Real-World Symptom Trajectories in Adolescents With and Without Suicide Risk Receiving Care from Rula Health: Retrospective Study

Abstract

BACKGROUND: More than 5 million US adolescents experience mental or behavioral health conditions, yet two-thirds remain untreated, and suicide is the second leading cause of death. These gaps highlight the urgent need for accessible care. Digital mental health interventions that integrate measurement-based care (MBC) and personalized mental health care provider matching offer a promising solution, but few studies have examined their real-world impact among adolescents at elevated suicide risk. OBJECTIVE: This study aims to evaluate symptom improvements among adolescents with and without elevated suicide risk receiving care from Rula Health, an MBC-based digital mental health intervention with personalized intake through mental health care provider matching. We aimed to (1) compare baseline demographic and clinical characteristics between adolescents with and without elevated suicide risk at intake and (2) examine depression and anxiety symptom trajectories over the first 12 visits between adolescents with and without elevated suicide risk at intake. METHODS: We conducted a retrospective analysis of real-world clinical data from adolescents who received mental health services through Rula Health. Adolescents were classified as no suicide risk or elevated suicide risk based on the Columbia-Suicide Severity Rating Scale. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) at baseline and before each session. Minimal clinically important differences were defined as a reduction of 5 more points for PHQ-9 and 4 or more points for GAD-7. Symptom changes were examined up to 12 visits. We used t tests and chi-square tests to compare baseline characteristics between suicide risk groups and linear mixed-effects models (adjusted for demographics and clinical factors) to assess symptom change and trajectory differences over time. RESULTS: The sample included 3533 adolescents in the no suicide risk group and 2712 in the elevated suicide risk group. The elevated suicide risk group had a greater proportion of female adolescents, younger adolescents (P<.001), non-Hispanic individuals (P=.002), and those with a primary depressive diagnosis, comorbid conditions, psychiatric involvement, and higher baseline PHQ-9 and GAD-7 scores (P<.001). The no suicide risk group attended more sessions and stayed in care longer (P<.001). Depression and anxiety scores decreased over visits (PHQ-9: B=-0.39; P<.001; GAD-7: B=-0.35; P<.001), with average improvements exceeding minimal clinically important difference thresholds. The elevated suicide risk group's depression and anxiety symptoms decreased at a higher rate than those of the no suicide risk group (PHQ-9: B=-0.32; P<.001; GAD-7: B=-0.18; P<.001). CONCLUSIONS: Adolescents with elevated suicide risk showed greater and faster improvement in depression and anxiety symptoms, reaching similar levels as those without elevated suicide risk by 12 visits. Rula Health's model can support high-risk youth in real-world settings. Future research should assess the impact of MBC and mental health care provider matching, including study designs that isolate their specific effects on outcomes.

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