Address mental health and well-being across the life span

Stanford Medicine experts discuss mental health and well-being across the life span

At the outset of COVID-19, the immediate focus was to stop the spread of disease through masking, social distancing and hand washing, while determining who and when to test and treat. Though these actions had a dramatic immediate impact, they didn’t address the long-term effects of behaviors and the COVID-19 environment on mental health and well-being.

At Stanford Children’s Health, researchers and physicians are uncovering how social determinants of health, including those shaped by the current pandemic, impact health years and decades in the future. These experts include Mary Leonard, MD, MSCE, professor and chair of the Department of Pediatrics and physician-in-chief at Lucile Packard Children’s Hospital Stanford; Lisa Chamberlain, MD, MPH, professor of pediatrics; and Ryan Padrez, MD, clinical assistant professor of pediatrics. “The greatest threat of the pandemic on children is not related to getting sick,” says Leonard, whose multidisciplinary research program has focused on the impact of chronic diseases on bone metabolism and nutrition across the life span. “The biggest threat from the pandemic to children is that they’re not in school, which often provides kids the meals and nutrition they need. So much of what happens early in the life course has lifelong implications.”

The impact of COVID-19 also could create a surge of other health issues, including those related to mental health. The National Institute of Mental Health estimates that only half of Americans with mental illness receive treatment. According to Stanford Medicine researchers, the pandemic amplifies the causes of mental illness and challenges with access. Two leading the way to address challenges that have long existed as well as those created by COVID-19 are Ruth O’Hara, PhD, senior associate dean of research and professor of psychiatry and behavioral sciences specializing in late-life disorders, and Victor Carrion, MD, professor of child and adolescent psychiatry and director of the Early Life Stress and Resilience Program.

Below, Chamberlain, Padrez, O’Hara and Carrion discuss Stanford Medicine’s approach to mental health and well-being in the COVID-19 era in greater detail.

Stanford Medicine’s considerations of mental health and well-being across the life span began well before the pandemic. Why has Stanford prioritized this, and what challenges exist?

Chamberlain: Pediatricians know that the well-being of children depends a great deal on the mental health and well-being of their parents. In 2017, Stanford pediatricians noticed significantly elevated stress levels in our local community. The largely immigrant community we serve was living with new levels of fear, and the children were not immune. We saw new complaints of headaches and stomach aches, sleeping disturbances, and challenging behaviors become increasingly common. These physical signs are often clues of mental health needs, such as anxiety or depression, being unaddressed.

Padrez: Unfortunately, a significant challenge in California is inadequate access to mental health services for families covered by MediCal or who are uninsured. Therefore, Stanford Children’s Health pediatricians partnered with an organization that seeks to expand access to mental health services by training primary care providers to be frontline mental health providers. The training, which begins with an intensive three-day weekend and extends over six months, empowers providers to diagnose and treat the most common mental health disorders: anxiety, depression and complex ADHD.

Beginning May 2019, 35 providers from Stanford and several other local clinics underwent this training, notably increasing mental health serving capacity for Spanish-speaking, low-income children and adolescents on the mid-peninsula. We are fortunate to have this infrastructure well in place now that the stress of COVID has arrived. With limited mental health services available during school closures, it has become even more critical that frontline primary care providers have the skills to diagnose and support mental health needs.

Carrion: Even before COVID-19, mental health was a serious issue in this country for people of all ages — though these issues have become only more acute since the start of the pandemic. In 2018, we had 48,000 Americans commit suicide. We also had 3 million adolescents in the United States experience a major depressive episode. Yet, about half to two-thirds of kids who need mental health services do not get them. The Bay Area isn’t insulated from these national trends. Because of this, Stanford Medicine has embedded itself in the surrounding communities. We are present in community agencies around the Bay Area, and our work even extends to our southern border, where we increase capacity for the workforce engaging with migrant families.

O’Hara: For decades, researchers and clinicians at Stanford have made substantial investments in understanding the trajectory of health and disease in older adults. Millions of adults in the United States experience psychiatric symptoms. At Stanford, we have outstanding clinicians and researchers in the Department of Psychiatry and Behavioral Sciences who lead the nation in some of the most innovative approaches to understanding and treating mental health disorders. Researchers at Stanford were among the first to reveal that early life adversity places an individual at significant risk for developing mental health disorders that do not emerge until later in life, underscoring that we have an opportunity early in the life span to place individuals on a better mental health life course. 

How has the pandemic shaped Stanford Medicine’s response to mental health and well-being?

Carrion: As COVID-19 forced people to shelter in place, we needed to provide innovative solutions to continue care. We responded by transitioning 70% to 90% of our clinical practice to remote care. Some services, such as child and adolescent psychiatry, are actually delivering care at higher rates than before COVID — an illustration of the increased need resulting from the now chronic stressor. Patients and families have responded positively to this transition as it is more convenient, which results in fewer cancellations. As chronicity ensues, however, we are needing to tailor interventions for those who require further assessment, such as youth exposed to interpersonal trauma, and the parallel need to maintain a confidential environment that at times can be challenging in Zoom meetings.

As COVID-19 forced people to shelter in place, we needed to provide innovative solutions to continue care

Our department also worked on providing psychological first aid and skills for psychological recovery to our first responders. This was such an effective intervention, we are now in the process of training behavioral health groups across the state on how to deliver this intervention to those they serve.

O’Hara: Over 15% of older adults suffer from a mental health disorder. The development of reliable and effective tools for delivering tele-mental health care and assessment has long been a priority in the field of psychiatry and here at Stanford. This is driven by the large number of older adults who lack sufficient access to mental health care providers. The pandemic has unquestionably accelerated the development of these tools, and our goal should be to pursue a long-term continuation of a remote and digital health model for the elderly who cannot easily access mental health care in their local environment. Experts here at Stanford have expanded the deployment of tools for remote mental health care delivery, including smartphone app-based therapy for depression and anxiety. Efforts to monitor and assess risk for mental health symptoms also extend beyond behavioral measures. For example, Stanford researchers are also actively developing methods to remotely assess sleep in both children and older adults, as it is an important indicator of cognitive, mental and physical health across the life span.

How is Stanford Medicine advancing mental health care?

Carrion: Through state-of-the-science research, broad education and innovative clinical practice, Stanford has recognized the need to not only address our current mental health crisis, but also to be in the forefront of what we may see after the current period. We are on alert for a mental health surge, and we are addressing this by increasing our workforce through technological and educational tools and translating our discoveries and practices into policies. Policy-building partnerships with neighboring counties and with the states’ Mental Health Oversight and Accountability Commission are key to our translational goals. 

O’Hara: Our Stanford National Institute on Aging and state-funded Alzheimer Centers are part of national and statewide initiatives to provide cognitive assessments, diagnoses and connection to treatment for older adults with cognitive and affective disorders. This has never been more important than during the COVID-19 pandemic. Older adults are at the highest risk of complications and death from COVID-19. However, by limiting their exposure to the virus, we also put them at tremendous risk for social isolation, which in turn increases their risk for poorer physical and mental health. Researchers at Stanford have reacted quickly to develop and disseminate remote and digital platforms to support the delivery of assessments and interventions for the mental health and well-being of millions of older adults afflicted nationwide.

As we look to the next several months, are there specific research areas that should be a focus as we continue to develop and inform new protocols during COVID-19 and beyond?

Carrion: We are getting prepared to enhance our efforts in epigenetics. The understanding of how environmental stress influences our genetic makeup and how these interactions lead to disease or resilience is pivotal in mental health. We also need a better grasp on how mental health conditions do not express themselves in a vacuum, but have their own developmental trajectory that may or may not be dependent on the individual’s developmental age.

We will understand better the overlap between conditions, anxiety and depression, for example, as we continue to enhance our understanding of brain function and behavior. Our cellular and multimethod approaches applying the principles of precision medicine to psychiatry are helping us understand how conditions may manifest differently in different individuals. Biopsychosocial methods that investigate the roots of distress in individuals of all ages will shed light into the root causes of alarming rates of depression, anxiety and suicide. For example, so many children are unhappy while trying to fulfill others’ expectations. Educational and health policies need to highlight the importance of discovering and expressing one’s strengths and identity.

O’Hara: I believe it will be very important to continue to develop our clinical and research efforts to assess and monitor risk for mental health symptoms using remote and digital approaches, at all stages of the life span. Before COVID-19, investigators at Stanford were already working to put in place hybrid, digital and virtual approaches to providing interventions for mental health disorders remotely. So many individuals with mental health symptoms are not able to obtain access to appropriate mental health care. By implementing these virtual approaches, we can go a long way toward providing the necessary interventions in real time to alleviate so much of the disability and struggle that accompanies mental health disorders.

On the biological front, the challenge of COVID-19 led to the implementation of more than 150 studies in the initial months targeted at understanding the devastating impact of this virus. I hope we can learn from this rapid deployment how to similarly advance more rapidly our understanding of the etiology of psychiatric illnesses, which have remained far too elusive.

How do you think stakeholders, either at Stanford or outside of Stanford, can get involved in improving mental health and well-being throughout the life span?

Chamberlain: Through innovation in the early childhood space, Stanford’s stakeholders have begun reimagining new systems that would support improved well-being for our youngest children and would ripple across the life span. The pandemic has revealed the enormous fragility and inequity in our early childhood system, a system that works only for high-income families. As any parent knows, the ages from 0 to 5 are critical: Neurodevelopmentally, it is an extraordinary time of rapid growth. The disruption of the early childhood sector by the pandemic, while incredibly concerning, may also lead to many advances in the way we can better support young children and their families.

Padrez: Stakeholders from Stanford — including faculty from the School of Medicine in pediatrics, the School of Education and the School of Business — are active in discussing new models to reach children who previously have fallen through the cracks of a fragmented system. It is in this collision of fields that new sparks of innovation can emerge, and it has taken the pandemic for us to confront that significant changes are needed. Perhaps the COVID pandemic has created the moment to overcome the silo that has often separated health and education policy for early childhood, and instead can lead us to an integrated approach.

O’Hara: We have seen many stakeholders extremely invested in mental health in the era of COVID-19 and who see a collaboration with Stanford Medicine as an avenue for making change. These include external stakeholders at the federal and state levels that have reached out to partner with us. 

For example, we have had discussions with the NIH about a statewide initiative with several governmental, academic and advocacy groups focused on improving dissemination of information related to the many health effects of COVID-19. The Stanford site is helping to lead the charge on mental health in the era of COVID-19. This idea of improving dissemination is a central issue for mental health and well-being. We have also had talks with non-governmental organizations about promoting access to mental health information. This includes discussions with the Kennedy-Satcher Center for Mental Health Equity about hosting a symposium, enabling us to tap into each other’s expertise and have greater reach across the country.