Why we owe it to our youth to take a critical look at the new recommendations from the American Academy of Pediatrics
You might expect that when the American Academy of Pediatrics announced their recommendations for universal depression screening for youth, everyone who works in the mental health field rejoiced.
I have to admit, when I first read about it on NPR’s website, I groaned.
Here at Erika’s Lighthouse, we’re often asked if we recommend that middle school and high schools screen their students for depression and if our classroom-based depression education programs include a teen depression test or screener.
The short answer to both of those questions is no.
It’s important to know that we’re not against depression screening for youth on principle. We’re always on the look-out for the magical solution or intervention that’ll make sure youth with depression are connected with the help they need as quickly and effectively as possible.
The problem is that when it comes to screening youth for depression, there’s a lack of research on whether this approach actually leads to better outcomes. There are also many important questions we should have answers to before implementing a universal screening policy.
What does “universal depression screening for youth” even mean?
Advising all pediatricians to universally screen their patients for depression starting at the age of 12 means that every single young person who steps into a doctor’s office will get evaluated for depression. This might include a written or electronic questionnaire and a follow-up conversation with the doctor if the patient scores above a certain threshold on the initial screener. Patients will receive a depression diagnosis ranging from mild to severe if they meet diagnostic criteria.
This all sounds pretty benign in theory, but we owe it to our youth to take a look at any proposed mental health initiative and truly evaluate whether it will lead to better outcomes. With every public health intervention, there are pros and cons, benefits and risks, costs and resources required. Putting time, effort and resources into one intervention often means not funding another. Is this proposed intervention the best bang for our buck? What are the risks involved? What are the desired outcomes and how will we measure whether we’re achieving them?
Sadly, we have yet to discover the one magical intervention that will make sure youth with depression don’t suffer in silence and get the help and support they deserve. These efforts truly take a village and most often a multi-faceted approach is still the best way to go.
Why are screeners popular?
It’s easy to understand the appeal of screeners.
We live in scary times. We want to protect our youth and support them in living meaningful lives. Some who work in professional capacities with teens are terrified they’ll get sued if they don’t do all they can to monitor the mental well-being of the youth in their care. Others are grieving the loss of a youth who died by suicide and are desperate to do whatever they can to prevent a suicide from happening again.
When we feel powerless, out of control, sad or afraid, it’s tempting to take action, any action, to alleviate those feelings. Implementing a screener – whether in a school setting or doctor’s office – can make us feel in control again, make us feel that we’re doing all we can to support teens’ mental health. We – the adults in the room – feel better.
However, it’s important to ask ourselves whether screeners do more than help the adults in the room feel better. Are they the best option or a knee-jerk or fear-based reaction? Ideally, we would utilize screeners not only because of their emotional appeal but because we have evidence that these tools lead to better outcomes for the youth in our care.
Here are 9 important questions we need to answer before implementing universal depression screening for youth:
1. Will universal depression screening lead to better outcomes?
We should at least have a decent idea of the answer to this question before making wide-sweeping recommendations to screen all youth ages 12 and up for depression.
We can’t make the assumption that universal screening is better than not screening without data to back that up. Interventions are not without consequences, and sometimes waiting to act or choosing not to act is actually the wiser move, and the one that may (sometimes counterintuitively) lead to better outcomes. Good intentions behind an intervention does not mean you’re guaranteed to have good outcomes.
One sentence in the guidelines for depression screening from the American Academy of Pediatrics casually begins, “Although no study compared outcomes between screened and unscreened groups…” I’m sorry, but that statement deserves more attention and discussion than half a sentence. Proponents of universal screening need to show us clear evidence that depression screening for youth leads to better outcomes.
It’s also important that we make sure we have a consensus on what outcomes are the most important to measure and monitor when it comes to universal screening. This helps us determine whether or not the intervention is working the way we intended it to work.
(A quick aside: This is a good place to point out that screening for depression is not the equivalent of evaluating a youth’s risk for suicide. This deserves far more discussion, but you can read a bit more about it here if you’re interested. Don’t buy claims that if you’ve screened a young person for depression, you’ve evaluated their risk for suicide.)
2. What is the impact of the screening process itself on youth?
What’s missing from these universal screening recommendations? The voices and opinions of the youth who will be directly impacted by this new policy.
At Erika’s Lighthouse, we are firm believers in featuring and honoring diverse youth voices, perspectives and experiences in our depression education and suicide awareness programs, videos and resources. When we create new materials, we not only ask the adults who will be teaching the program for their input, we also ask the students. Their opinions matter to us.
It also matters to us how our programs impact them. It’s one of many reasons why we’ve conducted two independent program evaluations with the help of Dr. Michael Kelly at Loyola University (read the middle school program results here and the high school program results here).
We want to know that our materials are having a positive impact on the youth who are receiving them. We can’t assume we are having a positive impact – we have to find out. If we were to find we were having no impact or a negative impact, we’d take that very seriously.
Anecdotally, I’ve spoken with many students at Erika’s Lighthouse partner high schools that found universal depression screening in their schools to be a scary and, quite honestly, traumatizing, process.
Imagine you’re sitting in class, three days after your school implemented a depression or suicide program that concludes with every student filling out a screener. You get a pass delivered to you that asks you to head down to the social worker’s office. Your classmates ask you why you were called out of class, and you’re embarrassed and nervous because you don’t know why. You find out that you were called down because you circled 5 out of 7 questions that might indicate you have depression. However, the way this intervention was handled might leave you distrustful of the adults in your school and less likely to ask them for help in the future.
Screening is not without risks, and we owe it to teens to do some research into how screeners affect them (both positive and negative effects). Dear American Academy of Pediatrics: Please do your homework to find out how this recommendation would impact youth and what they think about your proposal.
3. What kind of training will doctors receive in order to be prepared to administer these screenings?
Youth should leave their doctor’s appointments feeling hopeful, empowered, heard, respected, cared for, and with a renewed sense of trust in medical professionals and adults in general. If this doesn’t happen after an appointment that includes a screener for depression, we have failed, in my opinion. Therefore, I’d strongly encourage training to go way beyond a simple “how to score the screener” and “what treatments to recommend” approach and include a lot of practice around how to have open, collaborative conversations with teen patients (and their parents!).
4. What are the most likely outcomes of universal screening?
Since we don’t know whether or not we’ll have positive mental health outcomes from universal screening, what are the outcomes we can reasonably predict at this time?
First, if we go from the current system (where some, but not all, doctors screen youth for depression, basically at their own discretion) to every doctor screening every teen at every appointment for depression, we can reasonably predict that we’ll see an increase in the number of youth receiving a depression diagnosis. Our initial reaction might be, “That’s great!” but I’ll discuss later why this is potentially problematic. There’s also a high likelihood of false positives, a common downside of school screeners too (more on school screeners for depression in a later post).
Second, if we see an increase in the number of youth receiving a depression diagnosis, it’s reasonable to assume that we would then see an increase in the number of youth receiving treatment, specifically, prescriptions for medications and referrals to mental health professionals.
5. Without evidence that youth are likely to benefit from universal screening, who are the people most likely to benefit from this recommendation?
Pharmaceutical companies. If we increase the number of youth diagnosed with depression, we increase the number of people who need treatment. If you go to a doctor’s office and say you’re struggling with depression (or a teen depression test administered at your appointment tells you that’s what you have), you’re more likely to walk away with a prescription than a mental health referral (more on this in a later post).
I would take the guidelines for depression screening for youth from the American Academy of Pediatrics more seriously if they included more diversity of voices and disciplines, especially when it comes to the lead authors. The first three lead authors of the guidelines are psychiatrists and two out of three of them have financial connections with at least one pharmaceutical company. Although of course it is unfair to group all psychiatrists together, most psychiatrists primarily rely on medication to treat mental disorders. I’d love to see more diversity at the head of this initiative.
6. What treatments or interventions will doctors recommend when a young person meets the diagnostic criteria for depression? What do we know about those treatments?
Just as we can’t assume that screening is better than no screening without doing our research, we can’t assume that treatment is always preferable to no treatment. There are times when treatment leads to poorer, rather than better, outcomes.
A huge missing piece of the new guidelines for depression screening for youth is an evaluation of the current treatments or interventions that are available for youth struggling with depression. It’s reasonable to assume that when someone screens “positive” for depression at their doctor’s appointment the next step that doctor is going to take is to talk about treatment.
Let’s be sure to have a data-driven conversation about current treatments and how effective they are (more on this in a later blog post). We shouldn’t recommend treatments until we’ve taken a closer look at how well they are (or aren’t) working and what outcomes are likely should we recommend one treatment over another.
Let’s also be sure to include lots of different kinds of “treatment” options in treatment plans above and beyond therapy and/or medication, including low-cost options like exercise, meditation, spending time with people you love and so on.
7. What’s the plan for ensuring that youth who screen positive for depression have adequate access to good help and are supported in getting connected with that help?
It is flat out irresponsible to slap the diagnosis of depression on young people and then leave it to them (and the adults in their lives) to figure out how to get good help. How involved are doctors planning to be in assisting families in the often nightmarish process of finding good help, ranging from the headache of navigating health insurance (if you have it), navigating cost (often a barrier even with insurance), and the fact that finding the right help is often a process of “trial and error?”
The young people we interviewed for our depression education and suicide awareness program and video for high schools spoke a lot about the challenges of trying to get help for depression. Sometimes there aren’t a lot of mental health resources where you live, sometimes the cost of treatment is prohibitive, sometimes the first therapist you go to isn’t the best fit.
Will doctors have the time and expertise (and patience!) to truly help youth find the right help? Will they receive training in how to collaboratively pick a treatment approach with their patients that take into account each individual’s unique circumstances, cultural background and so on? Will youth be encouraged to express their opinions and preferences around what kind of teen depression help they think would benefit them most?
We can’t slap on a depression diagnosis and then abandon youth and their families as they attempt to muddle their way through the disaster that is our healthcare system. It’s irresponsible. “First do no harm.” We better have our act together and a plan in place before implementing a policy like universal screening that will most likely result in more youth looking for care.
8. Where is the discussion around social factors that are significant contributors to mental health struggles in youth?
We live in a world where people kill one another and people don’t have enough to eat. Many of our youth lead difficult lives where their basic needs for nourishment, shelter, safety and loving relationships are not met. Others face crushing pressure to constantly achieve, are bullied via social media or rejected by their communities for who they are. If that’s not disheartening, I don’t know what is.
We need to have conversations around the social factors that contribute to depression and embrace the need for social change if we truly want to reduce youth suffering (more on this in a later post).
9. What now?
If I wake up one day and research has shown that screeners are the way to go, I will happily jump aboard that train. At the moment, we have a lot of work to do before confidently saying they are an effective and safe intervention.
Here’s what we can all do in the meantime:
Educate yourself. Don’t take research at face value.
My high school statistics teacher taught me to never take a statistic or research proclamation at face value. This paired with my natural tendency to question everything means any time I read a news report related to mental health I dig deeper. News reports of statistics or research findings are often overly simplified or the promise of a new intervention is over hyped.
Granted, I am in the privileged position of having access to journal articles. It’s not always easy to get to the source materials (more on this in a later post).
Ask for data.
We deserve well-researched public health initiatives. These public health concerns are too important to tackle willy-nilly and spend precious resources on unless we have data to back them up. If we don’t see evidence to back up a new recommendation, we have the right (and, I would argue, the responsibility) to ask for it.
Teach the youth in your life to self-advocate and where they can tap into help if they need it for themselves or a friend.
A huge part of the Erika’s Lighthouse approach to teen depression education and suicide awareness is empowering students with the language and knowledge they need to advocate for themselves should they need help. It’s very important that teens know where in their school and community they can get help. Our resources and teen depression videos can support you in teaching these important skills to the youth in your life.
Participate in the conversation and ask that more voices are heard.
The more people and diverse perspectives involved in the conversation about screeners, the better. Lend your voice to the conversation, whether you’re coming at it from the perspective of researcher, mental health practitioner, educator, parent or youth. Let’s have a great dialogue around this. I believe we will find the best solutions working collaboratively with one another.
Remember that we all have a role to play in making sure youth with depression get the help they need and deserve.
It’s important to know that I am in no way against involving pediatricians in efforts to make sure that youth with depression get the help they need and deserve. This is a community effort and primary care doctors can absolutely play an important role in checking in on their patients’ mental health.
But a screener is a single in moment time, most likely administered at most once a year. It might lull us into a false sense of security that we’ve done all we need to do to support the mental well-being of our youth.
Most of us have youth in our lives we see far more frequently than that. We can play a key role in supporting their mental well-being. Ask them how they’re doing. Listen. Get them additional support when they need it. If you’re a parent of a child with depression, educate yourself. If you work with youth in a school setting, find out what you’re doing around depression education in your building. In whatever way feels right to you, let’s work together to create a world that’s a better place for young people and their mental health.
Sarah Griebler is our Director of Program Development. She is passionate about mental health education and having open and collaborative conversations about how to best support our youth. She encourages you to add your voice to the conversation around universal depression screening for youth and to contact her if you’d like to connect further.