A Deep Dive into CA’s mHealth Effort to Support Youth Mental Health

February 13, 2024 - As healthcare stakeholders attempt to stem the youth mental health crisis in America, many have turned to digital health technology. The latest to do so is the California Department of Health Care Services (DHCS), which has launched a statewide endeavor to get behavioral health applications in the hands of youth who need them the most.

Mental healthcare issues among American youth are on the rise. The proportion of high school students experiencing persistent sadness or hopelessness has grown from 28 percent in 2011 to 42 percent in 2021, according to the Centers for Disease Control and Prevention’s (CDC) most recent Youth Risk Behavior Survey. Further, the percentage of high school students seriously contemplating suicide jumped from 16 percent to 22 percent between 2011 and 2021.

“Nationwide, the rates of anxiety, depression, and self-harm amongst children and youth and young adults has been climbing,” said Autumn Boylan, deputy director of the Office of Strategic Partnerships at the California DHCS, in an interview with mHealthIntelligence. “This started many years ago and is not directly a result of the COVID-19 pandemic, but certainly, the pandemic worsened a trend that was already trending in the wrong direction for kids in terms of their behavioral health outcomes.”

While federal plans to improve mental health outcomes among American children and adolescents are critical, actions at the state level are equally important. In 2021, Governor Gavin Newsom launched the Children and Youth Behavioral Health Initiative (CYBHI) as part of his Master Plan for Kids’ Mental Health. The initiative, a five-year, $4.6 billion effort, aims to create an integrated system to address behavioral health issues and substance use disorders among youth in California.

A cornerstone of this initiative is DHCS’ newly launched Behavioral Health Virtual Services Platform, which provides two free behavioral health services apps for children and their families.

While making mHealth apps widely available can certainly help expand access to much-needed services and resources, these efforts must be appropriately targeted to boost behavioral healthcare outcomes, access, and health equity. 

YOUTH BEHAVIORAL HEALTH NEEDS IN CALIFORNIA

National behavioral health trends among youth are reflected at the state level in California. A study conducted by the University of California at Los Angeles shows that 29.3  percent of Californian adolescents reported symptoms that meet the criteria for serious psychological distress, while 15.7 percent reported symptoms of moderate psychological distress.

The study analyzed data from the 2019 California Health Interview Survey, which polls Californians on health outcomes.

The study also shows that sociodemographic factors significantly impact mental health outcomes. Nearly two-thirds of adolescents in families with incomes below the federal poverty level reported moderate to serious psychological distress, and adolescent females were 1.5 times more likely to report serious psychological distress than their male counterparts.

Further, 36.4 percent of adolescents who identified as gender-nonconforming reported serious psychological distress, as did 42.9 percent of those who self-identified as multiracial.

Amid this high prevalence of mental health issues among youth, there is a concerning lack of mental healthcare providers in the state.

“There just aren't enough licensed practitioners in the state to be able to meet the level of demand that, unfortunately, we're seeing amongst our kids,” said Boylan. “And the availability is further limited amongst uninsured populations, people of color, people of lower incomes, and people with disabilities.”

The mental health provider shortage also results in longer wait times when young people seek help.

Other major barriers to receiving mental healthcare are financial challenges and the ongoing stigma attached to seeking this type of care. However, the COVID-19 pandemic has helped mitigate the stigma, making people more accepting of the fact that mental health is a real challenge that needs to be addressed, particularly among youth, Boylan noted.

LEVERAGING MHEALTH APPS TO BOOST YOUTH MENTAL HEALTH

To expand and ease access to behavioral healthcare, California DHCS launched two mHealth apps targeting different age groups.

The Soluna app, powered by Kooth Digital Health, connects people aged 13 to 25 with resources to support various mental health conditions, including stress, anxiety, loneliness, and bullying.

The app offers self-guided therapeutic content and tools, including journaling prompts, podcasts, self-assessments, and videos; peer support spaces moderated by trained mental health professionals; and professional support through synchronous messaging, drop-in chats, and ongoing coaching. Coaches can communicate in 19 languages, including Spanish.

“Kooth’s research has found that effectively supporting youth mental health requires reducing barriers to access and promoting individual autonomy, ensuring mental health support is readily available for young people when and how they need it,” said Bob McCullough, vice president of clinical strategy at Kooth, in an interview with mHealthIntelligence.

BrightLife Kids is aimed at a younger demographic, namely children from infancy to 12 years old. The app, created by Brightline in partnership with the California DHCS, offers parents and caregivers digital tools and resources, coaches, and peer support communities to help them guide their kids through mental health challenges.

The tools and resources include articles, videos, and exercises to help address common issues like tantrums, sleep problems, lack of self-esteem, and challenging transitions. Users can also access one-on-one coaching based on cognitive behavioral therapy (CBT) approaches through phone, video, and chat.

“Prevention and early intervention are critical to help ensure issues do not escalate later in life. When issues remain unaddressed at a young age, they can have devastating impacts on a child’s well-being and growth,” said Amrita Sehgal, vice president of business operations and growth initiatives at Brightline.

Further, each app can connect users to crisis or emergency services when needed. Boylan noted that there are care navigators within each of the apps that help connect young people and their families to services in the community, including services offered by their health insurance plans, schools, and community-based organizations.

The California DHCS conducted an extensive market scan before partnering with Kooth and Brightline.

“We looked at over 450 different platforms [and] existing digital services offerings globally, and we did a ton of key informant interviews,” Boylan said. “We convened an expert think tank. We talked with youth and parents and caregivers across the state. We interviewed over 300 youth as a part of this project, and ultimately, we also did a request for information and interviewed vendors specifically.”

Taking into account the perspectives of youth and parents and the vendors’ experience with providing digital behavioral health support to youth and families, DHCS selected BrightLife Kids and Soluna for the project.

The apps are offered as part of the CalHOPE program at no cost to Californians. DHCS runs the state’s CalHOPE program, which provides a wide array of services to build community resiliency and help people recover from disasters. The services include individual and group crisis counseling, individual and public education, and community networking and support.

Part of the reason the apps are offered through CalHOPE is to leverage the marketing and goodwill that the program has already generated, Boylan noted. Information about the apps is featured prominently on the landing page of the CalHOPE website.

Not only that, but providing mental health services and support via smartphone and tablet apps was also a strategic decision.

“We wanted to give young people a new way to be able to access care in a way that is familiar to them,” Boylan said. “And kids — literally where they are is on their phones. They do so much through their phones today. They communicate with their friends; sometimes, they communicate with their parents even when they're in the other room. They do their homework, they learn about the world around them, they interact with each other…So, it just seemed like the natural next step to really provide access to young people where they are, on their phones.”

The goal of offering the mHealth apps for free statewide is to improve mental health outcomes by intervening early to address feelings of sadness and loneliness among youth, reducing suicides and suicide attempts, and mitigating the escalation of symptoms related to anxiety and depression that could lead to a mental health crisis, emergency department visit or hospitalization.

In addition, California DHCS anticipates the apps will help alleviate some pressure on behavioral delivery systems and licensed mental healthcare practitioners in the state by offering preventative and early intervention-focused care options. These options could help support young people before they get to the point where they need to see a licensed practitioner, which should ultimately reduce wait lists and improve access to licensed providers in the long term, Boylan said.

The California DHCS expects app utilization to gradually ramp up over time. The agency is working closely with Brightline and Kooth to drive adoption and engage with health plans, local educational agencies, county behavioral health departments, community-based organizations, and advocacy organizations across the state to raise awareness about these offerings.

“That is also one of the ways in which we can address the digital divide issue because certainly, we did research about how many kids in this age group and parents actually have access to smartphones,” Boylan said. “And while it’s quite a large percentage of the population, it's not 100 percent of the population.”

Thus, the state health agency is partnering with schools and community-based organizations to provide access to the apps via tablets in spaces where youth gather.

Boylan also noted that word of mouth is one of the best ways to raise awareness.

“So, if a kid uses it, they tell their friends, peers, then those kids use it, and they tell somebody — that's how young people spread the word, and that's how adoption works for young people,” she said.

To assess the impact of the apps, the agency plans to collect data as part of a larger evaluation effort within the Children and Youth Behavioral Health Initiative. Research and data analytics consultancy firm Mathematica has been contracted to examine how well behavioral health interventions, including the apps, are moving the needle on mental health outcomes, Boylan explained.

Making a measurable change in outcomes is the ultimate goal of the billion-dollar statewide initiative, which joins county-level mental health efforts to change the landscape of behavioral healthcare access among youth in California.

“It's really laying the foundation and developing infrastructure for that more coordinated, youth-centered accessible system where people can find the support that they need when they need it, where they need it, and in a way that they're most likely to access care,” said Boylan.