Addressing Students' Mental Health Needs via Telehealth

Children and adolescents face a wide variety of mental health challenges, ranging from coping with the death of a loved one to major depression with suicidal ideation. An adolescent's behavioral health issues can impact friendships, relationships with family members, and academic achievement [1]. Rates of depression and anxiety in children and adolescents have been steadily increasing over the past 15 years. In 2017, 13.3% of the US population aged 12-17 had at least one major depressive episode [2].

In North Carolina, suicide is the second leading cause of death for adolescents, and this rate has doubled in the past 10 years [3]. In 2017, 16% of all North Carolina adolescents and 43% of LGBTQ adolescents reported considering suicide within the past year [4]. Despite these growing numbers, less than half of students with a major depressive episode received treatment [4]. Currently, 84 of the 100 counties in North Carolina contain at least one Health Professional Shortage Area (HPSA) for mental health, resulting in decreased access to care [5].

Providing behavioral health services in schools through school-based health centers has been shown to be highly effective in increasing adolescents' access to care [6]. However, bricks and mortar school-based health centers are more likely to be found in larger schools in urban areas due to the financial challenges of providing care in schools with fewer than 500 students [7]. Over the past 15 years there has been a steady growth in the use of telehealth to provide these services in schools, with resulting improvements in access to care and in the health outcomes of adolescents with anxiety and/or depression [8].

Currently in North Carolina there are two programs using telehealth to connect students to mental health services. East Carolina University's Department of Family Medicine, with funding from the Health Service and Resources Administration, provides access to mental health care at all 12 schools in Duplin County. Prior to the implementation of the program in the fall of 2017, there was very limited access to mental health services for students who did not have severe impairments. Now any student can be referred by a teacher, guidance counselor, or the school nurse to be assessed and receive therapy from one of two licensed marriage and family therapists or doctoral students in psychology. In the wake of Hurricane Florence in the fall of 2018, the program saw a significant increase in visits focused on trauma and loss that arose from the storm (internal data, ECU Department of Family Medicine).

The second program is a pilot in Pender County Schools focused on supplementing the in-person care currently available in all 18 schools with care provided by telehealth. The therapists are provided by Coastal Horizons, a private nonprofit based in Wilmington, North Carolina. If successful with the pilot, they plan to expand supplemental behavioral health care via telehealth in schools during the spring of 2020.

The use of telehealth to provide mental health services in schools is gaining national attention due to increased focus on school violence and increased adolescent suicide rates [9]. Texas Tech's Telemedicine, Wellness, Intervention, Triage and Referral Program (TWITR) currently provides access to mental health screening, psychiatric evaluation, and counseling in 24 Texas school districts with a focus on identifying and evaluating students who are at a risk of harming themselves or others [10]. Based on early successes, efforts to replicate this program are currently underway in multiple states.

North Carolina has seen great success in improving access to adult emergency psychiatric care through the North Carolina Statewide Telepsychiatry Program (NC-STeP) [11]. Building on this experience, North Carolina has the potential to develop a statewide school-based mental health program accessed through telehealth. While the TWITR program is focused on identifying and providing care for students with a high level of risk, the North Carolina statewide network should also focus on providing brief interventions for students who are wrestling with issues that, while less intense, are still having an impact on their daily lives. Unlike the NC-STeP program, which focuses on acute issues, a school-based network would have the ability to provide longitudinal care for students. By drawing from a network of providers across the state, it will be easier to match a student's personal preferences and specific needs to a therapist who specializes in a specific area, potentially resulting in an improved therapeutic relationship. Additionally, creating a statewide network would allow capacity to be shifted to schools with acute needs in the event of a natural disaster, a school emergency, or other issues. Creation of a sustainable statewide network will require the collaboration of the Local Management Entities-Managed Care Organizations, the North Carolina Departments of Education and Health and Human Services, individual schools, and behavioral health providers.

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