Reflecting on Our Research to Inform School-based Depression Screening
Editor's Note: This post is part of this year’s “Back to School” series in which our experts and guest authors discuss the need to support the health and well-being of youth as they return to school. For more, follow our hashtag #PolicyLabGoesBacktoSchool on Twitter.
In 2020, depression affected an estimated 17% of U.S. teens. Depression in teens often goes unnoticed and more than half of depressed teens do not receive treatment, which can lead to suicide and other negative outcomes. As the COVID-19 pandemic has only exacerbated these concerns, state leaders are considering opportunities to support youth mental health. In New Jersey, for example, the Departments of Education and Children and Families will support schools in annually screening youth in grades 7-12 for depression starting in the 2022-23 school year through a new grant program. New state legislation provides guidance for these screenings—including consent protocols, communication with caregivers and types of tools that may be used.
In light of this recent legislation standing up the grant program in New Jersey, our team is reflecting on how our research can inform schools’ efforts to launch school-based screening programs. Over the past 2 decades, we have screened more than 4,300 youth ages 11-17 for depression through our school-based prevention research. These students were from middle and high schools (7th to 10th grades) in New York, New Jersey and Pennsylvania. We used a well-validated screening tool and chose a score based on the literature to identify youth with elevated symptoms who might benefit from participating in a depression prevention program.
Across all youth screened, more than 30% had elevated scores, suggesting they might benefit from prevention or early intervention for depression. Nearly 3% of students screened had scores indicating more significant depression symptoms. Females and older teens were more likely to indicate higher levels of depression symptoms. Starting in 2019, we began to screen students from the Greater Philadelphia area. Notably, from 2019-2021, 67% of students screened in the Greater Philadelphia area had elevated scores on the screening and 8% were experiencing more significant symptoms. The increases we have seen in the past few years mirror those reported by others, although some of our more recent data predate the COVID-19 pandemic.
How can our experiences inform new initiatives?
Based on what we've seen in our own research, there are several lessons learned that could inform school-based screening efforts in New Jersey and other states. First, our data and others’ suggest that schools need to be prepared that they might identify a substantial proportion of youth who would benefit from services.
Second, we have found different rates of caregiver consent across our studies. Tailoring education about the New Jersey depression screening initiative to caregivers, teens, and school personnel will be critical for maximizing the number of students who can benefit from such screening and thus help ensure the equitable implementation of this program.
Third, there are a number of factors that should be considered in the screening tools selected, such as the length of the measure, ease of administration and scoring, as well as whether to utilize a tool that includes questions about suicide risk. Regardless of which measure is selected, it will be important to make sure schools are equipped with safety procedures for responding to suicide risk.
Finally, schools should weigh the pros and cons of different symptom cutoffs for determining depression severity. Using a lower cutoff will help identify more students who might benefit from prevention or early intervention (which has been the goal in our work), but will also yield a higher rate of false positive screens and may exceed schools’ capacity for providing support. Alternatively, a more stringent cutoff will lead to a smaller subset of students being identified, but could miss students with lower symptom levels who would still benefit from prevention or intervention services.
Long-term considerations for universal screening
Should the New Jersey school-based screening grant program prove feasible and clinically impactful, it will be critical to plan for scaling the screening program and long-term sustainability for state-wide implementation. Increases in funding and workforce expansion will be required to grow and sustain school-based depression screening programs and school-based services to support those who are identified. As New Jersey and other states consider and support mental health screenings for youth, it will be important for policymakers to consider how to scale up successful initiatives to promote national school-based depression screening and interventions for identified teens.
As a nation, we have made recent strides to support youth mental health. A 2021 U.S. Department of Education study found that 97% of the 170 schools surveyed are presently taking some steps to support their students’ well-being. Screening for depression and other mental health problems enables us to identify youth that need prevention and treatment services. Overall, the New Jersey program represents an important initiative for identifying youth who are at-risk for depression. With proper infrastructure to support addressing that risk and connecting youth to care, this can be a promising model for other states to learn from to determine how to implement and sustain their own school-based mental health screening programs.