Creating a Behavioral Health Vital Sign

Filling a Gap in Mental Health Care

There is an urgent need for innovations in delivering mental health care. According to the 2023 State of Mental Health in America Report, 21% of U.S. adults are experiencing a mental illness, and 16% of youth report experiencing at least one major depressive episode in the past year, with more than 2.7 million young people experiencing severe major depression. At the same time, more than half of adults with a mental illness receive no treatment; among youth with major depression, 60% go without mental health care. Cost and stigma are primary obstacles, but with a national shortage of mental health providers, access can be difficult, too. For instance, half of the U.S. population lives in a “Mental Health Professional Shortage Area.”

Solutions like Ellipsis Health could help fill the gap.

Kim explains that the typical process for seeking mental health help includes identifying a provider (and ensuring you have a way to pay), making an appointment (which may include a long wait), meeting with them and completing a screening process — likely with a stranger a young person may not fully trust. But with the Ellipsis Health tool, “screening can be done remotely at the adolescent’s convenience.” That may mean a parent doesn’t have to take time away from work and a student doesn’t have to miss class. Kim notes that because the Ellipsis Health screening is done in private — just a youth and their computer, tablet or smartphone — there is less worry about whether they’ll answer questions truthfully, Kim notes.

Aratow emphasizes that accuracy is important. “Some people might underreport [symptoms of anxiety and depression], some may overreport. What we’re trying to do is get beyond that. When you’re talking, you can’t fake both your words and the acoustic aspects of your speech.” In addition, he says, clinicians may make mistakes, such as combining questions or not asking screening questions verbatim, which could lead to an incorrect assessment of symptom severity.

The tool can also track symptoms over time. Aratow says that although measurement-based care is proven to decrease costs and improve outcomes, it is underutilized. The Ellipsis Health tool could help change that. “We’re not just monitoring when the patient is with a provider, but in between, so you can catch people who are deteriorating. You catch the person before they go into crisis.”

Kim adds, “We don’t have enough clinicians to screen and treat everyone who needs it. That’s the problem the mental health field is facing now. This study is trying to address that. This could be a universal screening. It’s convenient, it’s remote, it can be done almost any time as long as they’re in a quiet room with a mobile device and Internet.”

Amber Olson, vice president of clinical operations for Aurora Mental Health & Recovery — the third-largest mental health agency in Colorado — helped to pilot test the Ellipsis Health tool before it was deployed to youth participants. She says the fact that the tool would be available to a youth any time “could help us better identify who would benefit from treatment and improve their access to care.”

The Ellipsis Health tool can help triage people, Aratow says. "Referring everyone indiscriminately — you don't have to do that. If you're sending everyone without proper assessment to a mental health professional, you're making poor use of this rare resource. You want to refer the patients who really need to see a mental health professional. Maybe others might need psychoeducational resources and self-help, some exercises and things they can do on their own, or their primary care provider."

Testing the Vocal Biomarker Tool with Adolescents

For the past year, Kim’s team has been collecting data from adolescents ages 11–17 (grades 6–12) who are receiving services via Aurora Mental Health & Recovery, which provides school-based clinics and counselors in Aurora Public Schools. All Aurora Public Schools middle and high school students were invited to participate as well. More than 160 youth have completed the screening process so far, and the research team is beginning to analyze preliminary results. Ultimately, the team plans to analyze data from at least 700 adolescents.

Kim notes that “We need participants at all levels: Those with no depression or anxiety, to those with severe depression or anxiety.”

For study participants, the process is fairly simple. Once parental permission is obtained, the participant receives a weblink and unique access code. They log in with a mobile device and complete three research tasks, which takes 15–20 minutes. Those tasks include providing basic demographic information and then speaking for about 90 seconds in response to an open-ended prompt asking whether anything has been bothering them lately. Once that is done, the voice data is securely transmitted to Ellipsis, where it is analyzed to screen for the presence of depression and anxiety symptoms and at what level of severity. Finally, participants complete standard screenings for depression and anxiety using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) measures, which allows the team to compare the Ellipsis anxiety and depression scores to those provided by well-established screening tools.

Kim says that in addition to the initial validation study, the research team — including University of Michigan School of Social Work Associate Professor Anao Zhang, GSSW doctoral student Keiko Yoneyama-Sims and University of Denver undergraduate psychology and biology major Penelope Doulis — hopes to obtain more funding to expand their research. They want to determine whether youths are more likely to use the Ellipsis Health tool compared to a typical electronic screening measure and whether the types of open-ended questions Ellipsis Health asks may be a better way to screen for anxiety and depression than simply asking adolescents about their symptoms.

They also plan to explore racial differences and disparities, and other potential biases. Participants are from one of the state’s most diverse cities and school districts. Kim says, “There may be biases in screening for people of color. That may be another area where technology may be an advantage. That’s why we’re collecting demographic data. We want to look at racial differences, gender, sex, sexual orientation … those are some of the additional questions we want to explore to see how technology might address universal screening.”

The Potential to Improve Mental Health Care

Ellipsis Health is not an app consumers can simply download via an app store and use independently. Currently, some large health insurers use the vocal biomarker technology, and health care systems could do the same. If the adolescent version is validated and then approved by the FDA, a district like Aurora Public Schools could provide it to students.

Kim says, “[The Ellipsis Health vocal biomarker tool] can allow a school mental health team to identify and monitor students who may need extra support, and it can empower students to understand how they’re doing when they’re struggling. To be able to be available any time could be a revolutionary way to help students struggling with mental health concerns.” He adds that it could also reduce the time the school mental health team spends on screening and evaluation, “allowing them to triage those students who are most elevated.” Meantime, students with milder symptoms could use in-app micro interventions while they’re waiting to see a provider. “This will help schools prioritize services to students.”

With approximately 17,000 middle and high school students (and more than 38,000 students in all), Aurora Public Schools is one of Colorado’s largest districts. It is also one of the most diverse, with students hailing from more than 130 nations and speaking 160 different languages.

“The fact that [the Ellipsis Health tool] could be quicker, the fact that it’s using a sample that’s representative of our community, that we could potentially get to students more quickly … that could potentially solve a problem we’re trying to find solutions for,” says Jessica O’Muireadhaigh, director of mental health and counseling for Aurora Public Schools. She notes that the district has been trying to find a screening tool that is less biased than those based on “normative” samples, which don’t represent the diversity of the district. And, she says, traditional screeners are usually done at the beginning of the schoolyear, and treatment decisions are made based on those results and then may not be revisited until the following year. But with a tool like Ellipsis Health, “You could do this any time,” which would allow schools to address student needs in real time.

Still, she says, solutions like Ellipsis Health would likely be just one tool in the toolbox for school mental health providers.

Kim adds, “We don’t see this as replacing counselors, but we see this as a first level of screening. School districts are looking at ways to screen for anxiety and depression so they can make sure those kids who are struggling aren’t falling through the cracks, so they can be provided the resources they need to thrive academically and personally.”

Aurora Mental Health & Recovery’s Amber Olson says, “As therapists, we cannot constantly be available to our clients, and because we are human, we might overlook or miss changes in our clients. Having an additional tool like Ellipsis to enhance our work with youth is a win for all of us.”