Comparing Universal versus Focused Screening for Depression among Teens in High School – The SHIELD Trial

BACKGROUND: The prevalence of annual major depressive disorder (MDD) episodes among US adolescents rose from 8.3% in 2008 to 14.4% in 2018. From 2005 to 2014, a substantial increase in MDD episode trends was observed for all racial and ethnic groups. 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: The goal of this study was 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. METHODS: This randomized clinical trial (RCT), conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted—meaning 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: targeted screening or universal screening. The study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 to 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), which is mandated in all Pennsylvania schools. The SAP decided on follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to the SAP. The universal screening group could also have targeted referral to the SAP for concerning behavior independent of the PHQ-9 findings. The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. The study also included a significant qualitative component (focus groups and interviews) to address community-specific barriers to MDD screening. The qualitative component was supplementary to the RCT aims in its focus on a greater understanding of the community perspective on MDD screening and barriers to help-seeking through descriptive content analysis. Following coding of all data, relevant themes were identified. Collaboration with the National Poll on Children's Health (NPCH) provided the opportunity to confirm themes identified in statewide qualitative work through electronic surveys administered to a nationally representative parent sample. Finally, quarterly stakeholder advisory board meetings were a key element of the project's success. RESULTS: Participants included 12 909 students, with 6473 students (50.1%) randomized to universal screening. Students were 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms (15.9% vs 3.1%), 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs (3.6% vs 1.0%), and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment (1.2% vs 0.5%). No differences were identified in planned subgroup analyses by sex or race and ethnicity. Qualitative analysis identified the following main themes: (1) parents and adolescents recognized MDD as a significant issue and acknowledged the value of school involvement in screening, but had concerns about confidentiality and results communication; (2) both groups agreed that adolescents would first speak with friends about MDD symptoms; and (3) neither group could clearly articulate how to help an adolescent with MDD. The summer 2019 NPCH survey furthermore demonstrated that most parents nationally (70.5%) responded favorably to school-based depression screening; a majority advocated for screening as early as middle school. The stakeholder advisory board participated in the creation of a lay brief of qualitative findings, the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) stakeholder study newsletter, and an MDD video for adolescents. CONCLUSIONS: In this RCT, universal school-based MDD screening successfully increased the identification of MDD symptoms and subsequent treatment initiation among adolescents, confirming the value of this approach in addressing this rising public health concern. Qualitative findings underscored the view that adolescents and parents are accepting of school involvement in mental health, a conclusion that was echoed on the national level. Parents would benefit from a clear understanding of the processes to address adolescent MDD. Stakeholder advisory board input was used to guide dissemination and community engagement efforts. LIMITATIONS: RCT outcomes data are limited by what information the schools provided. The team clarified missing or discrepant information, but outside referrals are not routinely logged by the schools, so this follow-up information was unavailable. The COVID-19 pandemic affected universal screening completion, which biased results toward the null. Study staff involvement may have increased the number of students who were successfully screened. Although trained, SAP staff are not mental health professionals and were not blinded to study group, so it is possible that biases affected the management of students identified in universal vs targeted screening. The participating schools represented a diverse group of students but were contacted based on prior relationships, responded to initial inquiries, and felt their SAP teams were well-equipped to handle increased referrals. The effect of screening may differ in schools with less confidence in their SAP teams.