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 + Related article