Scalable Mental Health Interventions for Children and Adolescents

Psychology PhD students from Stony Brook University working in the Schleider Lab for Scalable Mental Health discuss what factors and challenges policymakers need to take into account and overcome when looking at rolling out interventions.

Mallary Dobias and Jenna Sung

Why do we need scalable interventions?

Mental health care was inaccessible before the global coronavirus pandemic. In 2014, only ~39% of English adults with symptoms of a common mental disorder reported current use of mental health treatment. For decades, structural and individual-level barriers have maintained a gap between treatment need and treatment access, including: high costs for services, lack of insurance coverage, insufficient childcare, constraints on time, and mental health-related stigma. Many youth avoid disclosing thoughts of suicide or self-harm to others, for fear of nonconsensual disclosure to caretakers or forced hospitalization. Even among people who decide to seek help, provider shortages often mean delaying or foregoing care. Those who access some form of support often discontinue care prematurely or miss their scheduled appointments.

COVID-19 has exacerbated the unmet need for mental health services, as new barriers have emerged alongside existing barriers to treatment—at a time when many people experienced an increase in their mental health-related symptoms. Social and economic inequity also guarantees that pandemic-related stressors (severe illness, hospitalization, death, economic strain, job loss, housing insecurity) hit people with minoritized racial/ethnic identities and sexual and gender identities harder than wealthy, white, cisgender and heterosexual people. These stressors, plus an already-too-limited pool of mental health providers, make it especially difficult for many to access effective and consistent mental health care. Limited, expensive treatment options ensure that access to mental health services remains inequitable and rare.

Despite decades of research on the inaccessibility of mental health care, many mental health treatments are designed and implemented in ways that ignore real barriers to receiving support. Few people have the time and resources necessary to consistently attend 12–16 weeks of in-person sessions during school or work hours; other treatments are delivered over the course of 4 or more months—often using multiple, resource-intensive components (individual therapy, group therapy, family therapy, and phone coaching) each week. These models of intervention play a crucial role in improving mental health among those who can access them. However, long-term, once-weekly (or more), and in-person therapy cannot be our only model of providing mental health support given the scale of unmet need. More than ever, people need accessible and scalable options to support their mental health.

What is a scalable mental health intervention?

Scalable mental health interventions are broadly defined as interventions designed for accessibility, given the reality of treatment barriers. For example, scalable interventions may choose to prioritize brevity (given limited time), flexible modality (given constraints on transportation and childcare), and/or anonymity (given fears of disclosure).

Some scalable interventions prioritize brevity by delivering in-person, condensed mental health treatment from a trained mental health provider. Condensed treatments require fewer weeks of travel/availability, and they can help providers quickly reach people when waiting lists are especially long. However, even abbreviated in-person mental health care requires access to transportation and scheduling availability to travel.

Treatments that are flexible in their modality (telehealth interventions, interventions delivered by lay providers, interventions integrated within existing educational or healthcare systems, digital interventions) can meet the needs of various treatment seeking populations. Scalable interventions with flexible modalities address barriers related to transportation needs, schedule constraints, and limited provider availability. Given that traditional models of psychotherapy are resource-intensive for providers and institutions (e.g. specialized training for providers, maintenance of extensive supervision, etc.), flexible modality interventions can be implemented in non-traditional settings like primary care and schools to accommodate already overburdened, resource-limited systems.

Finally, one type of scalable intervention—single-session interventions (SSIs)—can prioritize each of the three principles (brevity, flexible modality, and anonymity). SSIs are brief interventions designed to make the most of a single interaction. Decades of research suggest that SSIs can help improve a variety of mental health symptoms, and more recent research suggests SSIs may help improve youth mental health symptoms even during the COVID-19 pandemic. SSIs can be delivered using multiple modalities (e.g., in-person, teletherapy, and digital self-guided support). People on waiting lists for outpatient psychotherapy rate SSIs as acceptable when administered by trained therapists (in-person and virtually); similarly, self-guided and digital SSIs are effective in supporting teenagers and parents. Digital SSIs can also be made anonymous for those wishing to seek support without identifying themselves. Importantly, while they can be effective as standalone supports, SSIs are meant to complement and extend (not replace) existing mental health infrastructure to better reach people.

How can policy power the dissemination of scalable mental health interventions?

The potential for policy to promote the use of scalable mental health interventions is excitingly boundless. Here, we will discuss a few concrete ways policy can facilitate the dissemination and implementation of these new models of treatment for youth.

While the potential and benefits of scalable interventions can be maximized in resource-limited systems, the implementation efforts in these settings have been met with several challenges. As school is already a large part of youth’s lives, the school system is a prime place to reach children and adolescents and implement early identification and intervention. Globally, schools are already providing many psychosocial supports such as providing school-based counseling and special accommodations for students with higher needs. However, many of these approaches require burnt out school psychologists, on average one school psychologist is serving 1381 students, to add to their responsibilities. Thus, advancing policy that supports the deployment of digital, self-guided scalable interventions that can be administered to the entire student body at once can allow students to access mental health services without stretching the resources that are already limited. Additionally, policymakers should consider ways to help incentivise schools to integrate scalable interventions (e.g., embedding treatments into course material directly, developing infrastructure to support programming).

Integrating scalable interventions in primary care or emergency room settings has been another unique avenue to capitalize on the strengths of scalable interventions. Primary care clinics in particular are the first line of providers to identify mental health difficulties for youth; however, most providers lack the resources to provide psychological services directly or even provide referrals. Despite the benefits the integration of scalable interventions in medical care models would have, the integration has been difficult due to a lack of reimbursement structures in place for non-traditional mental health interventions. Understandably, the lack of insurance reimbursement codes or payment models make it unsustainable for providers to implement scalable mental health interventions. Advocacy for policies that can push this agenda forth is essential to the success of embedding scalable mental health interventions beyond labs and into real-world settings.