Ruth Adewuya, MD: Hello. You are listening to Stanford Medcast, Stanford CME's podcast, where we bring you insights from the world's leading physicians and scientists. This podcast is available on Apple Podcast, Amazon Music, Spotify, Google Podcast, and Stitcher. If you're new here, consider subscribing to listen to more free episodes coming your way. I am your host, Dr Ruth Adewuya. This episode is part of our hot topics mini-series. And today, I will be chatting with Dr Steve Adelsheim on the topic of mental health and well-being in youth and adolescents. Dr Steve Adelsheim is a clinical professor and associate chair for community engagement at Stanford's Department of Psychiatry, directing the Center for Youth Mental Health and Wellbeing.
Steve's work is focused on early detection or intervention programs for young people. And he leads the effort to bring allcove to the US, an integrated youth mental health model which opened in June, 2021 in Palo Alto and San José, California, with plans to open in five other California sites over the few years. Dr Adelsheim also co-leads PEPPNET, the national clinical network for early psychosis. Steve also co-directs the Media & Mental Health Initiative in Stanford's psychiatry department, and works in youth suicide prevention, tribal mental health, integrated care, and telehealth. He previously spent many years leading school mental health efforts for the state of New Mexico and served as the state's psychiatric medical director. Thanks for chatting with me today.
Steven Adelsheim, MD: Thanks so much for having me. It's an honor to be here.
Adewuya: The coronavirus pandemic has triggered a rise in mental health and behavioral health issues across the general population here in the US. How has the pandemic specifically impacted mental health in children, adolescents, and young adults?
Adelsheim: Even before the pandemic, we really had a crisis in terms of a lack of support and access for young people in terms of mental health care. We know that half of all mental health conditions start by the age of 14, and three quarters by the age of 24. And yet we don't have, across our country, systems in place to really identify and link young people to early care. And they weren't in place even before the rise of the pandemic. And certainly, since that time, we've continued to see increasing rates along with the isolation of our young people. And the grief experiences our young people have gone through and the losses and the inability to have the regular socialization. The data's really shown we have increasing rates of depression in our young people, increasing rates of anxiety within our young people, increasing rates of suicide attempts within some population certainly nationally, increases in emergency room visits for mental health issues.
All of these has increased while at the same time we haven't had an increase in our provider workforce for youth mental health. We're now going on two years around these issues. Everybody's tired and everybody's felt losses. We've continued to see increasing need for support for our young people who now are moving back to school, but at the same time school sometimes is stopping and is jumping back and forth. And the flexibility required not only for our young people, but for their families is just really overwhelming our systems of support that did not have enough availability even before the pandemic began.
Adewuya: If you were to go back to March 2020, what changes do you think you would have made in educational policies to perhaps lessen the pandemic's impacts on youth mental health?
Adelsheim: I spent many, many years directing school mental health programs at the state level in New Mexico before I came to California. One of the things that we were really involved in was trying to support a broad continuum of school mental health care for young people. At the same time, the stigma issues made it complicated. The challenges around reimbursement. The whole question for some of the educators within schools, our job is to educate. It's not to provide health care for young people. We really worked hard with many schools across the state and nationally to create opportunities to link young people earlier to care.
I think one of the things that would've been helpful would've been to continue to work to break down that stigma, to build out the broader infrastructure linkages so that every young person could access early mental health care. I was involved in some national efforts around school mental health for many years. And even the question of screening in schools, because that's where the kids are, for mental health conditions like we do for hearing, like we do for vision, and there was a lot of pushback. That mental health issues were private issues. They were family issues. They didn't belong in schools. And so I think part of the wish would've been that we could have more normalized school mental health support more broadly. We could have built on some of those linkages more directly to community-based services.
Adewuya: You pointed out a statistic that I thought was very important and I wanted to spend some time on it. You said 50% of mental health disorders have their onset by age 14.
Adewuya: And was it 75% before the age of 24? You just mentioned how there was pushback in terms of where the screening should take place, but what is the significance for screening?
Adelsheim: One of the issues is how do we identify young people, half of whom may be starting to have symptoms under the age of 14, and help ensure that the early intervention is available for their mental health conditions, just like it is for their asthma or their obesity or the other health related issues that young people may be developing? And the stigma around mental health has always been such that it's been more complicated to do those screens. The issues around reimbursement for mental health care have made it not as much of a financial incentive available to whether it's health plans or even on the Medicaid side to really do that early identification.
Adelsheim: And as a result, when you look at the data about how long people are taking, where they're having symptoms before they access mental health services, all the data says that if you have your symptoms as a young person, it's often six or seven years that you're going with symptoms before you're accessing treatment. And we know now that early intervention works as well for mental health as it does for any other kind of health condition. And yet we don't have a public mental health continuum of care established in the country. So that's one of the things that we've really been working hard to start to frame and establish in the programs we become involved with over time.
Adewuya: I know that in this conversation we cannot cover all of the signs, but what are some of the signs to look out for when someone is having a hard time dealing with some of the stressors of what is going on now?
Adelsheim: One of the things we're seeing more often is young people dealing with more depressive kinds of issues. Often what we see when people are becoming more depressed is they sometimes start to withdraw more and get more isolated. They may have more trouble concentrating. When people are having trouble with depression, their sleep can go in either direction. Some people have early morning awakenings, or have trouble sleeping, or wake up a lot in the middle of the night. Other people will sleep incredibly long periods of time. People have changes in appetites. Sometimes people will eat a whole lot more, some will eat a whole lot less, but what's important is the change and the overall sense of increasing hopelessness, increasing sadness, loss of interest in regular types of activities.
For young people in particular, what we often see is increasing irritability. Young people will talk about having sort of a fuse that's shorter than usual. Like little things that didn't use to bug a person so much, now they can no longer tolerate and they get angry more easily. For schools, it might mean that a young person who's been a wonderful student, their grades might start to drop for the first time because they're not concentrating. They're not focused. They're not motivated. Someone might say a name to them and in the past they would let it go, but with that shorter fuse, they may be getting into a fight at school for the first time in their lives. And as much as we see those as behavioral issues, sometimes it can be the result of increasing depression as well.
When we look now, also there's a lot of work going on on early intervention for psychotic illness, which is when people are losing touch with reality. And one of the things we start to see is people like clinical high risk or having symptoms of early psychosis and in addition to the things we've talked about, there might be more overall withdrawal, less self-care in terms of hygiene. Sometimes people having different experiences of colors, changing or vivid sounds or vivid images. And also, people might find that they start to wonder, am I hearing whispers? Am I hearing other sounds? Am I starting to move towards hearing different voices? Is my brain maybe playing tricks on me? So there are all those kinds of symptoms as well in which recognizing them early and linking young people to early support can also be really valuable.
Adewuya: It seems to me that there are three pathways, per se, in which youth would be able to engage in early intervention. At school, as you mentioned, or their parents, or through a clinician. Are you seeing that most people are coming in through teachers, or are you seeing it from parents in your area and with your population?
Adelsheim: So one of the challenges that we really see by not having these screening and early intervention models is that most people are actually coming into systems through a crisis point. And that really becomes a big part of the issue by virtue of not generally having easy accessible symptoms or not having easy points for places to come in. Young people are coming in feeling suicidal to an emergency department, or getting in a fight at school, or having a drug overdose because they're self-medicating to try to address their mood or their other issue. And so what we see is a lot of crisis services at the point for young people to enter systems in terms of care. And what we'd really like to see is the ability to have spaces where young people can feel comfortable coming in on their own, whether it's to a school health program or a school-based health center, or some of the community programs that we've been working to develop designed by and for young people to feel comfortable, to be able to come in before things actually reach a crisis point.
The only other place that I would mention to your point is young people who are brought in by their families maybe to their primary care provider. And so we see that happening fairly often as well. And there's been a big national investment in creating models to provide behavioral health backup support and consultation for primary care providers when they're having that young person in their office. And there's clearly a major mental health issue here, but this is beyond what I was trained to manage. They have a phone number and a contact right away where they can reach out, whether it's to a child psychiatrist or a therapist or some other consultant through a program that they can speak to right away to help guide them on the next steps towards that person's treatment as well.
Adewuya: Mental health disorders can often involve consequences for physical health. For example, an eating disorder treatment typically involves not only therapy, but also care from nutritionist and primary care physicians. How can innovative models of mental health care interface with traditional physical health care?
Adelsheim: We've been looking at models to really try to develop integrated primary care and mental health. Not only for families, but also for a lot of young people, the stigma around acknowledging a mental health issue can be really quite large. And if you can create spaces where you can have both primary care and mental health related services in an integrated way, for that young person who feels comfortable going in to talk about their headaches or about their stomach aches that may have an underlying anxiety disorder or depression issue, you have a setting where they can go in and have those conversations. And then by the second or third visit, you get to the underlying mental health condition. And then you can do a warm handoff to a mental health provider who may also be on site or with a strong linkage to that provider to then also allow that service to happen.
And like you're saying, with eating disorders, the sooner you can recognize what's behind that person's weight loss or their self-image, the sooner you can link that young person to the appropriate care for what may be the underlying issue. Lots of times families feel if there is a mental health issue, it's their fault. What have they done wrong? And how could they have caused this problem in their child? So often there's a fair amount of blame around having mental health issues. We all have mental health issues in all of our families, but we don't talk about it.
Let me share one more thought related to this that I think also makes it tricky, is this whole notion of informed consent and confidentiality. There are a lot of young people that don't always feel comfortable sharing with their parents the issues that they're dealing with. Can you, or should you create settings where young people can go in and have those confidential conversations or give their own consent for their own mental health care? Most states have state laws that allow for that at varying ages. It gets tricky in terms of who has to share that information with a parent or when that happens or just the overall impression of what it means to keep that information from a family member.
Adewuya: I can only imagine for clinicians and teachers who are trying to navigate this, understanding the boundaries and what they can and cannot do to help the young person. It sounds very complicated and challenging.
Adelsheim: Also, if you're that student and you can share certain things if the person is employed by the school and know that it'll be private versus what you can share if the person is employed by a health care agency, that would be private. We don't train our young people to say, "Who does your paycheck come from?" For the student too. And that's always really complicated in terms of trying and figure out what they can share with who and what's private and what's not. So I think for everybody, it's a little messy.
Adewuya: Students of the current generation have shown unprecedented willingness to speak openly about mental health. However, as you mentioned, there's still stigma and mental health can still remain a taboo subject. Does the effect of stigmas differ between communities or mental health conditions?
Adelsheim: For sure. And I think to your point, I think we're seeing a generational shift in terms of openness to talk about mental health issues. And our young people are much more willing to speak to their mental health challenges. We're seeing it in our professional athletes now across the world, whether it's a tennis event or the Olympics. It's been shocking to the world to have these young people lead the way in terms of having openness to conversations. Culturally, different communities have different levels of comfort in terms of talking about and acknowledging mental health issues. How one addresses those in the context of culture become very important.
And in addition to that, within many of our different cultures, even the interpretation of mental illness or mental health challenges or what it means when someone has an experience that maybe is not grounded in what we have as our typical sense of reality, that may be a spiritual experience within some cultural groups or maybe an ancestral related experience. How we help other people interpret their own experience within the context of their own culture becomes very important. Having respect for and understanding of different cultural interpretations experience is now certainly more important than it's ever been. I'd say also for our young people, sometimes it takes a leap beyond their older generation to risk going out and getting mental health care when they feel like they need it when their parent or their grandparent might feel like, from a cultural perspective, those aren't conversations you have outside the family.
Adewuya: What do you think are some steps that clinicians can do or that the general population can do to reduce that stigma?
Adelsheim: These conversations that have been happening nationally and internationally, I think, are very helpful. Some of our colleagues, for example, at the group Bring Change to Mind have started these high school clubs for mental health advocacy and awareness. And I think they've done a really nice job of supporting young people to have those conversations at school. Many of the young people that are involved in our youth advisory groups with our allcove programs or some of the other efforts have really taken steps to give talks, provide leadership and speak out to families around these issues.
One of the things that I find in some of the communities that I've been involved, when young people are really feeling challenged about not being successful or doing well enough, really encouraging their parents or their caregivers to really acknowledge their own challenges and their own moments of having mental health difficulties or stress. We as parents, and I'm a parent of four children, we don't tend to share our own challenges in such a way our children are sort of left perceiving us as just being people who are making their way through the world. Our children don't often get exposed to our challenges or our failures or our trials, or those are the other members of our families. So I think having direct conversations about the different relatives in our families that have faced challenges or our own experiences and how we picked ourselves back up and what resilience has looked like in our own families.
Adewuya: Obviously, in this time of the pandemic and even before, youths have turned to social media and online communication platforms to maintain social connection. How can the social benefits of these platforms be leveraged while minimizing the harms that we're seeing from social media?
Adelsheim: Some of the young people that we've been working with, they've started, for example, Instagram and website group called GoodforMEdia. Their focus was really to be able to share stories with other young people about their own experiences in terms of their own mental health from the use of social media. What worked well for them, what the challenges have been. Being able to talk about the impact has allowed other young people to then speak to their own experience as well. And creating spaces for those conversations has also been really important.
And when you reach out and talk to young people that have been dealing with issues of depression and isolation, sometimes they will talk about how painful it is to see other people get all these likes and to see them be so popular and how hard that is. But at the same time, many of those same young people are really able to find support, whether it's through different websites or different peer groups, where they can talk about their own emotional challenges and find other people that have dealt with the same experience, give them recommendations for where to get support and find ways to build on that.
And I think what we're seeing is our young people are talking about how to look at social media in a way that will preserve the well-being of young people that isn't tied necessarily to just giving you the next ad for how you can look better, but really be able to support you and being able to build out those linkages to other colleagues and peers who are finding ways to deal with things in a resilient and positive way.
Adewuya: You are a clear advocate for a continuum of support for youth that incorporates multiple touchpoints in their school and family lives, including social, emotional learning and mental health education. How has the Center for Youth Mental Health and Wellbeing built a continuum of support? Can you expand on the work that you're doing?
Adelsheim: We have really focused on this whole early intervention piece that we've been talking about. And really, some people call this period from 12 to 25 the second zero to three, in the sense that young people are still going through brain development, they're learning how to adjust to changes in their lives socially, emotionally, biologically in terms of neuronal development, pruning of pathways that aren't generally being used as much, learning how to stop themselves from getting involved in dangerous behaviors and how to learn from them. This is also the period where young people for the most part are developing mental health challenges if they're going to. Creating systems and pathways for young people to come in early and get that support, to build out this public mental health continuum of care has been really important to us.
And so we've been trying to do it in a number of different ways, and they've involved developing youth voice by creating spaces for integrated youth health care and mental health care the young people feel comfortable going to. And these are based on models that have been developed in Australia. The headspace program that have been the clinical programs of which there are 140 across Australia, the Foundry program in British Columbia, the Jigsaw program in Ireland, the YWHO program in Ontario. And many other international partners that have helped guide us in the development of bringing these models to the United States as well.
And within the context of these programs, we're trying to create comfortable spaces for young people to come in on their own or with a friend for early mental health support, the primary care piece, which we talked about as being so important in terms of integrated support, support for education or job training, early addiction and treatment, and then peer support, because we really feel like young people derive value from hearing from their other young adult. And as we've started these sites in California and the United States, we're calling these sites allcove. And really this sense of as a place for all young people in a cove to able to have a safe, supportive harbor where young people can go to get the kind of support they need.
And as we're starting allcove in the United States and Santa Clara County in California, it's the first time a country's tried to create this model that doesn't have national health insurance, which also adds for a whole level of complication, because we want to support everybody that comes in the door regardless of insurance status. Really trying to link it to the school health and mental health programs. We're trying to link it to these early psychosis programs as well. And really look at all of this as a public mental health continuum of care for young people.
Adewuya: When it comes to the work that you're doing, whether with allcove or with the Center for Youth and Mental Wellbeing, schools or extracurricular organizations or community centers, what is the role of community partnerships to promote mental wellness?
Adelsheim: Community partnerships are clearly at the core of this work. And our role outside of Santa Clara County has been to sort of support other communities in building out this model. So we're really implementation support providers. But within the framework of each allcove site is a core youth advisory board that is made up of young people reflecting the diversity of each community. And that really adds a clear voice to the types of services available, does a lot of the outreach to the other young people in the community. At the same time, each allcove site has a community consortium, which is made up of city and county partners, other young people, the voice of families, other health care organizations, other networks that are really able to guide what happens at each site that are also able to be outreach partners and advocates for each site.
And when we envision these types of services, really have a sense that there are multiple agencies that are coming together at an allcove site to provide the services as well. And within that framework, there might be people who have a housing program that will come on site to link young people to housing. There may be people that run an eating disorders program that will come on site to help build that warm handoff for an eating disorders types of program. People that will come do wellness activities for us. Being able to be linkage across communities is critical.
Adewuya: I think what's incredible and compelling about what you've just said is how you have intentionally put the voices of young people at the center and the core of the work that you're developing. They're really kind of leading the charge, I suppose, is what I'm hearing. I know we've mentioned the allcove program, but we also know about the Media & Mental Health Initiative, which really speaks to what we were talking about earlier. Can you talk more about that initiative and what young people are doing there?
Adelsheim: Our Media & Mental Health Initiative is good for media related efforts, but the young people that we've been working with are also doing a lot of speaking more broadly about the importance of youth voice and even from different cultural groups. We partner quite a bit with members of the native American community across California, our partners at Two Feathers Native American Family Services, and with support from the Indian Health Service to put together conferences around the native youth voice and native youth mental health related services the last few years. One of the areas that's been really important for our Media & Mental Health Initiative has been around how the media writes about issues related to suicide. There's data that really clearly says that young people are at greater risk for suicide contagion. That young people who read stories that are done in a certain way about another young person's suicide might be more at risk to die by suicide.
And that issue came up around the TV show, 13 Reasons Why, for example. And data says that there was a large number in youth suicides in the three to six months after the show because of how it described suicide within the show, the way the show was done. And there were a lot of efforts that went into trying to decrease that risk, but many of the young people we've worked with, particularly because we've had youth suicide clusters in the Palo Alto area where Stanford is, have been very involved and outspoken about pushing back on media that really haven't followed what are the national guidelines for reporting safely on suicide in order to decrease risk. And how do we educate the media as partners? People are really worried about the safety of their friends and colleagues and really want to have a big impact.
Adewuya: I know that there's a lot more initiatives that are happening and I just wanted to let the listeners know that we will be linking everything that Dr Adelsheim has just mentioned in the description of the podcast so that you can click to those resources from the link below. The Surgeon General's Advisory of mental health crisis signals a national recognition of the need for action. Do you think that this announcement will lead to lasting change?
Adelsheim: I want to be hopeful.
Adelsheim: I want to be hopeful that it will. These issues have come up before, but I think right now because of the pandemic, there is national recognition of the losses our young people have faced. And I think what you see in the Surgeon General's Advisory is the recognition that it's really time to finally acknowledge the needs of our young people. The recognition of the early stage at which mental health challenges start, the importance of creating the workforce, the importance of listening to young people who know best what they need in terms of support and guidance from the rest of us, so that as they move on to become the future for our country, that they have the tools and skills they need to bring us through the challenging times that are ahead for all of us.
Adewuya: What would your key takeaway be for clinicians, or parents, teachers, or counselors? So let's start with clinicians.
Adelsheim: If you're seeing young people, probably the greatest chance that the challenge they're facing is a mental health challenge. If you don't feel you have the capacity to help them address it, to continue to advocate and build for those programs that will create the opportunities for us all in behavioral to back you up, to get you the tools you need and/or to be able to create the workforce in the systems, particularly around child and adolescent mental health, so you have a system to refer to for support because right now you don't. Also, I would say that if US clinicians can help us advocate for and help the rest of the community understand the power of young people… Often adolescents get a bad name. And it's really time to acknowledge how wonderful our generation is right now of young people and the importance of their voice, and really continue to support them in getting the things they need to be able to succeed and thrive.
Adewuya: For our parents and teachers, our school counselors, what would you say to them?
Adelsheim: Well, I would first say thank you for the work that you're doing and for the challenges that you've all been facing, particularly in the schools right now. It's been so hard for everyone and everybody's tired. And so I would say thank you for sticking with it and being there. What I would say is ask your administration for additional support and to be able to have your community partners come in and support you as well as the students that you're working with. I think there's a fair amount of self-care that we're all really needing right now. Whether we are school counselors or teachers or administrators or parents, we need find ways to exhibit our own sense of self-care, our own sense of resiliency and model it for our kids.
Like we mentioned at the very beginning, we've had a crisis in youth mental health from before the pandemic. And I think we all need to come together to advocate for expanded resources and support. And as we all talk about our own mental health challenges, we'll continue to break down that stigma, which will increase the chance that the services and the reimbursement and the allcove programs and these other models will be more available to us and our families.
Adewuya: Thank you so much for chatting with me for this hour and just sharing all of your insights on this incredibly important topic.
Adelsheim: I'm really grateful for the chance to do it. And thank you for your interest.
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Clinical Professor, Psychiatry and Behavioral Sciences
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