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Over the past two decades, there has been increasing international concern over the prevalence of mental health difficulties amongst children and young people. In the English context, particular concerns have been raised about the "state" of girls' and young women's psychological health. Figuring highly in both academic and media debate is the impact of school pressures and the performance demands placed on girls in relation to academic achievement. In this systematic review, we map the reported achievement-related factors affecting girls' mental health emerging from the peer-reviewed qualitative literature. Five databases were searched for literature published from 1990-2021. Additional search strategies included forwards and backwards citation chasing and hand searching. Eleven texts met our inclusion criteria. The themes of fears for the future, parent/family-related pressures, competitive school cultures, and gendered expectations of girls' academic achievement emerged from the located texts. It was when pressures were "imbalanced" and felt in the extreme that mental ill-health/anxiety was more likely to be experienced. We go on to introduce the theoretical model of the "mental health/achievement see-saw" and argue for its use as a conceptual tool to engage with deep-rooted complexities around the relationship between gender, mental health and academic achievement. We contend that the "see-saw" model has potential utility to academics, educational practitioners, and policy-makers, and might be usefully translated into practice in the form of biopsychosocial interpositions in schools that move beyond more surface-level attempts at mental health promotion and that seek to empower, de-pathologise and challenge entrenched structural inequalities.