Universal MDD screening increases identification, treatment initiation in Pennsylvania study

A school-based approach to universal screening for major depressive disorder (MDD) in adolescents successfully increased identification of MDD symptoms and led patients to treatment initiation who otherwise may not have been treated, researchers found.

The prevalence of MDD among adolescents has skyrocketed in recent years, jumping from 8.3% in 2008 to 14.4% in 2018, Deepa L. Sekhar, MD, MSc, of the Department of Pediatrics at Pennsylvania State University College of Medicine in Hershey, Pennsylvania, and colleagues explained in JAMA Network Open. To help identify MDD in these patients, the U.S. Preventive Services Task Force (USPSTF) recommended primary care screening for all adolescents ages 12-18 years; however, there are substantial disparities in MDD screening, as over 60% of adolescents in the U.S. do not have access to routine preventive health care and primary care MDD screening is inconsistent between racial, ethnic, and religious groups.

Schools, Sekhar and colleagues argued, may present an ideal setting to “(1) evaluate universal adolescent MDD symptom screening, (2) compare the effectiveness of universal versus targeted MDD symptom screening, and (3) address disparities in MDD screening.” To test this hypothesis, they conducted the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) randomized controlled trial (RCT) to compare the effectiveness of universal school-based MMD screening for initiation of mental health treatment compared to targeted screening among Pennsylvania public high schools.

The SHIELD study randomized 14 participating schools into one of two groups:

  • 9th and 11th graders assigned to universal screening with 10th and 12th graders assigned to targeted screening.
  • 10th and 12th graders assigned to universal screening and 9th and 11th graders assigned to targeted screening.

All 9th through 12th grade students were eligible for participation aside from those whose parents opted out or students with disabilities deemed unable to participate by the school, they explained. Screening was conducted using the Patient Health Questionnaire-9 (PHQ-9).

Targeted screening followed current school practice: if a student exhibited behaviors suggestive of MDD, they were referred to the Student Assistance Program (SAP), a professionally trained team including school staff liaisons from mental health agencies. “The SAP uses a team process to gather and review data on observable behaviors or symptoms prompting the referral. The SAP does not diagnose, but after review, students confirmed to require intervention are referred for follow-up school-based and/or community-based services, which may be based on screening or assessment by a SAP liaison from a community behavioral health agency,” the study authors wrote.

Students in the universal screening group were administered the PHQ-9 electronically during school hours by the study team. Students with a PHQ-9 score higher than 10 were referred to SAP using the same process as in the targeted screening arm; those with suicidality (based on a score of one or greater for PHQ-9 item nine) were reported to designated school staff on the day of screening, regardless of total score.

The SHIELD study’s primary outcome was the percentage of students confirmed by SAP with MDD symptoms that warranted further evaluation who initiated recommended treatment. The study included a total of 12,909 students (median age 16 years; 6,963 male [53.9%]), of whom 2,687 (20.8%) were Hispanic, 2,891 (22.4%) were non-Hispanic Black, 5,842 (45.3%) were non-Hispanic White, and 1,489 (11.5%) were multiracial or of other race or ethnicity.

Ultimately, 6,473 students (50.1%) received universal screening and 6,436 (49.9%) were randomized to targeted screening.

The study authors found that “universal school-based depression screening successfully doubled student initiation of MDD treatments and services, providing clear evidence of the benefit to addressing USPSTF screening beyond the clinic walls.”

Among the findings:

  • Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms.
  • Those who received universal screening had 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs.
  • Students who received universal screening had 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment.
  • While females, attendees of more rural schools, and non-White participants were more likely to be detected by univsersal screening versus targeted screening, planned subgroup analyses found no differences in MDD treatment initiation by sex or race and ethnicity.

Sekhar and colleagues also found that of 1,226 students who screened positive for MDD, 929 (75.8%) lacked SAP confirmation that a referral was warranted. “In more than 80% of cases, although direct referral to outside services or meetings with school staff were recorded, no further information was documented by the school SAP, so students did not meet criteria for the primary outcome,” they added. “Among 297 students confirmed with MDD symptoms in need of follow-up, 180 (60.6%) failed to engage in services or treatment. The primary reasons were inability to obtain parental permission (81 [45.0%]), the student already being in treatment (61 [33.9%]), and student refusal (20 [11.1%]).”

Estimates of MMD identification, confirmation, and treatment initiation rates in this analysis “are likely conservative owing to Covid-19–related school closures limiting screening completion (7% of students),” the study authors noted. For this reason, along with the previously mentioned cases that did not meet the primary outcome, “the actual number of students successfully identified and treated for MDD is likely higher than recognized by our results,” they argued.

In an editorial accompanying the study, Sisi Guo, PhD, of the University of California, Semel Institute for Neuroscience and Human Behavior in Los Angeles, and Grace Bai Jhe, PhD, of Boston Children’s Hospital and Harvard Medical School, noted that, to their knowledge, the study by Sekhar et al is “the first large-scale randomized clinical trial to examine depression screening as a universal intervention in schools… These results complement the findings from smaller previous trials, bolstering the utility of depression screening in schools.”

However, while the universal screening approach examined in the study improved the detection of adolescent depression, Guo and Jhe argued that 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 one 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.”

Guo and Jhe also argued that the utility of school-based screening in connecting adolescents with MDD treatment should not diminish the significance of clinical settings: “Primary care remains an important access point for youth mental health services,” they wrote.

Instead, they concluded that schools and primary care systems can offer complementary points of entry into mental health services for this population.

“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,” they wrote. “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.”

Study limitations cited by the authors included reliance on what information schools were able to provide; the impact of the Covid-19 pandemic on universal screening completion, which “biased results towards the null;” the involvement of study staff may have improved the numbers of students successfully screened; SAP staff are not mental health professionals and were not blinded to study group, and it is therefore possible that biases impacted management of students identified in universal versus targeted screening; and the impact of screening in schools with less confidence in their SAP teams may be different.

  1. A school-based approach to universal screening for major depressive disorder (MDD) in adolescents successfully increased identification of MDD symptoms and doubled treatment initiation compared to targeted screening, according to findings from a large, statewide, randomized clinical trial.

  2. While universal screening for MDD identified and confirmed more cases than targeted screening for females, non-White students, and students in rural areas, there was no significant difference in treatment initiation in these groups.

John McKenna, Associate Editor, BreakingMED™

In the past 3 years, Sekhar reported receiving funding from Pfizer through the American Academy of Pediatrics, the Penn State Clinical and Translational Science Awards Program, and a Eugene Washington Patient-Centered Outcomes Research Institute Engagement Award. In the past 3 years, coauthor Waxmonsky reported receiving research funding from Supernus and consulting with Intracellular Therapeutics and Adlon Pharmaceuticals. Coauthor Kraschnewski reported receiving grants from Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality during the conduct of the study and grants from Merck outside the submitted work, and she reported currently serving on an advisory board for Sanofi to address health disparities for influenza vaccination in primary care.

Guo and Jhe had no relevant relationships to disclose.

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Topic ID: 87,55,730,138,192,55,921