Beyond the psychiatrist’s office

The rise of mental illness among young people is as daunting as it is undeniable. The rate of adolescents aged 12-17 in the U.S. who suffered a major depressive episode nearly doubled from 8% in 2007 (according to Pew Research Center) to 15.1% in 2018-19 (according to the Centers for Disease Control and Prevention).

Yes, 2007 is the year that the iPhone debuted, and we’ll save the debate of correlation versus causation for another time. However, the deleterious effects of social media — online bullying and the displays of curated perfection, to name two — on maturing psyches are well established.

And yes, the CDC report occurred before the isolation of the pandemic curbed the socialization that teens not only crave but also need on the road to adulthood. More recent information — a 2022 U.S. Substance Abuse and Mental Health Administration survey — indicates that among adolescents aged 12 to 17 in 2022, 19.5% (or 4.8 million people) had a major depressive episode in the past year.

Paul King, the president and CEO of Stanford Medicine Children’s Health, gives a cold-eyed assessment of the challenges in addressing young people’s mental health needs.

“Everybody seems to be searching for what to do,” King said. “Mental health seems to be an intractable problem, one for which demand has always and probably will always exceed supply in terms of the nation’s mental health professionals’ ability to provide services to these kids.”

Yet King, a 40-year health care administrator, understands the unique position that children’s hospitals hold, not only in the medical community but also in the minds of the public.

“If we can begin to treat mental health as a childhood disease, then maybe we can prevent some of the school shootings, some of the mass shootings, some of the tragedies that we’re seeing in society, because those people haven’t been diagnosed and treated appropriately younger in life.”

Paul King, president and CEO of Stanford Medicine Children’s Health

“We can be that organization that brings together the mental health professionals, the schools, the community, organizations, the parents, the kids themselves,” King said. “What children’s hospitals can do uniquely is serve as a convener.”

“I think there’s a recognition that none of [the medical providers] can solve these problems by ourselves. And so we have to reach out and partner with others and really listen to the kids in terms of what they think they need, or what they believe is most helpful,” he said.

To better serve mental health needs, Stanford Medicine faculty and staff are finding ways to support young people beyond their medical offices, working with schools, parents, municipalities and community organizations to bring stakeholders together and provide psychiatric care and expertise.

Some, for example, have helped establish San Francisco Bay Area suicide prevention programs. Others are supporting the provision of mental health care and well-being services to immigrant youth in Half Moon Bay, California, the site of a January 2023 shooting spree witnessed by children and families that killed seven people, all immigrants. And others launched a growing network of youth mental health centers throughout California. 

“Do we have the knowledge to make things better? Yes,” said Antonio Hardan, MD, the director of the Child and Adolescent Psychiatry Division at Stanford Medicine, who describes himself as an optimist. “But it’s trying to implement the knowledge at all levels. That is a little bit challenging,” said Hardan, who primarily works with children with autism.

A positive development, Hardan said, is that all young people who use Stanford Medicine’s outpatient services, from doctor’s offices to surgical centers, will receive suicide mental health screening starting in 2025. Another initiative focuses on educating parents — including an online course developed by Hardan and colleagues for parents of young children with autism.

“This is increasing capacity in the system by utilizing parents, who are so committed to their kids and are with them much more than I, as a clinician, can ever be,” Hardan said. “That’s why working with fathers and mothers and providing them with strong parenting skills is very, very important to help them manage some of the behavioral and emotional challenges of their children.”

As King and Hardan see it, the stakes for addressing young people’s mental health troubles are colossal.

“If we can begin to treat mental health as a childhood disease,” King said, “then maybe we can prevent some of the school shootings, some of the mass shootings, some of the tragedies that we’re seeing in society, because those people haven’t been diagnosed and treated appropriately younger in life.”

Here are a few ways Stanford Medicine faculty and staff work with community members to support youth mental health:

Paths to suicide prevention:
Project Safety Net and the HEARD alliance

When Mary Gloner receives a phone call from the Palo Alto, California, police that a local teenager has died by suicide, the news arrives with the surges of emotion common to grief: sadness over learning someone had been in such pain, anger that society had failed the student.

But Gloner, the chief executive officer of Project Safety Net, also allows herself to focus on hope — hope that one suicide will not beget another — and implements a plan she has prepared for responding to just such a tragedy. 

During the past 15 years, Palo Alto has experienced two suicide “clusters,” in which several local young people ended their lives in a matter of months. Project Safety Net was created after the first cluster, in the 2009-10 academic year, to coordinate the efforts of local schools, government and the mental health community to curtail the contagion of suicide and to promote youth mental health and well-being.

“There are some adults who say, ‘Children are not Buddha. We know better.’ … I try to think of it this way: You are the coach and the mentor — the caring adult to guide them.”

Mary Gloner, the chief executive officer of Project Safety Net

The nonprofit exists, in part, because of the work of Stanford Medicine professionals such as Shashank Joshi, MD, and Sherri Sager. Joshi is a professor of psychiatry and behavioral sciences who helped establish the organization and served as a founding board member. Sager, recently retired as senior vice president and chief governmental relations officer at Stanford Medicine Children’s Health, secured critical financial support from Lucile Packard Children’s Hospital Stanford.

“It’s like an emergency preparedness response,” said Gloner, who joined the nonprofit after the second cluster, in 2014-15. After a suicide, the organization activates the crisis response team — assisting local schools with expertise, promoting grief support meetings and serving as a communications hub.

Community conversation and action are crucial after a suicide, said King but, in the aftermath of a tragedy, that doesn’t come easily.

“…There was a lot of pain,” said Gloner of a recent death. “There was stigma. There was conflict. There are people who did not want to talk about suicide but to focus more on well-being. And there were some who said, ‘No, we need to talk about suicide.’”

Project Safety Net’s staff members talk about suicide because the kids are talking about it. “The goal,” said Joshi, is to “help to empower the youth voice in thinking about how we can support their mental health. We’re asking, ‘What is it that will help you really feel like you’re a part of this community?’ And we’re saying, ‘Your voice matters, we care about you and we care about you thriving.’”

Striking the right balance between listening to children and leading them is the tricky part, Gloner said. “You want to take care of children, and you want to keep them safe. There are some adults who say, ‘Children are not Buddha. We know better.’ I leave that be. I try to think of it this way: You are the coach and the mentor — the caring adult to guide them.”

Another outcome of the all-hands-on-deck response of parents, educators and doctors after the first cluster of deaths was the launch of the Bay Area-based HEARD Alliance in 2009, a collaboration of health care and education professionals to assemble best-practice resources on a website and develop strategies to promote mental health and prevent suicide.

Funded by Stanford Medicine Children’s Health and other groups, the organization has produced a 300-page document — co-written by Joshi — to meet those goals. This  toolkit, which has been accessed more than 200,000 times on the organization’s website, is a guide for implementing suicide prevention policies required of all California schools serving students in kindergarten through 12th grade.

Now on sabbatical, Joshi is directing some of his energy to working with professionals across the country who are interested in forming similar collaborations in their communities.

And he’s advocating for curtailing pedestrian access to the site of many of the tragedies in Palo Alto, the local train tracks, by gathering data on costs, meeting with city officials and talking with administrators from the rail system. He and his team are also researching what other communities have done to prevent access to train tracks — and the success of their efforts.

“Mental illness is much less stigmatized because young people have been able to tell their stories and feel seen and heard.”

Shashank Joshi, MD, professor of psychiatry and behavioral sciences

“It’s starting with a literature review, which systematically examines the world literature on safety at train tracks of every kind of train — commuter trains, freight trains, bullet trains. What is the standard of prevention? What’s the state of the art according to the science?”

The eruption of the second suicide cluster in 2014-15 illustrates the elusive quality of progress in treating mental illness. Depression among young people has increased. So has anxiety. Yet so has outreach and destigmatization and increased awareness of the importance of good mental health.

“Talking about mental health as part of overall health is common, expected, everyday,” Joshi said. “Mental illness is much less stigmatized because young people have been able to tell their stories and feel seen and heard. Our community has also found out how common mental health challenges are, a part of everyday life.”

Awareness in and of itself is not a solution. But it is a start, a quickening of pace, toward solving any societal ill, be it smoking tobacco, climate change or mental illness.

Healing in Half Moon Bay:
Ayudando Latinos a Soñar

Ryan Matlow, PhD, grew up south of Palo Alto in Watsonville, California, an agricultural community where many speak Spanish and no English. Matlow’s background is not Latino, and his first language is English, but childhood friends spoke Spanish so he learned the language.

His exposure to cultural, financial and language gaps led him to a career in child clinical psychology, specializing in addressing traumatic stress in children, especially where immigration plays a role. A clinical associate professor of psychiatry and behavioral sciences, he has served as an advocate for children separated from their families at the U.S.-Mexico border and held in immigration custody.

Now, living in Half Moon Bay, California, where about a quarter of the population is Latino, Matlow and other Stanford Medicine health care providers are working with the community organization ALAS (for Ayudando Latinos a Soñar, which means Helping Latinos Dream).

The nonprofit aims to promote mental health and social wellness within the area’s largely Latino farmworker community through arts and cultural practices originating in Mexico and Central America, such as playing mariachi music and performing folklorico dance.

Starting in 2011, the organization has grown to provide mental and physical health care and social work case management. In 2023, ALAS received a Stanford Medicine Outstanding Community Partner Award and is supported in part through funding from Stanford University — including a Stanford Impact Labs seed grant and a research grant from the Stanford Office of Community Engagement.

Speaking at a Stanford Medicine Community Health Symposium last year, the founder of ALAS, Belinda Hernandez-Arriaga, PhD, told of an experience that spurred her to create the organization.

Hernandez-Arriaga, a social worker, said one of her cases involved the young daughter of an immigrant farmworker who suffered recurrent abdominal pain. Doctors conducted tests and found no physical cause — and suggested the pain might have an emotional source. They recommended mental health support, which Hernandez-Arriaga provided.

“… She drew for me a picture of a mama cat and a baby cat with tears streaming down their faces. She x-ed out the mama cat, and on the top she put, ‘No Papers,’ and on the baby cat she put ‘Papers.’ ”

Belinda Hernandez-Arriaga, PhD, an assistant professor of clinical psychology at the University of San Francisco

“Three months into our treatment, she drew for me a picture of a mama cat and a baby cat with tears streaming down their faces. She x-ed out the mama cat, and on the top she put, ‘No Papers,’ and on the baby cat she put ‘Papers.’ That began the story of realizing the immigration trauma that so many have,” said Hernandez-Arriaga, an assistant professor of clinical psychology at the University of San Francisco.

The shootings in Half Moon Bay last year that killed seven farmworkers — five Latino and two Chinese immigrants — compounded that trauma for many, Matlow said.

Before the shootings Matlow and his graduate students had begun helping ALAS evaluate the efficacy of its cultural programs.

“Obviously, for immigrant families there is bias or discrimination, threats to social identity, loss of culture,” Matlow said. “These cultural arts programs are designed to counter that, design a space where kids can build community and connect with their cultural assets. We wanted to capture the impact. This sort of research drives funding. It helps provide validity and legitimacy to the approach ALAS is taking in their offerings.”

Stanford Medicine physicians work with ALAS to provide care as well. For example, Christina Buysse, MD, a developmental behavior pediatrician, and Anne Berens, MD, a postdoctoral medical fellow, are building evaluation programs for children in the community with developmental disabilities.

After the 2023 shootings, ALAS stood on the front lines of survivor assistance, with Stanford Medicine physicians among those providing mental health care support. Rona Hu, MD, a clinical professor of psychiatry and behavioral sciences, provided emergency assistance and crisis support for survivors who speak Mandarin. Matlow and Nancy Ewen Wang, MD, a professor of emergency medicine, collaborate with ALAS to support the Spanish-speaking community.

“We’re thinking about how we can organize and mobilize a system for providing longer-term care to complement what ALAS provides, anticipating that there will be ongoing stress,” Matlow said. “Sometimes the trauma sets in later. It’s a gradual recovery process.”

Just for youth: allcove

Steven Adelsheim, MD, has been working for decades to increase access to mental health care for youth and is a driving force behind allcove, a network of low-cost mental health care centers geared toward people aged 12-25 years that is now expanding across California.

“Opening the first allcove center and knowing we were finally able to give young people the support they need was a tearful moment for me,” said Adelsheim, a clinical professor of psychiatry and behavioral sciences. “It is amazing that there is so much interest in allcove and that the model it’s based on is expanding internationally, but there is still so much to do to overcome barriers to accessing care.”

These barriers include the stigma still associated with mental illness and a strained behavioral health workforce. The result is that though half of all mental health disorders start by age 14, a majority go untreated. Trained as a child psychiatrist, Adelsheim knows the importance of diagnosing mental health disorders as soon as possible.

“Early intervention is critical for mental health; we know it works for mental illness as well as it does for other conditions such as obesity, childhood asthma and HIV/AIDS,” said Adelsheim. “allcove provides an opportunity for us to both normalize mental health care and to make care accessible.”

Adelsheim’s efforts began in schools, but when he learned about a mental health care clinic system for youth in Australia called headspace, he jumped at the chance to bring the model to the United States.

The model embeds mental health care centers throughout the community, making them accessible even when schools are closed, and all are run in partnership with young people. Adelsheim secured funding from the Robert Wood Johnson Foundation to explore the feasibility of bringing the model that became allcove to the U.S., and the network launched in 2021.

“It is so important that youth have a place to go, and the allcove model is creating access where there wasn’t any before.” 

Steven Adelsheim, MD, a clinical professor of psychiatry and behavioral sciences

There are allcove centers in the California cities of Palo Alto, Redondo Beach and San Mateo, with centers in development in South Orange County and Sacramento. New funding from the state Department of Health Care Services will bring allcove to six more locations. Each center works with a consortium of local agencies and nonprofits.

The Santa Clara County Behavioral Health Services Department, for example, runs allcove Palo Alto, with Stanford Medicine Children’s Health providing adolescent medicine services. Financial support for allcove comes from many organizations, including Stanford Medicine Children’s Health, the California Mental Health Services Oversight and Accountability Commission, and the Lucile Packard Foundation for Children’s Health.

The allcove model involves youth in all aspects of what happens inside the centers. Each site has its own advisory group made up of 16- to 25-year-olds, many of whom have lived experience with mental health challenges.

These groups work to make sure anyone who walks into an allcove center feels welcome, whether they are enjoying the colorful, comfortable seating in the lobby or are completing intake forms that have been rewritten to use inclusive language. The approach is effective: Young people logged more than 4,000 visits to allcove Beach Cities in Redondo Beach in the year and a half after it opened.

“Valuing youth input also lets allcove constantly evolve to quickly meet the needs of the community,” said Nina N., who served as a youth adviser for four years starting when she was in high school. Because of that experience, Nina is now working toward a career in health policy so she can continue to break down barriers to care. (Nina’s surname has not been used to protect her privacy.)

Clinicians and staff collaborate with youth advisers to create workshops based on community needs, on topics such as the importance of sleep or how to manage stress. The centers also offer programs to build community and a sense of belonging — for example, game nights at all centers, DJ classes at allcove Beach Cities and “hooked on crochet” classes at allcove Palo Alto.

At no or low cost to them, visitors to allcove can receive individual, group and family therapy in addition to medication therapy. Each center also offers drop-in appointments and a menu of additional services that all reinforce mental health, including substance use treatment, physical health services, peer and family support, and education and employment support.

“When researchers study the effectiveness of models like allcove, a common question they ask youth is, ‘If you hadn’t come here today, where would you have gone?’ and usually the answer is, ‘Nowhere,’” Adelsheim said. “It is so important that youth have a place to go, and the allcove model is creating access where there wasn’t any before.”

— Contact Ivan Maisel and
Kimberlee D’Ardenne at medmag@stanford.edu