Universal Depression Screening in Schools—Promises and Challenges in Addressing Adolescent Mental Health Need

The incidence of youth aged 12 to 17 years reporting a major depressive episode in the last year increased from 8.3% in 2011 to 13% in 2016. Despite the steady rise in need, treatment for depression remains woefully low, with only one-third of adolescents receiving the care they need.¹ A major barrier to treatment occurs at the stage of problem identification. As an internalizing disorder, depression is far less likely to be detected by adult gatekeepers compared with externalizing problems, such as substance use and conduct behaviors.² To improve the detection of youth depression, the US Preventive Services Task Force recommended screening for all adolescents aged 12 to 18 years in primary care settings with adequate support for diagnosis and treatment. However, there is growing evidence that depression screening has limitations when it is only delivered in clinical settings. Notable barriers to universal screening in primary care settings include inconsistent screening and follow-up procedures as a result of time constraint, lack of available mental health resources, limited clinician education and training, and difficulty integrating screening into existing clinical workflows. This situation is concerning because a failure to consistently apply universal screening across all patient groups in primary care with adequate follow-up care may further exacerbate existing disparities in the identification and treatment of depression.^3,4

In JAMA Network Open, the study by Sekhar and colleagues⁵ moves depression screening beyond the clinic walls; the Patient Health Questionnaire-9 (PHQ-9) was administered as a universal intervention in high schools to improve depression identification and treatment initiation. Between 2018 and 2020, 12 909 adolescents in 9th through 12th grades in 14 Pennsylvania schools were randomized to receive the intervention of universal screening with the PHQ-9 or the usual school practice of targeted screening, whereby adolescents who exhibit behaviors suggestive of depression are referred to professionally trained staff for review. Compared with the control condition of targeted screening, youth in the universal depression screening condition had 5.9 times higher odds of being identified with depression symptoms, 3.3 times higher odds of being confirmed to warrant treatment, and 2.1 times higher odds of starting depression treatment. Subgroup analysis showed that adolescents who are female, attended rural schools, and identified as other race or Hispanic ethnicity were more likely to be detected by universal screening than usual school practice, although there were no sex or racial and ethnic differences in treatment initiation between the 2 conditions.

Schools have long been lauded as the de facto provider of mental health services for youth by reducing barriers commonly seen in specialty settings.⁶ This is, to our knowledge, the first large-scale randomized clinical trial to examine depression screening as a universal intervention in schools. With an active comparison group, the study demonstrated that universal screening has added benefits over existing school practice for identifying and connecting adolescents to needed mental health services. Universal screening was particularly effective at detecting depression in adolescents who are traditionally underdiagnosed, such as those in racial or ethnic minority groups and those living in a rural setting, although these differences disappeared at the stage of treatment. These results complement the findings from smaller previous trials, bolstering the utility of depression screening in schools. Unlike previous trials that focused on problem identification, Sekhar and colleagues⁵ followed adolescents from screening to treatment initiation. The comprehensive follow-up is consistent with the US Preventive Services Task Force’s recommendation that diagnosis and treatment options be available after screening. The academic-school partnership at the heart of this study is also noteworthy. Using a participatory action approach, Sekhar and colleagues⁵ collaborated with their school partners to adapt existing school resources to deliver the interventions. Studies have shown that when researchers incorporate local knowledge and resources, new interventions are more likely to be adopted and sustained over time.⁷ Similarly, the choice of a freely available and portable screening instrument is critical to future replications and extensions of this study. Finally, the study sampled a diverse adolescent population that enabled more in-depth assessment of how screening affected youth from different sex, racial and ethnic, and geographic backgrounds.

Although universal screening improved the detection of adolescent depression, several important questions remain. First, how does depression screening influence the service use of adolescents who report subclinical symptoms? The current study defined positive cases as youth whose PHQ-9 scores were above the clinical cutoff and whose symptoms were verified by trained staff. This selection prioritized those most in need of services but left out youth who may be symptomatic and benefit from early intervention. Second, the primary outcome of this study was treatment initiation, defined as receipt of at least 1 recommended treatment. How does depression screening affect engagement beyond the first session? Future studies should consider factors such as attendance, participation, and completion of recommended treatment when assessing the downstream effects of depression screening. Lastly, more research is needed to determine the feasibility of such large-scale universal screening beyond the controlled settings of the current study. The schools that elected to participate in this study were well equipped with the resources to administer the screening to all eligible students, to follow up with positive cases to confirm symptoms, and finally to link them to appropriate services. Not all schools have the financial, human, and infrastructural capital to adequately support routine mental health screenings. In the age of COVID-19, schools may be extraordinarily taxed, and existing disparities may widen for schools with the fewest resources and most vulnerable student populations. To overcome these barriers, both longstanding and newfound, more equitable funding and policies are necessary to ensure that staff are adequately trained and schools remain accessible to all youth.

Although the study by Sekhar and colleagues⁵ proved schools to be an important bridge in connecting adolescents with available treatment, we should not abandon the original clinical setting that the US Preventive Services Task Force first recommended for depression screening. Primary care remains an important access point for youth mental health services. With the expansion of the Patient Protection and Affordable Care Act, there are numerous models emerging to demonstrate the benefit of integrating behavioral and medical services in a single setting. Behavioral health integration within the patient-centered medical home model is a promising strategy to reduce barriers and increase access to mental health care among pediatric populations.³ The patient-centered medical home is a well-recognized approach to primary care that aims to provide patient-centered, comprehensive, and coordinated care involving a diverse team of health care professionals; emphasize the need for greater access to care; and promote effective practice of population health management. With integrated behavioral health, primary care can be viewed as the medical home for both physical and behavioral health care. This model allows for a collaborative relationship between mental health care professionals and primary care clinicians and addresses barriers to screening and follow-up care to individuals presenting with depression.

Schools and primary care systems are 2 potentially complementary points of entry to mental health services. Both medical and school professionals have the ability to establish trusting long-term relationships with young people through routine contacts in classrooms and primary care clinics. As experts in child development and learning, medical and school professionals also have the unique ability to identify mental health problems early and place them in meaningful contexts for youth and caregivers. With appropriate training and support, schools and primary care systems are well positioned to help adolescents, particularly those from underserved communities, access mental health services.

Published: November 5, 2021. doi:10.1001/jamanetworkopen.2021.32858

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Guo S et al. JAMA Network Open.

Corresponding Author: Sisi Guo, PhD, University of California at Los Angeles, Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, Los Angeles, CA 90095 (sisiguo@medent.ucla.edu).

Conflict of Interest Disclosures: None reported.