• Integrative Care for Santa Cruz Kids
• Innovative Diagnostic and Treatment Services
• Designing for Transitional-Age Youth

One in four adults in the U.S. lives with a mental health condition such as anxiety, depression, bipolar disorder, schizophrenia or substance use disorder. Anxiety is particularly prevalent, affecting some 40 million adults, while another 17.3 million—plus 3.2 million adolescents — experience at least one major depressive episode each year. Many people grapple with multiple mental health challenges at once, and left untreated, these conditions can significantly impair their quality of life.

Mental health disorders span all ages, genders, races and socioeconomic groups. Depression could affect a popular teenage girl just as it could a 65-year-old retiree. A successful businessman may live with bipolar disorder just as a 20-something artist might. Even a young child with a loving family and seemingly few stressors may experience anxiety just as a frazzled stockbroker could.

Despite these realities, mental health was long viewed as less important than physical health. Thankfully, this outlook is changing. Even so, mental health services are still lacking nationwide. And even when support is available, many hesitate to seek help or have difficulty accessing it. Research shows that, on average, people wait eight to 10 years to pursue professional assistance.

Common roadblocks to getting help include the stigma surrounding mental health challenges and the fact that patients often misunderstand or downplay their symptoms. Also, many commercial health insurance plans separate mental health coverage from physical health coverage, which can impede access to care. Lastly, psychiatrists, psychologists and therapists often lack the bandwidth to take on new patients—or they don’t accept health insurance and their hourly rates are steep.

To address these barriers, Sutter Health and the Palo Alto Medical Foundation are evaluating mental healthcare through multiple lenses. Researchers, clinicians and design teams are working to identify gaps in services and obstacles to access and developing potential solutions. They are piloting and implementing new care models and acquiring new technologies to aid diagnosis, treatment and follow-up care. The ultimate goal is to ensure that every community receives exceptional mental health support.

Integrative Care for Santa Cruz Kids

PAMF pediatricians are seeing more and more mental health conditions among their patients. “Between 1993 and around 2005, I’d see one or two children a year exhibiting anxiety, depression, suicidal ideations or bipolar disorder,” says Bruce Block, M.D., a PAMF pediatrician in Santa Cruz. “Now I see at least one or two every day. It’s concerning how much these conditions have increased over the last decade, especially depression and social anxiety.”

While there is no single cause — anything from homelife to hardwired genetics can influence a child’s mental well-being — "it’s clear that cell phones, iPads and other devices play a huge part in social anxiety,” Dr. Block says. “Many kids have never lived in a world where there weren’t all these devices, so they never learn how to express themselves or interact with others.”

Until recently, PAMF pediatricians referred these patients to psychiatrists and therapists outside of Sutter Health, and it would often take months to secure an appointment — if they could even find an affordable professional accepting new patients. Then about five years ago, Dr. Block spearheaded an initiative to change this. Backed by $3 million in philanthropy funding, his team piloted a new model of mental healthcare delivery in Santa Cruz.

“Our goal was to create a program that provides mental health services for the 100,000 patients of PAMF’s Santa Cruz Division,” Dr. Block says. “We hired psychiatrists, psychiatric advanced practice clinicians, social workers and counselors to co-locate in our primary care clinics. We also trained more than 80 primary care physicians to screen for mental health issues and treat mild to moderate cases.”

Once the pilot proved successful, the Santa Cruz Integrative Behavioral Health Program took root and flourished. “Our philosophy is to support primary care physicians in addressing mental health needs,” says Marla Reckart, M.D., the first psychiatrist hired and now the program director. “When they can’t treat a child, they send the patient to us, then we discharge them back to primary care.”

This model has enabled more children to receive mental healthcare — and promptly. For example, Dr. Block recalls a 9-year-old patient who exhibited serious obsessive thoughts and compulsions. “I thought, wow, this kid needs to see someone right now,” he says. “I walked down the hall and asked our social worker to come say hi to this little guy and set up a time to see him. They had a brief visit on the spot, then met again the next week and four or five times after that — and that was all the boy needed.”

More recently, the program has expanded to include adult care. “The obstetrics department sees many women with mental health conditions, especially postpartum depression,” Dr. Block says. “These patients had to go through primary care for help, but our program has grown enough that we can co-locate therapists in OB.”

Now, in addition to psychiatrists, there are many mental health professionals integrated with pediatrics, OB/GYN, family medicine and internal medicine at all six primary care clinics in the Santa Cruz Division. Next, Dr. Block hopes this model can spread to all PAMF divisions.

Innovative Diagnostic and Treatment Services

PAMF has also advanced mental healthcare by offering cutting-edge therapies. For instance, Brian Tang, M.D., a developmental and behavioral pediatrician in Los Altos and Fremont, recently secured philanthropy funding from PAMF’s Grants and Disbursements Program to acquire QbTest. This computerized assessment for attention deficit hyperactivity disorder allows doctors to diagnose ADHD earlier in life, when intervention is most impactful.

Another innovative treatment, transcranial magnetic stimulation (TMS), will soon be offered at PAMF’s San Carlos Center for patients living with severe depression who haven’t found relief from medication or talk therapy. This noninvasive treatment places a magnetic coil over the scalp to stimulate specific brain regions that modulate depression symptoms. With a $150,000 grant from the PAMF Grants and Disbursements Program, the San Carlos team ordered a TMS machine and hired experienced psychiatrist Noah DeGaetano, M.D., to lead the program. He has begun evaluating patients who may benefit from TMS and aims to begin administering the therapy by year’s end.

Also made possible through Grants and Disbursements, the PAMF Mountain View Center now provides auricular acupuncture, which involves inserting thin needles into particular points around the ears, for patients living with depression or anxiety. The grant money enables two PAMF psychiatrists to take an intensive acupuncture training course. Armin Nassiri, M.D., recently completed it and has begun administering the treatment, while a second psychiatrist will start the course in December and then provide auricular acupuncture in Palo Alto and Los Altos. The two physicians will offer traditional acupuncture as well.

“Additionally, we will soon offer shared medical appointments to provide auricular acupuncture in small-group settings,” says Shahna Rogosin, M.D., chair of psychiatry and behavioral health at PAMF. “Initially, we’ll offer appointments for anxiety and depression and later for sleep issues and chronic pain.”

But PAMF’s shared medical appointments aren’t limited to acupuncture. This format has become popular among patients seeking other types of mental health support. For instance, clinicians in Santa Cruz, Mountain View, Fremont and San Carlos now offer cognitive behavioral therapy group sessions to help taper insomnia sufferers off of sleep medications.Older adults, especially, benefit from shared appointments, particularly the healthy aging sessions, which convey tools for managing depression, isolation and physical pain that often present later in life. Plus, group appointments foster connections between patients, which can minimize loneliness and sadness.

Designing for Transitional-Age Youth

Older youth, those from about age 16 to 24, are very prone to anxiety and depression. “Young adults who are graduating high school, going to college and figuring out what they want to do in the future have high stress levels,” Dr. Rogosin says. “In our community, many teens want to go to top-tier schools and their parents have high expectations for them, which can create an overwhelming amount of stress.”Like other patient groups, transitional-age youth often struggle to access timely and appropriate care. Intent on better serving this demographic, the Sutter Health Design and Innovation Team is working alongside Sutter System Mental Health, Mills-Peninsula Medical Center and PAMF psychiatrists such as Dr. Rogosin to identify gaps in care and craft solutions.

Endowed with a $20 million gift from Michael and Judith Gaulke, the Design and Innovation Team takes a design-based approach to addressing healthcare challenges. Led by Chief Innovation Officer Chris Waugh, the team’s project managers, researchers and designers first study a particular healthcare journey in-depth, then collaborate with clinical teams to devise solutions and partner with outside developers as needed to bring ideas to fruition.

“Whenever we seek to address a challenge or solve a problem, we focus on the human user,” says Vandana Pant, director of strategic initiatives. “This ensures that our solutions come from a place of empathy and understanding the needs of individuals and families.”

When focusing on youth, the Design and Innovation Team interviewed and observed 59 patients and families of diverse backgrounds from five Sutter Health acute mental healthcare facilities and the Peninsula and South Bay communities. “We asked, how might we support those dealing with mental health challenges in the right way at the right time?” Pant says. “We started by trying to understand patient journeys before, during and after acute care episodes. We looked at the entry points to mental healthcare, the reasons people first interact with the system, patient expectations and how much alignment there is between their needs and our services.”

Through the interviews, recurring themes emerged that illustrated what living with depression or anxiety can look like. The team also spoke with 40 mental health practitioners to understand the gaps in care from clinicians’ perspective. Collectively, this information helped them pinpoint key opportunity areas they could help address.

One of the biggest opportunities they identified is to improve the patient experience following discharge from a Sutter Health acute mental healthcare facility or program. “What happens when patients go back to their homes, schools and communities?” Pant asks. “Who makes up the caregiving ecosystem around them? Where is there a lack of support for both youth and caregivers? How can Sutter Health assist young people and their chosen caregivers in finding help to cope, stabilize and stay well every day?”

The Design and Innovation Team wrapped up its foundational research this year. “Philanthropy brought us a seed donor, Inger Bischofberger, who was interested in supporting this work,” Pant says. “This gift, which Sutter Health matched, allows us to take our learnings and codesign a solution with youth and their caregivers. We opted to focus on 15- to 22-year-olds who’ve been diagnosed with moderate to severe depression with related anxiety, the area in which we believe we can have the maximum impact.”

Now, the Design and Innovation Team is working with clinicians across Sutter Health plus youth advisors and external subject matter experts on the next phase of the project. In this phase, the team will develop and pilot a web- and mobile-friendly digital platform with human touchpoints to provide intensive assistance for youth in the days following their transition from acute care, as well as ongoing support for them and their caregivers.“Philanthropy continues to collaborate with us, both by supporting the existing gift and launching an additional campaign in the South Bay to see how we can address the highest points of vulnerability while fostering resilience in everyday settings,” Pant says.

Based on their findings, the team proposes a platform that will connect youth to multiple means of support, such as delivery of evidence-based clinical modules, peer connections, volunteer opportunities, coaching and mobile applications that foster mental wellness. “Once we have that platform developed, we aim to pilot it over six months next year in the Peninsula region,” Pant says. Following the innovation cycle, the team will assess the pilot’s impact, iterate and determine options for scale.