A New Approach to Youth Mental Health

JOEL BERVELL: My guest on this episode of The Dose is Dr. Kevin Simon, a triple-board-certified psychiatrist in child and adolescent psychiatry, adult psychiatry, and addiction medicine. Dr. Simon is also a health policy expert. He directs the Justice Clinic at Boston Children’s Hospital, where he provides specialized care to youth and young adults with dual diagnoses of mental health and substance use disorders. He’s also an assistant professor of psychiatry at Harvard Medical School.

I’m so happy Dr. Simon has made time to join me for this update. Last time he was on The Dose was in March of 2022, painting a searing portrait of the impacts of the pandemic and the crisis in mental health care for young adolescents of color. A few months later, Boston Mayor Michelle Wu appointed Dr. Simon as the city’s first ever chief behavioral health officer, saying that for a city known around the world for its standard of health care, quote, “We simply do not have enough mental health workers to meet our city’s needs. So we will be training more and more diverse community-based mental health workers.”

Dr. Simon, thank you so much for coming back on The Dose to share your insights as I know you’re very busy on that mission in Boston right now.

KEVIN SIMON: Yeah, no, thank you for having me.

JOEL BERVELL: Now that you have the role of Boston’s first chief behavioral health officer, you have a budget, a strategy. I want to talk about how that’s all evolving. It’s your third year in this role, and I’m curious what you think is possibly scalable for other cities.

KEVIN SIMON: Yeah. So, year one, which was 2022, we were really thinking about, “Okay, what does it actually look like from a public health perspective to be a city where mental health is in all policy, and mental health is at the table?” And really in terms of thinking upstream because the resources are limited and we can’t only place resources in direct care service because they’ll just run out too quickly.

Okay, what are the avenues in which we can create a plan with the feedback of constituents and citizens and community groups? And so this is where we start, we thought to ourselves, “Okay, let’s focus on youth mental health,” because many people — the youth themselves, teachers, parents, loved ones — many people were identifying youth mental health being an issue. Now, what do we do with it? Well, there’s help that young people need in schools because they spend a lot of time in school.

Then there’s a thought about, “Oh, could we upscale individuals that just engage with young people?” Because there’s a lot of nonprofit community agencies in Boston, but I’m sure many other cities that do programming specifically for young people, who undoubtedly bring to them concerns that are in the mental health realm. Yet, you’re thinking to yourself, “Oh, I’m not a therapist. Not exactly sure what to do with that.”

We also heard from schools. A young person brings something up and it’s Thursday, but they bring up the thing from Monday and they’re like, “Let’s call 911.” And this happens, and the young person gets to our emergency room, gets an evaluation, and we’re like, “Okay, but we’re going to discharge you. This isn’t an acute crisis.” Well, many people are frustrated by that. The parent, the school, they’re like, “What? Why didn’t you do anything?” And so then it becomes, okay, let’s really understand communication. What are languages, right?

So, a crisis for me is one thing. A crisis in a classroom is another thing. A crisis from an ER or EMT perspective is another thing. So, we’ve taken several steps to say, “Wait a minute, let’s actually look at the full landscape. Let’s bring as many partners together across our city.” So, Boston Police Department, Boston Public Health, Boston Public Schools, many departments that engage young people.

But then also, we do recognize that training is important. And so, we’ve had an idea about training several hundred residents of Boston who will undoubtedly end up coming back to be providers, clinicians, back into Boston public schools. So that way people see, our students see, parents see people who look like themselves represented in the clinicians that are going to be engaged.

The framing was what we were doing really year one. Year two, we’ve had the allocation of the resources to many community agencies. And so we’re implementing it. And now two into three, we are really trying to see, “Okay, what’s our next move in terms of the investments that we’re making from a year and a half ago?” We fully recognize that some are going to yield fruit soon, but there are going to be some that it takes time.

And so, in terms of your question, which was, what’s scalable? So, I think what’s scalable is the idea of investing in young people. And so for instance, we’ve had youth advisory boards. I think other cities can have youth advisory boards.

And then in terms of the partnerships, so, we’ve partnered with UMass Boston to support the training of citizens who want to go back to school or who are pursuing school to work in mental health. Many cities, obviously, have local universities.

So I think that there are multiple things that we’re doing locally that could be done in other municipalities and nationally.

JOEL BERVELL: I love that. This all takes resources and it’s important as you mentioned, to see where those resources are going, where they’ve come from, so that we can make sure that they stay around if it’s actually doing good work in the community.

KEVIN SIMON: Right.

JOEL BERVELL: You’ve written a lot, especially in JAMA Open recently about the mental health impacts of racism on Black teens. I’m curious, what are the specific supports that you see that Black adolescents need? And then are places like schools linked and supports that you see working?

KEVIN SIMON: Yeah, so the JAMA Open article was a reflection on a study that looked at, are there things that we can do or that have been done to mitigate racism? And so, there is evidence, and I don’t think that this would be surprising to people that when youth, but particularly in this context, Black youth are supported, when they’re uplifted, when they’re surrounded by individuals, whether they do or don’t look like them. So there doesn’t necessarily have to be racial concordance.

But when they are surrounded by individuals that are supportive of them, they actually can and have demonstrated greater resilience in the experiences that they have being who they are and what they look like. And so, in terms of what does that look like? It looks like the teacher, or the coach, or the school counselor, or the parent really recognizing that how we communicate, literally, how we say, “You are good. You can do this,” combating the negative kind of automatic thoughts that we sometimes hear, “Oh, I’m not good at math.”

Literally, there’s documented evidence that when we are able to really counter the narrative that is sometimes kind of flooding some kids’ minds in terms of the negative, we actually can be pretty protective of Black youth. And, yes, those are things that actually can be done by a general lay person. You don’t need a master’s degree, you don’t need a medical degree to be able to be supportive of somebody.

JOEL BERVELL: Absolutely. And in the way they’re talking about, it reminds me a lot of the idea of fixed versus growth mindset.

KEVIN SIMON: Correct, correct.

JOEL BERVELL: But also having those people around you that are allowing you to see those mindsets and how it can shift your belief in yourself and your belief in the community and the resources that you have around you, which I think is so, so key. How are apps and tech being used to close this gap right now, as well?

KEVIN SIMON: Yeah, so this is a good question. And then, yes, there is some evidence depending on demographics. So, for the general population, there has been evidence in terms of depression and anxiety, the use, for instance, of AI chat box or therapy chat boxes in the adult population demonstrating efficacy in helping to lower some of the anxiety and depressive symptoms. So, that does exist.

There are a bevy of apps, not all of them well vetted, but they do and can create communities for individuals to feel connected. I have had patients describe to me participating in a group. They don’t know the people, but they do feel a connection because those who have selected to be a part of the group share a commonality.

And that commonality might be anxiety, it might be LGBTQIA–related identity, it could be an eating disorder identity. And so, we fully recognize that in terms of a holistic approach, we often are asking them to engage in some other social activity. It just happens to be that now that social activity can potentially be on an app. And so, there are some pros to it, but there obviously are potential risks that also exist in those kind of platforms.

JOEL BERVELL: Absolutely. And I have to go back to one that you mentioned, the AI tool piece of it. I’m always very curious about that because as they become more integrated into health care, I’m curious what role you see them playing in mental health, both in expanding access, but then also the ideas of privacy, accuracy, or even equity.

KEVIN SIMON: Yeah. So, there have been anecdotes, long-form journalism that has been done about some, not just the AI chat boxes, but online mental health platforms. And one of the challenges, well, let me talk about the opportunity.

The opportunity does exist to widen access because, truthfully, there are about, at least for a child psychiatrist, there are about 8,000 of us, I think, nationally. That’s a very small number for as many millions of kids exist, right?

JOEL BERVELL: Absolutely.

KEVIN SIMON: And then if you start talking about some of your rural areas, it’s going to be very difficult to identify a therapist. And so, it is potentially possible that an AI tool improves access. So that’s great.

The challenge is, and we tend to see this is, maybe if it’s for mild, it’s fair. Maybe if it’s for moderate conditions, potentially it’s fair. The challenge is the young folks that I see, and the young folks I know that many of my colleagues see, are past mild and moderate.

And so, when you now get to a severe case of depression and you’re potentially having suicide ideation with intent, or your anxiety is so great that you can’t go to school, and I’ve had situations, 8-year-old screaming at their parents, “No, I’m not going. I will not go.” I’m not sure how useful an AI tool will be there.

And, I’m particularly cautious about the idea of an AI tool being utilized and the AI tool not having the humanness to understand really what’s happening, right? Because if someone’s, for instance, in acute distress, you’re now asking that person who’s in acute distress to then somehow be calm enough to engage the tool. That’s very difficult to do.

And we see this, for instance, to bring it inside the hospital, where someone could be so distressed that they have difficulty engaging a nurse who’s trying to be appropriate and calm and engaging. And, unfortunately, we’ve also seen instances where the AI tool did not respond appropriately, and young people have acted on the response of the AI tool. So, there’s definitely promise, but there definitely also is significant risk. And so, we still have to be very cautious.

JOEL BERVELL: Absolutely. I appreciate that nuance that you pointed out there. I want to transition a little and talk about substance use, especially among young people. I’m curious maybe vaping is a good place to start, especially because it gives such a high concentration of concentrated formulation. In my own clinic, I see a lot of patients that are using vaping right now, but then not understanding the dangers of it. Would love to get your thoughts on substance use trends and what’s happening around that.

KEVIN SIMON: Yeah. So, in reference to substance use, particularly among young people, we do see . . . So, nationally, the data actually would suggest that there is a dropping of overall substance use, which is great. The challenge is the ongoing substance use that is present is still in the millions, so that’s a problem.

And then also, in terms of youth-related substance mortality, that is also going up. So, there’s a paradox here. That implies the supply of where young people are getting their substances, because they’re clearly not going potentially to the dispensary or to a place that an adult could go, that supply is adulterated with other things. And so, if you don’t know where you’re getting this substance from, you place yourself at risk for an unintended consequence. So, that is something that I would say first.

In terms of particularly vaping, yes, it is common and we see it occurring younger and younger. And the challenges that exist are, I’m holding a pen. They have vapes that are smaller than this pen that no parent could probably detect. A teacher probably can’t detect it.

They, unfortunately, have smart vapes that look like little handheld devices that if you just looked at it from afar, you’d be like, “Oh, that must be like a new toy.” It’s not a new toy. It’s actually like a Bluetooth device that can play the phone call. You can have a phone call on it.

JOEL BERVELL: Oh, wow.

KEVIN SIMON: And you can put up to inhale and get a vape. So, there are definitely, unfortunately, is a, what seems to be, although no company would acknowledge this, it seems to be that there’s a target toward the younger youth population in terms of the colors that are utilized, the flavors that are advertised. I have patients who are in the 11-year-old, 12-year-old age range, who have began to engage in nicotine and/or marijuana, cannabis vaping.

And I’m thinking about when I’m with a patient, they’ll ask the question, “Well, isn’t this safer than smoking?” And it’s like, “Well, it’s a very good question. Yes, technically it is. However, well, you never were smoking.” So, for a certain population, yes, if we transition the person from a traditional cigarette to a vape, that is a form of harm reduction. But if you’re 12 and you never were smoking, it’s like, “Well, the fact that you’re doing it is not safe. And the population that this is intended for to help them off of a cigarette, you’re not that population.” And, yet, because they’ve already started to engage, they’ve already, unfortunately, gotten that dopamine fixed.

JOEL BERVELL: Yeah, I think that’s so important. It’s relative to what? Right? If you’re smoking, it’s healthier, but if there’s nothing healthier than not starting to vape in the first place.

KEVIN SIMON: Yes.

JOEL BERVELL: And when we talk about youth mental health and substance use, should we also be talking about undiagnosed or untreated or undertreated, ADHD, even autism spectrum issues? Is there a connection at all and a link to engagement?

KEVIN SIMON: Yeah. So, this is a beautiful question. It is not uncommon that there are untreated mental health conditions that we learn about when we’re doing a full psychiatric or substance use evaluation where we’re now asking about the history and, “Hey, when did you start?”

And I’ve had patients who are 17, 18, 19 seeing me because they have a cannabis-induced psychotic episode that landed them in the hospital. Now they’re in the outpatient world, and I’m coming to learn, “Oh, wait a minute. You’ve had anxiety for a while. You actually were engaging in, I’d call it nonsuicidal self-injury because cutting, scratching, but you never engaged in therapy. You never engaged in medication management.”

And then something traumatic or stressful, distressing happened. And it seemed to you at the time that engaging with the cannabis or engaging with the substance seemed to relieve some kind of distress. However, when you’re introduced to that so early and you have not learned other mechanisms by which to be able to calm yourself down, you then use it again. And then use it again.

And then you’ve actually created a pattern now. It’s actually not even causing you to feel distress, but now when you don’t have it, you feel even heightened stress.

And so, that is something that I see pretty regularly. And so the undiagnosed mental health conditions, depression, anxiety, definitely ADHD, for sure. And we have evidence that untreated ADHD does lead to the risk of engaging in substances. And I do have colleagues that have also found autism in the greater percentage showing up to substance use clinic.

And then as a consequence of the substance use engagement, which becomes apparent to somebody that, “Oh, you need help.” Well, actually, they needed help long before the engagement with the substance, but at that time it might’ve been more invisible, right? “Oh, he’s, he or she is kind of quirky” or “Well, you know, she doesn’t like to hang out.”

And it’s like, well, we’re dismissing true concerns that young people may be having and trying to bring up to someone. But it’s . . . Unfortunately, stigma is really still prevalent. It’s not uncommon that I meet people and they’re with me and they still feel shame about the idea that they have quote–unquote, “a mental health condition.” It’s like, it’s okay. If you had diabetes, you wouldn’t be like, “Don’t treat it.” No, let’s figure out, let’s manage it.

And I’ve seen it when I was a fellow, I rotated in a chronic headache clinic. I’d say 95 percent of that was mental health conditions, but people were far more comfortable because it was a quote/unquote, “headache clinic” to come and talk about it. So, we do see this pretty regularly and widely in our patient population.

JOEL BERVELL: And I think even physicians and clinicians, we have a bias that we have to get through when it comes to really thinking about it as mental health diagnoses that can be treated for patients.

KEVIN SIMON: For sure.

JOEL BERVELL: And I see this, as well, all the time now in my residency in internal medicine where we’re really having to look at everything, but recognizing that so many people maybe left something behind because it didn’t seem like it was real enough in that sense. I want to turn to prosocial initiatives. What approaches have you seen work best both within communities and at home?

KEVIN SIMON: Yeah. So, there’s a movement now for Art Pharmacy, is the name of the organization. But really what they’re doing is pairing with primary care providers. And the doc might recognize, “Wait a minute. You’re actually not being social. You’re not going out.”

And so, health care institutions are actually being able to literally prescribe, “Hey, here’s a free ticket for you to go to the museum. Here’s a free ticket for you to participate in an art event.”

Again, I would count this as mental health–related. So, our Boston Public School students have free admission on certain days of the month to go to the science museum, art museum. These are things that get you out into community, get you out exploring, and being able to experience a calm, nonstressed environment. And I would hope that other municipalities can think about that.

Another thing that we do in terms of partnership, so we really do want people to just kind of have a good positive relationship with law enforcement. And so, our Boston Police Department has a unit that is strictly about community engagement. They have an ice cream truck. You see them engaging in community in a positive way to give young kids and, really, families the visual of, we are here to help and we are here to serve.

And our Boston Public Library, we recognize, oh, wait a minute. We have homeless shelters that we manage. Yet, during the day, they got to get cleaned. And so, people can’t stay there during the day. So, sometimes, where did they go? They go to the library.

“Oh, wouldn’t it be great if we had a clinical social worker at the library that could help, maybe help people figure out what resources that they could apply for?” And so, you put a social worker in a public library. Interesting enough, they get utilized.

JOEL BERVELL: Love that, love that so much. I know that you, personally, have devoted yourself to looking ahead and strengthening the efforts to bring more Black students into the field. When you were on the podcast in 2022, you talked about the reality that about 5 percent of child psychiatrists are Black or brown. So, racial concordance with care is just not possible in some instances. I’m curious if you can give us an update now, today, about what the pipeline is looking like and if there’s momentum towards recruiting and retaining students?

KEVIN SIMON: Yeah. So, in reference to the pipeline or the pathway of diverse students entering into, for instance, medical school, I do recognize that there’s been differences, post–Supreme Court decision-making. However, I can say, as it pertains to, for instance, psychiatry, and again, this is specific to just medical school and those that have the opportunity to get to fourth year. There has been an uptick steadily over the last several years of more individuals pursuing psychiatry. So that’s great. In part, yes, there will be more psychiatrists, and so if there’s more psychiatrists, you then have an opportunity to have more child psychiatrists. So that is there.

We do see significant interest in pursuing mental health careers. So, from that side, I am rather hopeful and optimistic. And there are states, Massachusetts is one of them, that is actually putting resources behind people pursuing mental health careers. If you’re a physician, if you’re a licensed clinical social worker, if you’re in mental health at all, you potentially could have some percentage of your loans forgiven if you work in underserved environment and community.

JOEL BERVELL: Absolutely. I love that. Well, going back to the pandemic. During the pandemic, you spoke on this podcast about the overwhelming demand for adolescent mental health care, emergency rooms that were filled up, patients waiting in hallways and weeks-long delays, oftentimes both inpatient and outpatient treatment. And I know at that time you noted that the crisis wasn’t new, but rather an acceleration of a trend from the prior decade when more and more adolescents were seeing broken care systems. Has that demand leveled off or has the capacity to deliver care increased?

KEVIN SIMON: Yeah. So, I can speak specifically to Boston, greater Boston area, and I suspect that this would also be true nationally. So, the demand has not necessarily decreased. We still see high numbers of individuals who are looking for services, parents who are looking for services. A week does not go by without someone reaching out to me to inquire about if I’m aware of somebody that’s taking new patients.

Now, some states and some cities have implemented programs that have been novel in the sense of, what are other ways that we can begin to address some of the demand? Because not all intervention needs to be in the context of in a hospital or in the context of in a clinic.

And so, I think, we are seeing more preventative measures, more emphasis now on what can occur from a school dynamic, and what can occur in and where people live, eat, and pray. So, locally, we are attempting to do that and funding that, given that training for clinicians, be that psychologists, psychiatrists, clinical social workers, that takes time. And so what can we do now? And that’s where we come with the models of, what are opportunities where we can actually upskill individuals that engage with young people to a better degree?

JOEL BERVELL: Yeah, I think that’s so important, meeting kids where they’re at. So like you said, schools and services where you eat, live, and pray, trying to find that wraparound services so it’s not having to be in the hospital.

Well, Dr. Simon, thank you again so much for joining me today and for sharing your words of wisdom and perspective. I think it’s clear, and I’m sure our listeners will hear this, just how deeply committed you are to reshaping systems and creating opportunities for young people, families, and communities to thrive. And I truly always say this, but leadership like yours is what’s possible when policy and practice work hand in hand. I know our listeners will take away not only a better understanding of the challenges we face, but also where progress can take us. So truly, thank you again for joining us today.

KEVIN SIMON: Yeah, no, thank you for having me. And thank you for sharing this kind of information to our larger public.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Kapper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Joel Bervell, and thank you for listening.