Youth in Crisis

In 2021, leaders of Blue Cross and Blue Shield of North Carolina (Blue Cross NC) visited each of the state’s 100 counties to better understand the challenges and needs of its residents.

One topic came up repeatedly during meetings across the state—the crisis in adolescent mental health.

“Across the board, they all spoke to mental health as being near the top of the list,” says Ellyn Saren, vice president of behavioral health at Blue Cross NC. “They talked about these kids feeling a lack of purpose, social isolation, and just loneliness, which probably started during the [COVID-19] pandemic. From my perspective, it’s almost an epidemic.”

The insurer wasn’t alone in this finding. At about the same time, the National Alliance on Mental Illness reported that nearly 130,000 youth ages 12 to 17 in North Carolina had self-reported depression. On a broader scale, one in every six U.S. youth face a mental health disorder each year, the organization said.

The listening tour and stark numbers spurred Blue Cross NC to announce a longterm commitment to addressing youth mental health. With the number of youth in need outpacing the number of available providers, the insurer has worked to increase access to in-network behavioral health care, exploring school-based programs and offering same-day and virtual appointments.

“We are really trying to seed the ground, if you will, to create some sustainable solutions,” Saren says. “Given what we see as an epidemic and challenges around access and the rural nature of many of our counties, that has really challenged us to think outside of the box. Like that saying goes, fail fast and learn fast.”

A March 2024 article in the Journal of the American Medical Association reported that the prevalence of mental health diagnoses among youth increased from 21% to almost 26% in U.S. households from 2017 to 2021. Medical spending for pediatric mental health rose by 45% during that same period. Spending increased among several different mental health conditions and for a range of services including medication, office visits, and emergency department care (the costliest kind of care). Households that included children with mental health conditions spent about $2,337 more than those without in 2021. And pediatric mental health costs accounted for nearly half of all youth medical expenditures that same year.

Much of the increase in cost is due to greater use of services. But a 2022 report for the Washington state insurance commissioner found that more expensive out-of-network providers represented 7.6% of all mental health services in the state from 2017 to 2022, versus 4.2% for other medical services. The price paid to mental health providers rose by 4% in those years in Washington.

Many groups are seeking solutions to the high demand for services and lack of access to providers. It will take a village—parents, employers, insurers, healthcare providers, and community organizations—to help children and adolescents struggling with mental health challenges.

Many Need Help, But Help Is Hard to Find

The mental health of U.S. youth has improved since the pandemic. In a 2023 survey of high school students across the United States, the Centers for Disease Control and Prevention (CDC) found the percentage of respondents who felt persistently sad or hopeless, or attempted suicide dropped slightly from 2021 to 2023.

But the numbers remain alarming. In that study, released in August 2024, 40% of respondents reported experiencing “persistent feelings of sadness or hopelessness.” Notably, 53% of young women reported feeling this way, compared to 28% of their male peers. The percentage was 65% for LGBTQ+ students, who tend to report having less support from their families and communities. And, according to a 2022 survey, 60% of these youth who would like to receive mental health services are unable to find any.

The report noted that sexual violence perpetrated against young women increased slightly during the pandemic, as did incidences of cyberbullying. Both of these can increase the risk of anxiety and depression.

“This is more significant than just having a bad day,” says Tamar Mendelson, director of the Center for Adolescent Health at the Johns Hopkins Bloomberg School of Public Health. “Especially for female students. More than half feel like this, and 27% reported considering suicide seriously. Girls, Hispanic students, those who are bullied, and LGBTQ+ and other students who are marginalized in one way or another could need mental health services.”

According to the CDC report, the number of students who had been bullied at school increased from 15% in 2021 to 19% in 2023. LGBTQ+ students reported worse mental health and more bullying than other students: 20% of LGBTQ+ students surveyed had attempted suicide, while the percentage for all surveyed students was 9%.

Those issues can endure for a slightly older population. In two 2024 reports on mental health in the U.S. workforce and among youth and adolescents, the Integrated Benefits Institute (IBI) found that anxiety rates are highest among people ages 18 to 24, reaching almost 40%, followed by 33% for people ages 25 to 34. Depression rates mirror this pattern, affecting 33% of those ages 18 to 24 and 25% of those from 25 to 34. Another 24% of individuals ages 18 to 24 reported feeling frequent experiences of loneliness.

Loneliness may be more prevalent among younger adults, as people who were married, had children, had higher incomes, and attended some kind of religious service regularly reported being less lonely. Many of these demographic factors come with age. These emotions are connected: more loneliness correlates with higher rates of depression and anxiety.

As with other areas of healthcare, access to providers and cost of care are top barriers to seeking help for these mental health issues. According to the IBI, the U.S. mental health workforce comprises about 373,000 practitioners. The need, however, is for about 505,000 nationwide.

The shortage is even greater for pediatric psychiatrists, who specialize in treating children and adolescents. The American Academy of Child and Adolescent Psychiatry (AACAP) noted in 2022 that there were only about 10,500 child and adolescent psychiatrists in the country. The amount of providers varied by state, but ranged from four to 65 for every 100,000 children in the United States. On average, there were about 14 child and adolescent psychiatrists per 100,000 children. AACAP has estimated that an adequate number would be roughly 47 practitioners for every 100,000 U.S. children.

The need for pediatric providers is stark considering that half of all people with a mental health disorder begin having symptoms before age 14 and 75% before age 24, according to AACAP.

The AACAP report also noted that only about half of the youth with a mental health disorder receive needed treatment. It did not explain why that is the case, but other sources offer insight into obstacles to care.

In one IBI report, among the respondents whose children needed mental health treatment but did not get it, the main barriers cited were cost (46%), inability to get an appointment (44%), and inability to find providers in their insurance plan’s network (33%).

“It can be really hard to find good treatment,” Mendelson says. “To the extent that parents have insurance through their employers, most cover youth mental health services. But they can be expensive, even when covered, and it can be hard to get recommendations for high-quality, evidence-based services, especially those that are culturally appropriate. It can be hard to find people who are bilingual or have cultural awareness, which is important.”

In North Carolina, about two-thirds of counties don’t have a child psychiatrist, Saren says. This lack of access spawned one of Blue Cross NC’s programs, Behavioral Health on Demand, with the goal of delivering needed services—be they in-home family sessions, same-day virtual appointments, or connecting families to nonemergent care.

Blue Cross NC has also worked to increase its network of pediatric mental health providers, including through outreach to community practitioners not already in-network. In addition, it has connected with national associations and trade groups related to social work, substance abuse, autism, and other mental health conditions to identify providers in local communities who could be brought in-network.

“It doesn’t solve the issue, but it’s our way of chipping away at it,” Saren says.

The Workforce Effect

A child’s mental health issue touches the whole family, including working parents and caregivers.

“It often impacts the family, just as when a family is dealing with someone with physical health issues,” Saren says. “It impacts them coming in to work and their performance while there.”

Researchers with the Kids Mental Health Foundation conducted in-depth discussions with 49 parents and surveyed another 1,975 working parents for a 2022 report on the impact of children’s mental health on resignations. Almost half of these adults said their work was somewhat or extremely disrupted on most days by their children’s mental health issues in the preceding year.

Among the parents who had children with mental health issues, 79% said they had taken a day off, left early, or come in late at least once a month because of an issue with their child. These parents also reported having more difficulty handling job stress, finishing difficult tasks at work, enjoying work, focusing on work-related goals, and having the energy to complete all their work. They reported being less present at work than those whose children didn’t have mental health issues.

Other research has borne out this effect. The 2024 IBI reporting found a twofold increase in absenteeism among caregivers whose children needed mental health treatment. Twenty-three percent of these working adults anticipated they would quit their job within a year of the survey; 54% of that cohort cited their child’s health as the reason for leaving.

Many of the adults caring for these youth also have mental health issues. Forty-seven percent had clinical anxiety or depression. They also reported having higher levels of “severe mental distress,” at 34% compared to 15% of caregivers who didn’t have children with mental health needs.

“Parents who have untreated mental health issues can be a big stressor for kids,” Mendelson says. “If a parent has a history of depression, and it runs in family, they should try to be aware that their child may be more vulnerable to it as well.”

Sometimes this family history can benefit children. If a parent has had a positive experience with therapy or taking medications, they may be more likely to provide these treatments for their children, Mendelson says.

Supporting Caregivers

Working parents dealing with their own mental health issues, or those of their child, likely won’t feel comfortable talking with their employers about the situation. The Kids Mental Health Foundation report found that only about one-third of people surveyed felt comfortable talking with human resources or their boss about this topic.

Employers may not directly be hearing that their employees, or their families, are dealing with mental health issues. Nonetheless, supporting employees with these struggles could reap benefits for retention, productivity, and workplace satisfaction.

Depression in the workplace costs U.S. employers about $44 billion annually due to lost productivity, according to the Center for Workplace Mental Health. While about half of adults with depression don’t receive treatment, seeking help can reduce absenteeism and presenteeism by 40% to 60%, the organization said.

“Investing in employee mental health support has a positive ROI,” says Carole Bonner, lead researcher for the IBI report on mental health in the U.S. workplace. “Every dollar invested in depression and anxiety treatment yields a $4 return in improved health and work performance.”

Employers have many avenues to support team members and their dependents who need mental health services, Bonner says. Employee assistance programs (EAPs) are one place to begin—per the U.S. Office of Personnel Management, these are voluntary programs of “free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.”

For example: These programs can be designed to emphasize counseling and therapy; employers can expand their network of EAP providers and increase quick access to care; and the number of free annual EAP visits can be increased for each beneficiary.

Employers can also ensure their healthcare benefits are comprehensive: offering free mental telehealth services as part of their package; making the cost of out-of-network mental healthcare equal to in-network care (particularly if in-network providers are sparse); and offering adolescent-specific mental health vendor solutions in the benefits package, Bonner says.

Insurers should strive toward making mental health coverage equal to physical health coverage, as mandated by the 2008 Mental Health Parity and Equity Addiction Act. Insurance providers should also ensure their plans have an adequate number of mental health providers, and that providers listed on their sites are still offering care and are actually in-network. Insurers can also fully cover behavioral health screenings for children.

The 2020 Consolidated Appropriations Act gave the 2008 legislation some teeth by requiring the creation and use by insurers of a comparative analysis tool to determine if they are complying with the Act. Initial checks showed insurers had work to do to reach parity, according to a 2022 Mental Health Parity and Addiction Equity Act report to Congress.

“It can sometimes feel like there’s so much that needs to be done, and no clear path to start,” says Christin Kuretich, vice president of supplemental products at Voya Financial. “It’s a good idea to first look at the barriers within your plans and services. If there are inadvertent or lingering exclusions or limitations placed around mental health, see what you can do to change or remove those barriers.”

Kuretich says insurers should seek opportunities to enhance or build new products and services around mental health. For instance, Voya recently changed its hospital indemnity insurance to include rehabilitation for mental health conditions and substance misuse. The company also updated its accident product to include therapy for mental health issues following an accident.

“Voya research found 56% of employees are likely to stay with their employer if they offer mental health benefits/resources, so it’s important for employers to implement mental health initiatives to support these needs,” Kuretich says.

Absenteeism and lack of focus at work are higher among caregivers of children with mental health issues. Because of this, Bonner recommends employers implement benefits including flexible work schedules, work-from-home options, and paid caregiver leave to support these families.

“Even having a suite of resources that includes free apps for people to check out could be good and some are really useful for adolescents,” Mendelson says. “There are also national hotlines that adolescents or their parents can call if they are in acute distress but there is no therapist in the picture.” The national suicide prevention number is 988. If youth or parents prefer to receive help via text, they can text HOME to 741741 to reach a crisis counselor.

In the IBI report, 41% of adolescents surveyed had used a behavioral app; of those, 93% said the apps were somewhat or very helpful. These apps can use cognitive behavioral tools to reduce anxiety and depression, offer therapy and community support, and send text reminders to increase positive thinking and reduce stress. Youth who liked the apps tended to have spent a lot of time using their smartphones and social media.

Another employer option is offering first aid training designed specifically to teach people how to identify and respond to mental health issues. Mental health first aid offers people the skills to support someone developing a condition or a person in crisis. Blue Cross NC has committed to training 3,700 people—including 100 area youth—and 10% of its workforce by the end of 2025.

“We want to ensure that people who interact with kids—parents, community agencies, etc.—will be able to understand when kids have an issue and what some of the resources are they can connect to if they don’t feel equipped to talk with kids,” Saren says. “We are looking to educate employers around the stigma of mental health with the goal of breaking that down, reducing delays in care, and promoting greater wellness.”

Another program that some insurers, including Blue Cross, offer is care navigation, which can be used for mental health services. Using this tool, staff, often clinicians or nurses, help plan participants find providers for various services and work to get an appointment in a timely manner.

Saren says when Blue Cross NC makes a presentation to a potential business client, it often highlights behavioral health programs. Employers are usually very interested in those offerings, she adds.

“As a person who has presented to a lot of employers, I think that it’s not just about that employer’s workforce, but it is also personally driven,” according to Saren. “We all know in our family or friends a young person who may be having some issues. Our goal is to understand those needs and figure out how we can develop a program that can support that need.”

Employer support for mental well-being in the workplace can also involve seemingly minor measures such as yoga classes or a stipend for gym memberships. Mendelson says Johns Hopkins instituted a policy to have no meetings at least one day a month.

“Some of these things might be quite small but are meaningful and show that you care about your employees’ mental health,” she says. “The more we take care of our own mental health, the better able we are to parent our kids who are having issues.”

Supporting families is especially important when children have more severe mental health issues.

“It is really expensive and traumatizing for kids and families if it gets to the point of a crisis,” according to Mendelson. “The police show up at a house and the kid is taken to the ER or psych ER and it is very stressful and very expensive. If you can deliver support to people—even without imminent problems—the cost savings is considerable. We just have to ask whether we want to pay now or later.”

Front-Line Care

Though pediatric mental health professionals might be difficult to find, primary care providers can often diagnose and treat these conditions.

In recent years, primary care visits have become increasingly used for mental health care. Reports show that anywhere from 40% to 70% of all primary care visits involved discussion of a psychological issue. Primary care visits that were specifically for a mental health concern were rising even before the pandemic, from 3.4% in 2007 to 6.3% in 2018, according to the National Ambulatory Medical Care Survey.

“For generations, primary care providers, pediatricians, and internists have been the first-line people go to for mental health care, partly because they don’t know where else to go, and partly because they come in with things they don’t identify as mental health problems,” says Dr. Richard Brookman, clinical professor of pediatrics at Children’s Hospital of Richmond at VCU. “People often come to primary care providers for things like chronic headaches, fatigue, accidents, and chronic stomach pain and end up with a mental health diagnosis.”

Adult primary care doctors generally have more training in psychology and prescribing mental health medications, Brookman says, while pediatricians’ residencies traditionally didn’t cover mental health as robustly. Pediatric specialists have, however, been writing prescriptions for Prozac and Zoloft for years without much formal training, he adds. Pediatricians have also been well-versed in treating learning problems and conditions like attention deficit disorder, which is often diagnosed in childhood.

In 2019, the American Academy of Pediatrics proposed mental health competencies for all pediatricians that included ability to communicate about mental health conditions, incorporation of mental health tools into primary care, psychological assessments, knowledge and skill of evidence-based mental health therapies, and a commitment to embrace mental health care as a part of pediatric care.

“There has been more awareness, and more screening of pediatric patients, and national organizations are empowering pediatricians to do additional training,” Brookman says. “It’s leading to more recognition in this space.”

In more than 40 years of adolescent medicine, Brookman has always had a large number of patients seeking treatment for mental health conditions. This is, in part, because his population of patients are low-income and insured by Medicaid, which tends to have a higher proportion of people with mental health conditions than private insurers. Virginia, like many other areas of the country, has clusters of mental health providers in major cities such as Richmond and Charlottesville, while other areas have none. Parents in cities with a dearth of providers often turn to pediatricians for their children’s care.

While Brookman and other pediatricians can screen and offer some treatment for mental health conditions, patients must often wait two to three months to see a doctor. If there is an acute issue, they can sometimes schedule an appointment within a couple of weeks. For a crisis, parents must use a pediatric emergency department.

One of the first things Brookman does as part of a mental health check is a suicide screening. He and other primary care pediatricians also try to secure what he calls a commitment of safety, which includes talking to youth about coping skills if they begin feeling worse or suicidal, helping youth identify social supports, and ensuring they are aware of emergency contacts if needed. Pediatricians also talk to parents or guardians about keeping firearms in the house unloaded, medications put away, and sharp objects secured.

“It’s one of the front-line things that PCs are encouraged and trained to do when evaluating for mental health issues,” he says. “We have to evaluate for suicide risk and safety planning. And we let families know that if something is bad, bring their child to the ER. And if they can’t get there, contact the police.”

Even though they can’t provide comprehensive care for youth, Brookman said primary care pediatricians can offer recommendations for coping with mental health issues and offer places families can seek additional help.

Virginia Commonwealth University (VCU) has a child psychology department in its hospital that has a federally funded program that provides mental health counseling for adults and youth, and has received funding specifically for treating diverse and rural youth. VCU psychology graduates can offer therapy as part of their training.

VCU primary care providers and pediatricians also have access to a state-funded program known as VMAP (Virginia Mental Health Access Program). This statewide program provides consultation, education, and care navigation for healthcare professionals treating children, young adults, and pregnant people.

“One of our jobs is to make sure families don’t drop the ball,” Brookman says. “We recognize that it is important and if their child doesn’t get treated, things can get worse. Sometimes we even try to pull strings and get a more urgent appointment when needed.”

Another option for care is through schools. Saren says Blue Cross NC is piloting a school-based program it hopes to roll out more fully next year.

The insurer is working with local school systems on ways to reimburse for school-based care. For instance, a social worker could deliver services to students in a school either in-house or virtually. BlueCross wants to understand schools’ capacity and technology needs to offer this kind of help.

Offering school-based interventions is an area of research for Mendelson as well.

“Schools are potentially really important places for mental health service delivery,” she says. “Particularly for low-income families, who are more likely to get help there.”

But schools have limited resources and the kind of behavioral health services they offer varies widely from one location to another. Some schools may just provide referrals for outside help; others might have counselors who can have one-on-one therapy sessions with students.

“It can be really helpful to have someone who can do basic assessments, and a counselor is likely to have knowledge of what local resources are available,” Mendelson says. “Some have more than one counselor and can provide therapy or group skills training.”

Some school counselors can provide mental health literacy at schools (much like they would first aid), where they educate families, students, and teachers about what it looks like to feel depressed or anxious and what to do if you see a friend experiencing these conditions. Counselors can work with kids on how to manage stress and identify emotions, which can help prevent more serious problems from popping up later.

“This kind of help can head off a lot of issues,” according to Mendelson. “For many students, a light touch might be all that is needed to get them back on track.

Teaching coping skills also helps over time because most mental health conditions are chronic; once they have depression, they are likely to have additional episodes, so when we can catch it early, it is really helpful. Suffering in silence is not helpful.”

Brookman agrees. Just like the placebo effect that occurs with some medications (including antidepressants), some basic mental health care can improve the conditions of many, though not all, youth.

“It’s the elements of recognition, compassion, counseling, communication, saying we care and bringing them [patients] back in that does seem to have some effect,” he says. “If they have to wait for therapy, we don’t just send them off for three months, we bring them back and let them know if anything deteriorates, they can call us. Some feel better and others don’t, but it’s not unusual that just doing something can make a big difference.”