Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents

Deepa L Sekhar,Leslie R Walker-Harding,Eric W Schaefer,James G Waxmonsky,Krista L Pattison,Perri Rosen,Jennifer L Kraschnewski,Alissa Molinari

doi:10.1001/jamanetworkopen.2021.31836

Abstract

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment. To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation. This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools. In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9. The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity. In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern. ClinicalTrials.gov identifier: NCT03716869.

Highlights

Adolescents in the universal screening group had 5.92 times higher odds of being identified with major depressive disorder (MDD) symptoms, 3.30 times higher odds of Student Assistance Program (SAP) confirming follow-up needs, and 2.07 times higher odds of initiating MDD treatment
No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity
The prevalence of adolescents reporting major depressive disorder (MDD) symptoms has nearly doubled in the last decade, increasing from 8.3% in 2008 to 14.4% in 2018.1 To better screen for and identify MDD, the universal screening. a Identified (US) Preventive Services Task Force (USPSTF) endorsed primary care screening in 2009 for all adolescents aged 12 to 18 years in settings with capacity to ensure appropriate follow-up, reaffirming this statement in 2016.2 The USPSTF review supported that screening instruments can accurately identify adolescent MDD and that treatment of adolescents with screen-detected MDD is associated with beneficial reductions in symptoms.[2]

Summary

Introduction

MDD screening has significant disparities.[3,4] Most US adolescents (>60%) lack routine preventive health care, limiting the ability of primary care to address this worsening public health concern.[5,6] primary care MDD screening is inconsistent, with inequalities by race and ethnicity and region, and potential worsening with the COVID-19 pandemic.[3,4,7] Additional gaps identified by the USPSTF include the need for large randomized clinical trials (RCTs) to understand the effects of MDD screening and to quantify the proportion of individuals with screen-detected MDD successfully treated.[2]. Schools create a more equitable setting for screening given that most adolescents attend, regardless of race, ethnicity, and socioeconomic status. An RCT of depression screening by Guo et al[14] in California middle schools found no effect of universal screening on treatment initiation

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Conclusion