Youth Mental Health Screening and Linkage to Care

Abstract

One Mind, in partnership with Meadows Mental Health Policy Institute, convened a series of virtual think tank meetings to identify foundational first steps towards creating an early screening and linkage-to-care initiative for mental health difficulties, including serious mental illness, in early adolescence through early adulthood in the United States. The current paper synthesizes and builds upon discussions from these meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. There was general agreement within the think tank on an initiative incorporating a staged assessment process, with a first stage brief screener for several domains of psychopathology. Individuals meeting the determined threshold criteria on this first stage initial screener would then complete a second stage in-depth screening and/or interview. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on symptoms acuity endorsed during the staged assessment. Overall, the think tank proposed steps and discussed additional considerations towards creating the first nationwide screening and linkage to care initiative, an initiative that could transform access to mental health screening and care.

Introduction

As with other forms of illness, intervening early in the course of a mental health condition is associated with better outcomes.^1–3 However, early intervention requires early detection, and mental health concerns are often mis- or undiagnosed. Even among youth endorsing mental health concerns, it has been reported that less than one-third receive mental health services.^4,5 There are several current barriers to care, including a previous lack of government investment in youth mental health care, as well as limited utilization of potentially important tools, including preventative initiatives and online tools. These barriers may be even more pronounced in historically marginalized communities.⁶ With such limited access or utilization of care among those with indicated need within the current mental healthcare landscape, prospects of early intervention prior to or even within several months of developing a diagnosable disorder are generally inadequate.

To better understand and develop a plan to address barriers to early identification of mental health difficulties including serious mental illness (e.g., psychotic symptoms, depression, suicidality, etc.) for youth and their families, One Mind in partnership with the Meadows Mental Health Policy Institute convened a series of virtual meetings (online Supplement for description of these groups, meeting attendees, and further description of the meetings). Meetings included clinicians, researchers, persons with lived experience, educators, and community leaders, who were asked to share their knowledge and insights about early identification via screening as a window to intervention. Recognizing that there has been a wealth of work and collaboration tackling many of these issues in other countries, ^7–10 the meetings aimed to work towards making early detection and linkage to care for mental health difficulties a reality for youth throughout the United States. Meetings centered on beginning discussions for the development and integration of a measurement-based care tool in youth-facing settings to increase early identification of mental health needs and linkage to evidence-based care.

The current paper aims to synthesize these discussions, which were framed around the need for evidence-based screening and linkage to care for youth and young adults living with mental health concerns, and the value of learning from and building upon existing programs across multiple settings. Although traditionally health care has been divided between pediatric and adult populations, members also generally agreed that it is important to develop inclusive initiatives for early adolescents and young adults, with an initial target age range of 10–24, given this age range is generally regarded as a period of heightened risk for emerging mental health concerns¹¹ (online Supplement for information regarding a survey assessing Think Tank member agreement regarding proposed initiatives). Settings for screening outside of traditional specialty psychiatric and mental health programs were of particular interest and included school, online, and medical (e.g., pediatric primary care, inpatient care, emergency rooms) settings. Targets of screening included psychosis spectrum, as well as depression, anxiety, suicidality, and mania symptoms. Further, there was agreement that screening must be followed by linkage to an appropriate level of evidence-based care.¹²

It is arguably more critical than ever to develop and implement a screening and linkage to care initiative in the United States. During the COVID-19 pandemic, some youth, especially those already at risk,¹³ have experienced significant increases in reported mental health concerns, leading groups such as the American Academy of Pediatrics to declare a national emergency regarding youth mental health.¹⁴ These increases are above already high levels of positive symptom screens in primary care settings, with estimates that, even when only screening for depressive symptoms, 56.4% screen positive.¹⁵ These concerning statistics are part of the impetus for the current increase in funding for improved access to child and adolescent mental health care.¹⁶ The think tank, recognizing these significant concerns, focused on developing specific steps towards creating an approach for pediatric settings (e.g., primary care, schools) to respond to increasing mental health concerns. This approach holds the potential to not only enhance access to mental health resources for youth, but also to reduce burden for providers by providing an approach for handling mental health concerns.

With the overarching aim of improving and expanding early identification of youth experiencing mental health concerns,^1–3,17 the current paper summarizes areas of general consensus within the think tank discussions and initial considerations for building and integrating the first initiative for nationwide screening and linkage to care. Considering many health systems in the United States face challenges providing quick and appropriate mental health resources and care following screening, we propose creating an efficient online platform for screening that can be used in a range of systems with capacity to connect need with recommendations for appropriate resources and care (e.g., medical settings, some school settings). This platform would include an existing general screening measure expanded to comprehensively probe a wider range of mental health symptoms once validated. Based on initial screening results (especially symptom distress and impairment), recommendations would be provided for additional second stage interview(s) and/or linkage to care options (Figure 1). In this paper, we review the previous screening and linkage to care work, then discuss the need for the think tank, followed by recommendations based on input from the think tank meetings. These recommendations include adapting existing screening measures and developing a staged assessment process for screening mental illness symptoms in youth from early adolescence and into early adulthood; continuing to develop a collaborative network for this initiative; and organizing online mental health resources.

Figure 1.

Example of potential staged assessment and linkage to care approach in school and medical settings. In this proposed model, youth in school and medical settings would complete a first stage brief screener to assess a range of psychopathology symptoms. Based on responses to this screener, youth endorsing mild psychopathology symptoms would be linked to Tier 1-level care, including psychoeducation. Youth endorsing moderate psychopathology symptoms would be linked to Tier 2-level care, including recommendations for additional screening, and individual, family, or other therapies, as indicated and available. Youth endorsing severe psychopathology symptoms would be linked to Tier 3-level care and receive immediate assessment of risk and potential linkage to crisis care. Several common barriers for the scalability of a screening and linkage to care initiative will include the need for training, resources, and monitoring outcomes [see Settings panel in figure for unique constraints for each setting].

*For psychosis spectrum symptoms, further assessment is warranted prior to specialty care referrals to minimize risk of stigma, misattribution, and delays to appropriate care.

What has previously worked in the U.S.?

Youth Screening Tools.

Systemically surveying a population via mental health screening can provide several benefits, including opportunities for prevention, offering a safe place to talk, signaling that mental health is important and reducing stigma, and beginning the process of detecting and treating mental health conditions. Strides have been made in developing and disseminating screening and assessment tools for early detection of mental illness throughout United States schools and primary care settings (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf for a list of several screening tools; Table S1 available online).^12,18–25 These tools were developed to screen for many domains of maladaptive behaviors and psychopathology, including general symptoms, anxiety, depression, suicidality,^23,26–28 and psychosis spectrum symptoms.^29,30 These existing tools can serve as a foundation and/or provide a template to facilitate the implementation of the current screening and linkage to care approach.

Staged Assessment Approaches.

Several screening initiatives have incorporated staged approaches for assessing mental illness symptoms, including psychotic symptoms.³¹ According to clinical staging theories, the earliest mental health difficulties tend to be non-specific symptoms that develop into a range of disorders.^17,32 In staged assessment approaches, only those individuals meeting a specified threshold on an initial screener progress to the next stage of assessment, such as a more comprehensive interview.¹ For example, researchers have developed a staged approach to assessing suicide risk in pediatric hospital settings that includes an initial symptom assessment, then a full suicide risk assessment if warranted.³³ Staged assessment efforts offer several important benefits. For instance, given the relatively low base rates of psychotic and other serious mental health disorders, only those youth meeting threshold criteria would be asked to complete a more comprehensive assessment, providing more effective resource utilization and reducing burden.³⁴ Further, previous staged assessment efforts have helped mitigate safety concerns by inviting individuals who endorse severe symptoms to complete a more comprehensive and presumably more accurate assessment of acuity and level of care needed.

Linkage to Care Efforts.

Although screening is important, experts agree that it must be followed with recommendations for evidence-based care for individuals endorsing elevations in symptoms (Table S2 available online for several examples of linkage to care initiatives).^12,35 Previous work indicates screening provided with sensitive feedback and support can offer improved linkage to care and clinical outcomes,^20,36,37 including reduced duration of untreated illness and reduced hospitalizations.³⁸ Previously incorporated beneficial components to the linkage to care process include incorporating knowledge of local resources, sharing information with treatment programs, and continuity between screening and further assessment or treatment.

Staged Linkage to Care Models.

Previous initiatives have indicated that staged care models, including multiple options for care based on an individual’s needs, have the potential to improve therapy efficiency.^39,40 In staged care, an individual is linked to a level of care that is appropriate for the symptom severity.² In tier 1 (mild symptoms), an individual may be given options for care including education and/or mental health apps. In tier 2 (moderate symptoms), the individual may be given options including therapy, pharmacological management of symptoms, or coordinated specialty care, as applicable. In tier 3 (critical symptoms), the individual may be linked to a mental health provider in the geographic area for more immediate triage of symptoms and potential linkage to crisis services. There have been several advances in the development and feasibility of stratified risk protocols for suicidality.⁴¹ Previous research indicates that regardless of intervention type, flexible treatment models engaging family and other supports are imperative if screening efforts are to result in successful engagement in care.^42,43

What is needed?

The think tank identified several gaps and barriers to early detection and linkage to care for mental health concerns (e.g., psychosis spectrum, in addition to mania, depressive, suicidality, and anxiety symptoms), ideally prior to the development of diagnosable disorders. See online materials for additional information about the think tank meetings; see Tables 1 and online Table S3 for additional considerations for a screening and linkage to care initiative.

Table 1.

Additional Considerations and Operational Challenges^a

Challenge	Additional Considerations
Screening and Linkage to Care
Collaborative efforts	The screening and linkage to care initiative will require building partnerships with care providers in a variety of settings (e.g., school, medical, local health and mental health departments) across the United States. In terms of the nature of these collaborations, once the screening process indicates a youth would benefit from care at a level beyond online resources (Figure 1), the online portal would provide recommendations for providers in the collaborative network. The development of this effort will likely necessitate starting with an initial piloting site(s) and scaffolding up to locations across the country, similar to other large-scale screening and linkage to care programs (e.g., Early Psychosis Intervention Network). This initiative would require a fund-raising effort, likely from a federal agency (e.g., SAMHSA, NIH).
Workforce requirements	The initiative will require resources and staff to maintain the online portal. These requirements will include updating educational content, linkage to care resources, mental health tools, and recommendations for care.
Continuity of care	This initiative will need to address how to handle continuity of care issues, such as youth moving or other interruptions to screening and/or linkage to care. This will be especially important in school settings where screening and linkage to care process can be interrupted by the end of the school year. During the first stage of the proposed project, screening with an adapted first-stage screener will take place in sites that are already screening and thus have continuity of care and linkage to care procedures. A number of strategies could be adopted such as developing care navigator services and/or developing procedures for secure access to protected health information within the screening and linkage to care portal.
Outreach and engagement	Such an initiative will require extensive efforts to inform and engage providers, the public, and related governmental agencies. See online Supplement for additional information about potential education initiatives. Although outreach will be an important part of the initiative, providers in locations with existing screening process may already be familiar with general screeners (e.g., the Pediatric Symptom Checklist).
Resources	Although additional funding will be required to develop, host, and maintain an online portal for screening and mental health resources (e.g., educational materials, mental health toolkits, therapeutic tools, caregiver navigators, recommendations for care), it is important to note that since routine psychosocial screening is now the standard of care in pediatrics and many educational settings, some aspects of the initiative, including first-stage screening, could be launched for little extra cost if the newly developed screener were substituted or used to supplement measures in use in settings already implementing screening. In other settings, additional investment could be justified by the promise of early identification leading to potential prevention of functional impairment and of more serious mental health care needs, both of which will result in the reduction of future costs to the system.
Ethics	The ethics of screening and linking to care in non-help-seeking contexts must be considered. It is possible that youth that meet thresholds for mental health concerns may experience distress resulting from either unexpected results or the stigma associated with mental illness.74 We contend that the burden of untreated mental health concerns outweighs these concerns. It is also possible that a nationwide screening effort may help reduce stigma. Regardless, continued advocacy for stigma reduction is needed.
Setting	There will be a number of unique obstacles for each setting; for example, in primary care, obstacles will include dealing with insurance, payment, and time constraints. For schools, unique constraints will include being bounded by the school year and added logistical hurdles in terms of coordinating with caregivers
Screener
Large age range	Validation will be required to ensure that any screener is adapted across age ranges. For the first-stage screener, different versions may be required for different age groups (e.g., ages 10–12 versus ages 22–24). Some items, especially psychosis spectrum symptom items, may need to vary depending on the age of the individual completing the screening (see Immediate Next Steps in online supplement, ‘Screening’ section). Some psychosis spectrum questionnaires, including the Prodromal Questionnaire Brief, have developed versions for youth as young as age 9.75
Consent	For youth under the age of 18, a parent or guardian will need to provide consent. Consent in school settings will require different logistical considerations than in medical settings. Although the regulations vary widely from state to state and even school district to school district, some
	secondary schools now ask parents to sign blanket consents that permit screening at any time during the school year. The screening program will also need to be sensitive to the particular set of complex challenges in place for youth in foster care.
Incorporating multiple informants	Information from caregivers about a youth’s symptoms may also be needed to guide the process, particularly at younger ages. Screening initiatives will ideally incorporate both youth and caregiver reports of mental health concerns. However, the addition and validation of caregiver reports and procedures would ideally occur once a first-stage screening tool is completed. These approaches may differ depending on the age range. Even for young adults completing screening measures, caregiver or significant other reports could strengthen the screening and care linkage process.
Privacy	It is important to consider issues related to privacy, including individuals being unsure of confidentiality limits. Concerns can arise regarding whether responses can be shared with family members, school staff, or even law enforcement. These issues require up-front efforts to ensure privacy and a safe place to discuss symptoms, as well as discussions of confidentiality boundaries. Additionally, all screening data will need to be housed in a secure manner, such as a HIPAA-compliant cloud-based online format. Protections would also need to be in place regarding access to any information contained on the online portal. We envision collaborating with one of the many companies that provide screening platforms that are fully secure and compliant as an essential part of the initiative.
Safety concerns	It is necessary to ensure procedures are in place for addressing safety concerns (e.g., symptom acuity). It may be necessary to validate a screening measure with and without suicide risk items. At least initially, screening with the new instrument will take place in locations that are already doing screening and thus have procedures and resources for handling safety concerns. As the initiative expands, procedures and staff will need to be in place for addressing mandated reporting issues, including reports for abuse, and neglect, and concerns regarding danger to self and/or others. Reporting requirements will vary by state. For immediate concerns about suicidal ideation and behavior, procedures will be required for contacting caregivers and linking to crisis resources. Protocols for secondary assessment of suicide/self-harm risk have been developed and shown to be feasible within diverse settings.33,40
Inclusivity considerations	Important considerations in building mental health screening tools include creating validated translations in relevant languages, ensuring a reasonable reading level, including audio capability, use culturally-sensitive techniques, and avoiding mental health jargon. Tool development and validation procedures will also need to address concerns and procedures for creating validated language translations, ensuring reasonable reading level of items, including audio capabilities, and identifying and screening individuals with intellectual and developmental disabilities (see Immediate Next Steps in online supplement, ‘Screening’ section).
Logistical issues	Logistical hurdles will need to be addressed according to setting, system, and population variables. Ideally, school settings would initiate the screening process at least once per year during the school year and medical settings would initiate the screening process at annual visits. Procedures will need to be in place to avoid youth completing multiple assessments in short periods of time.
Developing second-stage screening efforts	After developing a first-stage screening measure, second-stage screening would be determined and updated according to additional discussions and available science. Some second-stage assessments will be able to be integrated into the online portal, although it is likely that some second-stage interviews will require trained interviewers, which will necessitate recommendations for appropriate in-person assessments.
Linkage to care
Lack of available evidence-based care	The screening and linkage to care initiative will create recommendations regarding how to overcome issues surrounding limited resources for addressing concerns, such as limited specialty clinics for addressing psychosis spectrum symptoms in certain geographic areas of the United States, especially rural settings (note, SAMHSA has funded 21 pilot sites recommending staged-care models for addressing these symptoms, although evidence for these models is still emerging). The increased use of telehealth during the pandemic indicates telehealth may be a viable tool for improved access to care in rural, frontier, or other communities with limited mental health services, although telehealth use may involve overcoming licensure issues if conducted across state lines. Over time, the initiative may need to work with communities to organize trainings to fill needs for evidence-based care. Furthermore, especially for youth experiencing mental health concerns without a diagnosable condition, there may be a paucity of evidence-based care. There is evidence that Cognitive Behavioral Therapy may mitigate distress. Additional research will be required to develop other evidence-based care for sub-threshold mental health concerns.
Development of online resources	Online resources will be available for anyone accessing the online portal, but specific resource recommendations will be provided for individuals linked to Tier 1 level care based on screening responses (Figure 1). Discussions and resources will need to be dedicated to adapting online psychoeducation, mental health toolkits, resources for reducing stigma, and other therapeutic resources for the online portal. See Table S4 available online for examples of currently available online mental health toolkits.
Logistical Issues	There are also a number of additional logistical issues that will need to be worked out as the program is piloted with each additional site. These issues will include ensuring that for referrals, telehealth options and/or providers that are geographically proximal to the youth in need of services are available, families with multiple youth in need of services obtain appropriate support, wait times for care are not prohibitively long, and issues with reimbursement are addressed.

^aNote, these additional considerations were not fully addressed during the initial think thank meetings and will require further discussions to develop procedures and recommendations for these important considerations.

Developing Collaborative Efforts.

One gap the think tank meetings identified is that system fragmentation has prevented youth mental health screening initiatives from taking hold within existing educational and health care systems; there is no nationwide tool or mechanism for screening across domains of mental health symptoms.⁴⁴ Delegating early detection of mental health concerns to psychiatrists and mental health specialists limits the capacity for large-scale screening, as many people never seek care at all and others do not get connected to specialists. Collaborative efforts building on previous screening efforts and expanding to other settings will be critical.⁴⁵

Addressing Limitations to Screening.

The think tank also identified several limitations to current screening initiatives. One possibility for improving a nationwide screening initiative is ensuring that first-stage assessment screening tools are efficient, do not require extensive training to implement,⁴⁶ and unlike many existing tools, effectively screen for serious mental health concerns including mania and psychosis spectrum symptoms.⁴⁷ The previous lack of inclusion of psychosis spectrum symptoms in screening efforts seems particularly relevant given the significant functional impairment associated with untreated psychosis, and the fact that as many as 88–96% of individuals who experience early symptoms of psychosis go undetected.⁴⁸ Several psychosis screening tools could potentially aid in early psychosis identification efforts.⁴⁹ Any screening and linkage to care initiatives should include broad assessment of mental health symptoms to incorporate the heterogeneity and fluidity of symptoms and trajectories across development.

Barriers to Implementation of Linkage to Care.

56%–79% of youth with mental health symptoms are not currently receiving mental health care (see figure available online),^50,51 as the majority of youth who screen positive for mental health concerns either do not receive help, follow up on referrals, continue with specialty care, or have access to mental health care. The think tank identified several interrelated barriers for youth and young adults who might benefit from early intervention. First, there is often limited access to services, as many programs are restricted geographically, are only available to those with particular types of insurance, and/or are fully subscribed and cannot take on new clients. Second, cultural attitudes and stigma contribute to high rates of either not utilizing services or early drop-out.^19,52 Stigma can be particularly challenging for individuals experiencing psychotic symptoms, symptoms that may be associated with negative perceptions that can hinder seeking care.⁵³ Third, it can be very challenging for youth and families to navigate the mental healthcare system for services. Even when services are available, they can require considerable financial resources, especially for individuals with inadequate insurance coverage. Fourth, instead of encouraging psychological interventions, the health care system has historically relied heavily on pharmaceuticals which can involve unwanted side effects that may lead to treatment dropout.^54,55 Additionally, U.S. health care systems are riddled with inequities, wherein differences exist in access to or quality of care according to race, ethnicity, and socioeconomic factors.⁵⁶ Each of the concerns outlined above are often even greater in historically marginalized communities.

Beginning to Address Barriers to Screening and Linkage to Care: Recommendations

The think tank began to develop several recommendations for a screening and linkage to care initiative. See Figure 1 for an overview of the screening and linkage to care initiative.

Developing Collaborative Efforts.

As mentioned, development and implementation of a screening and linkage to care online platform will require numerous national, state and community collaborative partnerships to leverage existing programs across a geographic region. This will involve partnerships with schools, medical settings (e.g., primary care, inpatient care, emergency rooms), and other community programs. It will be necessary to expand the current involvement of the think tank to involve a number of other areas of expertise. It will be important to reduce barriers for professionals as well, such as reducing impediments to reimbursement for providers in the collaborative network (e.g., bundled payment models to incentivize screening and linkage to care, full reimbursement for screening and assessment). See Table 1 for more details and several additional important considerations for a screening initiative.

Adapting Existing Screeners.

One potential avenue to reach as many youths as possible is incorporating a staged assessment using an online platform introduced in primary care and/or school settings. A staged approach is needed to balance sensitivity and specificity of screening for mental health concerns. Incorporating multiple stages of screening will aid in specificity, as each successive stage of screening will provide a more comprehensive assessment of endorsed mental health concerns, reducing rates of individuals meeting the threshold for linkage to care. Screening for a wide array of symptoms is important to identify those experiencing a variety of mental health concerns.⁵⁷ It will also be important for first stage screening to assess distress and impairment to avoid excessive rates of meeting screener thresholds and to mitigate issues surrounding focusing on specific diagnosis given the fluid nature of youth mental health concerns.³²

In the first stage, an initial screener could be utilized for several psychopathology domains (Figure 1; computerized adaptive testing could be incorporated to improve efficiency and reduce burden^25,58). Individuals meeting threshold criteria on the initial screener could receive recommendations for a second stage more in-depth screening and/or interview, which could presumably be administered either online or in-person. Several tools already exist that could be potentially adopted as a first stage measure to examine symptoms in individuals aged 10–24. The Pediatric Symptom Checklist (PSC²⁷) is one of the most widely used screens covering a range of psychopathology domains. Other potential measures may require shortening to function as brief first stage screeners [e.g., Child Behavior Checklist (CBCL),⁵⁹ the Behavior Assessment System for Children,⁶⁰ and the Kiddie-Computerized Adaptive Tests²⁵]. Although these existing screeners are developed for youth, several have been used in adult populations (e.g., PSC) or have versions that can be used in young adults (e.g., the adult version of the CBCL is the Adult Self Report)⁵⁹.

One possible way to leverage existing tools is to adapt a brief symptom checklist such as the PSC that has been implemented in a variety of non-specialty settings to ascertain clinically relevant information from youth (e.g., distress, impairment) related to experiences of depression, anxiety, mania, suicidality, and psychosis. Additional content considerations may include important contextualizing factors, such as stressors.

Inclusion of Psychosis Spectrum Symptoms.

Given the paucity of psychosis spectrum symptom coverage in measures such as the PSC, one possibility would be for youth to complete an additional psychosis symptom screener following the initial screener, such as the extensively validated Prodromal Questionnaire-Brief (PQ-B),^29,30 Prime Screen,⁶¹ or a brief two-item psychosis screen.⁶² Alternatively, adding additional psychosis spectrum questions to existing screening tools may provide an effective path towards identifying youth with these symptoms. Those who meet threshold criteria for the psychosis domain could receive a recommendation for an interview assessment of psychosis spectrum symptoms.⁶³ Although the think tank members generally agreed on the importance of incorporating psychosis spectrum items into the initial screener, it will be important to ensure appropriate threshold criteria, examine symptoms in the context of distress and impairment, and thoroughly examine psychosis spectrum symptoms in second-stage screening, to minimize the risk of false positives.³¹

Validation Efforts for the Adapted Screener.

To enhance and ensure generalizability, an expanded screener with additional queries would benefit from validation in a large general population sample of youth from early adolescence through early adulthood (online Table S3). It will be important to validate the screener using a demographically diverse sample across race, ethnicity, sex, and age groups. Measurement strategies that are not sensitive to cultural and racial/ethnic differences have the potential to over, under-, or misdiagnose already marginalized groups. Another consideration will be whether such a measure can validly assess psychopathology across early adolescence through early adulthood. After the development of the adapted screener, additional validation efforts could build towards establishing thresholds incorporating distress and impairment specifically for the adapted measure. Efforts would include administering the screener alongside clinical interviews to examine sensitivity and specificity of the tool for detecting individuals with clinically relevant mental health concerns. It will be essential to examine whether thresholds for different domains need to be normed for characteristics such as age, sex, race, and ethnicity.^49,64 It is likely that thresholds will need to vary depending on setting,⁶⁵ although research is needed to determine if this is necessary.

Developing a Screening and Linkage to Care Platform.

Screening must be following by effective linkage to care. There are several possibilities for a screening and linkage to care approach. Given the urgency of the problem, it may be useful to create online platforms tailored to communities and containing an online screening portal (note, there will be a number of logistical and ethical hurdles for implementing such a platform, see Table 1 for discussion of some of these issues), access to psychoeducational materials, and links to care resources, incorporating progress made by previous initiatives (e.g., NAMI, treatment locator and access lines created by groups such as SAMHSA and Mental Health America; Table S2 available online).

Utilizing staged care models as a template could help facilitate the implementation of linkage to care efforts. In terms of utilizing a staged-care model, based on the screening results, the platform would offer resources that are appropriate for the level of symptom severity. For individuals with tier 1 symptoms, or recommendations for programs, clinics, and local resources for individuals with more significant symptoms (Figure 1). One option recently discussed is the possibility of creating a youth mental health service capable of acting as an entry point for all help-seeking youth.⁶⁶ This care entry point would ideally flexibly address changes in youth mental health concerns, incorporating a staged approach that can address a range of severity of mental health concerns. For individuals identified without a diagnosable condition but experiencing distress and/or impairment, there is evidence that treatments, such as Cognitive Behavioral Therapy, can be utilized to target emotional distress.

To reduce burden and increase accessibility, it also will be important to include as many online resources as possible (Table 1; Table S4 available online for examples of currently available online toolkits). There is evidence that ~90% of adolescents experiencing significant depressive symptoms currently seek information online.⁶⁷ Further, recent evidence indicates youth are increasingly more comfortable engaging in mental health services online than in-person.⁶⁸ Evidence suggests that 72% of youth indicate interest in accessing online therapy if experiencing mental health difficulties,⁶⁹ although interest does not necessarily translate to engagement in online treatments.⁷⁰ The COVID-19 pandemic has further highlighted the potential value of online technologies meeting the mental health needs of the community, especially under-served and remote communities.⁷¹ Of course, it will be critical to continue to include recommendations for in-person services for those for whom face-to-face screening and care may promote engagement or for those without access to stable internet or computers/phones.

Whenever possible, youth should be linked to appropriate evidence-based care with demonstrated benefits, as there is evidence that linkage to treatment-as-usual has fewer benefits (see Table 1 for considerations regarding limited resources for some mental health concerns).³⁶ Further, research should examine whether linking to care is more challenging outside of a care context (e.g., in educational settings). Additionally, a youth mental health platform should ideally include options for affordable care for individuals without adequate insurance coverage and/or financial resources. There are a number of other considerations for scaling up the linkage to care program, including having uniform training procedures, adequate resources, monitoring outcomes including cost effectiveness of the program, and attending to unique barriers encountered at individual sites (Table 1 and online Supplement for additional considerations, including the importance of educational initiatives and measuring outcomes).^72,73

Summary and Conclusions

Improving screening and linkage to care efforts in the United States is arguably more important than ever given increasing mental health concerns associated with the COVID-19 pandemic. Despite this need, over the course of a series of meetings, think tank members consistently reported that there are major gaps in our ability to a nationwide screening and linkage to care initiative. One of these major gaps includes the need for a more comprehensive yet efficient screening measure. This initial screener could be incorporated into a staged screening process that includes in-depth second stage screening/interview and linkage to care for more symptomatic individuals (Figure 1). To identify mental health concerns as early as possible, it will be important to initiate screening in a variety of settings not traditionally focused on identifying mental health concerns (e.g., schools, pediatrician offices) potentially using an online platform through which positive screens could be referred for additional assessment. Another identified gap is the need to develop a linkage to care system, including evidence-based resources and providers in a community and piloting a staged linkage to care model using these resources (Figure 1). Under such a model, attention would need to be paid to issues such as consent, adequate coverage of psychosis spectrum symptoms, safety concerns (e.g., acuity of symptoms), health inequities, reducing provider burden, developmental and cultural differences, developing online tools, and payment models (Table 1 for additional concerns). The think tank also emphasized the importance of creating collaborative efforts and building upon previous work.

The think tank began the process of developing a U.S.-based screening and linkage to care initiative. The think tank only discussed some of the important issues that will need to be addressed for such an initiative, and the recommendations are just the first of many steps that will be needed to develop and implement such a screening tool (online Supplement for an assessment of think tank member agreement for proposed initiatives). One immediate first step is further expanding the collaborative network and expanding think tank discussions to elaborate on developing the screening to linkage to care initiative (online Table S3). A second step is adapting and validating a broad mental health symptom screening measure or measures to include psychosis spectrum symptoms and assure validity in early adolescent through early adulthood populations to support a staged assessment process. A third step is organizing currently available online mental health resources for eventual inclusion in an online screening and linkage to care portal for use as mental health resources. Additional steps will evolve out of the results from these initial steps.

Although developing a nationwide screening and linkage to care approach in the U.S. is a massive undertaking, the think tank meetings identified initial steps for a pathway addressing current structural and systemic problems in the current youth mental health system. There will be numerous considerations for the development of this initiative, as indicated in the text and Table 1. Piloting, validation, and implementation studies will be required to overcome obstacles and to reduce burden on providers. In addition to the potential for significantly improving youth mental health, having a system to screen and link to care will alleviate burden from providers, who need efficient and effective steps for responding to youth mental health concerns.

Highlights:

• A series of virtual think tank meetings identified potential first steps towards an early screening and linkage-to-care initiative for youth mental health concerns in the United States

• Discussions included developing a screening and linkage to care initiative with a staged assessment process, including a first stage brief universal screener for several domains of psychopathology.

• The think tank discussed that screening must be followed by recommendations for linkage to an appropriate level of evidence-based care.

• Considerations included addressing health inequities, validating adapted screening measures, reducing time and resource burdens for providers, and developing a collaborative network.