Annie was stuck. Diagnosed with severe depression in her teens, she experienced days where mental illness slowed and dimmed her inner and outer worlds. “I couldn’t move or talk. The most I could do was twitch my fingers. And everything was like I was full of tar.”

Now 23 years old and taking courses in college, treatment and support to manage her depression have helped to open a path for Annie toward freedom and independence.(1)

Annie’s story may be familiar to many. Recognizing Mental Health Awareness Month, consider these statistics:(2)

• 1 in 6 U.S. youths aged 6-17 experience a mental health disorder each year
• 50% of chronic mental illnesses begin by age 14, and 75% by age 24
• Suicide is the second-leading cause of death among people aged 10-34
• 1 in 100,000 children aged 10 to 14 succumb to suicide each year
• Depression affects 20-25% of Americans aged 18+ each year

As the novel coronavirus pandemic ushers in uncertainty that may evoke anxiety, depression or other mental health concerns for today’s youth, what would a new vision for their mental health look like? Sutter researchers and their collaborators across Sutter’s integrated network may offer a new path forward.

Early Interventions to Support Youth with Mental Illness
“Suicide cuts short the lives of individuals and leaves the survivors struggling with their grief and efforts to understand,” says Kristen Azar, RN, MSN/MPH, a researcher at Sutter’s Center for Health Systems Research (CHSR). “Healthcare providers can play a significant role in preventing suicide through risk screening and supportive follow-up care.”

Azar helps lead a new study at Sutter on depression and suicide risk.(3) She and CHSR colleague Ellis Dillon, Ph.D., are measuring the effects of a suicide screening tool called the Columbia Suicide Severity Rating Scale (C-SSRS) that was implemented in 2019 across Sutter’s hospitals. The screening tool was selected for its potential to enable earlier identification of people at increased risk of suicide, including people with depression.

The new study will determine if standardized use of C-SSRS across Sutter’s hospital emergency departments, inpatient settings and behavioral health acute care facilities can improve early detection of suicide risk in youth and adults, and help guide follow-up care. C-SSRS is the most evidence-based tool of its kind for early detection of depression and suicide risk.

Azar and Dr. Dillon’s project also seeks to measure suicide screening practices across Sutter ambulatory clinics and hospitals, and hopes to advance the efforts of Sutter’s Anna Kiger, DNP, DSc, MBA, RN, NEA-BC, and Ernell de Vera, RN, MBA, who implemented screening utilizing C-SSRS in the inpatient setting.

“Screening all inpatients by C-SSRS will help us detect at-risk patients early, for early and personalized treatment and support. Further, screening by C-SSRS will facilitate easier reporting and analysis of electronic health record (EHR) data on patient outcomes, strengthening our ability to care for patients with severe depression and those at high risk of suicide,” says Dr. Dillon.

Over the next 18 months the research team will examine the impact of screening patients for major depression and suicide risk using C-SSRS.

“Using this screening tool, we can study how different approaches to screening impact the detection, follow-up care and clinical outcomes of individuals with severe depression or who may be at high risk of suicide,” says Tam Nguyen, Ph.D., director of Ambulatory Care, Mental Health Services & Addiction Care at Sutter, and clinical advisor of the suicide risk screening study.

A New Vision for Youth Mental Health
Beyond screening, helping youth like Annie develop resilience to manage their mental health in their everyday lives may also help reduce suicide risk and decrease the incidence of severe depression among Sutter’s patient population.

Dr. Dillon helps lead a strategy to do so: She and CHSR co-director Alice Pressman, Ph.D., MS, partnered with Sutter Mental Health Services and experts in Sutter’s Design & Innovation team to launch and measure the impact of the project, Youth Mental Health Reimagined.

Supported by a $1 million gift from the Bichofberger family and matching funds from a Sutter Match Grant,(4) “the project embodies our collective vision to meet a clear need for at-risk youth and create a new narrative that eliminates stigma. When we eliminate stigma, we break down the barriers between mental and physical health, and start to remove a huge barrier in access to care,” says John Boyd, Sutter CEO, Mental Health Services & Addiction Care. “Mental health is human health, and we owe it to today’s youth to shape care that’s more engaging and connected to the way they live their lives.”

“We launched Youth Mental Health Reimagined as a response to the growing need for easily accessible and more robust, non-clinical mental health support for teenagers and young adults with depression, as well as their caregivers,” says Dr. Pressman.

Youth Mental Health Reimagined supports patients by providing tools and tips (e.g., a mood tracker, mindfulness exercises, as well as tips for better sleep, nutrition and physical activity) and connections with live docents. Collectively, the approach—dubbed “Scout”, and delivered virtually with people-powered support—provides resources to youth with depression who are receiving primary care or who are transitioning out of acute care settings.

The project will be implemented across inpatient and outpatient behavioral health programs at Sutter’s Mills-Peninsula Medical Center (MPMC) and in some primary care settings at Sutter’s Palo Alto Medical Foundation (PAMF).

“We used human-centered design to create ‘Scout’ as a means to help youth build resilience in real-world settings,” says Chris Waugh, Sutter Vice President and Chief Innovation Officer. “We’re thrilled to offer Sutter patients and their caregivers these resources that leverage research, creative and engaging design, and the top-quality care made possible by Sutter’s integrated network. It’s our way to help make mental health care more engaging and patient-focused, and bring support to people in their everyday lives.”

Although some existing youth mental health programs include a behavioral component and technology-based resources, Youth Mental Health Reimagined is one of the first of its kind in the U.S. to include caregivers in a holistic approach to care.

“Family and other caregivers are an essential part of the treatment and recovery process for young people with severe depression or other mental illness. They can help youth develop coping skills and healthy relationships that build resilience, and help keep them safe during periods of crisis. Youth Mental Health Reimagined gives caregivers a new opportunity to support the youth by helping them navigate ‘Scout’-delivered resources,” says Linda Strassia, Manager of Behavioral Health Clinical Services, whose team at MPMC will recruit youth to pilot test Youth Mental Health Reimagined.

Approximately 300 Sutter patients aged 13-26 years with moderate-to-severe depression and related anxiety will be enrolled to the study through December 2020, with additional patients enrolled in 2021. Two caregivers per study participant will also receive guidance on supporting patients.

Participants will be asked to complete periodic surveys to help the study researchers assess the impact of ‘Scout’ resources on patient outcomes (changes in youth quality of life, social support, physical, and mental health) and on caregiver outcomes (changes in knowledge and behaviors towards providing care and support for youth with depression).

Youth like Annie have the opportunity to experience new outcomes made possible by such mental health support. In her words, “at some point, you have to figure out what tools you have for the situation. So that’s the thing. I think it’s really important for people to have that support structure in their everyday life.”

• Find mental health resources at Sutter.
• In a Crisis? Call the Suicide Prevention Lifeline (800) 273-TALK (8255)

How Sutter research translates ideas into solutions for mental wellness:

Beyond the projects described above, health systems researchers at Sutter have led other studies to help address potential gaps in caring for people with mental illnesses.(5,6)

Adolescent behavioral health:
Completed in 2018 and funded entirely by community donors, this five-year project evaluated the PAMF Adolescent Behavioral Health program. The study measured changes in primary care provider attitudes toward adolescent behavioral health, uptake of navigation services for adolescents, and uptake and outcomes of care management provided by a nurse practitioner and a cognitive-based therapy intervention called COPE (Creating Opportunities for Personal Empowerment).

Serious mental illness and emergency department utilization:
Azar recently completed research suggesting that subtypes of severe mental illness may predict patterns of emergency department use. The results of Azar’s research were published last year in Population Health Management.

This study showed that patients diagnosed with serious mental illness seek care at multiple emergency departments within a geographic region (versus any one hospital’s emergency department). These frequent utilizers of the emergency department constitute a small percentage of the population but account for disproportionally high healthcare utilization and costs.

“The findings highlight the importance of cross-institutional collaboration between health systems. This includes approaches to share data and analytics, as well as to deliver care that addresses the needs of patients with serious mental illness who frequently visit the emergency department,” says Azar.

References:

1. Annie’s real name was not used in this story, though her story is real.
2. National Alliance on Mental Illness and National Institute of Mental Health.
3. The research study “Suicidality: Examining screening, detection and follow-up care within a large multispecialty healthcare system” is funded by Janssen.
4. The gift from the Bichofberger family will support the Mental Health Reimagined pilot—Sutter Health’s pioneering system-wide engagement to transform the way people in our communities understand and talk about mental health.
5. Yang, Yan, et al. “Primary care provider utilization and satisfaction with a health system navigation program for adolescents with behavioral health needs.” Translational Behavioral Medicine 9.3 (2019): 549-559.
6. Erlich, Kimberly J., et al. “Outcomes of a brief cognitive skills-based intervention (COPE) for adolescents in the primary care setting.” Journal of Pediatric Health Care 33.4 (2019): 415-424.