This paper is in the following e-collection/theme issue:

Methods and Feasibility Studies (369) e-Mental Health and Cyberpsychology (1415) Depression and Mood Disorders; Suicide Prevention (1293) Anxiety and Stress Disorders (1015)

Published on in Vol 12 (2023)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/45666, first published .
Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

Authors of this article:

Mara Eyllon1 Author Orcid Image ;   Michelle Dalal2, 3 Author Orcid Image ;   Laura Jans4 Author Orcid Image ;   Ian Sotomayor4 Author Orcid Image ;   Gabrielle Peloquin1 Author Orcid Image ;   James Yon5 Author Orcid Image ;   Rochelle Fritz5 Author Orcid Image ;   Jessica Schleider4 Author Orcid Image
Article Authors Cited by (1) Tweetations (3) Metrics

    Protocol

    1Practice Research Network, Reliant Medical Group, Worcester, MA, United States

    2Northeastern University, Northeastern University Health and Counseling Services, Boston, MA, United States

    3Department of Pediatrics, Chan School of Medicine, University of Massachusetts, Worcester, MA, United States

    4Department of Psychology, Stony Brook University, Stony Brook, NY, United States

    5Behavioral Health Department, Reliant Medical Group, Worcester, MA, United States

    Corresponding Author:

    Mara Eyllon, PhD

    Practice Research Network

    Reliant Medical Group

    5 Neponset Street

    Worcester, MA, 01606

    United States

    Phone: 1 6178754554

    Email: mara.eyllon@reliantmedicalgroup.org


    Background: Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap.

    Objective: We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department.

    Methods: Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time.

    Results: The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023.

    Conclusions: SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers.

    International Registered Report Identifier (IRRID): DERR1-10.2196/45666

    JMIR Res Protoc 2023;12:e45666

    doi:10.2196/45666

    Keywords

    adolescents; behavioral health care; mental health; primary care; single-session interventions 


    Overview

    Among adolescents, the incidence of depression and anxiety has increased significantly over the past decade. In 2019, 37% of adolescents (in the United States) experienced symptoms of sadness or hopelessness, while 21% received a diagnosis of major depressive disorder and 9% were diagnosed with an anxiety disorder [1]. Exacerbating the crisis in youth mental health, the COVID-19 pandemic led to unparalleled disruption in the day-to-day lives of youth and adolescents. School and social events were put on hold, and they observed the consequences of COVID-19 in their families and communities, resulting in a 2-fold increase in depression and anxiety [2].

    Despite the rising prevalence of mental health concerns among adolescents, 75% of adolescents with mental health conditions do not receive appropriate care [2] due to a lack of access and acute shortages of qualified pediatric mental health clinicians [2]. Primary care providers are increasingly called upon to identify and intervene with mental health concerns [3], and it is therefore critical for pediatric primary care providers to have effective tools to offer to patients and their families to help manage symptoms. However, such resources are often not available to primary care providers, and patients often wait months before receiving care from licensed mental health professionals following a referral from primary care. Self-guided and web-based single-session interventions (SSIs) are an effective treatment for adolescents with mild to moderate mental health concerns [4] and may provide a stopgap for patients in need of more intensive care who are waiting to receive services. This paper presents the protocol for a novel clinical process for pediatric and integrated behavioral health care providers to refer adolescent patients to use the SSI platform Project YES (Youth Empowerment and Support) at a large group medical practice with an integrated behavioral health department.

    Access to Mental Health Care Among Adolescents

    In 2021, the surgeon general declared a mental health emergency, prompting responses from multiple sectors to allocate resources to pediatric mental health care [5]. Yet, despite such calls, the population-level mental health of adolescents has worsened throughout the pandemic as growing patient needs are compounded by acute shortages of qualified providers [2,6]. While more than half of all adolescents with mental health concerns do not receive any treatment, even among those who are treated, most do not complete a full course of evidence-based treatment and rarely attend more than 3 to 4 sessions [7]. Beyond the issue of supply and demand, barriers to accessing and completing a clinically appropriate course of treatment for mental health concerns are many. Among adolescents, stigma, shame, and beliefs about who seeks mental health care may inhibit adolescents from accessing necessary interventions [8]. Confidentiality from parents is another important barrier and the Adolescent Health Care Barrier Survey revealed that nearly 40% of adolescents reported forgoing mental health services because they did not want their parents to know [9]. These barriers highlight the need for evidence-based tools which are both acceptable and directly accessible to youth presenting with mood- and anxiety-based symptoms.

    SSIs are designed to be intentionally brief, flexible, and potent. Digital SSIs, which can be web-based and self-guided, are a sustainable and low-cost means of disseminating evidence-based treatments at scale [4,10]. SSIs do not rely on patient-provider ratios and can be offered to many patients by just a few providers in under 5 minutes. Their broad accessibility can reduce stigma around mental health concerns and help to normalize the use of appropriate care, whether a patient is going through a challenging time or working through a persistent mental health condition. Furthermore, SSIs can be disseminated in a variety of settings, such as schools and through social media [10,11], and adolescents can use SSIs with confidentiality from their parents. Despite the demonstrated efficacy of SSIs disseminated through social media, they are seldom made available in pediatric health care settings. As digital technologies are increasingly leveraged to close the gap in mental health care, SSIs may provide an additional resource for providers to deploy to adolescent patients.

    Evidence for SSIs

    Given their demonstrated effectiveness and flexible nature, web-based SSIs allow youth to access mental health support when and where they need it. A growing body of evidence suggests that SSIs hold the potential to reduce a variety of mental health problems. In a meta-analysis of 50 randomized controlled trials targeting youth mental health issues, SSIs were effective (Hedges g=0.32) in improving several clinically relevant outcomes [12]. Notably, SSI effectiveness did not significantly differ between therapist-administered and self-administered interventions. In addition, shorter (<60-minute) interventions were found to be as effective as longer SSIs [12].

    In a randomized controlled trial, a virtual, self-administered growth mindset intervention reduced depression symptoms in high-symptom youth 9 months after completion [13]. Other trials of digital SSIs teaching growth mindsets similarly demonstrated their potential to reduce depression symptoms [14-16]. In a diverse group of adolescents recruited from all 50 US states, 2 SSIs improved youth agency immediately postintervention and decreased anxiety, depression, hopelessness, and restrictive eating behaviors 3 months later [17]. Importantly, these SSIs appear to be similarly effective for youth of diverse racial-ethnic identities, gender identities, subjective family social status, and sexual orientations [18].

    Web-based SSIs have been evaluated in a more naturalistic setting through an open-access web-based platform called Project YES [19]. Project YES allows adolescents (aged 11 to 17 years) to choose from 3 web-based interventions, each of which spans approximately 30 minutes and includes a core element of evidence-based treatment [10]. Youth may choose from Project Personality (which teaches that personality traits can change), Project CARE (which centers on the benefits of self-compassion), or the Action Brings Change (ABC) project (which encourages youth to engage in activities to improve their mood). Youth can complete as many interventions as they would like, as often as they choose to, and entirely free of charge. In a pilot trial, adolescents who completed an intervention through the Project YES platform experienced immediate improvements in hopelessness, self-hatred, perceived control, and agency. In addition, youth rated the interventions as acceptable, and 34.32% of youth who started an intervention completed it [10]. This surpassed completion rates for other digital interventions in naturalistic settings (1%-28%) [20].

    Project YES has also been culturally adapted and translated into Spanish for youth living in San Antonio, Texas. Through a series of semistructured focus groups, San Antonio youth stakeholders shared their lived mental health experiences and co-designed the adapted interventions [21]. San Antonio youth who completed an intervention in English experienced immediate improvements in hopelessness, self-hatred, and perceived agency. Similarly, youth who completed a culturally adapted and translated intervention experienced immediate improvements in self-hatred [21]. The completion rate was 49.6%, and the interventions were rated as acceptable by youth [21].

    Each SSI in Project YES includes shared core elements thought to underlie its effectiveness. Namely, the interventions (1) present youth with brain science to validate the concepts introduced in the activity, (2) empower youth by placing them in an “expert” role, (3) promote retention of the material with “saying is believing” exercises, and (4) include vignettes from peers and valued others [19]. Conceptually, the SSIs operate by shifting proximal beliefs or behaviors (eg, hopelessness, agency, expectancy that change is possible), which are thought to spark behavior change underlying a longer-term reduction of internalized symptoms [17,22]. SSIs are designed with a few key assumptions: (1) something good can come in 1 session, and 1 session may be the last; (2) change can, and is expected to, occur in the moment; (3) and individuals already have the inner capacity to alter their thoughts, emotions, and behaviors to create meaningful change [23]. Altogether, web-based SSIs, such as those in Project YES, are promising options for delivering brief, evidence-based mental health support with the potential to fill need-to-access gaps [24] for youth experiencing mental health problems.

    Although SSIs disseminated through social media have been explored in other contexts, less is understood about how to optimize their implementation in primary care settings and integrate them into existing clinical workflows. Identifying best practices for integrating SSIs into current pediatric provider workflows may give providers an additional resource to recommend to their patients experiencing symptoms of anxiety or depression. To this end, the primary objective of this quality improvement pilot is to establish the feasibility and acceptability of delivering a SSI to adolescents with mild to moderate depression and anxiety in pediatric primary care and behavioral health.


    Setting

    Reliant Medical Group (RMG) is a multispecialty group medical practice in Massachusetts. With 19 clinics, RMG provides services to 240,000 patients per year, including 64,000 pediatric patients, 29% of whom have been diagnosed with a mental health condition. RMG has an integrated behavioral health department in which patients are triaged by a licensed mental health care provider from primary care to integrated behavioral health services within RMG or in the community. The pediatric behavioral health team has 13 providers, including psychologists, master’s level clinicians, nurse practitioners, and psychiatrists who handle prescribing needs. However, the integrated model only serves one-third of the patient population. In 2021, a total of 1910 pediatric patients who were not appropriate matches for the integrated care model were referred outside of RMG to receive services in the greater community. RMG also has a practice research network that includes a team of research scientists and coordination staff to oversee research studies and evaluate quality improvement initiatives. This protocol was developed by a multidisciplinary team including a research scientist, pediatrician, pediatric psychologist, and pediatric psychiatrist in collaboration with the Lab for Scalable Mental Health at Stony Brook University.

    Study Design

    This paper describes a quality improvement pilot designed to evaluate the feasibility and acceptability of disseminating Project YES in primary and behavioral health care, as well as evaluate short-term changes in mental health outcomes among participants.

    Patient Screening

    Figure 1 displays the clinical workflow for screening and referring patients to Project YES. First, as part of routine mental health screening during well-child visits, pediatric primary care and behavioral health providers or their medical assistants administer either the 17-item Pediatric Symptom Checklist (PSC-17) [25] or the Youth PSC-17 (Y-PSC-17) [25] to all patients aged between 13 and 17 years. When the total internalizing symptom score is elevated on either of these scales, follow-up screeners such as the Patient Health Questionnaire-9 (PHQ-9) [26] and the General Anxiety Disorder-7 (GAD-7) [27] are administered. Information from these screeners is used to determine whether patients meet criteria for a clinical diagnosis on the spectrum of depression or anxiety and whether routine follow-up is necessary. The PHQ-9 and GAD-7 screeners are also routinely administered as independent screening tools by behavioral health providers as part of the behavioral health visit. Providers will have the opportunity to refer patients to Project YES when the following criteria in Textbox 1 are met:

    ‎
    Figure 1. Clinical workflow for referring patients to Project YES.
    Textbox 1. Inclusion and exclusion criteria.

    Inclusion criteria

    • Patient is aged between 13 and 17 years.
    • Patient meets at least one of the following criteria at the visit or in the preceding 3 months: (1) Patient Health Questionnaire-9 (PHQ-9) score >5; (2) Y-PSC-17 or PSC-17 internalizing score ≥5; (3) total Youth 17-item Pediatric Symptom Checklist (Y-PSC-17) or 17-item Pediatric Symptom Checklist (PSC-17) score ≥15; and (4) General Anxiety Disorder-7 (GAD-7) score ≥5.
    • Comfortable speaking and reading in either English or Spanish.

    Exclusion criteria

    • Active suicidal ideation (score ≥1 on question 9 of the PHQ-9, if completed).

    Best Practice Alert

    When a patient meets the eligibility criteria, a best practice alert (BPA), displayed in Figure 2, will be triggered in Epic, RMG’s electronic health records (EHR) system. The BPA pop-up screen provides instructions for referring a patient to Project YES, including a brief overview of Project YES, its potential benefits, and how to access it. If the patient indicates that they are interested, the provider can offer SSI in 1 of 2 ways:

    1. Send the patient a QR code or a link to participate in the SSI through MyChart (the patient front-end of Epic). The MyChart message will include a link to Project YES at the Lab for Scalable Mental Health website and instructions for participating.
    2. Provide the patient with a QR code displayed in the BPA that patients may scan using their mobile device, allowing for the retrieval of Project YES for later use. The QR code is also included in the after-visit summary for later use. The QR code will direct patients to Project YES at the Lab for Scalable Mental Health website.
    ‎
    Figure 2. Best practice alert screen.

    Educating Providers on Project YES

    First, to ensure representation from participating departments, the implementation team included a pediatrician from the pediatrics department and a pediatric clinical psychologist and pediatric psychiatrist from the behavioral health department. Initial permission and buy-in were sought from the key leadership, including the chief of pediatrics and chief of behavioral health, before designing the workflow. The SSI workflow is targeted toward pediatric and behavioral health providers, including pediatricians, nurse practitioners, clinical psychologists, and master’s-level mental health clinicians. All pediatric medical providers and integrated behavioral health providers will be given a brief presentation by members of the implementation team at monthly department meetings, 4 weeks before launching the workflow, and again the week before launch. The introductory presentation covers the gap in care that SSIs can fill, the core elements of Project YES and its 3 interventions, an example of 1 of the SSIs, the evidence base for Project YES, and instructions for referring patients to Project YES during care. Monthly check-ins at department meetings will be held to review processes, answer questions, and gather assessments as well as informal feedback. The monthly check-ins are led by the pediatric behavioral health lead, who is available to answer any questions and address and track comments or concerns. Her contact information is also provided on all materials in the event a provider has questions in real-time.

    Each unique clinic also holds individual site meetings where the behavioral health lead will reiterate the core components of Project YES to the staff and providers at each individual clinic. This will also provide the lead an opportunity to introduce new clinical team members to the intervention and referral processes during their orientation. To allow for broader dissemination of information, a monthly behavioral health newsletter sent to all staff in behavioral health and pediatrics will also contain information about the intervention. Lastly, additional materials, such as the PowerPoint slides and other informational materials, will be posted to department shared drives for on-demand review.

    Patient Participation

    Patients will receive an invitation to participate with a link to the SSI and instructions for participating through MyChart (Multimedia Appendix 1). The patient will click on the link in their MyChart messages that will take them to the Lab for Scalable Mental Health’s website. They will be asked to select the module they want to participate in and indicate that they are aged between 13 and 17 years and a patient at RMG in Massachusetts before beginning. The patient will not enter any potentially identifying information. By entering that they are an RMG patient, the Lab for Scalable Mental Health will be able to filter RMG’s data for the program evaluation. Before and after completing the module, the patient will be invited to complete a series of anonymous, optional questionnaires within Project YES’ Qualtrics interface. In the event a participant in Project YES experiences distress, the Project YES platform provides a “Need help now?” button on the main website and on each page of the platform that leads to [28]. The linked page provides immediately accessible crisis resources such as the Crisis Text Line, the National Suicide Prevention Lifeline, and a Hotline for LGBTQ+ Youth.

    Data Collection

    Provider referral records will be collected through RMG’s EHR, and anonymous patient engagement and outcomes data will be collected within Project YES’ Qualtrics interface by the Lab for Scalable Mental Health and sent to RMG for analysis. Table 1 describes the specific data to be collected and the corresponding methods of analysis.

    Table 1. Overview of data collected and analytic methods.
    DataItemsAnalytic methods
    Behavioral health and primary care providers: EHRa data

    • Number of eligible patients seen.
    • Number of referrals made.
    • Reasons indicated for not providing SSIb (patient inappropriate, not interested, or other).
    • Number of patients selecting QR code versus MyChart message access.
    • Descriptive statistics: proportion of providers in each department offering SSI.
    Patients: engagement metrics and feedback
    • Number of RMGc patients who entered the site.
    • Total number of patients who completed the SSI.
    • Program Feedback Scale
    • Descriptive statistics.
    Providers: data collected at monthly behavioral health and pediatric department meetings
    • Acceptability of Implementation Measure (AIM).
    • Feasibility of Implementation Measure (FIM).
    • Intervention Appropriateness Measure (IAM).
    • Descriptive statistics.
    • Repeated measures ANOVA.

    aEHR: electronic health record.

    bSSI: single-session intervention.

    cRMG: Reliant Medical Group.

    Provider Measures

    A total of 3 implementation outcome measures will be collected from providers to evaluate the implementation of Project YES. Each outcome measure consists of 4 items rated on a 5-point Likert scale ranging from “completely disagree” to “completely agree.” The scales demonstrate high reliability, with Cronbach α reported between .85 and .91, structural validity indicated by factor loadings between 0.75 and 0.89, and test-retest reliability coefficients between 0.73 and 0.88 [29].

    Acceptability of Intervention Measure

    The Acceptability of Intervention Measure (AIM) measures the appeal of an intervention to target providers (eg, Project YES meets my approval) [29].

    Intervention Appropriateness Measure

    The Intervention Appropriateness Measure (IAM) measures whether an intervention is fitting and relevant to the target participants within a given setting (eg, Project YES seems applicable) [29].

    Feasibility of Implementation Measure

    The Feasibility of Intervention Measure (FIM) measures whether implementing a given intervention is achievable within the setting given the time and resources required to carry it out successfully (eg, Project YES seems doable) [29].

    Participant Measures

    The following measures are the same as those described in previous reports on Project YES; however, in the context of this data collection, we include both the English and Spanish versions. Additionally, this study implemented a single-item question in both English and Spanish surveys, asking whether the participant was a patient with RMG. Only data from participants who select yes to confirm patient status with RMG and report being between the ages of 13 and 17 years will be included in the final analysis.

    Demographics

    Participants will identify their age range (provided in ranges to maintain anonymity: 10 years or younger, 11-12 years, 13-15 years, 16-17 years, 18 years or older), sex assigned at birth, gender identity, sexual orientation, race or ethnicity, how they learned about Project YES, and whether they are patients at RMG in Massachusetts.

    Program Feedback Scale

    The Program Feedback Scale (PFS) [30], which is routinely used to evaluate acceptability and user perceptions of SSIs [4,21,23,31] asks participants to rate agreement with 7 statements indicating perceived acceptability and feasibility of their selected SSI (eg, “I enjoyed the program”) on a 5-point Likert scale (1=“really disagree;” 5=“totally agree”). The scale was adapted from existing, validated acceptability assessments of digital interventions; adaptations from existing scales were necessary to exclude items that are inapplicable to web-based SSIs (eg, items referencing frequency of use or interest in continuing to revisit the program). The PFS will also assess participants’ open-response feedback. PFS item scores may be evaluated individually or through a mean score across items. Mean responses to each PFS item will be evaluated separately to gain insight on the acceptability in specific domains (eg, ease of use and understanding, enjoyability).

    Ethical Considerations

    This quality improvement project was exempted from review by the Optum Office of Human Subjects Research Institutional Review Board (IORG0010356) as it was deemed not human subjects research.


    The program was initiated in November 2022 at 1 site to ensure Epic components functioned as intended and then expanded across all sites in December 2022. The program will continue for 6 months before the program evaluation will commence; however, referral, implementation assessment, and patient engagement data will be reviewed iteratively to identify any adaptations that need to be made. Data analysis and manuscript writing are expected in the summer of 2023.


    Overview

    Closing the gap in pediatric mental health care requires rethinking how care is delivered and innovative models to overcome the common barriers of face-to-face therapy while delivering effective, evidence-based treatments. Calls for innovation in mental health care have been made [32,33] and COVID-19 has catalyzed the development of digital technology for mental health [34,35]. Such technology is not often available in primary care settings. Single-session treatments, which provide a single session of face-to-face psychotherapy to patients, have been explored in mental health care settings, reporting medium to large effect sizes [36-38], although they are not as commonly deployed in primary care settings. Importantly, compared to single-session treatments, SSIs may be self-guided and rapidly disseminated among patients by providers without special training. Given that the modal number of psychotherapy sessions patients attend is 1 [7], while a minimum of 12-20 sessions may be required for symptom resolution, SSIs developed with the explicit intention of resolving symptoms in just 1 session are not only more accessible but may also be a more appropriate approach to improving treatment for adolescent mental health conditions. In addition to being a front-line intervention for primary care providers, SSIs may also be leveraged by behavioral health providers and offered as adjunctive or follow-up care for traditional face-to-face therapy.

    Strengths and Limitations

    Offering patients SSIs in primary care and behavioral health settings is an efficient and cost-effective approach to narrowing the treatment-to-service gap in adolescent mental health care. Approaching this as an implementation project will allow us to understand the feasibility, acceptability, and appropriateness of SSI delivery in a pediatric primary care and integrated behavioral health setting and thus identify potential barriers and facilitators providers may face when offering Project YES to their patients. This information may be used to iteratively adapt the clinical workflow described to streamline the process for providers and patients alike, thus improving uptake. This protocol was developed in close collaboration with a pediatric clinical team and feedback from leadership to ensure that it is relevant, efficient, and can be easily grasped and deployed by providers. Further, making the SSIs accessible to patients with a wide range of symptoms may help reduce stigma around mental health care. Finally, adolescents who may otherwise forgo behavioral health services due to concerns about their confidentiality from their parents can use the SSIs privately without their parents being notified.

    Nonetheless, there are several limitations to the study design. Participation is contingent on elevated scores on the screener questionnaires. However, patients who may not meet clinical criteria may also benefit from the SSIs, which can be effective for subclinical internalizing symptoms. To address this, future iterations of this project may explore expanding referrals to all adolescent patients, regardless of meeting screening criteria, or advertising the program on waiting room monitors and in other patient-facing materials. Additionally, this work is only being piloted at a single-group medical practice in Massachusetts and may not be generalizable to other populations. Furthermore, RMG has a predominantly White, English-speaking patient population. Although the intervention is available to Spanish-speaking patients, more work may be needed to understand its feasibility and acceptability in other clinical contexts and among diverse patient populations. Finally, without the use of a placebo-control group to control for potential effects of participating in an SSI in and of itself, the effectiveness data from this study may overestimate potential improvements in symptoms.

    Conclusion

    While this work explores the dissemination of SSIs in primary care and pediatric behavioral health, SSIs have great potential as a proactive approach to the prevention of mental health concerns. Future work could explore the provision of SSIs to a wider range of adolescents in primary care to examine their potential upstream preventive effects. Furthermore, previous research indicates that parents of adolescents may also benefit from SSIs that are as brief as 15 minutes [4]. While the present workflow was designed to be accessed confidentially by adolescents, SSIs may be effectively disseminated to adolescent parents in primary care settings to raise their expectations for treatment, thus improving patient engagement [4].

    SSIs are highly accessible and potent interventions that effectively help to fill the adolescent mental health treatment gap at low costs and require minimal provider time and resources. We anticipate that referring patients to Project YES will be both feasible and acceptable for primary care providers, and its use will be acceptable and effective for patients.

    Acknowledgments

    ME, MD, JY, RF, JS, and GP contributed to the conceptualization and implementation of the intervention. ME, MD, LJ, and IS wrote the original draft. All authors reviewed and approved the manuscript. JS has received research and grant support from the National Institutes of Health Office of the Director (DP5OD028123), National Institute of Mental Health (R43MH128075), National Science Foundation (2141710), Health Resources & Services Administration (U3NHP45406-01-00), the Upswing Fund for Adolescent Mental Health, the Society for Clinical Child and Adolescent Psychology, and the Klingenstein Third Generation Foundation outside of the submitted work. The preparation of this paper was supported in part by the Implementation Research Institute (IRI) at the George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (R25MH080916). JS is an IRI Fellow. ME and GP receive support through the Practice Research Network, which is funded by OptumLabs, part of United Health Group.

    Conflicts of Interest

    JS receives consulting fees from Kooth, LLC and Woebot Health; is Co-Founder and Co-Director of Single Session Support Solutions; and receives book royalties from New Harbinger, Oxford University Press, and Little Brown Book Group.

    Multimedia Appendix 1

    MyChart message to patients who elect to participate.

    DOCX File , 15 KB
    1. Bitsko RH, Claussen AH, Lichstein J, Black LI, Jones SE, Danielson ML, et al. Mental health surveillance among children - United States, 2013-2019. MMWR Suppl. 2022;71(2):1-42. [FREE Full text] [CrossRef] [Medline]
    2. Ghafari M, Nadi T, Bahadivand-Chegini S, Doosti-Irani A. Global prevalence of unmet need for mental health care among adolescents: a systematic review and meta-analysis. Arch Psychiatr Nurs. 2022;36:1-6. [CrossRef] [Medline]
    3. Findling RL, Stepanova E. The workforce shortage of child and adolescent psychiatrists: is it time for a different approach? J Am Acad Child Adolesc Psychiatry. 2018;57(5):300-301. [CrossRef] [Medline]
    4. Schleider JL, Dobias M, Fassler J, Shroff A, Pati S. Promoting treatment access following pediatric primary care depression screening: randomized trial of web-based, single-session interventions for parents and youths. J Am Acad Child Adolesc Psychiatry. 2020;59(6):770-773. [CrossRef] [Medline]
    5. Protecting youth mental health: the US surgeon general's advisory. US Public Health Service. 2021. URL: https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf [accessed 2023-06-29]
    6. Health workforce shortage areas. Health Resources and Services Administration. 2021. URL: https://data.hrsa.gov/topics/health-workforce/shortage-areas [accessed 2021-11-23]
    7. Harpaz-Rotem I, Leslie D, Rosenheck RA. Treatment retention among children entering a new episode of mental health care. Psychiatr Serv. 2004;55(9):1022-1028. [FREE Full text] [CrossRef] [Medline]
    8. Moskos MA, Olson L, Halbern SR, Gray D. Utah youth suicide study: barriers to mental health treatment for adolescents. Suicide Life Threat Behav. 2007;37(2):179-186. [CrossRef] [Medline]
    9. Samargia LA, Saewyc EM, Elliott BA. Foregone mental health care and self-reported access barriers among adolescents. J Sch Nurs. 2006;22(1):17-24. [CrossRef] [Medline]
    10. Schleider JL, Dobias ML, Sung JY, Mullarkey MC. Future directions in single-session youth mental health interventions. J Clin Child Adolesc Psychol. 2020;49(2):264-278. [FREE Full text] [CrossRef] [Medline]
    11. Schleider JL, Mullarkey MC, Fox KR, Dobias ML, Shroff A, Hart EA, et al. A randomized trial of online single-session interventions for adolescent depression during COVID-19. Nat Hum Behav. 2022;6(2):258-268. [FREE Full text] [CrossRef] [Medline]
    12. Schleider JL, Weisz JR. Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. J Am Acad Child Adolesc Psychiatry. 2017;56(2):107-115. [CrossRef] [Medline]
    13. Schleider J, Weisz J. A single-session growth mindset intervention for adolescent anxiety and depression: 9-month outcomes of a randomized trial. J Child Psychol Psychiatry. 2018;59(2):160-170. [CrossRef] [Medline]
    14. Perkins AM, Bowers G, Cassidy J, Meiser-Stedman R, Pass L. An enhanced psychological mindset intervention to promote adolescent wellbeing within educational settings: a feasibility randomized controlled trial. J Clin Psychol. 2021;77(4):946-967. [FREE Full text] [CrossRef] [Medline]
    15. Osborn TL, Rodriguez M, Wasil AR, Venturo-Conerly KE, Gan J, Alemu RG, et al. Single-session digital intervention for adolescent depression, anxiety, and well-being: outcomes of a randomized controlled trial with Kenyan adolescents. J Consult Clin Psychol. 2020;88(7):657-668. [CrossRef] [Medline]
    16. Miu AS, Yeager DS. Preventing symptoms of depression by teaching adolescents that people can change. Clin Psychol Sci. 2014;3(5):726-743. [FREE Full text] [CrossRef]
    17. Schleider JL, Beidas RS. Harnessing the single-session intervention approach to promote scalable implementation of evidence-based practices in healthcare. Front Health Serv. 2022;2:997406. [FREE Full text] [CrossRef] [Medline]
    18. McDanal R, Shen J, Fox K, Eaton NR, Schleider JL. Predicting transdiagnostic symptom change across diverse demographic group in RCT. PsyArXiv.. Preprint posted online on October 14 2022 [FREE Full text] [CrossRef]
    19. Schleider JL, Dobias M, Sung J, Mumper E, Mullarkey MC. Acceptability and utility of an open-access, online single-session intervention platform for adolescent mental health. JMIR Ment Health. 2020;7(6):e20513. [FREE Full text] [CrossRef] [Medline]
    20. Fleming T, Bavin L, Lucassen M, Stasiak K, Hopkins S, Merry S. Beyond the trial: systematic review of real-world uptake and engagement with digital self-help interventions for depression, low mood, or anxiety. J Med Internet Res. 2018;20(6):e199. [FREE Full text] [CrossRef] [Medline]
    21. Shroff A, Roulston C, Fassler J, Dierschke NA, Todd JSP, Ríos-Herrera A, et al. A digital single-session intervention platform for youth mental health: cultural adaptation, evaluation, and dissemination. JMIR Ment Health. 2023;10:e43062. [FREE Full text] [CrossRef] [Medline]
    22. Schleider JL, Abel MR, Weisz JR. Do immediate gains predict long-term symptom change? Findings from a randomized trial of a single-session intervention for youth anxiety and depression. Child Psychiatry Hum Dev. 2019;50(5):868-881. [CrossRef] [Medline]
    23. Schleider JL, Sung J, Bianco A, Gonzalez A, Vivian D, Mullarkey MC. Open pilot trial of a single-session consultation service for clients on psychotherapy wait-lists. Behav Ther (NYNY). 2021;44(1):8-15. [CrossRef]
    24. Manvelian A, SJL. Digital single-session interventions: promoting resilience across the lifespan. Int Syst Study Behav Dev. 2020;2(80):11-13.
    25. Jellinek MS, Murphy JM, Robinson J, Feins A, Lamb S, Fenton T. Pediatric symptom checklist: screening school-age children for psychosocial dysfunction. J Pediatr. 1988;112(2):201-209. [CrossRef] [Medline]
    26. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals. 2002;32(9):509-515. [FREE Full text] [CrossRef]
    27. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. [FREE Full text] [CrossRef] [Medline]
    28. Accessible crisis resources. Lab for Scalable Mental Health. URL: https://www.schleiderlab.org/yes-resources.html [accessed 2023-07-02]
    29. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. [FREE Full text] [CrossRef] [Medline]
    30. Schleider JL, Mullarkey MC, Weisz JR. Virtual reality and web-based growth mindset interventions for adolescent depression: protocol for a three-arm randomized trial. JMIR Res Protoc. 2019;8(7):e13368. [FREE Full text] [CrossRef] [Medline]
    31. Dobias ML, Chen S, Fox K, Schleider JL. Brief interventions for self-injurious thoughts and behaviors in young people: a systematic review. PsyArXiv.. Preprint posted online March 3, 2020 [FREE Full text] [CrossRef]
    32. Kazdin AE. Annual research review: expanding mental health services through novel models of intervention delivery. J Child Psychol Psychiatry. 2019;60(4):455-472. [CrossRef] [Medline]
    33. Kazdin AE, Rabbitt SM. Novel models for delivering mental health services and reducing the burdens of mental illness. Clin Psychol Sci. 2013;1(2):170-191. [CrossRef]
    34. East ML, Havard BC. Mental health mobile apps: from infusion to diffusion in the mental health social system. JMIR Ment Health. 2015;2(1):e10. [FREE Full text] [CrossRef] [Medline]
    35. Friis-Healy EA, Nagy GA, Kollins SH. It is time to REACT: opportunities for digital mental health apps to reduce mental health disparities in racially and ethnically minoritized groups. JMIR Ment Health. 2021;8(1):e25456. [FREE Full text] [CrossRef] [Medline]
    36. Perkins R. The effectiveness of one session of therapy using a single-session therapy approach for children and adolescents with mental health problems. Psychol Psychother. 2006;79(Pt 2):215-227. [CrossRef] [Medline]
    37. Perkins R, Scarlett G. The effectiveness of single session therapy in child and adolescent mental health. Part 2: an 18-month follow-up study. Psychol Psychother. 2008;81(Pt 2):143-156. [CrossRef] [Medline]
    38. Barwick M, Urajnik D, Sumner L, Cohen S, Reid G, Engel K, et al. Profiles and service utilization for children accessing a mental health walk-in clinic versus usual care. J Evid Based Soc Work. 2013;10(4):338-352. [CrossRef] [Medline]

    ‎
    ABC: Action Brings Change
    AIM: Acceptability of Intervention Measure
    BPA: best practice alert
    EHR: electronic health record
    FIM: Feasibility of Intervention Measure
    GAD-7: General Anxiety Disorder-7
    IAM: Intervention Appropriateness Measure
    PFS: Program Feedback Scale
    PHQ-9: Patient Health Questionnaire-9
    PSC-17: 17-item Pediatric Symptom Checklist
    RMG: Reliant Medical Group
    SSI: single-session intervention
    YES: Youth Empowerment and Support
    Y-PSC-17: Youth 17-item Pediatric Symptom Checklist

    Edited by A Mavragani; submitted 24.01.23; peer-reviewed by K Perreault, L Reid-Chassiakos; comments to author 26.04.23; revised version received 04.05.23; accepted 05.05.23; published 09.08.23.

    Copyright

    ©Mara Eyllon, Michelle Dalal, Laura Jans, Ian Sotomayor, Gabrielle Peloquin, James Yon, Rochelle Fritz, Jessica Schleider. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.08.2023.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.