Rates of anxiety and depression among young people are the highest they've been since 2013, when Colorado first began collecting this data. Driven by the urgent state of youth mental health, an effort is underway in Colorado to identify kids who need behavioral health help before they are in crisis.
New legislation to establish statewide mental health screenings will expand on similar programs already in place at some schools, particularly those with school-based health centers. These screenings are sets of standardized questions about depression, anxiety, and self-harm meant to identify students who might be struggling.
Senator Dafna Michelson-Jenet, who was one of the lead sponsors of the screening bill, became committed to youth mental health issues after her son survived a suicide attempt at school when he was 9 years old. This legislation is one of several mental health-related bills she has worked on over the years.
“He had fallen through the cracks, despite me having knowledge and access and privilege and fighting all the way for him the whole time,” she said. “He still fell through cracks.”
Colorado's new legislation focused on behavioral health screenings is meant to identify kids with undiagnosed mental health issues. Glenwood Springs High School has had a screening program in place since 2020. In fact, all students 12 years and older who go in for medical or behavioral health care are automatically screened for mental health issues.
"Depression and anxiety are a lot of the the biggest concerns that we see. And increases in anxiety particularly following COVID," said Kendra Nagey, the medical director for Mountain Family’s school-based health centers, which includes the facility at Glenwood Springs High School.
The school-based health center here, located across from the main office, is open for services ranging from dental exams to vaccines to counseling. The facility is one of five school-based health centers run by Mountain Family in the Roaring Fork and Eagle River Valleys. Last year these providers served over 2,500 students. Most are uninsured or on Medicaid.
Providers here use a few different screening questionnaires, including the PHQ-2, a widely-used, evidence-based depression screener, consisting of just two questions.
Nagey said that providers can also use their own words to better connect with students.
“So some of the basic questions that we ask is ‘Have you felt down, depressed or hopeless in the past couple of weeks … have you felt like you're not having as much fun doing some of the things that make you, you?” Nagey said. “Personally, one of the things that I do is asking a specific question about, ‘What do you do, what makes you feel better when you're sad?’”
‘Very high levels of mental health issues’
In 2021, according to the Healthy Kids Colorado Survey, 17% of teens seriously considered suicide. 40% reported persistent sadness and hopelessness. These numbers are much higher for girls as well as teenagers with varying gender identities and sexual orientations.
For Nagey and other clinicians, the idea is to normalize conversations around mental health by making the questions and conversations more approachable.
She hopes that asking students about sleep and diet and mental health at the same time will reduce another barrier: stigma.
“If all of these things end up being kind of in the same breath or have the same level of importance, I think that it's something that does help to normalize that conversation,” Nagey said.
Students who screen positive for possible concerns are referred to the health center’s behavioral health department. Occasionally students will be sent out for specialized treatment but the providers say they can handle most needs in-house.
This setup removes some barriers to care, including cost and transportation issues: these school-based health centers accept Medicaid and offer sliding scale discounts to uninsured students.
'It’s been a recipe for failure'
These screening conversations are becoming more common in Colorado schools as access to behavioral health care remains a challenge across the state. Some communities, particularly in rural areas, have a true therapist shortage. Others don’t have enough therapists who take insurance.
In addition to the dozens of school-based health centers that have screening programs, Colorado lawmakers recently passed a mental health screening bill for 6th to 12th graders.
“If you are a student, what this looks like is your grade will come down at a particular time and there will be curtained booths set up with some ability to dampen noise so that you're not hearing what the students are saying in between booths,” said Senator Dafna Michaelson-Jenet.
Inside the booth, a provider is required to use evidence-based screening questions to identify possible mental health issues. Within 48 hours, students and parents must be notified of any concerns.
“‘Hey, we think you could use therapy.’ And fewer than 24 hours if we think there’s a crisis,” Michelson-Jenet said.
This type of legislation is spreading across the country. This year, lawmakers in Utah and Louisiana passed screening bills. New Jersey is working to implement school-based depression screenings.
Michelson-Jenet sees this coupling of screening and counseling as one answer to a big problem: Lack of access to care.
“From the insurance perspective, we have a whole host of therapists opting out of insurance. And many people, I would say most people, can't afford to pay out of pocket,” Michaelson-Jenet said.
Add in those who lack insurance completely: as of 2021, that was around 380,000 Coloradans, including 50,000 kids.
“It's been a recipe for failure for many of our students,” she said.
The existing youth mental health crisis worsened during the COVID-19 pandemic; for many kids, those stressors have changed but have not subsided. Last year, the U.S. Preventive Services Task Force recommended anxiety screenings for young people from ages 8 to 18, noting a moderate benefit.
Bunmi Olatunji, a psychologist who runs Vanderbilt University’s Emotional & Anxiety Research Laboratory points to benefits of screenings beyond the early identification of students who need help.
“I think the other benefit that we don't oftentimes talk about is that it also provides a context for people to start to pay attention, if you will, to what the risk factors are,” Olatunji said. “So for a young person, let's say a 14 year-old, even just being asked questions about feeling nervous or anxious or whatever, plants the seed that that's something for them to pay attention to.”
But Olatunji and other experts worry that communities will not be able to meet the behavioral health needs uncovered by increased screenings.
“Screening in the absence of treatment does not help anyone. And that's the primary concern,” said Daniel Mullin, a psychologist at UMass Chan Medical School.
State and federal laws require insurance companies to cover mental health and medical care in the same way. Still, the barriers to getting therapy are huge. According to the 2021 Colorado Health Access Survey, in 2021, nearly half of residents who went without needed mental health care said it was because they had trouble getting an appointment. Nearly 60% were worried about the cost.
While access looks different community to community, the state is dealing with a behavioral workforce shortage, particularly among providers who accept insurance. According to Colorado’s Division of Insurance, the state has received an increasing number of complaints from clinicians who face barriers getting into insurance networks. This summer, the division directed insurance companies to loosen those credentialing requirements and to cover pre-licensed clinicians.
“This kind of screening is all built on this fantasy that if you just help these people and you give them a phone number and you recognize the problem, somehow they'll get the treatment that makes the difference,” Mullin said. “And that, that's just not, that's not reality on the ground.”
In Colorado, the plan is to meet that need with existing services including a state-run therapy program called I Matter, which offers six free virtual appointments to school-aged kids. But, for now, that program is only funded through the summer of 2024. Plus, the state estimates that meeting the increase in demand for I Matter’s services due to the screening program would cost an additional $8.2 million.
The legislation sends $475,278 in funding to Colorado’s Behavioral Health Administration to create and administer the screening program.
‘We don’t know what they’re going to do with that data’
Before the state can get a real sense of how many students will need help and what it will actually cost, schools have to opt-in to the screenings, which are also called assessments.
“The resolution is to allow parents and allow more parental guidance to allow their kids to opt-in,” RE-2 school board president Tony May said during an August meeting on student wellness.
RE-2’s school board, which represents a district in Garfield County, has discussed passing a resolution against the screening bill.
“We don't even know what the assessments are. We don't know what they're gonna do with that data,” May said.
Colorado’s Behavioral Health Administration is working to select a mental health screening company to carry out the screening program statewide. The legislation requires that the screening tool be evidence-based and that participating schools post the mental health questionnaire online so that families and caregivers know what sort of questions will be asked.
During the August meeting, school board members outlined worries related to data privacy and parental rights. Under the screening legislation, parents would have the chance to opt their kids out. Parents must be notified of any mental health concern identified during the screening. The screening company will be responsible for keeping these records and is required to provide de-identified data to schools within six months of the screenings taking place. These records can be released only with written consent from parents or from a student over 18 years old.
At the August meeting, behavioral health staff urged school board members to keep an open mind about the statewide screening program.
“If one of those screenings saves a kid’s life, what value do we put on that?,” asked Michelle Zinser, a counselor at Rifle High School.
According to Amanda Vaughn, a social worker who now runs the district’s family resource center, 12 young people in the area, from Parachute to Aspen, died by suicide, homicide or accidents last year. The mental health needs that followed were huge.
“We’ve lost quite a few students,” Zinser said. “I’m just concerned that there are students out there that need supports that we don’t know about. That’s how I feel.”
Schools have until May to opt-in to the screening program for the next school year. In RE-2, in Garfield County, the school board and counselors discussed holding listening sessions with families to find out how they feel about mental health screenings. But for now, the resolution and community meetings are both on hold.
KUNC is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S.. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in select states across the country.
