What Can a Digital Mental Health Tool Do for Teens? with Jessica Schleider, PhD

[00:00:04] Erin Spain, MS: Today's guest says, a major driver of today's youth mental health crisis may be the inaccessibility of timely, effective mental health care. Dr. Jessica Schneider aims to solve this problem with a bold evidence-based approach, single session interventions or SSIs. These are structured research-backed programs designed to deliver meaningful mental health support to young people in just one encounter. Her research shows that even one well-designed session can lead to lasting improvements in youth and adult mental health. She's an associate professor of medical social sciences at Northwestern University, Feinberg School of Medicine, and the director of the lab for scalable mental health, where she's experimenting with what accessible, scalable care can look like. We welcome her to the show today to talk about her research and the power of a first and only intervention, and the fight against the youth mental health crisis. Welcome to the show. 

[00:01:02] Jessica Schleider, PhD: Thank you so much for having me. 

[00:01:03] Erin Spain, MS: Well, it's wonderful to have you here, and I first want you to set the stage for us. You've described the youth mental health crisis as not only a crisis of increasing illness, but of inadequate access. Talk to me about that, and what do you think are the most important factors driving this crisis that we're seeing here in America? 

[00:01:23] Jessica Schleider, PhD: So this crisis is nothing new. Although I think that the news media and public conception of the crisis has really spiked since the onset of the COVID-19 pandemic and the sudden loss of access to supports that many folks, especially young people, experienced across the country in the world. But there are really three driving factors among many. But three that I think are particularly important in helping us understand why this crisis has emerged. First of all we've spent, you know, 50, 60 years as a field clinical psychology, psychiatry, mental health research, identifying and developing effective interventions for youth mental health problems. Unfortunately. Those interventions are broadly not being delivered and not being accessed by those who need them. And today about 80% of young people with significant mental health needs in the United States don't ever access services. That has to do with a variety of barriers that they face, including provider shortages. That's a huge one. Yeah So there simply aren't enough providers. There's not enough supply to meet the immense demand for youth mental health support. Beyond provider shortages, a second reason that many youth fail to access mental health support when they need and want it is because supports aren't located where youth can actually access them. Most traditional evidence-based supports or if therapies in general are located in health systems at freestanding clinics. Places where youth have to actively travel to and the logistics of traveling and continuously paying for services are often infeasible for many families in need who are facing all sorts of logistical barriers to care. Youth, if we, if we actually talk to them and ask them how they'd like to access and seek support, most of them say, well, I just go on my phone. Or I just go online or I talk to my friends. So supports aren't located where youth are actually looking first and sometimes exclusively for the support that they need. The third reason that so many interventions don't have their intended effect for youth is because despite our efforts to develop multi-session interventions that last weeks or months that are effective. The most common number of times that somebody actually interfaces with any form of mental health support based on national insurance reimbursement data is one. So we've spent a really long time creating treatments that simply don't match how people are actually interfacing with healthcare. 

[00:04:02] Erin Spain, MS: This one single encounter covering this, was this a big revelation in the mental health community that folks are only really having this one encounter. 

[00:04:12] Jessica Schleider, PhD: I wanna say that it was a big joint revelation and we all realize this together and are collectively shifting our thinking and models of care. But not so much. This statistic is often news to audiences I present to my colleagues. Despite working in the field for. Sometimes many decades often, you know, clinical psychologists and psychiatrists are trained to treat folks who do show up for services, right? These are the lucky 20% of individuals who get through all of these difficult barriers, get in the door. And although early dropout as a, is a common concern many of these clinicians aren't close enough to the problem to really see the scope of it across the nation. So. I do think it's been a bit of a blind spot for clinical psychologists who are, of course, because that's all that we are exposed to, operating from the perspective of serving those who are able to get through all of those obstacles. 

[00:05:11] Erin Spain, MS: You actually published a study in JAMA Pediatrics where you found that state parental consent laws also have a miserable impact on whether or not teens get treatment. What does that mean? Talk to me about these state laws and the significance that this has on these barriers to 

[00:05:27] Jessica Schleider, PhD: Sure. So this is so important to our work right now and in shaping how we think about what truly. Scalable interventions need to look like because it's not just the logistics and the cost of care, it's also policies that make them intermittently accessible to young people who need them. So what we've learned throughout our research with youth digital mental health interventions and youth interventions in general, is that we get very, very different populations of young people and very different sample sizes when we require parental consent for youth to take part in our trials, which is standard versus when we secure a waiver of the requirement. That's typically there for parental permission for adolescents to self-refer into interventions, specifically when we waive that requirement. When adolescents are suddenly empowered to choose whether or not they want to try out a low intensity, safe mental health tool that they can go through completely on their own, we get far more diversity. The folks coming into our studies, we get racial ethnic diversity that is totally uncharacteristic of traditional clinical trials. We get sexual and gender minority participants that would otherwise be excluded from care often because they're not comfortable asking their parents for help. And that led us to dig into what it is about this single. Change this requiring or not requiring parental permission. That makes a big difference. So we started doing qualitative studies with teens and when we asked teens who couldn't access care for depression, which is one of our focus areas, what got in the way? I. About 32 to 42% across multiple samples said it was their families, their parents not necessarily that their parents were declining their requests to seek out treatment, but that they simply weren't comfortable going to their parents to ask for help. And if you live in a state where a parent is required to refer their under 18-year-old child for treatments, and you're not comfortable going to your parent, you are out of luck. So we decided to do a policy mapping study, which was the one that was published in JAMA Peds late last year. And we actually found that state level policies have a measurable impact on their own, on whether or not teens with depression access treatment. 

[00:07:51] Erin Spain, MS: mean, could this be a message to parents as well, the results of this study? What could parents take away from this new information? 

[00:07:57] Jessica Schleider, PhD: I think it's a message to everybody who cares about young people's mental health. And I think it's a prompt and reminder for parents to proactively. Approach these kinds of conversations with their, with their adolescent children in particular, but also their younger children. So they grow up knowing that they're able to ask for help in the environments that they're in, and they know how to ask for help. So modeling that early on. Signaling acceptance of support, seeking and signaling that you're going to be there for your child and you're going to help them and advocate for them. And finding the support they need is critical because if those conversations don't happen, teens are left being uncertain and hesitating at points of actual need.  

[00:08:41] Erin Spain, MS: Well, your research lab, you are really going all in on these single session interventions and in a recent study you published in the annual review of Clinical Psychology, you confirmed that these single session interventions can significantly improve mental health outcomes. So talk to me about this, your approach, what's happening right now, and. How are you designing these interventions to work in your lab? 

[00:09:03] Jessica Schleider, PhD: Absolutely. So I wanna preface this by saying, well, two things. First of all, I don't believe that single session intervention should replace anything else that is already available in the mental healthcare ecosystem. That's one of the initial questions I get from fellow clinicians and colleagues in my field is, but how can you say that all treatments should just be one session? That's not what I'm saying at all. I am saying that we need something like. Single sessions and other types of low intensity interventions to bridge the gap, that would be totally unfillable. And we know it's already unfillable by existing interventions. So that's the first piece. The second piece is that single session interventions are nothing new. I did not invent them. They have been practiced since before I was born. So the first book that was published on single session interventions came out written by a clinician named OSHA Talman an Israeli psychologist. Who had been practicing single session therapy in his practice and finding that one session was sometimes surprisingly impactful and reduced the need for additional care for many of his clients. And so we're building on a long history of practice based evidence. As well as drawing from brief intervention research and other neighboring fields to psychology, like social psychology and public health, which aren't often integrated. But those are the histories and traditions that we're drawing on in, in doing this work. So it's not just us, my journey into studying single sessions started more than 10 years ago. As a graduate student in clinical psychology, I got incredibly frustrated working in you know, low resource community clinics and seeing that many families that I was. Treating could not come back after the initial assessment by no fault of their own. And all I do in the initial assessment is ask a bunch of questions that don't actually help them. So I started to wonder, is there something I could be doing in that first session that could help them even if they couldn't come back? So I started looking into the literature and found there was a whole. scope of studies on this topic, but they were all kind of called different things, so nobody had synthesized all of it. And that initial meta-analysis that I published in 2017 became the basis for the work that my lab does studying what can be accomplished in a single session. So in terms of how we think about developing and designing single session interventions we think of single session interventions, first of all, as an umbrella term that can include, supports that are designed to affect some kind of clinically meaningful change in one encounter that can be either digital and self-guided interventions. So things are completed online or on devices and things that are provider delivered, delivered by clinicians, either lay providers, so providers without professional training or licensed professionals. And we see the digital single session interventions as bridging gaps for folks. Who don't ever make it in the front door of a mental health clinic, right? Folks who are looking on social media for support, who can be connected with a digital single session tool right away, whereas the provider delivered single sessions, we see as more bridging gaps within healthcare systems, such as for folks on long waiting lists for treatment, which were a huge problem and actually lead to deterioration if they're too lengthy once folks seek out help. So in either case. These single sessions are structured such that they promote a sense of autonomy. The idea that, you know, your actions affect your future. The notion of relatedness, like there's somebody out there who understands and cares about you and has been where you are and gotten through it. It. And competence, like all of the SSIs, teaches a really specific granular skill that helps somebody learn better how to deal with a problem in front of them. And those facets, autonomy, competence and relatedness. Those are really the mechanisms of change through which a single session encounter can help people take that best next step towards a future that's better, that's valued. And that's a little bit freer of their, of their symptoms. 

[00:13:23] Erin Spain, MS: You mentioned tools that someone can take away from this one time encounter. Can you gimme an example of what those might look like? What tools could they take out into the world?  

[00:13:32] Jessica Schleider, PhD: Absolutely. These tools are also nothing new to psychologists. We've been studying them in longer term multi-session interventions for decades. But each single session intervention essentially takes a kernel of a longer multi-component evidence-based treatment and synthesizes it down to a unit, a minimally viable unit that can still have an effect. So one of our interventions, as an example, teaches the idea that. What you do can shape how you feel. It's extremely simple. But what that corresponds to is the skill in cognitive behavioral therapy of behavioral activation. So we help people understand through interactive, self-guided exercises personal mood experiment that we guide people through and the creation of an action plan. We actually show and tell them, here is how you can take. Steps to engage in activities that you value, that make you feel like you, to help you support a better mood when you're feeling stuck. And every single person who goes through this behavioral activation, SSI, which we call the A BC project, action brings change. They end up with a personalized action plan for taking valued based steps in their own life to manage their mood more effectively. And this is one of several single session interventions that we've tested in large RCTs, randomized controlled trials found actually can reduce adolescent depression even 

[00:14:58] Erin Spain, MS: Wow. 

[00:14:58] Jessica Schleider, PhD: later compared to active control conditions. And it's available for free for anybody to use on our lab website. 

[00:15:04] Erin Spain, MS: And your lab website has a lot of tools. I mean, how many different projects are you piloting right now with these digital tools? 

[00:15:13] Jessica Schleider, PhD: Too many arguably. We, I mean, the goal is to create single session experiences, encounters that are accessible anywhere, anytime for whatever problem or difficulty somebody happens to be presenting with. So we need a library of them. To really be able to pivot so people can select, that's what that problem is. The one I resonate with that skill is the one I need right now. I'm gonna try this one. And especially, you know, if time is so precious, and especially for folks who are not necessarily treatment seeking, who are finding these interventions online, while they're scrolling through a social media feed, we need to make sure we're hitting exactly the right target. So as a result, we're. Testing, deploying, disseminating, implementing at least, 20 different single session interventions in different settings all over the country and the world, including primary care schools within social media platforms, is just in time supports for folks who type for, for example, suicide into the search bar. So indicating that they need some help right away. Through one of our nonprofit partnerships, they actually do get offered a single session intervention in those moments. So we're, we're trying all the things we can think of to figure out how to disseminate these brief interventions that we have sufficient evidence for at this point to really scale up. 

[00:16:31] Erin Spain, MS: And you mentioned these are going to people around the world. Accessibility is a huge part of what you're doing. These are coming to folks in their own native language in many cases as well. Tell me about this undertaking and how important it is to add that kind of cultural competency into what you're doing. 

[00:16:47] Jessica Schleider, PhD: Sure. So we've been incredibly fortunate as we've expanded this work. And I think because we make all of our intervention materials freely available, which is unfortunately atypical in the intervention science field, colleagues and, and, and potential collaborators all over the country have approached and, and the world really have, have. Reached out to our lab asking if they can embark on a project, a collaboration to culturally adapt and translate the evidence-based digital single session interventions that we've built. So we've been incredibly lucky to partner with so many different folks and talented individuals to do just that.The suite of single session digital self-guided tools for teens on our website are now available in at least nine different languages. We're working on several more that will be posted soon. It's been a really rewarding process, not just to build these interventions for youth living in parts of the world where. The mental health infrastructure for young people is non-existent, but getting to actually test the utility and acceptability and effectiveness of these interventions in different languages such as Polish and Ukrainian and Arabic and Spanish, and a host of others. But it's, it's been really exciting to see, how much this model of providing support resonates with what folks who are close to the daily problems and accessibility actually see as being a good solution? 

[00:18:14] Erin Spain, MS: Can you share some anecdotes or success stories with me of what you've heard as a result of some of these interventions? 

[00:18:21] Jessica Schleider, PhD: Absolutely. So one of our team's favorite parts of doing this research is going through the qualitative feedback, the written feedback that we get from adolescents. On how they responded to our interventions. Much as I love to see the numeric points on their depression score go down months later, it's a little bit more exciting to see them write a personal note to you that says, I feel understood for the first time. Or, I feel like I can talk, I can verbalize what I'm experiencing now, or I feel ready to ask for more help. And that's really important too, is what we see is. Not only are the single session interventions that promote, you know, autonomy competence relatedness, helping to reduce symptoms directly, but they're also supporting young people in feeling motivated and able to ask for more support if they need it. So the effects are really twofold. I think one of the best ways to see the impact that Teens report having from these interventions is to go to our website and click on Project yes. Project, yes stands for Youth Empowerment and Support. And if you click on the advice center in Project Yes, that is actually, a repository that we keep, because after every single session intervention that a team completes, we ask them, Hey, do you wanna give advice based on what you just learned in your own experience to others? And if you want us to, we'll share that advice publicly on our project. Yes. And anonymously on our project Yes. Website. So you can actually scroll through and see feedback from teens. Across the country and across the world on what they learned from the interventions and what they would advise their peers to do in times of distress. Which I think really speaks to the impact that these interventions can have. And of teens to 

[00:20:16] Erin Spain, MS: Hmm. 

[00:20:16] Jessica Schleider, PhD: wanna help themselves, but help others too. 

[00:20:19] Erin Spain, MS: I mean, this whole project in your lab is a really beautiful illustration of implementation science in action. Tell me about moving your lab here to Northwestern and the Infras and the infrastructure here that's allowed you to really dive into this implementation of the research. 

[00:20:35] Jessica Schleider, PhD: Absolutely. So this move was just so ideal for the work and mission that we share in, in, in so many ways. And you know, I started the lab in 2018 and spent the first. Five years of my career at a university that I thoroughly enjoyed being at. And learned pretty quickly after five years of doing randomized trials and effectiveness testing of do SSIs work. We had our answer. Yeah, they can work for some people in some circumstances. They can both reduce symptoms and increase motivation for further outreach. And it came to this point of I can't just keep running the same clinical trial over and over again. We already know the answer. We really need to shift our focus from intervention science to implementation science, the science of getting what works out there in a systematic and sustainable manner. To actually reduce disparities in access to care and implementation science is inherently a team sport. It is not a solo activity. So I knew that our lab needed to move to a place with a community of implementation, scientists doing community partnered research. Multi-sector research at a large and impactful scale. I knew I needed to begin a community with other folks doing digital mental health research at a large national scale to really move the needle on population health. And I. Northwestern was the obvious place to do that. With the influx of experts in implementation science and with the Center for Behavioral Intervention Technologies here, it's a huge hub for all of the things that our lab tries to integrate, which is this population health perspective, implementation and intervention science and digital mental health for scale. situating our work within this environment has just allowed us to. Really skyrocket the scope of, of our work, expand the array of community partners we're able to meaningfully work with and really grow towards the goal, which is to get evidence-based tools out to everybody who needs them at precise moments of need. 

[00:22:49] Erin Spain, MS: I would like to hear a little bit more about the community partners that you've been able to work with and establish here. Tell me about that. 

[00:22:55] Jessica Schleider, PhD: Sure. So moving to Northwestern, one of the great things was that I moved from a position where a lot of my time was spent teaching and doing clinical supervision, which I love to an environment where I felt like I could be most effective in what I'm, I feel I'm best at, which is the science and running a team that extra bandwidth and the infrastructure at Northwestern to support non-traditional kinds of partnerships and research contracts and services agreements has given us so much freedom to explore new types of partnerships with different agencies and entities. One that I'm particularly excited about is a partnership that involves many different partners including in the nonprofit space and the state government space. 

[00:23:40] Erin Spain, MS: Hmm. 

[00:23:41] Jessica Schleider, PhD: So for this project, we're actually, our lab has a established a, a relationship with the state of Montana, 

[00:23:48] Erin Spain, MS: Okay. 

[00:23:49] Jessica Schleider, PhD: Which is almost entirely a federally designated mental healthcare provider shortage area to disseminate single session digital interventions across the state and create. Basically toolkits for pediatricians, for schools, and for parents to be able to learn about what single session interventions are and offer them sustainably in their organizations. So for this project, we're working with a psychiatry clinic called Frontier Psychiatry as well as a nonprofit pediatric primary care organization called Montana Pediatric. We have funding from the state as well as donors to basically deploy, test, and sustainably implement a platform of single session interventions across the state. And that platform is something that we've built in collaboration with a nonprofit partner, coco, which is a digital, mental health nonprofit company that builds basically they're our, they're our tech partner.Right. They help us build the ssis into an infrastructure that we as scientists are not equipped to. 

[00:24:55] Erin Spain, MS: Right. app 

[00:24:57] Jessica Schleider, PhD: So it's actually a, just a publicly available website. 

[00:25:02] Erin Spain, MS: Yep. 

[00:25:03] Jessica Schleider, PhD: and it's available through Coco's interface. And the reason it's not an app is because downloading something is actually a barrier to access and a lot of. 

[00:25:12] Erin Spain, MS: to the URL, type 

[00:25:13] Jessica Schleider, PhD: Exactly, and that makes it anonymous for teens to use too, so they don't have to give away any personal information in order to access the intervention. Which we found in our focus groups with young people is extremely important because they're worried about what will happen to their information or who will be told that they're using this with all those partners, we're, we're working on this mixed methods implementation, 

[00:25:35] Erin Spain, MS: Wow. 

[00:25:36] Jessica Schleider, PhD: Intervention science, large-scale statewide study where hopefully we'll be able to see at scale, what can these really do when deployed sustainably across the state. 

[00:25:46] Erin Spain, MS: There's been a recent Feinberg study published showing that there is a lack of access to mental health care in these rural areas, and this is a big problem for teens and young adults. Can you just talk to that a little bit as well? 

[00:25:58] Jessica Schleider, PhD: A hundred percent. And you know, one of the, another faculty member or research assistant professor in my lab, Dr. Erica Kody this is a big focus of their research, is understanding how single session interventions can support rural populations. They Previously did a year of their clinical training in Alaska in a super small town where really there are no options for care and they're bringing that passion for the work to the single session intervention space. So they actually let us study a year or so ago looking at whether single session interventions could produce equitable effects in young people in rural areas. Versus urban areas in the country. 'cause we do nationwide clinical trials. And what we found was that we were actually. Coming up with an over-representation of rural teens in our studies. So these interventions may circumvent some of the barriers to access you know, often facing rural communities. But they also were just as acceptable and just as effective for these young people as for their urban counterparts which was really exciting and. Kind of set the stage for this partnership with Montana. And that's one of the reasons that the community partnership we're pursuing is so critical because it's not just that we drop this preexisting intervention suite into this, the state and say, okay, now it, it'll just go. We have to actually tailor. The components of the interventions, the stories, the narratives that are included in the single session interventions to make sure that people in that community see themselves in this platform and program that it's built for them. That it's clear that we took their needs into account. And the dissemination toolkits that we're creating for pediatricians and schools have to be fit to the context that 

[00:27:44] Erin Spain, MS: Hmm. 

[00:27:44] Jessica Schleider, PhD: and the resource limitations that they're up against. So because we're partnering with Montana Youth, Montana Providers, Montana.Schools to build out and refine all of these tools. We're optimistic that what we end up with will actually be able to sustain in their community. 

[00:27:59] Erin Spain, MS: There's  so many exciting things happening in your lab right now, and in some ways it feels like just the beginning. You're just launching a lot of these programs. What is your hope for the future? What would you like to see happen in the next five or 10 years in your lab? 

[00:28:12] Jessica Schleider, PhD: My hope for the future is that single session interventions are a ubiquitous layer of support that exists in this country's mental healthcare ecosystem. A layer of support that can. Serve people as and when and where needs arise, such as when they first seek out support on the internet. Or they first call into a clinic and they're put on a six month wait list. If, if they, if all clinics just offered single session supports for folks waiting for treatment, we could actually see. population scale reductions in severity of problems that people are starting treatment with population level increases in the speed with which people could recover. And if single session interventions were just built into, you know, large online platforms that. Millions of people access every single day. We could catch so many problems before they worsen to crisis points. And we know that once they do, it's much, much harder to treat people effectively. And we increase risk exponentially for outcomes like suicide. So I wanna see a change in the mental healthcare ecosystem where single session interventions are just. Something that everyone knows about and everyone can access as needed. I also wanna see systems like insurance reimbursement change to accommodate single session interventions. Right now, there's no real mechanism through public insurance anyway, for reimbursing for an intervention for somebody on a waiting list, for example, because they're technically not a patient yet and they haven't gotten a diagnosis yet, so. What code are you gonna use? We're actually working with community health agencies in the department of mental health in Pennsylvania to test out a new temporary reimbursement code for that exact purpose. We're hopeful if we can show through our pilot in the state that single session interventions for folks on wait lists are helpful. We'll become permanent and maybe other to take it up. I think just openness to single session supports that needs to change knowledge that needs to and structures and systems that support their sustainable implementation would need to change. And hopefully our lab can be a part of all those shifts. 

[00:30:20] Erin Spain, MS: Thank you so much for sharing all the work that's happening in your lab and your vision for the future as well. We really appreciate it. 

[00:30:27] Jessica Schleider, PhD: My pleasure. Thanks so much for having me. 

[00:30:30] Erin Spain, MS: Thanks for listening. Please click the bell to receive notifications about our latest episodes and follow us on social media at NU Feinberg Med to stay up to date with our latest research findings. 

Physicians who listen to this podcast may claim continuing medical education credit after listening to an episode of this program.

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Identify the research interests and initiatives of Feinberg faculty.
2. Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Disclosure Statement

Jessica Schleider, PhD, has received grant or research support from Kooth. Content reviewer Patricia Franklin, MD, MPH, has nothing to disclose. Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose. FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

All the relevant financial relationships for these individuals have been mitigated.