Abstract
The prevalence of annual major depressive disorder (MDD) episodes among adolescents in the United States rose from 8.3% in 2008 to 12.8% in 2016. Despite the US Preventive Services Task Force 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, many adolescents are missed, as more than 60% lack annual preventive health visits and MDD screening remains inconsistent. To compare the effectiveness of universal school-based screening for adolescent MDD vs the existing process of targeted screening based on observable behavior. Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 Pennsylvania public high schools among at least 9650 students enrolled in 9th through 12th grade. Students will be randomized by grade to either targeted screening (current process) or universal screening (intervention). Students in the targeted screening arm will complete mandated school health screenings, which do not include an MDD screening. These students will be observed through the academic year for referral to the Student Assistance Program (SAP), required in all Pennsylvania schools. If a student exhibits behavior concerning for MDD raised by any contact (eg, teacher, parent, peer, or self-referral), SAP will triage the student and provide follow-up recommendations. Students in the universal screening arm will complete the validated Patient Health Questionnaire-9 (PHQ-9) from September through December of the academic year. The PHQ-9 includes 9 close-ended questions and is scored from 0 to 27. Students with a positive result (ie, score >10) will proceed to SAP triage. Students in the intervention arm will also be observed for behavior concerning for MDD during the school year, potentially prompting SAP triage referral. The primary outcome will be the proportion of adolescents referred to SAP triage who are recommended for additional MDD-related services and successfully engage with at least 1 SAP recommendation. Observers will not be blinded to patient groups, and an intention-to-treat analysis will be used. The SHIELD trial began with 3 schools during the 2018-2019 academic year. Screening in the intervention arm with the PHQ-9 is currently underway for the remaining schools, with a goal of completion of all PHQ-9 screenings by December 2019. This trial addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated. ClinicalTrials.gov identifier: NCT03716869.
Highlights
Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 public senior high schools in Pennsylvania to evaluate the effectiveness of universal screening for identifying major depressive disorder (MDD) and engaging students with resources
Meaning The SHIELD trial directly addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated
The prevalence of annual major depressive disorder (MDD) episodes among US adolescents rose from 8.3% in 2008 to 12.8% in 2016.1 Approximately 30% of adolescents with MDD report some form of suicidality, with more than 10% making a suicide attempt.[2]
Summary
The prevalence of annual major depressive disorder (MDD) episodes among US adolescents rose from 8.3% in 2008 to 12.8% in 2016.1 Approximately 30% of adolescents with MDD report some form of suicidality, with more than 10% making a suicide attempt.[2]. Significant increases in MDD episodes have been observed for all racial and ethnic groups except non-Hispanic black individuals, who demonstrated a smaller but still increasing trend.[4] The most striking increase in MDD episodes has been for women across all racial and ethnic groups.[1,4]. Data from Healthy People 2020, based on the National Ambulatory Medical Care Survey, found that 2.1% of adolescent primary care office visits included MDD screening from 2005 to 2007.5 a study using National Ambulatory Medical Care Survey data[6] found primary care adolescent MDD screening was 80% less likely for Hispanic adolescents compared with non-Hispanic white adolescents. Similar inequalities were reported for women, who were 3 times more likely to have MDD but less likely to be treated than men.[1,2] Despite the US Preventive Services Task Force (USPSTF) 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, MDD screening remains inconsistent.[5,7,8]
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