As health care professionals delivering care to girls and adolescents, we must first be aware of the serious and important role played by mental health within this group of patients, with the goal of early detection of those who are vulnerable and at risk.

The hormonal and biological changes associated with puberty make the adolescent period a time of profound psychological and social transformation. The social world and peer interactions become increasingly important. The adolescent spends more time with peers than with their family and form more complex peer relationships. The importance of obtaining peer social approval increases and peer influence is heightened.

Gynecologists may be the only health care professional having a consultation with the adolescent and this provides a tremendous opportunity to address not only gynecologic problems and disease, but also the psychosocial determinants of health.
During consultation, all healthcare providers need to create opportunities to develop life skills and provide health services with safe and supportive environments. Gynecologists should develop skills to create a safe, nonjudgmental and supportive environment during consultation. The use of widely available screening tools allows for early detection of those who are at risk, permitting referral for supportive care, early interventions and management of mental health concerns. Mental health care professionals could also be trained primary care providers. The high frequency of mental health disorders and their associated negative consequences on reproductive health, render them a major health priority compared to other childhood chronic health conditions, such as obesity and asthma. Therefore, this document is a call for action for scientific societies, policy makers, professional associations, and providers of care for girls and adolescents globally to address mental health needs of girls and adolescents.

Global perspective of Mental Health Disorders

Globally, 10-20% of children and adolescents are affected by mental health disorders. This is equal in low, middle, and high-income countries. The prevalence of diagnosed mental health disorders across the world has increased, with three quarters of mental health disorders now identified before the age of 25. The worldwide prevalence of anxiety disorders in children and adolescents has been reported to be 6.5%, any depressive disorder 2.5%, attention-deficit hyperactivity disorder 3.4%, and any disruptive disorder 5.7%. The association between mental health disorders and suicide is well established. Some key problems that directly relate to teenage depression and anxiety are suicidal thinking (or behavior), and substance abuse. Teenagers who hide their depression and anxiety from parents and friends are at greater risk, and healthcare providers should be alert of these disorders, and their signs. Health providers should screen teenagers for signs of depression and suicidality privately to obtain as much accurate information, just as for sexual health and substance abuse.

Suicide is a global public health problem. Close to 800 000 people die by suicide every year. This equates to one person every 40 seconds. Suicide occurs in all regions of the world. Indeed, 79% of global suicides happen in low- and middle- income countries. More important worldwide, it is the second leading cause of death amongst 15-29 year-olds. The association between suicide and mental disorders is well established.

Many suicides happen impulsively in moments of crisis. A previous suicide attempt is the strongest risk factor for suicide. Other risk factors include experience of loss, loneliness, discrimination, a relationship break-up, financial problems, chronic pain and illness, (gender-based) violence, (domestic) abuse, and conflict or other humanitarian emergencies.

In the scientific literature, the evidence indicates that transgender adolescents have elevated rates of suicidal ideation and attempt compared with cisgender adolescents. Future research examining adolescent suicidality should also include transgender adolescents, so that the mechanisms of suicidality among transgender adolescents will be explained, helping to inform future intervention and prevention strategies designed to reduce suicidality within this vulnerable population.

How are mental health issues in adolescents affecting gynecological health?

The menstrual cycle can be used as a vital sign, not only for hormonal and medical conditions but also as a window into the psychosocial and mental health of adolescents. It is both affected by psychosocial stressors and at times directly affects the mental health of adolescents. Anovulation, which is common in normal adolescence and visible as menstrual cycle irregularity, can all be triggered by eating disorders or malnutrition, sleeping disorders or a stressful environment. In addition, heavy menstrual bleeding and painful cycles can interfere with school and social activities that can affect mental health. Depression and anxiety increase the perception of pain. In adolescents this may be manifest as severe dysmenorrhea or chronic pelvic pain, especially in girls who have a history of physical or sexual abuse.

Normal adolescence may be a time of risk taking, however adolescents with major
psychosocial stressors and/or mental health issues may engage in acting-out
behavior or substance use, which increases their risk of unsafe sexual behavior. This increases the risk of unplanned pregnancy or a sexually transmitted infection. These risks are augmented in teens thar are neglected or abused.

While most gynecologists are not comfortable treating psychosocial and mental
health issues in adolescents, providing a point of detection and referral, as well as a supportive environment and management of gynecologic sequelae is within the
scope of practice. Asking about trauma and abuse and referring to appropriate
authorities and counselors should be routine part of practice. Recommending the
use of long acting reversible contraceptives (LARCs), frequent sexually transmitted
infection (STI) screening, and encouraging condom use in girls with high risk sexual behavior can provide a safety net until better decision-making skills are developed. Finally, for girls with significant psychiatric illness, the gynecologist should be aware of the side effects of some psychiatric medications such as antipsychotics like oligomenorrhea and hypoestrogenemia induced by elevated prolactin.

What did COVID-19 bring to this issue?

The Covid-19 pandemic has aggravated and accentuated the issue of mental health in adolescents as it has affected them socially, academically, and emotionally, and for many, generating a large negative impact that cannot be fully appreciated at this point of time.

In this global pandemic, an adolescent’s individual, familial, and social vulnerability, as well as individual and familial coping abilities, impact upon resilience and risks for long-term mental health.

Consequences of the Covid-19 pandemic have included extended home confinement, virtual education and deprivation of social interaction, intrafamilial violence and overuse of the internet and social media. All these factors can influence the mental health of the adolescents.

Besides previously recognized risk factors for poor mental health such as abuse and trauma, increased reliance on virtual education resulting in social isolation, as well as pressure from and social media may be leading to increased depression and anxiety.

Young people’s use of social media results in less face to face communication, overdependence on being “liked” for social validation, shaming by peers over appearance or behavior, and even pressure to keep up with discussion for 24 hours leading to impaired sleep. Girls are more vulnerable to the negative effects of social media than boys.

Closing remarks

All providers of reproductive health services caring for adolescents should take into consideration the role of the psychosocial determinants of health, and should utilize tools and skills to screen for mental health issues, and timely refer adolescents detected at risk.

Call to action

1. Screen adolescents for major psycho social stressors and mental health issues that affect reproductive health, and be able to refer adolescents in a timely manner for help.
2. Promote the development of enhanced mental health services. Despite global recognition of the importance of mental health promotion and prevention in children and adolescents, a gap remains between need and available resources.
3. Include education and training in gynecology society meetings on identification and management of psychosocial determinants of health, especially as they affect gynecologic health.
4. Recognize the long-term impact of Covid-19 on the mental and reproductive health of adolescents.

14 March 2021

This advocacy statement has been endorsed by:
FIGO (International Federation of Gynecology and Obstetrics),
RCOG (Royal College of Obstetricians and Gynaecologists), and
EBPCGO (European Board and College of Gynaecology and Obstetrics).