Repeated mental health screens in the schools

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child depressionA Dr. Simon Williams calls for repeated screening for depression in the schools, not once but regularly from age seven onward. You can see the press release here, but BMJ has his article behind a pay wall, so you either have to have a subscription to BMJ, order the article through a University library website, or send an email to Dr. Williams (simonwilliams@northwestern.edu ) requesting it. But here’s an excerpt.

Dr. Simons asks

Why then, despite this mounting evidence, and in a time where other types of screening (including bowel, breast, cervical, and prostate screens) are becoming more common in the UK, do we not already have school based mental health checks?

Many mental health problems across the lifespan including depression first express themselves in childhood and adolescence. Mental health problems limit academic performance and social development. But most mental health problems in children go untreated or inadequately treated, with schools and families, as well as the children themselves, bearing the costs. So how could anyone oppose repeated mental health screens in the schools?

It was once thought that if problems are serious and common and a means existed for screening for them, we should screen. Now it’s recognized that there has to be evidence that screening improves the outcomes of the people who are screened if it is to be justified. Lots of previous recommendations are being dropped. And the burden of proof whether we should screen falls on those who propose it, not those who remain skeptical.

Choosing wisely

The World Health Organization dropped recommendation for screening for intimate partner violence. Not because it’s believed that intimate partner violence is not a public health problem, but because studies do not show that routine screening improves women’s health or prevents exposure to more violence. Certainly there are situations in which professionals should ask whether women are victims of violence, but that’s not routine universal screening.

choosing wiselyMedical organizations in a number of countries have collaborated in Choose Widely programs that are reconsidering the evidence for screening. Many forms of screening are now discouraged: for breast cancer among young women, prostate cancer, ovarian, and lung cancer, and dementia.

Screening for childhood depression

Even the best screening instruments for depression do not produce a diagnosis suitable for decision-making about treatment. Screening must involve two stages, the administration of a brief screening instrument, and follow-up of children who screen positive with interviews to determine whether they actually are clinically depressed.

Most children screen positive on mental health inventories are false positives—they would not be suitable for mental health treatment. But determining that requires interviewing them. And that consumes resources that could be applied to improving the treatment of children who are already known to have mental health problems.

A fragmented system of care for child depression

Unless mental health professionals are stationed in schools or other personnel are given special training, determining whether a child screening positive is clinically depressed requires referral to outside professionals. Without these follow-up interviews, children who screen positive could falsely be labeled as having a mental health problem.

Teachers and other professionals agree on the need to address mental health problems and the costs of them going unaddressed, but they disagree about the labeling of who should get treatment. Teachers prefer to label troubled or troublesome children as having emotional or behavioral problems. They also miss a lot of childhood depression. Teachers also tend to resist what they see as stigmatizing labels like depression. The problem is that many of the children causing teachers’ problems do not have treatable mental health problems. So, there’s a mismatch between the children who teachers believe need treatment and those for whom mental health professionals feel can be diagnosed and referred into evidence-based treatments.

Let’s think about the fate of children who screen positive for depression or other mental health problems. Many of them won’t get further evaluation, and are left with a stigmatizing label that is not accurate. Furthermore, many of them who are true positive still won’t get adequate treatment. Their problems will remain with additional problem of stigmatization.

In many health systems and particularly the UK, responsibility for determining whether children who screen positive actually have treatable problems fall upon physicians who generally lack training or interest in making such evaluations. There is the risk that physicians will proceed to prescribing medication without obtaining formal diagnosis. Medication is not first line of treatment for most depressed children.

Cognitive behavioral therapy has been shown to be effective for children and adolescents, but access it is difficult. There are long waiting lists in countries like the UK or the Netherlands where psychotherapy is free or low cost. A child identified as depressed during the school year might have to wait until the school year is over before getting a first session of therapy.

In the United States, Medicaid provides coverage for treatment of low income children, but most psychologists do not accept Medicaid because its reimbursement is too low.

A classic book on screening states

Screening must be delivered in a well functioning total system if it is to achieve the best chance of maximum benefit and minimum harm. The system needs to include everything from the identification of those to be invited right through to follow-up after intervention for those found to have a problem.

Schools may seem the ideal place to identify children with mental health problems, but they are not the ideal situation to treat these problems. Furthermore, even within medical systems that have the capacity to treat mental health problems, the quality of care is generally inadequate and simply poor, with an adequate follow up.

For screening to improve child outcomes, we would need a very different organization of care and better communication between the educational, social services, medical, and mental health systems. There are formidable challenges to that happening.

Dr. William cites a meta-analysis, a systematic integration of data from lots of studies, as demonstrating the value of preventive interventions for depression. However, he’s confused in equating the evaluation of specialized programs of treatment with the evaluation of screening. Most children who were screened for mental health problems in the schools couldn’t access such programs. Furthermore, when you look closely at the studies in the meta-analysis, many of them are pitifully small and of low quality.

It would not be appropriate to generalize from the studies anything could conceivably be integrated within routine care on a large scale.

Should we simply ignore mental health problems in children? Of course not, but it would be much better to use scarce resources to improve the care of children we already know have mental problems, rather than put more children into a fragmented system of care that is not working well.

Dr. Williams estimates that it would cost £18million to screen every 7 year old in the UK one time, but recommends repeatedly screening all school age children.

follow your heartRegular mental health screens for children would be ineffective, costly, and would probably have negative consequences.

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