Robin Thomas matriculated at Stanford University in the fall of 2008, and after a few months he was thinking about leaving.

"I was not happy. And I did not understand why," he recalled. "I made it to the greatest school in the country, it was sunny, the campus was beautiful, and yet I was sad."

Thomas knew that mental illness ran in his family; his mother was diagnosed with clinical depression and had been on a steady prescription of Prozac. Still, Thomas refused to consider that he was suffering from the same affliction.

"I felt saying I was depressed would be a cop out, that I was just making excuses. I blamed myself and believed I was the only one who could fix it."

Thomas considered himself the archetypal "Stanford Duck," a metaphor well-known to Stanford students: On the surface he looked composed and happy, but beneath the surface he was paddling furiously to stay afloat emotionally. Maintaining the image of placid contentment meant bottling up his depression.

"I felt guilty because I felt I was rejecting an awesome privilege, and I didn't feel able to open up to anyone because it would sound ungrateful," he said.

Thomas returned sophomore year thinking a fresh start would help, but his depression persisted. He checked himself into Stanford's Counseling and Psychological Services (CAPS), but he did not make much progress.

"I'm not sure if there was a whole lot CAPS could do for me because I was really good at arguing with myself and rationalizing how I felt," he said.

But it was when Thomas finally opened up to some of his fellow students that he discovered something surprising.

"I found there were lots and lots of other students going through exactly what I was going through, but were afraid to talk about it," he said. "I kept hearing that they thought they were the only ones."

Over time, and as he spoke with more and more of his peers, Thomas concluded that what Stanford needed was an open dialogue that suspended judgment about how people were feeling.

"I wrote a couple articles for the Stanford Daily, and I started sitting in the middle of White Plaza with a sign that said, 'Let's talk about anything.' I was pleased by how many people approached me to talk and was both sad and unsurprised that a lot of people were quietly suffering like I was. I thought that would be the best way for me to contribute," he said.

Thomas ultimately dropped out of Stanford.

Emily Dolph, 22, had a similar mindset as Thomas when she was a high school student in Gilroy and a college student at San Francisco State University. She was an excellent student but was constantly unhappy with herself. She wanted everything and thus never felt she was doing enough.

"I was convinced I had to be perfect, not only in school but socially. When I felt sad I convinced myself that I was a cry baby and could get over it. A lot of my depression came from me beating myself up. I really did not like myself," she said. "The people who I at the time considered my friends were particularly hurtful. There was a constant pressure to look good, be thin, get the best clothes and ace tests. I had to have it all, down to keeping my hair perfectly in place, or nothing."

The pressure continued even at San Francisco State. The summer before her junior year she attempted suicide. After recovering she was diagnosed with clinical depression and enrolled in La Selva, a mental health services clinic on California Avenue in Palo Alto that's part of the Momentum Health Group.

For too many people like Thomas and Dolph, what exacerbates their despair is not so much depression, which thanks to decades of research is treatable, but their reluctance to seek help, according to James Millsap, executive director of La Selva. Simply put, many people who should, and could, be receiving effective treatment are not.

"Something stops them. What stops them is not only their condition, which saps their energy and willingness to reach out, but also things they hear on the television set and the people around them that people with mental illnesses are crazy, dangerous, losers, weak or whatever. So then the solution is to start hiding what they feel and that ultimately leads to tragedy. That is the real enemy out there: It's stigma," he said.

Other local mental health experts agreed.

"Twenty-four percent of U.S. citizens have a mental health condition in any given year and 57 percent of citizens will suffer from a mental health condition at least once in their lives. I actually believe those numbers to be conservative estimates," said Michael Fitzgerald, executive director of behavioral health services at El Camino Hospital. Fitzgerald also helped start El Camino's After-School Program Interventions and Resiliency Education program (ASPIRE). The program is designed to provide treatment for teenage youth who are experiencing anxiety, depression or other symptoms related to a mental health condition.

"This is a huge concern. Kids aren't getting help oftentimes because of stigma: Mental health concerns are portrayed very negatively in our society. Kids, particularly in regions such as the Silicon Valley, can feel enormous pressure to get into Stanford or a similar university. The pressure of being a kid seems worse now, on top of adolescence being inherently stressful," he said.

That pressure is felt among both young people and working adults.

"A lot of stigma comes from the expectations set by the people around us," said Annie DiTiberio, who was associate director of La Selva and now works at another mental health provider in Palo Alto that partners with La Selva. "What is the theme of this place? It's wealth, it's stories of extraordinary success at a rapid pace, it's hyper competitive both in school and work."

Setting extraordinary expectations can be a mental burden that can both aggravate a mental illness like depression and make stigma even harder to overcome, DiTiberio said. The strongest evidence of this cultural phenomenon is who does not come in for help, rather than who does. The demographic patterns are surprisingly specific.

"I have noticed that males who are successful lawyers, or work at startups, and are typically in their 40s really struggle with coming in. The few who do come in I can almost see a physical battle in their faces because they are so apt to blame themselves and eager to convince themselves they do not have to be here. Their self-stigmatization is incredibly powerful," she said.

"Stigma is pervasive throughout," said Dr. Laurie Leung, associate director of mental health programming at the San Jose nonprofit Asian Americans for Community Involvement (AACI). "The general perception is that mental health services are for people who have severe psychotic episodes or other extreme conditions."

Counseling and mental health services cover a large spectrum of problems and levels of severity. Targeted, time-limited consultations can address a specific issue, while longer term care is used to stabilize and return someone to baseline level of functioning. Inpatient care is needed when the individual could no longer provide for his or her own well-being, Leung said.

In short, says Julie Lythcott-Haims — former dean of freshmen at Stanford, Gunn High School parent and author of the upcoming book, "How to Raise an Adult: Break Free of the Overparenting Trap and Prepare Your Kid for Success" — Palo Alto, as well as the broader society, is facing a cultural problem.

"Confronting stigma necessitates confronting our habits, values and culture," she said. "Our kids are adopting the exceedingly high, narrow and rigid definitions of success endemic in the Palo Alto community, which undermines their mental health and wellness. We need to drop the facade that everyone is doing amazingly well, broaden our definition of success, and at the same time make it easier for people to talk about their mental health problems."

Dealing with stigma in mental health treatment is at least as challenging as treating the symptoms of mental illness, Millsap said.

"Depression and other mental illnesses are as real as any physical affliction," he said, "but they are easy to dismiss or ignore because it is not as dramatically physical as say a broken limb, and it can easily be mistaken as an attitude problem." (See sidebar.)

Stigma is even more invisible because it manifests in language, entertainment and sometimes people's most basic internal assumptions and instincts. These create barriers that can be more difficult to overcome than any mental illness.

Stigmas exacerbate depression

Eight years ago Kristin Dawson, 47, was convinced there was something physically wrong with her.

"I kept checking myself into emergency rooms. I was breathing quickly, had trouble swallowing and was rapidly losing weight. Every time doctors said I was likely suffering from a mental illness I rejected what they said. It turned out they were right," said Dawson, a Redwood City resident.

Dawson worked in Silicon Valley and was afraid her company would find out. She feared having a reputation at work as being mentally ill and therefore unstable, and possibly even seen as unemployable at any job in her industry.

Dawson was so self-stigmatized that she initially refused to see a psychologist and was terrified of getting diagnosed and being put on medication.

"I thought being on medication meant losing control over myself. I thought I would be numb to my life," she said.

Dawson also didn't like the connotations she associated with people who have mental health problems.

"In movies and television the villains are all suffering from mental illnesses. It's the go-to explanation when a tragedy happens like a mass shooting or the recent plane crash in the Alps. I did not want to be put in the same category as those people. Ironically, I was as much of a participant in creating stigma as everyone else," she said.

Dawson was finally diagnosed with bipolar disorder and depression and received treatment including medication and therapy training, but only after she became intensely suicidal. She credits La Selva for saving her life. Today, she's no longer afraid of her illness.

"I feel more in control of my life than I ever have in the past eight years. It's disturbing to think that the hardest part was getting over my own perceived stigma about mental illness and medication. I still go through episodes of anxiety and depression, but now I know how to handle them. My relationship with my spouse and family is stronger than ever," she said.

Stigma doesn't just come from people's self-perception, which in any case is usually adopted from the culture around them, but also from cultural stereotypes.

"There's particular stigma directed toward the Asian community that is perpetuated by the 'model-minority' stereotype," said Leung of AACI. Roughly, the stereotype advances the notion that Asians are perfect, they strive for the top schools and the highest-earning industries, she says.

Partially as a result there are a lot of students of Asian heritage who are going day-to-day unaware that they have a mental health issue or unwilling to seek treatment because that means admitting to a fault or needing help, she said.

Leung notes that within the Asian community, as is the case with other immigrant groups, more recent immigrants are more likely to be unaware of mental health issues than their more Americanized counterparts.

"The Asian community is still battling stigma against seeking help for physical health, never mind mental health. There remains a belief among some members of the Asian community that you should not visit a doctor unless you are very, very sick."

The stigma created by a culture of extraordinarily high expectations is neither an Asian construct nor does it exclusively affect Asians, however.

Sammy Kotmel, a 17-year-old Caucasian female, was a sophomore at Burlingame High School when she got a B in a class, her first ever.

"The 'B' shattered what was so important to her, which was her straight-A identity," said Maja Nelson, her mother.

Kotmel had been diagnosed with obsessive-compulsive disorder as a freshman, which contributed to her sterling academic record. Since as early as middle school Kotmel was fixated on getting admitted to colleges like Harvard, Yale and Stanford. She insisted on studying for the SAT in the 8th grade, a full three years before she was due to take the test. But what drove her to excel also put her at risk. The "B" threw her into a deep, severe depression. She attempted suicide.

Kotmel's parents never applied pressure on her to get straight A's or even take all the advanced courses she enrolled in, Kotmel said. They both went to relatively average colleges and have good jobs.

"The pressure came from the culture I grew up in," said Kotmel, now a junior attending Mercy-Burlingame, a private high school. "Certainly a lot of my pressure was self-created, but it was all based from what I was exposed to. There seemed to me a rigid, inflexible logic that getting straight A's was the only way I could get into an elite college, which was the only way I could get a good job, which was the only way I could hope to have a good life. My neighbors were evidence to me: They attended Ivy League schools; they have a huge house with four seemingly perfect kids. That had to be me."

"It was tricky for us to find good resources," Nelson said. "There's a lack of willingness in the community to open up, and even as a parent I felt stigma against reaching out. Burlingame is a lot like Palo Alto in that families work to perpetuate an image of high success and that everything is fine. We were lost, and we didn't know where to go."

What Nelson did find, though, was an "underground" network of parents who had kids who were suffering from mental health illnesses and able to discreetly connect parents to therapists and other caregivers.

It was when Kotmel was hospitalized that they learned of the ASPIRE program in Mountain View's El Camino Hospital.

"A lot of our program is to talk and think about what success really means and to get a bigger picture of what life is about. We want to equip young people with skills they'll need to get through life," Fitzgerald said.

Students enrolled in the ASPIRE program can receive credits that go toward their high school diplomas.

"We are trying to destigmatize mental health by treating it as something you have to learn and practice. It is real work; the course lasts eight weeks. And we sponsor the kids in the rare event that insurance does not want to pay," Fitzgerald said.

Today, Kotmel is doing and feeling a lot better, even though she got two B's this past semester. She's lightened her course load, only taking one AP class in her favorite subject, biology. She's no longer as concerned about the SAT or college admissions as she once was; she knows she is a good student and will excel no matter where she decides to attend.

Sadly, like Emily Dolph, she's had to shed friendships with peers who were either sources of anxiety or could not bring themselves to understand Kotmel's condition. But the friendships that survived are stronger than they were before, Kotmel said. Moreover, with the skills she gained at ASPIRE she feels psychologically robust. She has taken up painting again, a creative outlet she abandoned during her years of obsessing about grades and college admissions.

"I'm no longer afraid of setbacks and feel comfortable in my own skin. I'm open about my illness, and I've made some changes, but I own it, it's a part of who I am and it won't stop me from living a good life. The ASPIRE program helped me because I started asking bigger, more important questions about what life is about," she said.

For Nelson, as soon as she and Kotmel became comfortable discussing mental health, an interesting phenomenon began to occur.

"So many parents have come out of the woodwork asking me where they can find help for their son or daughter," Nelson said. "People were breaking their silence as soon as they knew someone that has gone through it themselves."

Efforts to combat stigmas

ASPIRE, AACI and La Selva are all conducting outreach and debriefing programs at Palo Alto Unified School District (PAUSD) high schools.

"We are working with PAUSD to create new programs that train parents and teachers to look out for signs and symptoms," AACI's Leung said. "We've been very active in collaborating with the schools. Parents and children have a lot of resources around, and we're hoping they can utilize these resources and know that there is support out there."

Fitzgerald applauded the district for taking decisive steps toward providing more resources for youth as well as for the parents who have been proactive enough to seek consultation at ASPIRE, though he wishes more parents would come in.

"Palo Alto is doing more than a lot of places to provide resources to young people, and we're seeing a lot of kids overcome their conditions and leading healthier, more fulfilled lives. We want kids to know they can make it, but that it requires support and help. Reaching out for help is an act of courage, not weakness," he said.

In addition to the ASPIRE program, the HEARD Alliance — which is a group consisting of organizational leaders including Fitzgerald from El Camino Hospital as well as leaders from Stanford Hospital, PAMF, Sutter-Mills Hospital, local schools and others — is working collaboratively to address concerns about adolescent treatment in the region. The group has created a website with resources for families and others to access: heardalliance.org.

For Millsap, he hopes that the spate of tragedies will spur people to face and overcome their prejudices against mental illnesses. La Selva is offering without fee a family support group for those with family members struggling with a mental illness. It meets the first and third Wednesday of each month at the California Avenue campus.

"We've seen discussions of the stigmatization of physical ailments like AIDS and breast cancer enter the mainstream and be overcome, and we in the mental health field feel like it's our time now. The tragic irony is that we are only now starting to see some positive movement after it's been too late for some of our kids," Millsap said.

After Thomas left Stanford he was finally diagnosed with clinical depression and prescribed Prozac, which Thomas said has substantially improved his quality of life.

"Getting diagnosed was actually a relief. It showed me that my thoughts about the world, my devaluing of my own life, is not really true. I have a disease that is shifting my perception of the world. The world doesn't suck; it's that I have a sickness that makes me think that way," he said. "I actually felt empowered. The most important thing a depressed person can do is to remind themselves that they have this sickness called depression and that it can be combated. It is not you; it is something inside of you. I'm now fully functional and I feel in control."

Dolph enrolled at La Selva and worked with DiTiberio. She said she initially felt ashamed.

"I would tell myself that I have no reason to feel like this. Nothing has happened to me that would lead me to depression. I do not have an abusive relationship or come from a broken home. But after enrolling in therapy, learning about depression and seeing other people there going through the exact same thing I was going through, I felt empowered," she said.

Today, Dolph still visits La Selva and regularly speaks on alumni panels. She's also taken up the arts as an outlet; she is the dance director at the Children's Musical Theater Company, where she teaches dance.

"I think if I were given the chance to talk to someone who is going through depression now and is too ashamed, embarrassed or scared to come out with it, I would tell them that depression is a disease," Dolph said. "You wouldn't be ashamed to go to the doctor for a virus or broken arm or any other ailment, so why be ashamed of getting help for this?"

ABOUT DEPRESSION

What is depression?

Depression is a mental illness. There are a variety of causes for depression. It can be situational: Something has happened in a person's life and he or she is struggling to effectively cope (e.g., the death of a loved one). Depression can also be clinical, meaning there is not an apparent cause to the depressive symptoms. Clinical depression can result from chemical imbalances in the brain. A family history of depression or mental illness can also result in an individual being more susceptible to experiencing depression. Depression is common and treatable.

What are common symptoms?

Some common symptoms include sadness; lack of pleasure in things that previously brought you pleasure; disrupted sleep, eating and concentration; and fatigue. Those around the depressed person may notice him or her acting differently, seeming exhausted often, not being able to perform the usual routine or having to work extremely hard to accomplish things that used to be easy (e.g., working eight hours in a day). You may attempt to "cheer them up" with things that usually bring them pleasure, such as a weekend away, but the loved one is still sad and unchanged by your attempts. An individual may also appear irritable and easily frustrated.

Who suffers from depression?

Anyone and everyone can suffer from depression. Almost everyone has had periods of feeling depressed, or at least exhibited signs of depression. Clinical depression has a strong genetic link, and statistics show people are more likely to exhibit depressive symptoms if someone genetically related has as well. Individuals who have experienced trauma may also be more susceptible to depression, especially if it is or was prolonged trauma.

Source: La Selva

WHERE CAN I SEEK HELP LOCALLY?

(Note: This is not an exhaustive list)

Youth

• ASPIRE, El Camino Hospital, 2500 Grant Road, Mountain View, CA 94040; 650-940-7000

All ages

• La Selva, 206 S. California Ave., Palo Alto, CA 94306; 650-617-1759

• Asian Americans for Community Involvement (AACI), 2400 Moorpark Ave., Suite 300, San Jose, CA 95128 ; 408-975-2730

• Stanford Hospital, Outpatient Psychiatry Clinic, 401 Quarry Road, Stanford, CA 94304; 650-498-9111

The Palo Alto Weekly has created a Storify page to capture the numerous voices, opinions and our news coverage on teen well-being. This page will continue to be updated. To view it, go to Storify.com.