Sarah Gentile was shocked to find, in the midst of a crisis with her teenage son, that there are no hospital beds available in Santa Clara County for adolescents who need inpatient psychiatric care.

They were in the emergency room at El Camino Hospital in Mountain View just before the start of the school year. Earlier, her son's psychiatrist had called to tell her that her son, who has lived with depression since he was 8 years old, had a suicide plan and needed to be hospitalized for a medication change. He was placed under what is referred to as a "5150," a 72-hour involuntary psychiatric hold for individuals believed to be a danger either to themselves or to others.

At the ER, a psychiatrist told Gentile that they needed to start the hours-long process of transferring her son to an available inpatient bed at another hospital.

"I said, 'What do you mean? He can't stay here?'" Gentile recalled. "They said, 'No, we don't have an adolescent facility here.'"

Her next, immediate thought: Let's take him to Stanford Hospital. But the Stanford School of Medicine's Department of Psychiatry and Behavioral Sciences, which boasts comprehensive outpatient psychiatric clinics for patients of all ages, also offers no inpatient care for adolescents.

Other patients and families who live in Palo Alto or surrounding cities have reported being similarly surprised to learn that a teenager in psychiatric crisis who is taken to a local emergency room will be transported away from renowned medical centers like Stanford or El Camino for hospitalization.

The closest hospital with adolescent inpatient beds is Mills-Peninsula Health Services in San Mateo, where Gentile's son stayed for 10 days. Beyond that, in the Bay Area, there is St. Mary's Medical Center in San Francisco, Fremont Hospital in Fremont and Alta Bates Medical Center in Berkeley. There are 648 total beds in California available for child and adolescent inpatient psychiatric care, compared to 5,522 for adults. (Click here to see a map of beds available in the Bay Area.)

The lack of inpatient adolescent psychiatric services is likely shocking to a community like Palo Alto that is not only reeling from several teen deaths by suicide this year but is also home to acclaimed medical facilities like Stanford Hospital and Lucile Packard Children's Hospital Stanford. (Read: Why so few hospital beds for teens?)

As of last week, 19 students at Paly and 31 at Gunn had been hospitalized for psychiatric episodes this school year, with more students on both schools' at-risk "watch lists," according to the schools' principals. Inpatient psychiatric services for adolescents, a sub-section of the medical system that has been shaped by typically low demand compared to other populations, is suddenly at odds with these numbers in Palo Alto.

Teenagers who are sent away from Palo Alto for more serious inpatient treatment are impacted not only during their hospitalization but also in the most critical time afterward. Some mental health professionals say the physical distance creates a disjointed system of care that can put the onus for follow-up support on families, schools or community-based organizations that may not be prepared or equipped to treat the youth.

The 5150

When individuals are placed under a 5150 hold — which can only be done by police officers, designated professionals who provide psychiatric crisis-intervention services or other mental health workers authorized by their county — they are taken to the closest emergency room.

For Palo Alto teenagers, that is typically the Stanford Health Care Emergency Department, where they are evaluated by an emergency medical team and then by the child and adolescent psychiatry team when a consultation is requested. The attending physician and fellow, both specialists in emergency medicine, collaborate with psychiatry staff to determine whether hospitalization is required for that patient, explained Samantha Dorman, media relations manager for Stanford Children's Health and Lucile Packard.

If hospitalization isn't necessary, the team creates discharge and follow-up plans. If hospitalization is needed, a transfer team locates the nearest available bed in a psychiatric unit in the Bay Area. This often takes several hours; Sarah Gentile's son waited for six hours before his transfer and Manon Piernot, a current Gunn High School junior who was hospitalized twice this year after seeking emergency psychiatric care at Stanford, five hours.

Both Manon and Gentile's son were transferred to Mills-Peninsula in San Mateo, which has 17 beds available for adolescent psychiatric patients.

Gentile said she was not allowed to drive her son to San Mateo while he was under the 5150 hold — this is a typical policy to protect both the patient's safety and the hospital's liability — so her family footed the $3,000 ambulance bill.

Another current Palo Alto student who wishes to remain anonymous described her transfer from Stanford to St. Mary's in San Francisco as traumatic — "an experience that harmed more than it helped me."

"I have never experienced anything more dehumanizing than being strapped onto a stretcher and driven for 45 minutes in an ambulance up to the city, surrounded by two bored EMTs who obviously thought there were much better things to be doing with their time," the student said. "I didn't blame them. I felt terribly guilty taking up room in the hospital I was originally put in in Palo Alto, and the feeling only worsened when it became apparent that finding room for 'another 5150' made me into more of an annoyance to the medical community than anything else."

Gentile said she felt a similar stigma attached to the process.

"You feel like you're being sent away, and your child is being sent away," she said. "If you really want to reduce the stigma (around mental health), you need to have the county you're living in at least support that level of service."

Getting to San Mateo for twice-daily required visits was also stressful and time consuming for her family, Gentile said. Inpatient units typically offer limited windows of time for visiting. Mills' visiting hours are noon to 1 p.m. and 7 to 8 p.m. on weekdays and noon to 2 p.m. and 6:30 to 8 p.m. on weekends.

Like Gentile, Manon and her parents were surprised to find out she could not access inpatient services at Stanford when she first went to the emergency department in December. But she has a different take on the transfer: She actually found the distance from her familiar, stressful world in Palo Alto incredibly helpful.

"I just wanted to go somewhere that wasn't Gunn," she said.

She also developed close friendships with other teens who were at Mills during her second hospital stay; they're still in touch.

For Manon, hospitalization — anywhere — made a life-saving difference.

"If I hadn't gone to the hospital I don't think I'd be here today," Manon said.

Roni Gillenson, program director for the nonprofit Adolescent Counseling Services (ACS), which has counselors at Palo Alto schools, said it does make a difference where a teen is hospitalized, as the hospital is responsible for connecting a patient with resources and follow-up support in the local community.

Gillenson offered the example of a former Gunn student about whom counselors were concerned but who was reluctant to seek care. When the student finally went in to talk to ACS — "clearly in need of a 5150" hold, Gillenson said — it was just one week after she had turned 18. As a legal adult, she was hospitalized at Stanford.

"If it was a week earlier, it wouldn't have been that smooth," Gillenson said. "(It made) a huge difference because all the resources are here. The community is here. It's not like they had to have her wait and find a bed and ship her off somewhere.

"That's where it gets really disjointed because after they're in the hospital, ideally, what the hospital is supposed to do is connect them with local resources. Well, if they're in Fremont or in San Francisco, even in San Mateo, it makes it a little more difficult to make sure that that continuity of care gets done."

Maria Daehler, a child and adolescent psychiatrist with a private practice in Palo Alto, said far-away hospitalization is also challenging when medical treatments for mental illness take weeks to have an impact.

"We don't have immediate treatment that works within a day or two in order to stabilize these kids," she said.

Facilities don't always provide the length of stay that a patient needs, Daehler said, and the distance can make it harder for families to be as involved in their son's or daughter's treatment. A page in Mills' "Adolescent Inpatient Program Orientation Handbook" stresses that parental participation in "therapeutic structured visits, family meetings, and psycho-education" is critical.

Gillenson said there is often inconsistent communication between Palo Alto schools and the hospitals, and students can receive insufficient discharge plans. If a teen mentions that school offers mental health services on campus, the hospital staff might write that into the follow-up plan without talking to someone at the school to make sure that's the best route, Gillenson said.

"What ends up happening is because there isn't that transition program that the kids automatically then get filtered into, oftentimes the kids come back to school because the hospital knows that there is some sort of mental health counseling on campus," Gillenson said. "We're there from 8 (a.m.) to 3:30 (p.m). We're not there on weekends. It's not an ideal referral."

Daniel Becker, longtime director of adolescent mental health at Mills-Peninsula Health Services, said his hospital does connect with patients' schools when they and their parents agree to it but that there is a need to develop a better system for the two bodies to communicate. He also noted that with the long waiting lists to get in to see mental health providers in the community, school personnel might seem like a more accessible support.

"How do we put together an optimal mental health care system? That's something that's a work in progress," he said.

Gentile said a behavioral therapist from her son's high school was in contact with Mills and even talked with her son on the phone while he was in the hospital. Manon said Gunn staff members were aware of her hospitalization. Her psychiatrist had contacted the school beforehand and her father spoke with Gunn administrators while she was there, who informed her teachers. Manon said the communication helped.

However, schools can be in the dark about a student's hospitalization if the parents opt not to tell the school. Gillenson said there is still a significant stigma attached to mental illness, which means parents might treat their children's return to school differently than following other illnesses.

"We argue, as mental health professionals — if your child had pneumonia or a broken wrist, there would be a doctor's note ... and when they come back from a psychiatric hospitalization it's just not treated the same way."

If the school is aware of a student's hospitalization, a "re-entry" meeting is set up upon his or her return with the parents, the school psychologist, Adolescent Counseling Services, a guidance counselor, administrators and a school nurse. They help the student decide what to tell peers and teachers about where they've been, work with teachers on which assignments can be excused to avoid added stress, talk about positive coping skills and identify people on campus to whom the student can reach out. Someone on the team also checks in daily with the student and makes sure he or she is connected with an outside mental health provider to continue care.

Manon said her transition back to Gunn was smooth. Her teachers were extremely supportive and understanding when she returned to school, though she had to complete a significant amount of makeup work. (After her first hospitalization, she came back during finals week.) What was more challenging, she said, was figuring out what to tell some of her classmates about her absence. She said she told most of her close friends, but it was difficult when it came to others with whom she isn't as close.

Intensive programs aid recovery

What does seem to be working within the local system is what comes after hospitalization: intensive outpatient programs that allow teens to return to school and their lives while still receiving significant and frequent psychiatric support services.

Following her second two-week hospitalization at Mills in late January, Manon entered the hospital's intensive outpatient program. For three to four hours after school every day, she participated in individual, group and family therapy and stress-management education. She said she actually was hospitalized this second time with the express purpose of getting into the outpatient program, which she hadn't been told about during her first hospitalization and which gives priority to patients coming straight from the hospital.

Manon stayed in the outpatient program for eight weeks, with the number of treatment days per week gradually tapering off. She called the program "amazing" and credited it with helping her to lessen the stress-inducing value she had placed on things like grades and college admissions.

"Going there and seeing people that were feeling the same thing that I was — that was extremely helpful," she said. "For once I wasn't talking to my friends about grades at school or their stress or my stress about school. We were actually talking about things that mattered, like our lives."

The value of — and demand for — intensive outpatient programs is high in the Palo Alto area. St. Mary's in San Francisco runs an outpatient educational and therapeutic program but only for students from the San Francisco Unified School District. The primary local option is El Camino's After School Program Interventions and Resiliency Education (ASPIRE) program, which keeps its cohorts small at eight to 10 teens and has a long wait list.

ASPIRE was created in the wake of the suicide cluster in Palo Alto in 2009 and 2010, after a community task force was convened to analyze the issue. Michael Fitzgerald, director of behavioral health services at El Camino, told the Mountain View Voice newspaper in 2013 that the group didn't simply want to hospitalize suicidal teens for a few days and then release them. The task force came to the conclusion that they would have to address the root of the problem.

"It's based around the concept of kids developing skills to manage their symptoms of anxiety and depression and stress that enters their life," Fitzgerald said in an interview with the Weekly.

ASPIRE requires a time commitment of at least four afternoons per week for eight weeks, with individual counseling, dialectal behavior therapy (a specific type of cognitive-behavioral psychotherapy used to treat mental health disorders), "expressive arts" and lessons on mindfulness and stress-management. Parents are also required to come in regularly for therapy and attend a group that teaches how best to support their children.

The program is more educational than, for example, the Mills' outpatient program, and El Camino staff takes pride in that. The hospital even offers academic credit to ASPIRE participants from the Mountain View Los Altos and Fremont Union high school districts. (El Camino this week received accreditation from the Western Association of Schools and Colleges, or WASC, which will allow the hospital to also offer credit to Palo Alto students.)

"Our belief is that this is a really good way to tear down stigma," Fitzgerald said of providing academic credit for the program. "It's still a validation of the work that they do and a different way of framing mental health treatment in terms of just, actually, it's an educational process."

But only small numbers of teens in crisis benefit from this popular program. Gentile tried to get her son into ASPIRE but was told it was full with a wait of several months. The family ended up piecing together their own version of an outpatient program: therapy with both a psychiatrist and a psychologist, weekly meetings with a depression/bipolar young adult support group in San Francisco (the closest one for teens they could find), in-home therapy for sensory issues and participation in the therapeutic services offered by his school.

"My son needed support services immediately after leaving the hospital in order to continue recovering," she said. "Fortunately, we were able to find, put together and afford the combination of private services."

El Camino is well-aware of the demand in the community. The hospital is in the process of doubling the size of ASPIRE as well as planning a middle school version and a similar program for young adults (ages 18 to 25) coming out of state custody or foster care, Fitzgerald said. Two Los Altos couples also donated $1 million each this year to El Camino, one to support ASPIRE and the other the hospital's behavioral-health services program, including a new $52 million behavioral health facility set to open in 2018.

Avoiding hospitalization through intervention, prevention

Lacking integrated, intensive outpatient programs like Mills' hospital-based program or El Camino Hospital's ASPIRE, other health care providers are taking different approaches.

In September, EMQ Families First, a statewide nonprofit that serves children and families, opened a small, short-term crisis stabilization unit in Campbell for children and adolescents who are at risk of suicide with the goal of preventing unnecessary hospitalizations. After a patient arrives, a team of nurses, psychiatrists and family specialists work with a timeline of 23 hours and 59 minutes to evaluate and release the patient with a plan for further care.

"At the end of that 23 hours, we have to make some decisions," EMQ Chief Clinical Officer Craig Wolfe said. "In most cases, the decision is the kid can go home with some family support or with our crisis transition team. In the majority of situations, we're able to avoid hospitalization."

The crisis stabilization unit — which only has seven beds — has served more than 700 youth since opening eight months ago, Wolfe said.

EMQ also operates a 24-7 mobile crisis unit in Santa Clara County for children and adolescents experiencing an acute psychological crisis. They perform 5150 assessments, take patients to emergency rooms and link families to agencies that offer longer-term mental health services in the community. The bulk of mobile crisis referrals come directly from schools' staff (who can't place students under the 5150 hold) and police officers, though individuals can also use the service, Wolfe said.

Stanford offers outpatient evaluation and treatment but no intensive after-school programs for teenagers like at El Camino or Mills. They have instead focused on "meeting kids where they are," with, for example, Stanford child and adolescent psychiatrist Shashank Joshi serving as the Palo Alto school district's mental health consultant, visiting campuses following a suicide and speaking at parent education nights and community panels. Through a partnership with the Tipping Point Community, a San Francisco nonprofit that fights poverty in the Bay Area, Stanford embedded a mental health clinician or "wellness educator" at East Palo Alto Charter School and JobTrain in Menlo Park to serve both students and parents.

Stanford mental health providers are also eying the continuum of care, hoping that better and more innovative prevention, education and outpatient services would decrease the need for emergency psychiatric care.

"The whole model of children coming to clinics is something that may even need to be revisited," Stanford child and adolescent psychiatrist Victor Carrion said.

This year, Carrion spearheaded the launch of a mindfulness curriculum for all 3,400 students in the Ravenswood City School District through a partnership with a southern California-based nonprofit that brings health and wellness education to K-12 schools throughout the country. Palo Alto Medical Foundation also started offering this year a free drop-in yoga class for teens on Tuesday afternoons.

"We have to come up with more things like that," Carrion said.

Carrion currently serves as chair of the state's Mental Health Services Oversight & Accountability Commission's evaluation committee, which is in the midst of collecting and analyzing data about outpatient programs throughout the state, he said.

"This is the type of data that we actually need as we ... concentrate on how can we work on the whole continuum of care rather than just the last point when someone needs to be hospitalized," Carrion said.

In the meantime, families are left to struggle with the emergency and support system. Just as Gentile was shocked to find out that there were no adolescent inpatient psychiatric services available in Santa Clara County, she was surprised at how hard it was to find a local, ongoing teen depression support group that was appropriate for her son. The Palo Alto chapter of the Depression and Bipolar Support Alliance offers a regular drop-in, peer-led support group at the Palo Alto VA Hospital, but Gentile said mostly adults attend.

Palo Alto Medical Foundation has since 1999 run a co-ed teen therapy group, which is now on Thursday afternoons and requires a minimum eight-week commitment and costs $59 per meeting. (Though Gentile's son's pediatrician is at PAMF, Gentile was unaware this group existed.) Palo Alto Therapy, a private therapy center in downtown Palo Alto, offers an eight-session "Stress to Wellness" support group for teens who are experiencing anxiety, depression or other mental health issues but have already been exposed to some cognitive behavioral therapy, as well as an eight-week "Tackling Anxiety" therapy class for both teens and adults. Both cost more than $500 and are capped at seven people.

So Gentile, a member of a special education community advisory committee that serves the Mountain View Los Altos High, Mountain View Whisman, Los Altos and Palo Alto Unified school districts, helped spark the development of a new adolescent support group that will launch at the Community Health Awareness Council (CHAC) in Mountain View this fall. The group will likely meet on a daily basis year-round (compared to other local programs where support groups only last for several weeks), with teens coming in on their own for support and their parents also meeting with CHAC staff at the same time, said Executive Director Monique Kane. The students and parents will also sometimes meet together, Kane said. The group will be free for any teens in the area.

CHAC also recently started a quarterly speaker series in which local teenagers talk to adults in the community about topics like anxiety, depression and academic stress.

Reflecting on her family's experience with local care, Gentile compared it to seeking help for her daughter, who suffers from a rare neuromuscular disease.

"It was easier for me to find services for my daughter than it was to find them for my son, and her (illness) is under the extremely rare category," she said. "Depression is common."

---------------

There is help

Any person who is feeling depressed, troubled or suicidal is urged to call 1-800-784-2433 to speak with a crisis counselor. People in Santa Clara County can also call 1-855-278-4204.

Other resources:

(Note: This is not an exhaustive list)

* California Youth Crisis Line: 1-800-843-5200; youthcrisisline.org

* Crisis Text Line (free, 24/7): text "start" to 741-741

* EMQ Families First Services: 877-41-CRISIS (877-412-7474)

* Trevor Project Lifeline, specializing in crisis help for GLBTQ youth: 1-866-488-7386

Local clinics that will triage and/or see individuals:

* Palo Alto Medical Foundation: 408-730-4370 in Palo Alto or 650-696-4666 in San Mateo

* Lucile Packard Children's Hospital Stanford: 650-723-7704 for children and teens

* El Camino Hospital ASPIRE Intensive Outpatient Programs: 650-940-7000 (Mountain View); 408-866-4021 (Los Gatos)

* Mills-Peninsula Intensive Outpatient Programs: 650-696-4666

For more resources, go to Resources: How to help those in crisis

Related content:

• Why so few hospital beds for teens?

• Simitian: Need for inpatient psych beds for teens is 'significant'

• Breaking the silence: How youth, adults overcame cultural stigmas against depression and got help

• Storify: Palo Alto community urges support for teen wellbeing