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

Abstract

IMPORTANCEAdolescent 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. OBJECTIVE 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. DESIGN, SETTING, AND PARTICIPANTS 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.Author affiliations and article information are listed at the end of this article.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial

“…The SHIELD study protocol and primary analysis have been previously published. [16][17] This study was approved by the Penn State College of Medicine Institutional Review Board. In brief, the 14 participating schools included a sample of both rural and urban schools with diverse student demographics.…”

“…In brief, the 14 participating schools included a sample of both rural and urban schools with diverse student demographics. 17 The two study arms in the RCT were targeted screening (control arm) and universal screening (intervention arm). Targeted screening is the current school process.…”

“…7,[10][11] Studies of suicide risk assessment embedded within a MDD screen such as the PHQ-9 find positive responses are associated with increased suicide risk, though negative responses do not reliably correlate with low suicide risk. [12][13][14][15] In the context of the Screening in High Schools to Identify, Evaluate and Lower Depression (SHIELD) study, a randomized clinical trial (RCT) using the PHQ-9 to evaluate the effectiveness of school-based screening for adolescent MDD, [16][17] addressing responses to item #9 regarding suicide risk was the question that placed the greatest burden upon schools for urgent/emergent student follow-up. The PHQ-9 was selected over the PHQ-A for use in SHIELD, as the PHQ-A includes two additional unscored items regarding suicide risk that were anticipated to be complex to address in a large-scale screening.…”

“…In advance of screening, parents received a letter detailing the project and the screening instrument, the PHQ-9, and were offered the opportunity to opt their student out of the study. [16][17] Students in the universal screening arm could also decline the PHQ-9 at the time of screening.…”

“…This was planned in the classroom or in a designated space, e.g., school library or auditorium, with direct entry into REDCap (Research Electronic Data Capture), a secure, web-based application designed to support research studies. 17,19 Students with a positive response to item #9 triggered an immediate electronic notification to research staff, who reported the information by student study identification number to predesignated school staff on the screening day for follow-up by the crisis team or the school Student Assistance Program (SAP) as detailed below. [16][17] As research staff only had access to the deidentified student study number, all subsequent follow-up J o u r n a l P r e -p r o o f was conducted by school staff who maintained the list tying student study number to identifiable information.…”