Suicide risk screening in high schools successfully identifies at-risk students

Suicide death rates have increased significantly among adolescents in the U.S. in recent years, according to the Centers for Disease Control and Prevention. But while children are typically screened for scoliosis, body mass index, and vision and hearing problems in school, mental health screening has not been standardized in school settings.

New research, led by the Penn State College of Medicine, has evaluated the effectiveness of a school-based, adolescent suicide risk screening and found that it successfully identified at-risk adolescents and increased initiation of mental health services.

"Unfortunately, more than half of U.S. adolescents lack routine preventive health care, which limits the ability of primary care to address this worsening public health concern," said Deepa Sekhar, associate professor of pediatrics and executive director of Penn State PRO Wellness. "Schools create a more equitable setting for screening given that most adolescents attend, regardless of race, ethnicity and socioeconomic status."

In previous research, the team had developed and tested Screening in High Schools to Identify, Evaluate and Lower Depression (SHIELD), a protocol to evaluate the effectiveness of school-based depression screening. The study used the Patient Health Questionnaire-9 (PHQ-9), a standard tool used by primary care providers to screen for symptoms of major depressive disorder. The team found that the universal depression screening approach in which everyone was screened was more effective than the existing process of targeted referral of students based on concerning behaviors such as acting out, failing classes or not showing up for classes.

"One of the challenging parts of the study was item 9 of the PHQ-9, which asks, 'How often have you been bothered by … thoughts that you would be better off dead or of hurting yourself in some way?'" Sekhar said. "Students with a positive response to this question required same day follow-up, which can be difficult for resource- and staff-limited schools."

While the PHQ-9 is not a suicide risk assessment tool, the team conducted a follow-up analysis to better understand the necessity of including suicide risk as part of screening.

The team worked with nearly 13,000 students in 14 Pennsylvania high schools. Half of the participating schools were randomized so that students in grades 9 and 11 received targeted screening and those in grades 10 and 12 received universal screening. The other half were randomized so that students in grades 10 and 12 received targeted screening and those in grades 9 and 11 received universal screening.

Students who were identified as at risk for suicide were referred to the Student Assistance Program, which is mandated in all Pennsylvania schools. Managers of this program then determined the follow-up procedure for these individuals.

The team found that adolescents in the universal screening arm had 7.1-fold greater odds of being identified as at risk for suicide, 7.8-fold greater odds of follow-up needs and 4.0-fold greater odds of initiating mental health treatment. The results were published in The Journal of Pediatrics.

"Although the PHQ-9 is a screening tool for major depressive disorder, we found that its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide," said Sekhar. "Our study confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth."