • et al.
      Translation and adaptation of the revised children’s anxiety and depression scale: A qualitative study in Belize.
      ,
      • Carvajal L.
      • Ahs J.W.
      • Lundin A.
      • et al.
      Validation of the Kriol and Belizean english adaptation of the revised children’s anxiety and depression scale for use with adolescents in Belize.
      ,
      • Marlow M.
      • Skeen S.
      • Grieve C.
      • et al.
      Detecting depression and anxiety among adolescents in South Africa: Validity of the patient health questionnaire-9 and generalized anxiety disorder-7.
      ,
      • Tele A.
      • Carvajal-Velez L.
      • Ahs J.W.
      • et al.
      Validation of the English and Swahili Adaptation of the PHQ-9 for Use Among Adolescents in Kenya.
      ]. These tools are essential for not only establishing the prevalence of disorders but also providing communities with opportunities for developing targeted preventive interventions for specific problems.
      Two unique studies capture data across more than 26 countries, including LMICs. The study reported by Erskine et al. highlights prevalence of the most common adolescent mental health disorders in three LMICs: Indonesia, Kenya, and Vietnam [
      • Erskine H.E.
      • Blondell S.J.
      • Enright M.E.
      • et al.
      Measuring the prevalence of mental disorders in adolescents in Kenya, Indonesia, and Vietnam: Study protocol for the national adolescent mental health surveys.
      ]. Also, de Castro et al., using Multiple Indicator Cluster Surveys in 26 countries, report that adolescents aged 10–17 years with functional disabilities and coexisting mental health problems were significantly more likely to present with symptoms of depression and anxiety than their peers [
      • De Castro F.
      • Cappa C.
      • Madans J.
      Anxiety and depression symptoms among adolescents in 26 low- and middle-income countries: Prevalence and association with functional difficulties.
      ]. These analyses of large datasets enable communities to identify special adolescent subpopulations where young people with disabilities may not be identified with mental health disorders.
      Van den Broek et al. provides a unique and important contribution to this supplement with its focus on expanding the workforce through the development of community-based approaches [
      • van den Broek M.
      • Hegazi L.
      • Ghazal N.
      • et al.
      Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.
      ]. With the high prevalence of mental health issues and the lack of mental health professionals, we need new options. Van den Broek et al. present results evaluating the accuracy of a modified Community Case Detection Tool implemented by community gatekeepers (teachers and community workers) to detect children and adolescents with significant mental health needs and encourage their families to seek help. Their results demonstrate that community gatekeepers using the Community Case Detection Tool are a promising strategy to bring care to a broader range of young people. It will be helpful to take this intervention to scale in different communities to identify the opportunities and limitations to this approach.
      The final three articles emphasize the importance of adolescent engagement in the design, implementation, and monitoring of the policies, services, and programs that affect their lives. Pavarini et al. reports on a survey assessing young people's aspirations for engagement and their perspectives on their roles in improving mental health services, the support they would need to enable them to make a difference, and the barriers they face [
      • Pavarini G.
      • Booysen C.
      • Jain T.
      • et al.
      Agents of change for mental health: A survey of young people’s aspirations for participation across five low- and middle-income countries.
      ]. The study reaffirms the value of peer-to-peer programs in schools and community settings and the need for mental health awareness programs that help young people understand mental health. This understanding would prepare them to be effective advocates for in mental health initiatives. El Omrani et al. and van der Westhuizen et al. underscore the value of ensuring that young people can be “equal stakeholders” in mental health responses, the need to ensure diversity in youth representation, and the value of qualitative analyses of focus groups to hear their voices [
      • El Omrani O.
      • Carmen V.A.
      • Bionat J.F.
      • et al.
      COVID-19, mental Health, and young people’s engagement.
      ,
      • van der Westhuizen C.
      • Carvajal-Velez L.
      • de Carvalho Eriksson C.
      • et al.
      Implications for mental health promotion and prevention interventions: Findings from adolescent focus group discussions in Belize, Kazakhstan, and South Africa.
      ].
      Taken together, the articles in this important supplement highlight four areas of future action. Kabiru and Blum summarize these four areas for future efforts to improve mental health measurement throughout the world [
      • Kabiru C.
      • Blum R.W.
      Strengthening the measurement of adolescents’ mental health at the population level.
      ].
      First, significant financial and human resources are needed to enhance the availability of valid, reliable, and comparable data on adolescent mental health.
      Second, efforts are needed to strengthen local capacity to generate, analyze, and use rigorous, disaggregated data on adolescent mental health conditions. Strengthened local capacity for adolescent mental health research ensures that research responds to local needs.
      Third, there is need to expand surveys that capture adolescents across the entire second decade of life and to include youth through the age of 24 years. Attention needs to be paid to especially vulnerable young people: those who are out of school, homeless, incarcerated, engaged with very high-risk behaviors such as commercial sex, and those with disabilities.
      Fourth, parents and other adult gatekeepers need to be fully engaged and understand that many mental health problems are the result of the environments and contexts in which young people live, including violence, abuse, gender inequality, interpersonal violence, and extreme poverty.
      In conclusion, these articles with their recommendations provide a blueprint for immediate action. We need to move forward with the data that we have in hand because adolescents, young adults, and families are waiting for us to provide the guidance to them.

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        The measurement of mental health problems among adolescents and young adults throughout the world.
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