Systematic, voluntary mental health screening of high school students can help identify those who are at risk for serious mental health problems, and can connect them with much-needed care, a study of almost 2,500 adolescents suggests.
In addition, students who are referred for school-based mental health services are generally less severely ill than their counterparts who are referred for community-based services, with lower rates of self-reported suicidal ideation, depression, and substance abuse as well as lower interviewer-assessed rates of prior suicide attempts and self-injury.
The findings, reported in the September 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, come from a study that set out to identify the extent to which at-risk youth are identified and connected with appropriate mental health services.
"Research on post-screening access to care has been hindered by a paucity of information concerning follow-up with students referred to services," wrote the researchers, led by Mathilde M. Husky, Ph.D., of the New York State Psychiatric Institute at Columbia University. "When information is available, it is often limited to the first outpatient visit. As a result, it is not known what proportion of referred youth drop out early from follow-up care."
During 2005-2009, some 4,509 ninth graders at six public high schools in suburban Wisconsin were offered systematic voluntary mental health screening. Students completed a computerized self-report assessment known as the DPS-8 (Diagnostic Predictive Scales–8, an abbreviated form of the Diagnostic Interview Schedule for Children–IV). Students were deemed to be "at risk" if they screened positive or were identified by screening staff as being in need of further assessment (J. Am. Acad. Child Adolesc. Psychiatry 2011;50:881-91).
After the screening, each student was seen for a one-on-one debriefing to discuss the results. Students who screened positive on the self-report or who asked for help during the debriefing stayed for a second-stage clinical interview. After that, the interviewer offered referral to school-based services, community-based services, neither, or both.
Of the 4,509 students, 2,488 (56%) provided both parent consent and youth assent, and were included in the final analysis. Of the 2,488 students, 489 (20%) were identified as being at risk. Of these, 74% were not receiving any mental health services.
Overall, 74% of students were referred to school-based services, whereas 53% were referred to community-based services. In addition, 76% of referred students received at least one follow-up visit and 56% received minimally adequate treatment, which was defined as "having three or more visits with a given provider, or any number of visits if termination occurred in accordance with the provider’s recommendation."
Compared with students who were referred to school-based services, those who were referred to community-based services self-reported higher rates of suicidal ideation (26% vs. 11%, respectively), depression (50% vs. 41%), and substance abuse (17% vs. 9%). They also had higher rates of certain interviewer-assessed variables, including passive suicidal ideation (51% vs. 31%), active suicidal ideation (21% vs. 4%), prior suicide attempt (17% vs. 6%), and self-injury (33% vs. 14%). The researchers said that these findings are consistent with a 2005 report from the Substance Abuse and Mental Health Services Administration, "suggesting that youth with more serious problems are more commonly referred to community providers."
Among adolescents who received a referral to school-based services, 80% received at least one visit, compared with only 42% of those who received a referral to community-based services. "Referral decisions may be driven by specific symptoms, current distress, student or family preferences, past treatment experiences, provider availability, [and] logistical and economic considerations, as well as a host of other factors that were not measured in this study," Dr. Husky and her associates stated. "Although schools remain important providers of mental health services, our findings suggest that the implementation of proactive efforts to link youth with serious conditions to services may best be achieved when both school and community mental health providers are available."
Dr. David Fassler
In an interview, Dr. David Fassler, professor of psychiatry at the University of Vermont, Burlington, characterized the study’s findings as generally consistent with those of previous reports. "Signs of psychiatric disorders, including suicidal ideation, are not uncommon in adolescents," he said. "Yet most young people with significant symptoms receive little, if any, treatment. Schools are a logical place to try and identify students who may need help, and to facilitate referrals, as appropriate. However, as this study demonstrates, accessing follow-up care often remains a challenge, particularly when services are located outside the school setting."
Dr. Fassler went on to note that the study’s findings "will be useful in the development of programs and policies designed to identify at-risk students. They will also help inform future research on school-based screening initiatives."