Q&A about mental health: Local experts offer their advice, guidance


As a community we are grieving. We have lost precious youth to treatable health conditions. We want our youth to feel encouraged in all they aspire to do, and will support them in finding their own way in the world.

In this endeavor, our schools are very aware of the need to prioritize teaching students how to understand and manage their busy lives beginning in the early grades through curricular elements, healthy activities, electives in wellness and mindfulness, and many other ways to address social and emotional health. However, we all know that care and support of our youth is a shared responsibility in our community and works best when we all take accountability and work together.

In our community forums, there has been much discussion about whether we can attribute any particular factor to the recent tragedies. Suicide does not have a single "cause." Many factors and life circumstances must be taken into account when trying to understand why someone would take their own life.

In response to the 2009-10 suicides among our youth, a detailed investigation with interviews of dozens of family, friends, and teachers was conducted. Academic stress in itself was not a major factor. For most of these young people (as is true nationally) depression, anxiety, sleep problems and severe distress about relationship issues, life transitions, and other aspects of mental health were key factors.

We must continue to address the myriad development and health issues in our youth, including mental health and resilience. It is also important to evaluate other possible contributing factors, such as academic and other performance stresses and expectations. These expectations can emanate from the youth themselves but, crucially, may be perceived by the youth as coming from their families and others involved in their lives, even when such messages about high performance expectations were well-intended or misinterpreted.

Solutions must come from all those who interact with youth, including schools, parents and family, friends, medical and mental health providers, community and faith leaders and mentors. All of our messages of support must be very clear.

Following national guidelines, we have conducted depression education and suicide-prevention training sessions with several thousand students at both Gunn and Palo Alto High Schools in Living Skills classes since 2010. The teachers in these classrooms have been a very important part of the "Wellness" effort that began after the PAUSD Board of Education enacted the Board Policy on Suicide Prevention in June of 2010.

Students have asked many questions regarding mental health in these classes. Common topics include "When does stress become distress?"; "My friend's been sad: When do I worry something is really wrong?" Below are a few of the most common questions and answers.

Q: When a friend is depressed, is it better to try to help them first or just go straight to a parent or psychiatrist?

A: It depends. If you feel like you can approach your friend and talk to them about your concerns, this can be a great first step, just as you would want your friends to take if they were worried about you. When you talk to your friend, encourage them to get help from a counselor or other trusted adult. If you've already tried this or aren't comfortable approaching them, talk to a parent, teacher, counselor, doctor or other trusted adult and let them know what changes you've noticed in your friend.

This adult should check in with your friend and make sure they get the help they need. Remember that by talking to an adult when you're concerned about a friend, you're not getting them into trouble you're getting them out of trouble.

Q: Why do so few teens get help for their depression or anxiety?

A: Some teenagers might not recognize that what they're feeling is depression. Others might not know where to get help for depression or realize that depression is a treatable health condition. Others might be afraid to let other people know what they're experiencing because of stigma or because they think that it's something they should be able to "get through" on their own.

Clinical depression is common (11-15 percent of all teens will experience some form of depression before high school graduation). It can be treated successfully with professional help, so it's important for you to reach out for yourself or for a friend once you notice the signs of depression we talked about in class. Depression isn't something you can or must just "deal" with on your own.

Q: About how long can it take for stress to turn into "distress," and then distress into depression?

A: It depends on the individual and the degree of stress. Not everyone responds the same to a given stressor, and although everyone feels some stress at times, not everyone develops "distress" or eventually, depression.

You may be more likely to develop depression as a result of a stressor, if you have a sibling or parent who has had depression, or you've experienced depression in the past, or you're dealing with other challenging stressors at the same time.

Coping strategies and resources (such as supportive friends, trusted adults, relaxing and fun activities, etc.) can help you effectively deal with a stressful event or circumstance. True depression is not something that can be dealt with effectively on one's own, and that good help is available in our schools and community.

Q: Is anxiety a form of depression?

A: No, anxiety is a different mental health issue, but research shows that anxious people may be more likely to develop depression. Anxiety can precede depression, but the two are commonly experienced together. For more information, see here.

Q: Can depression be cured by positive thinking alone?

A: Though positive thinking can be an important part of having a healthy and resilient life, positive thinking by itself does not treat clinical depression. Talk therapy with antidepressant medications, if needed, are the only proven treatments for teen depression.

Some forms of therapy work on correcting the negative thought patterns that people who are depressed might find themselves trapped in. This is a process that requires professional help and supervision.

Q: What if I get signs of depression but it's on and off?

A: It's important to recognize the difference between an occasional depressed mood, which everyone feels transiently at some time, and true clinical depression. A clinical diagnosis of depression requires that the symptoms be present nearly all the time, every day for at least two weeks. However, if you're concerned about how you're feeling, talk to someone who can help.

Signs and symptoms of depression include the following:

• Feelings of sadness

• Loss of interest or pleasure in normal activities

• Irritability, frustration, or feelings of anger, even over small things

• Changes in sleep habits (either insomnia or excessive sleeping)

• Changes in appetite (decreased or increased)

• Agitation or restlessness (pacing, hand-wringing, inability to sit still)

• Fatigue, tiredness, slowed thinking, loss of energy even small tasks seem to require a lot of effort

• Feelings of worthlessness or guilt, fixation on past failures/mistakes or self-blame when things aren't going right, worrying

• Trouble thinking, concentrating, making decisions, and/or remembering things

• Frequent thoughts of death, dying, or suicide

• Crying spells for no apparent reason

• Unexplained physical problems (especially pain-related), such as back pain, headaches, or stomachaches.

Q: How can we get help in our community?

A: There are lots of resources! Talk to your parent or the parent of a friend you're concerned about to determine the cause for the feelings and if anything can be done to help (answers: yes, it may be depression, and yes, something can be done to help!). You can talk to a guidance counselor or school-based mental health counselor through Adolescent Counseling Service (ACS) , or another trusted adult at school. Of course, primary care doctors can be a great first contact as well and can evaluate and often treat directly. If needed, they can refer to mental health professionals.

There are other resources in the community, such as the ones listed here.

Shashank V. Joshi, MD, is Director of the School Mental Health Team at Lucile Packard Children's Hospital; Meg Durbin, MD, is Regional Vice President for Care Coordination at Palo Alto Medical Foundation; Sami Hartley is the School Mental Health Coordinator for LPCH and the HEARD Alliance in Palo Alto.

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5 people like this
Posted by Paly Parent
a resident of Palo Alto High School
on Nov 14, 2014 at 8:31 am

Thank you for this information.

I am more concerned with the fact that nowhere do we seem to be given or getting a message that at some level we have to let our teens be teens, behave like teens, and be treated as teens. They are not young children, but they are not adults yet. They still need some fun in their lives and yes, they still need to be able to make a few mistakes without it destroying their lives.

I want to see more prevention of mental health issues, rather than identifying that someone has it. I want to see more good clean fun, without challenge or repercussions in their lives. I want to see some places where they can hang out, behave like teenagers, and not worry about academics, sport, college, and anything competitive. I want to see some mentors who are not teachers, coaches or parents. I want to see something that is not the pressure cooker environment that most of them live in.

Too often teens are expected to behave like college students. They are not. Their bodies are still growing. Their hormones are just starting to kick in. Their maturity levels vary with nothing to do with age. They are scared to do badly on a test, to get sick, to get dropped from the team or to lose out to someone who is having a better day. They haven't yet learned to find their strengths and able to deal with their weaknesses. When a mistake does occur, they feel that it is the end of the world. They can't shrug it off and vow to do better next time, because as far as their world is treating them, it is still there in their grade or on their school transcript.

This is not a Palo Alto situation alone. Our education system nationwide has to change. We have to let the high school aged kids of this country be kids, have fun, and grow up a little more slowly. It is not lowering standards or expectations, but facing the reality that kids just need to be kids who will make mistakes, who still need to mature and will turn out fine with just a little less than perfection in their lives.

2 people like this
Posted by Another Paly parent
a resident of Midtown
on Nov 14, 2014 at 8:46 am

Along the lines of prevention, I would like to see better responses to students' needs and requests, so that they know they have a voice, that they can affect change and that adults are listening. Specific examples include lack of action from school administrators regarding student editorials requesting intramural sports--a way for kids to let off steam and play noncompetitively--and figuring out how to create space for that instead of making excuses, as well as addressing significant inconsistencies in grading--for example, the self-cited stress of having an unclear or unpredictable verbal participation component in grades. How about a principal's response section to newspaper editorials?

8 people like this
Posted by Time for Change
a resident of Adobe-Meadow
on Nov 14, 2014 at 10:27 am

I have a comment/concern about what is written above about the past suicides. According to Dr. Joshi, he writes that it is his opinion that "Academic stress *in itself* was not a major factor."

I would like to know two things:

- What does "in itself" mean here? That is very unclear. Yet it seemed important to put it in italics in the article, suggesting that it did play a role of some kind, just not "in itself." The role it surely played is the one that research has identified which is that it leads to sleep deprivation and anxiety, which causes depression and other mental health issues.

This is given away in the next sentence of Dr. Joshi's article, where he says that his investigation did uncover that sleep problems and anxiety and depression DID play a role in the deaths. I believe what this means is that Palo Alto's suicides are explicable in part with a model of indirect effects of academic stress:

Academic stress >> sleep deprivation >> anxiety/depression >> thoughts of self harm

Since suicide never has a single cause and always has a complicated causal model, the fact that academic stress "in itself" isn't a cause is a meaningless sentence since literally NOTHING "in itself" is ever a cause.

- Why is Dr. Joshi always so eager to dismiss school reform as a meaningful goal? Why does he set up a straw man for the community:

Unless suicide is caused by academic stress "in itself" we should forget it and instead teach students how to manage the ridiculous demands on them. Our schools, according to Joshi, are already doing great at that ("our schools are very aware of the need to prioritize teaching students how to understand and manage their busy lives").

This is ridiculous. Every parent will tell you that their lived experience with their teens is that they have a staggering workload that is as overwhelming as it is unnecessary. Anyone with eyes can look around and see the proliferation of for-profit tutoring centers. Palo Alto might have more tutoring storefronts than Starbucks at this point.

Survey after survey lists workload and difficulty as the most important issues of teen well-being in Palo Alto. Why is our district mental health consultant (and he is a paid consultant, so perhaps that should be disclosed and considered in evaluating his comments) constantly telling us that it isn't an issue?

Yes depression and anxiety are important issues. But environmental factors play a role in causing and exacerbating these conditions.

Marc Vincente has more wisdom about what needs to happen than I find in this article and he has 20 years of teaching Gunn students under his belt so I would be more inclined to listen to him and he says our kids have too much damn homework.

QPR training is only going to take us so far (obviously). Parents and students need less work. As brave Gunn junior Martha Cabot says in her video, the homework load is "ridiculous." District consultants and doctors like Meg Durbin who are not going to deal with the reality of our situation and act instead as representatives or even apologists of a broken system aren't going to have credibility.

Our kids are crying out for relief from backbreaking workloads and stress. Is it good for them to be under this stress? Is it a benefit to them? Is it making them better learners, human beings, or citizens? How is it healthy to be sleep-deprived? Why are we doing this to them? What possible purpose could there be for this other than that it is how it is currently being done and change is hard?

Why are doctors who specialize in kids telling us that we don't have to listen to our kids but can offer them suicide prevention training instead of improved health and well-being.

2 people like this
Posted by Wondering
a resident of Another Palo Alto neighborhood
on Nov 14, 2014 at 11:14 am

I appreciate experts speaking.

I have a couple of questions.

1. What diagnosis are they are referring to for medication? Is medication required for mild symptoms as well? What would be considered mild?

For adults, exercise has been found to be as effective as some medications, is there any such research for teens?

2. Online time. Practically every factor which is a concern for depressed teens - from sleep, relationship distress, and academic stress is to a large extent hyper fueled by social media, and time spent online. Is online time an issue?

4 people like this
Posted by Junior Paly Parent
a resident of Midtown
on Nov 20, 2014 at 12:07 pm

I would like to add to the comment by Another Paly Parent about the lack of action from school administrators regarding requests for intramural sports to help kids let off steam and play noncompetitively.

Paly athletics are very competitive. There are MANY kids who would enjoy baseball, basketball and other team sports but aren't 'above the cut' -- It's very sad when a kid has played team sports for years but when they arrive at high school they don't make the team. Where do they then go to play for fun that doesn't require a costly club membership? It's a void that intramural sports could fill -- giving kids an outlet for exercise (healthy for the brain) and comradery (healthy for the soul) -- that has nothing to do with social media and computers.

4 people like this
Posted by Former Paly Mom
a resident of Palo Alto High School
on Nov 20, 2014 at 1:35 pm

Those who are on the Paly teams sacrifice their GPAs, plain and simple. My two children were hardworking, good athletes who could have been on the boys lacrosse and girls volleyball teams but the time commitment was too great, and the likelihood for a college scholarship was nill, as it is for most high school athletes. Both teams require two hours of practice each day and on game days, players are required to stay and watch all the other levels of games, so freshman play their game, then watch JV and Varsity games, arriving home at night. PAUSD is a college prep district and working on homework on the bleachers is not ideal or easy. Add private coaching and clinics, and there is little time for studying or for honors or AP classes.

Like this comment
Posted by Am I missing something?
a resident of College Terrace
on Nov 20, 2014 at 3:11 pm

"Where do they then go to play for fun that doesn't require a costly club membership?"

Whatever happened to pick-up sports in the park with your friends? Why can't kids organize these activities themselves?

2 people like this
Posted by Former Paly Mom
a resident of Palo Alto High School
on Nov 20, 2014 at 3:31 pm

@Am I missing something?: AYSO is a soccer league for fun, non-competitive play and they offer teams up to 12th grade. Other than that, there are other organized extracurriculars nowadays. Back in the day, it was only softball, soccer and the basic boy sports. Now, there's much more available for children.

As for pick-up sports in the park with friends, kids prefer to be on technology when they have a free moment. That is, when they have a free moment. PAUSD high schools require a lot of homework, depending on the teachers. It's not like back in the day when we had 1-2 hours of homework and a lot of free time after school and on weekends. Times have changed and it's not pretty.

2 people like this
Posted by What about the $$ cost?
a resident of Crescent Park
on Nov 20, 2014 at 4:25 pm

Mental health care is expensive and in our experience, most/many providers (therapist, psychologists, psychiatrists) nearby do NOT accept health insurance. I can't blame them, they charge $165-225 an hour and our insurance, Blue Cross, reimburses them $61.00. PAMF has ONE child psychiatrist on staff, he is terrific but works part time.

So even when students are willing to get help, true mental health care can be inaccessible for many reasons. As wonderful as ACS is at the schools, the "therapists" are generally interns who are supervised by a professional.

@am I missing something - while kids can play "pick up games" at the park, there simply aren't enough kids with free time to play and the parks are often booked by organized team sports.

Like this comment
Posted by Am I missing something?
a resident of College Terrace
on Nov 20, 2014 at 8:03 pm

" there simply aren't enough kids with free time to play"

Then who will be playing in the intramural leagues?

2 people like this
Posted by what about the $$ cost?
a resident of Crescent Park
on Nov 21, 2014 at 10:15 am

@am I missing something - there is a big difference in organizing intramural sports at a school site (with a whole school full of potential players) vs. finding enough kids randomly at a park to play. I do see a lot of semi-organized games on Sunday at the Jordan field.

Sorry, but further commenting on this topic has been closed.

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