Question: "I have been asked to do an analysis of the pros and cons of doing school-wide screening for depression and suicide prevention. What resources or data should I use in doing this analysis?"

Response: There is a great deal to discuss about large-scale first-level screening related to such matters (and indeed related to screening of all emotional, behavioral, and learning problems experienced by children and adolescents). Screening is a popular activity, and screening for depression and suicide is becoming a very hot topic (e.g., see the Children's Mental Health Screening and Prevention Act of 2003). It is likely to become more so since it is prominently featured in the report from the President's New Freedom Commission on Mental Health (see Goal 1.Recommendation 1.1 Advance and implement . . . a national strategy for suicide prevention -- http://www.mentalhealthcommission.gov/reports/finalreport/fullreport.02.htm)

And, of course, there are a multitude of references to consult.

Recently, we were involved in a discussion of this matter, and the following is the gist of what we had to say (including references to basic resources):

As researchers who have always included screening as a major focus of our work, we have tried to urge a balancing act in approaching such activity on a large-scale. This is essential because the best assessment instruments available still have significant methological limitations. The tendency in studies of screening initiatives has been to deemphasize discussion of such major methodological concerns as incremental validity and utility and the overall number of Type I and Type II errors (false positives plus false negatives), etc.

Thus, while it is good that they can point to some empirical support and can even argue they have the best data available, practitioners still do not have access to really good instruments for large-scale screening of suicide. And, from a public health perspective, we have to be careful that we don't put all our eggs into screening at the expense of underwriting interventions to improve the conditions that lead kids to suicide and afflict them with other psychosocial problems.

Discussions of large-scale screening have been cyclical, usually reflecting the dialectic process. In the last few years, the political and economic emphasis has been toward wider use of first-level screens (without a parallel emphasis on enhancing follow-up assessments to detect false positives and on ensuring essential help is available and accessed). We anticipate that over the next few years there will be a strong reaction and another review of the limitations and potential negative consequences of any set of policies and practices that mainly stresses large-scale first level screening of emotional, behavior, and learning problems. Ironically, such a reaction already can be seen in the backlash to Learning Disabilities assessment as reflected in proposed changes in IDEA. The reauthorization proposals clearly intend to replace the current emphasis on testing with what they are calling Response to Intervention (RTI).

Our reading of the best scientific evidence (see the NIMH Selected Bibliography on Suicide Research - - 1999 http://www.nimh.nih.gov/research/suibib99.cfm), is that there is a great deal more research that must be done before we should invest in the enterprise of large-scale screening for suicidality and clinical depression among children and adolescents.

See, for example, the following references and resources that have relevance to school-based screening for depression and suicide prevention.

1. For a major review of the state of the art related to instruments used for screening, see the summary and recommendations (pp. 198-201) in

   "Assessment of Suicidal Behaviors and Risk Among Children and Adolescents" (August 14, 2000) by David B. Goldston, Ph.D., Wake Forest University School of Medicine -- Online at: http://www.nimh.nih.gov/research/measures.pdf

   Among his conclusions: " ... as part of the validation procedures for measures of suicidal behavior, it is common to demonstrate that the suicidal behavior instrument correlates in a predicted way with other related constructs such as depression and hopelessness (convergent validity). However, there has been insufficient attention paid to discriminate validity, or the degree to which suicidal behavior does not correlate with constructs with which it should not. There also has been insufficient attention paid to issues of incremental validity, or the degree to which a test provides information not available elsewhere. "...studying the clinical characteristics of juvenile suicidal attempts has not been a particularly fruitful exercise to date. Empirical data about the clinical characteristics of suicidal attempts have not been shown to be related to course or response in therapy, have not been used to demonstrate that certain types of therapy are any more or less effective with specific suicidal behaviors, and have not been found to be related to future behavior. Beyond simply using instruments that assess clinical characteristics of suicidal attempts for descriptive purposes, there is a need to better understand the significance of those clinical characteristics." ...."Unfortunately, there are a limited number of prospective studies which have identified risk factors with predictive utility that might be candidates for potential intervention (it makes sense to intervene with variables that portend later risk, rather than current or past risk). There are even fewer studies in which assessment measures have been administered on multiple occasions and which might yield data on the effects of repeated test administrations. And it almost goes without saying that there is a paucity of controlled intervention studies with suicidal youths - studies which might yield clues about the usefulness of different measures related to suicidality."

2. From the perspective of primary care and EPSDT, it is worth noting the U. S. Preventive Services Task Force (USPSTF) Recommendations and Rationale Statements. See "Screening for Depression: Recommendations and Rationale" in the American Family Physician, August 15, 2002 (hftp://www.aafp.org/afp/20020815/us.html). They state: "The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression .... The benefit of routinely screening children and adolescents for depression are not known .... The predictive value of positive screening tests is lower in children and adolescents than in adults...."

3. With specific reference to school-based screening in this arena and the likelihood that such screens will balance Type I and Type II errors in favor of false positives, see the recent review: "Youth Suicide Risk and Prevention Interventions: A Review of the Past 10 years" in the Journal of the American Academy of Child & Adolescent Psychiatry, 2003; 42(4): 386-405. It states: "The few studies that have examined the efficacy of school-based screening (Reynolds, 1991; Shaffer and Craft, 1999; Thompson and Eggert, 1999) found that the sensitivity of the screens ranged from 83% to 100%, while the specificities ranged from 51 % to 76%. Thus, while there are few falsenegatives, there were many false-positives ......

4. Another strand related to this discussion is the treatment available for students who are depressed. You probably are aware of the recent U.S. Food and Drug Administration's Public Health Advisory (on 10/27/03) to health care professionals. It deals with "Reports of suicidality in pediatric patients being treated with medications for major depressive disorder." They will hold an advisory hearing on this on 2/2/04. A major concern raised is that children and adolescents identified are being prescribed medications which have dire iatrogenic effects.

5. With specific respect to the Columbia Teen Screen, see the Journal of the American Academy of Child & Adolescent Psychiatry, 2004; 42(l) 71-79. This report is from the staff at Columbia and focuses on the Columbia Suicide Screen and also cites a range of screening instruments. They state that their instrument has "reasonable specificity identifying students at risk for suicide. A second-stage evaluation would be needed to reduce the burden of low specificity.... As with other suicide risk instruments, the CSS has the potential of having high (0.88) sensitivity at the expense of specificity..."

6. Another relevant resource is the SAMHSA, Center for Substance Abuse Treatment, Treatment Improvement Protocol (TIP) Series 31 "Screening and Assessing Adolescents for Substance Use Disorders." It seems to do a pretty good job in outlining many of the concerns that would be similar to depression and suicide prevention screening. (e.g., when to screen, when to assess, how to involve the family, legal issues of screening, including confidentiality, duty to warn, and how to communicate with other agencies, etc.).

7. Finally, we are always in the process of trying to strengthen our online resources to provide better responses to requests such as yours. Based on your inquiry, we will revisit the following Quick Find topic pages currently on our website. (These pull together our Center materials, links to online documents, and Centers that specialize in a specific topic.) You may want to look over what we have if you are looking for more and if your work produces or turns up other resources we should list, we hope you will let us know.
   Current related Quick Find topics on our webbsite:
   • Assessment and Screening (http://smhp.psych.ucla.edu/qf/p1405_01 htm)
   • Depression http://smhp.psych.ucla.edu/qf/depression.htm)
   • Suicide Prevention (http://smhp.psych.ucla.edu/qf/p3002_02.htm)

   In addition, the Quick Find on Empirically Supported Interventions (http://smhp.psych.ucla.edu/qf/ESTs.htm) provides support for programs for promotion of healthy development, prevention, and school-wide interventions that present strong argument for evidence based interventions that provide an alternative to screening for problems.

There were a number of responses to this matter.

1. "In a school wide screening done at an urban middle school, 1400 kids were screened and after further interviews about 15% needed services, a psychiatric interview, or both. The result, as the researchers said, was not worth the manpower, time and money that was put into the effort.

   Also, you need to have the resources to back-up and send the kids if you uncover mental health issues. It's not fair to the parents or teens to ask for information and not have the services ready if needed. Other difficulties included parental permission and school permission. The screening were not foolproof: there were some false-negatives, there were many false-positives. Some kids tested positive for depression and after interviewing were found to be fine; the opposite was also true – kids who said they were fine, were later referred for mental health services for depression.

   A better idea might be to do an all inclusive survey asking kids about different topics from sexual activity to drug use to relationships to dating. This might give you a better idea of issues troubling the student body and then target intervetions that can reach a wider audience."

2. "If you are dong a broad, school wide suicide assessment, you need to have enough mental health professionals and resources to meet with each and every student who is suicidal in an immediate and effective way to ensure the safety of the children you are assessing."

3. "You might be interested in research we have done on screening for emotional distress in middle school students. We used a classroom-based questionnaire. Mental health professionals conducted follow up assessments with the high scoring students. More than half of the students who received follow-up were determined to need additional support (e.g., tutoring, counseling, after-school activities). Community mental health service referrals were recommended for 15% of high scoring students."

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UCLA Center for Mental Health in Schools
Dept. of Psychology, P.O.Box 951563, Los Angeles, CA 90095.
tel: (310)825-3634
email: Linda Taylor ~ web: https://smhp.psych.ucla.edu