
Launch HN: Daybreak Health (YC S20) – Online counseling designed for teens - alexalvarado
I&#x27;m Alex, one of the cofounders of Daybreak Health (www.daybreakhealth.com) along with Luke and Sid. We help teens feel better, build skills for life and achieve their goals through online counseling. Our licensed counselors provide evidence-based counseling to teens through online video sessions, messaging, and a mobile app.<p>The evidence supports that behavioral therapy like CBT and DBT is effective. It works to treat diagnosable conditions like anxiety and depression, and it also works to help young people feel happier and achieve their goals [1][2][3][4][5]. But too often teens don&#x27;t get the mental health support they need because it is stigmatized, difficult to schedule and attend, and expensive. At Daybreak we bring counseling to the teen on a digital device and we charge less than half the cost of a traditional therapy session.<p>In October of 2018, my younger brother nearly lost his life due to the lack of accessible mental health resources supporting our young people. He is not alone. 1 in 5 teens struggle with a diagnosable mental health condition, but estimates suggest that up to 1 in 3 actually struggle with anxiety - or between 6 and 10M total teens [6][7]. That means the odds are greater than 50% that if you are the average parent raising a family in America with 2 kids, one of your children will struggle with a mental health condition in their teens.<p>To make matters worse, 80% of teens who need mental health support do not receive care today [8]. This results in deteriorating academic performance, increased rates of juvenile crime and substance abuse, and suicide rates that are at an all-time high. Every day, 17 young people commit suicide in the US. It is the #2 cause of death among 15-24 year olds, after accidental injury and ahead of homicide [9]. This isn&#x27;t a niche problem.<p>Our current system makes mental health support nearly impossible to get for a teen. Stigma makes it hard to admit to yourself you want support, let alone talk about it with your parents. There is a shortage of therapists who specialize in adolescents, making it hard to find a therapist that is close enough to drive to on a weekly basis. Private practice therapy averages more than $200 per session. Even if you could afford to pay, you&#x27;re going to be met with 2-3 month wait lists. And when you finally do arrive, you sit on an awkward couch in an environment that you may not be comfortable in.  That is why an average of 11 years pass between when a teenager first needs mental health support and when they eventually start receiving it in their 20s or even later [10].<p>That is why we started Daybreak Health. Everything we’ve built is designed intentionally for teens and their parents.  Teens can download the Daybreak mobile app and are instantly connected to a live guide (Mon-Fri 7am-7pm) who asks about mental health goals and needs.  After a video assessment where we loop in the parent, we create a plan and match teens with a counselor based on goals, needs, interests, hobbies and more.  Once matched with a counselor, teens meet with them once a week through a 50-minute video call, and can message them on a daily basis through the app.   Our counselors help teens develop emotional life skills and work towards goals in a personalized plan that has thematic focus on teen-specific areas like school, healthy relationships and more.  Teens can also meet with small moderated groups of other teens on those same topics.  And parents are a core part of the process, starting with the assessment, through planning and regular progress reports.  For all of this we charge an $89&#x2F;week subscription, less than half the price of a single 50-minute session in traditional private practice.<p>Dr. Neha Chaudhary, our lead Clinical Advisor, is a foremost expert on adolescent mental health and co-founder of Stanford&#x27;s Lab for Mental Health Innovation. Together with her and experts from UCSF we have designed a program for teens grounded in clinical science, while at the same time reimagining the way it is delivered to teens.  The core of our clinical program is rooted in evidence-based methods like DBT and CBT, but we have taken these approaches and brought them into an easily digestible online experience.<p>But there is a problem: stigma around mental health stops people from sharing their great experiences with counseling, so its benefit is under-appreciated. If you know any parent or teens who might benefit from counseling, make sure they know about its benefits. And if you have thoughts about how to solve the awareness problem, or any stories you can share that may help us better understand the needs of teens and parents, we would be grateful. Thank you!<p>Sources:<p>[1] <a href="https:&#x2F;&#x2F;www.sciencedirect.com&#x2F;science&#x2F;article&#x2F;abs&#x2F;pii&#x2F;S000579670700246X" rel="nofollow">https:&#x2F;&#x2F;www.sciencedirect.com&#x2F;science&#x2F;article&#x2F;abs&#x2F;pii&#x2F;S00057...</a><p>[2] <a href="https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC3073681&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC3073681&#x2F;</a><p>[3] <a href="https:&#x2F;&#x2F;acamh.onlinelibrary.wiley.com&#x2F;doi&#x2F;abs&#x2F;10.1111&#x2F;j.1475-3588.2006.00433.x" rel="nofollow">https:&#x2F;&#x2F;acamh.onlinelibrary.wiley.com&#x2F;doi&#x2F;abs&#x2F;10.1111&#x2F;j.1475...</a><p>[4] <a href="https:&#x2F;&#x2F;acamh.onlinelibrary.wiley.com&#x2F;doi&#x2F;abs&#x2F;10.1111&#x2F;camh.12112" rel="nofollow">https:&#x2F;&#x2F;acamh.onlinelibrary.wiley.com&#x2F;doi&#x2F;abs&#x2F;10.1111&#x2F;camh.1...</a><p>[5] <a href="https:&#x2F;&#x2F;www.tandfonline.com&#x2F;doi&#x2F;abs&#x2F;10.1080&#x2F;09638230601182094" rel="nofollow">https:&#x2F;&#x2F;www.tandfonline.com&#x2F;doi&#x2F;abs&#x2F;10.1080&#x2F;0963823060118209...</a><p>[6] <a href="https:&#x2F;&#x2F;www.cdc.gov&#x2F;childrensmentalhealth&#x2F;access.html#ref" rel="nofollow">https:&#x2F;&#x2F;www.cdc.gov&#x2F;childrensmentalhealth&#x2F;access.html#ref</a><p>[7] <a href="https:&#x2F;&#x2F;www.nimh.nih.gov&#x2F;health&#x2F;statistics&#x2F;any-anxiety-disorder.shtml" rel="nofollow">https:&#x2F;&#x2F;www.nimh.nih.gov&#x2F;health&#x2F;statistics&#x2F;any-anxiety-disor...</a><p>[8] <a href="https:&#x2F;&#x2F;www.cdc.gov&#x2F;childrensmentalhealth&#x2F;access.html#ref" rel="nofollow">https:&#x2F;&#x2F;www.cdc.gov&#x2F;childrensmentalhealth&#x2F;access.html#ref</a><p>[9] <a href="https:&#x2F;&#x2F;www.nimh.nih.gov&#x2F;health&#x2F;statistics&#x2F;suicide.shtml" rel="nofollow">https:&#x2F;&#x2F;www.nimh.nih.gov&#x2F;health&#x2F;statistics&#x2F;suicide.shtml</a><p>[10] <a href="https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC1361014&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC1361014&#x2F;</a><p>Visit us at www.daybreakhealth.com
======
chewzerita
I may not have anything actionable to say, but I can at least tell my side of
the story. I am a teen in the US mental health "system." It has been quite a
ride to say the least. I was living with debilitating anxiety and depression
going into a new school, but I didn't even know it. I am thankful for my
parents for calling a crisis number to get someone to talk to. It has been a
tough few years trying to regain the time I was left untreated. Medication and
regular (individual and group) therapy has been a huge help with anxiety and
depression, as well as my ADHD and schizophrenia. I am finishing up my time at
a therapeutic high school and will be attending RPI in the fall (at least for
now it looks like I will be going to campus, yay!). It has been a struggle,
but because of the support I have received, I am in a much better place than I
was.

During the whole quarantine, I have had no complaints about online therapy
(unlike online school). I can say personally you do not lose out by going the
online route. It is certainly more convenient, and because it is (mostly) one
on one, you don't have the issues that come with a 50 person zoom call. I
really appreciate that you get parents on board because having an open dialog
is extremely important.

I have two specific questions though: (0) How will you deal with crisis
situations? How are you planning to take on the legal responsibilities that
come with that? (1) Any potential solutions to improving access to
psychiatrists and medication? Therapy is just one piece of the puzzle to my
ongoing recovery. Medication really helps, but I am concerned that these teens
might miss out on that important part.

Thank you for doing what you are doing. If I did not get help, I probably
would not be here leaving this comment today.

~~~
alexalvarado
Thanks so much for sharing your story. It is stories like yours that inspire
us every day, and that will inspire more teens and parents to seek treatment.
And I'm happy to hear that your treatment has put you in a better place, and
you are headed off to RPI. To address your questions:

1) Crisis situations: safety is our #1 priority. We create a safety plan that
includes coping skills, strengths, local resources and people to contact. If a
crisis situation arises we have this in advance as a resource. We recognize
online can create more challenges than in person for maintaining a safe
environment, so we also refer patients who we believe might need more
intensive care to in person treatment.

2) We firmly believe telehealth is a great vehicle for psychiatry. We haven't
quite arrived there yet, but it is on our 'roadmap' to have psychiatrists. And
in the meantime, we refer out for teens who need medication support.

Thanks again for sharing your story!

------
aerioux
Integration with medical systems would be amazing; my friends at top tier
universities (e.g. Berkeley) want mental care but aren't sure if it's covered

from my experience there has been a constant refrain about CAPS (Counseling
and Psych - usually called CAPS in school systems) departments everywhere
being

1) hard to access 2) underfunded 3) unresponsive

super excited for this product :)

~~~
alexalvarado
Thank you! We would love to work with CAPS departments. Out of curiosity, do
you have any people you could introduce us to who might be able to tell us
more about CAPS at specific schools?

------
mangoman
Congrats on the launch. I think this is an important issue and it is good to
see some focus on this area.

How did you arrive at your pricing? I am curious how, if a therapist normally
costs $200 per session, you can offer it at less than half that price? Are the
counselors certified differently? What's unique about Daybreak that makes it
cheaper to offer therapy?

Another question I'm curious about - do you address medication at all? How
does that work, do you have psychiatrists that patients can talk with? Or is
medication out of scope?

Congrats again!

~~~
alexalvarado
Thanks for the kind words.

On Pricing - our counselors are certified to practice and pass a rigorous
interview process ensuring the highest quality. All are licensed to practice
in California and have 5+ years experience working with adolescents. The
primary differences are: 1) real estate (our therapists work from the comfort
of their homes, so we don't have that cost), 2) cost of living (because we can
work with therapists in varied geographies, their cost of living may be lower
than in the highest demand/need geos), 3) value prop (adolescent-focused
therapists want to work with us because of our flexibility and focus on teens
which is rare to find)

On medication - today we refer out if patients need medication. It is an area
we are actively thinking about how to better serve in house!

------
vegannet
Access to healthcare is a big challenge in the US because of cost: your
pricing seems to be very accessible but I’m curious if you have any specific
ideas around how you can make therapy more accessible to people who can’t
afford these prices.

I guess my question is whether your vision is a digital version of traditional
therapy, or if you see your mission as making therapy more accessible which
_currently_ is digital traditional therapy but could evolve substantially over
the coming years?

~~~
alexalvarado
Thank you for the great question about access: access and quality are our twin
aims when it comes to delivering mental health support to teens. The product
is in service to those aims.

So to answer your question: our current product reflects what we think is the
best solution to increase access to therapy while maintaining quality. Over
time, as we learn more, the product could evolve to become even more
accessible (e.g., more digital) if we are able to maintain quality with that
solution.

One other piece I'll say on access: for a healthcare company the 'insurance
plans' control the keys to access. From Day 1 an important part of our
strategy is pursuing reimbursement so that the cost of our services reaches $0
for teens and families who need it and cannot afford the out-of-pocket cost.
We are not there yet, but it is our goal!

------
pal_9000
Great job! What would you say are the most challenging gaps between online
sessions compared to traditional in-person sessions? What are your plans to
bridge the gaps?

~~~
alexalvarado
Very important area to explore. Let me first start by saying the the evidence
suggests that telepsychiatry is as effective as in person therapy for
adolescents (article link below), and our data shows that it is more engaging
as measured by session attendance and number of weekly engagements.

That said, there are three primary challenges in the online environment.

First and most simply, it is harder to create rapport online. We require for
that reason that all of our teens use the video sessions (in addition to
messaging and the app), and we place high importance on the match itself
(which we can do since we have a group of diverse counselors across California
geos). We also place high importance on the therapeutic alliance and give our
counselors techniques during training to develop that online.

Second, privacy can be a challenge in small or crowded homes. We work closely
and set expectations with parents to ensure that our teen clients receive
privacy during their session times.

Third, online counseling is still primarily best for mild to moderate acuity.
At the more severe acuity levels, or with psychotic disorders for example, we
haven't yet nailed how to treat online effectively and safely. We screen
members during the assessment and refer them out if in-person counseling is
better. We also put an emphasis on our online safety plan, which gives us
knowledge of parent whereabouts and trusted contacts in the case that a crisis
situation does escalate.

Link to efficacy of telepsychiatry in adolescents:
[https://togetherthevoice.org/wp-
content/uploads/2020/04/AACA...](https://togetherthevoice.org/wp-
content/uploads/2020/04/AACAP-Telehealth-Clinical-Update.pdf)

------
eganist
This is cool. Do you have any documentation around the security controls
implemented to protect sensitive communications between patients and
therapists? Among others? I presume this is ultimately still protected
information under HIPAA

~~~
alexalvarado
Thanks. This is an important question. You are exactly right that under HIPAA,
there are a few basic data protection requirements. These encompass
administrative, physical and technical requirements. A few examples of the
technical requirements: all protected data must be encrypted at rest and in
transit, each medical professional authorized to access PHI must have a unique
identifier to monitor access, and automatic log-off must be implemented to
protect data. We've architected from Day 1 to be able to meet these needs. You
can read more about HIPAA requirements here: [https://www.hhs.gov/hipaa/for-
professionals/security/laws-re...](https://www.hhs.gov/hipaa/for-
professionals/security/laws-regulations/index.html)

~~~
btown
Amazing - you all are doing vital, lifesaving work! Curious - did you
determine that you needed to use any existing software systems to help with
regulatory compliance, such as any big-name EMR solutions and/or single-sign-
on with the same? Or were you able to meet HIPAA requirements with standard
web application tools & stack? Do you feel any choices of language, database,
even things like advisory board, etc. made this easier to do?

~~~
alexalvarado
Working with existing software systems make this compliance much easier. Many
of the big name service providers (Twilio, Sendbird, Auth0, Heroku, AWS, etc)
have out-of-the-box HIPAA compliancy. And working with an EMR is tablestakes
for a healthcare provider, we definitely did not build that from the ground
up! Our work is about bringing these solutions together into a unified UX and
ensuring compliancy / security across the stack, while gradually introducing
secure and compliant native functionality. Language itself does not have a
huge impact (we've seen it done in many different languages), but having the
right advisor can make the build process a lot easier if they know what to
look for!

------
zoomablemind
Congrats on the launch!

Question: your site emphasizes a "guarantee of good counselor match".
Importance of a rapport and trust between coach and teen (especially) is hard
to overvalue.

How does this guarantee translate into practical terms? Is it a guarantee to
have access to/try all currently available coaches before making the choice,
or more like a "money back" kind of guarantee?

~~~
alexalvarado
Definitely agree the rapport and 'alliance' between the two is paramount!

How it practically plays out: teen members can switch between counselors on
our platform if they are not satisfied with their first match. If they don't
find a match that is a fit within the first few sessions, we do offer a money
back guarantee.

We do also focus in the upfront assessment on gathering the input we need from
both the teen AND the parent to make the matches we select higher quality.
This input includes goals, needs, specialty areas, interests and hobbies --
among other inputs.

------
hereme888
"That is why an average of 11 years pass between when a teenager first needs
mental health support and when they eventually start receiving it in their 20s
or even later."

As a medical student interested in psychiatry and rehab, that is mindblowing
and touching.

I really with you the best with this!

------
euse42
I’d also love to learn more about increasing access for young people. I spent
many years working with low income teens and unfortunately this pricing is
entirely out of reach. Do you have any plans to offer free services for the
young people most in need who could never afford to pay out of pocket.

I’ve also worked with young people whose parents, even if they could have
afforded it, didn’t believe in therapy and weren’t willing to support their
child’s efforts to obtain it. So yet another reason why access is super
important.

Just as a reference point, I run OkaySo, we offer free support on sex,
relationships, and identity to young people. Happy to chat and connect. elise
at okayso dot co (not com)

Thanks for this work!

~~~
alexalvarado
Thank you for your great comment and for your important work at OkaySo.

We recognize that our current pricing, while an improvement over private
practice, is still out-of-reach for much of the country. Our plan is to: 1)
continue to evolve the product to reduce cost of care while maintaining
quality, 2) pursue partnerships with health plans and eventually Medicaid
(which covers the lowest income teens) so that our services can be offered for
free to those teens. We are very open to other funding models to increase the
access of our services for teens as well! I'll reach out to learn more

------
tkt
Thanks, this is a vital service, especially now when many teens are struggling
and virtual is the only option. Designing specifically for virtual may be an
advantage over therapists who usually work in person, but are now trying to do
the same thing online, but may see challenges in adapting their approach. I
didn't see this on your FAQ. Can your counselors prescribe medications, or
make referrals if they think it may be needed?

~~~
alexalvarado
Thanks for the kind words! We do believe designing for virtual first offers a
lot of advantages vs. tacking it on to a traditional practice.

You ask a great question, and we'll add it to our FAQ. We currently refer out
for the medication prescription needs, and are evaluating bringing the
capability in-house.

------
archarios
Are y'all hiring JS devs at all? I'd love to work for a company with such a
great mission.

~~~
alexalvarado
Thanks for the kind words about our mission! We aren't currently but that may
change in the next 6 months. Can you shoot me a note alex at daybreakhealth
dot com and I will connect you to our CTO?

------
loceng
What's your current understanding with the problems and/or pitfalls of
psychiatry? Serious question.

------
pryelluw
There is very noticeable lag when navigating the site. Clicking the counselors
link takes seconds to open. This on a top of the line android phone.

I strongly suggest you do performance a/b testing.

~~~
desireco42
It seems that template they use is just terrible.

It is not trivial for this service how your website looks. It should provide
some confidence that you know what you are doing.

~~~
alexalvarado
Thank you both for the usability feedback, on both the performance and the UX
side. We will absolutely take that into account in future iterations. And
agree 100% with performance testing!

~~~
pryelluw
Btw, I dont think the site is terrible. The lagging made it hard for me to
learn more about the product. Hope it didnt come off as snarky

------
djsumdog
I'm pretty skeptical about online therapy. Creating yet another abstraction
between human and human seems to be going entirely in the wrong direction.

One of the big issues with the lockdown was that many municipalities
considered substance abuse meetings (AA and others) as non-essential. These
types of programs do not work anywhere near as well online. Meanwhile liquor
stores remained open as essential.

~~~
alexalvarado
Thanks for the push, this is something we think about a lot.

I'll start by saying that we look to data to drive our perspective here. The
the evidence suggests that telepsychiatry is as effective as in person therapy
for adolescents (article link below), and our data actually shows that it is
more engaging as measured by session attendance and number of weekly
engagements than traditional therapy benchmarks. The way teens engage with the
world is changing (to more digital), and rather than try to swim against the
current, we hope to reach the most teens by meeting them where they are, and
then changing their behavior in ways that matter. Our programs do focus on the
importance of things like limiting screen time and developing healthy
relationships.

Ultimately I won't disagree with you -- in-person is at least as effective and
for many people can be more effective. However, what we are hoping to do is
increase access to those people for whom going to an in person session might
present to high a barrier, whether it be geographically, financially, or from
a stigma perspective.

Article on efficacy of telepsych: [https://togetherthevoice.org/wp-
content/uploads/2020/04/AACA...](https://togetherthevoice.org/wp-
content/uploads/2020/04/AACAP-Telehealth-Clinical-Update.pdf)

~~~
toomim
Actually, online therapy can be _more_ effective than in-person:

[1]
[https://www.thelancet.com/journals/eclinm/article/PIIS2589-5...](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370\(20\)30186-3/fulltext)

[2] [https://healthsci.mcmaster.ca/news-events/news/news-
article/...](https://healthsci.mcmaster.ca/news-events/news/news-
article/2020/07/08/therapy-delivered-electronically-more-effective-than-face-
to-face)

