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. Author manuscript; available in PMC: 2015 Oct 6.
Published in final edited form as: Rep Emot Behav Disord Youth. 2009 Fall;9(4):91–96.

The Case for School-Based Depression Screening: Evidence From Established Programs

Erin McCormick 1, Kelly Thompson 2, Ann Vander Stoep 3, Elizabeth McCauley 4
PMCID: PMC4594945  NIHMSID: NIHMS180106  PMID: 26451134

Abstract

This paper reviews the evidence base supporting early detection of depression through school-based screening. An overview of the rationale for school-based depression screening is presented. Evaluation highlights from established screening programs based in secondary schools that have been reviewed in the mental health, public health, and educational literatures are described. Presented in greater detail is the University of Washington's Developmental Pathways Screening Program including a summary of research findings that have supported its development and implementation.

Adolescent depression constitutes a major public health problem. By age 18, an estimated 20% of the U.S. population experiences an episode of major depression, and as many as 65% of adolescents report depressive symptoms (Kessler et al., 1994; Lewinsohn et al., 1993). For adolescents depressive episodes typically last 7-9 months, and 5-year recurrence rates approach 70% (Lewinsohn et al., 1995; McCauley et al., 1993; Rao et al., 1995). Depression is associated with adverse outcomes, including poor school performance, substance use problems, and suicide (Armstrong & Costello, 1999; Fergusson & Woodward, 2002; Glied & Pine, 2002; Rao et al., 1995; Rohde, Lewinsohn, & Seeley, 1996; Vander Steop et al., 2000). The World Health Organization has cited depression as the leading cause of disability worldwide and as the fourth leading contributor to the global burden of disease (World Health Organization [WHO], 1996, 2004).

Intervention with adolescents experiencing subclinical signs of depression can significantly reduce depressive symptoms and the incidence of depressive disorders (Clarke et al., 2001; Gillham et al., 1995; Jaycox et al., 1994; Horowitz & Garber, 2006; Garber et al., 2009). For adolescents already experiencing depression, early identification and appropriate intervention can result in relief from depressive symptoms, a reduced number of recurrences, and improvement in academic performance (Allgood-Merten, Lewinsohn, & Hops, 1990; Brent et al., 1997; Garber & McCauley, 2002; Garber, 2006; Kahn et al., 1990; Kazdin & Weisz, 1998; Lewinsohn & Clarke, 1999; Shochet et al., 2001). Longitudinal research indicates that obtaining treatment for adolescent depression leads to a significant reduction in the risk of depression during adulthood (Feehan et al., 1993; Harrington et al., 1996). This reduced risk for long-term adverse outcomes underscores the necessity for early identification. However, depression is more challenging to detect than externalizing conditions such as attention deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder.

This paper reviews the evidence base that supports early detection of depression through school-based screening. An overview of the rationale for school-based depression screening is presented as well as evaluation highlights from established programs based in secondary schools that have been reviewed in the mental health, public health, and educational literatures. Described in greater detail are the University of Washington's Developmental Pathways Screening Program and the growing evidence base that supports its development and implementation.

Addressing Depression from a Public Health Perspective

Studies suggest that only one-fourth to one-third of depressed adolescents receive treatment (Mills et al., 2006; Weist et al., 2007; Zuckerbrot et al., 2007). Among those who seek treatment, access is not equally distributed. Indeed, factors such as race, ethnicity, language, culture, age, gender, financial status, and insurance status affect service utilization (Cassano & Fava, 2002), with historically marginalized and stigmatized populations having the least access to necessary services (Mills et al.). In 2003, the New Freedom Commission reported the discrepancy between recognized mental health needs and the receipt of necessary mental health services (Center for Disease Control [CDC], 2003). The failure of the national mental health system to address the emotional health needs of our youth heightens the necessity for alternative solutions. A promising early intervention is found in the public health arsenal: screening. Screening interventions that detect early signs of depression implemented in conjunction with programs that provide support to those who screen positive have the potential to halt disease progression and reduce the long-term negative outcomes associated with early onset of the disease (Cole, Luby, & Sullivan, 2008).

Early Detection and Prevention in Secondary Schools

Schools serve as an ideal setting for the early detection of emotional disorders. The public school system touches the lives of most American children, especially those from historically disadvantaged and vulnerable populations. Because of their broad reach, school-based mental health (SBMH) programs can access youth who are typically missed by interventions that are only available in the health care sector (Cuijpers, van Straten, Smits, & Smit, 2006; Mills et al., 2006; Vander Stoep et al., 2005; Weist et al., 2007). Schools have begun to extend mental health services to students as part of coordinated school health programs (SBMH) (Weist et al.). SBMH programs reduce barriers to learning, increase contact with students, and expand the scope of engagement strategies addressing educational, emotional, behavioral, and developmental needs (Weist et al.). Research describes the shift from clinic-based to school-based mental health interventions, asserting that 70-80% of school-age children who receive mental health services access them through their schools (Chatterji et al., 2004).

Parents, teachers, and school counselors can readily identify some forms of emotional distress, especially those that manifest as disruptive behavior problems. However, the “quieter” forms of distress that manifest their effects on thoughts and feelings, rather than behavior often go unrecognized in children and adolescents until serious manifestations, such as suicidal ideation or behavior are evident. Systematic assessments that target internalizing symptomology can assist in identifying at-risk students (Cole et al., 2008; Mills et al., 2006; Zuckerbrot et al., 2007). Because children may be reticent to reveal their negative cognitions and emotions and report potentially stigmatizing information in face-to-face evaluations, researchers have developed and validated self-report screening tools to tap childhood internalizing symptoms (Scott et al., 2009). These tools accurately differentiate distressed from non-distressed children and can be administered confidentially in group settings.

Support for screening is founded on the belief that mental illness has identifiable traits and is highly treatable when identified (Gould et al., 2005). For a screening program to be worthwhile, it should be capable of identifying cases in early clinical stages, and it should lead to the application of effective intervention during this preclinical phase. If both of these criteria are met, the screening program will be effective in halting disease progression (Hennekens & Buring, 1987). Completing a depression screen presents low risk to students but has the potential to yield high benefits in terms of morbidity, disability and mortality reduction (Kent, Vostanis, & Feehan, 1997; Weist et al., 2007).

Children routinely receive physical check-ups that include examination for illnesses, such as scoliosis with a low prevalence. However, children rarely receive emotional health check-ups, despite the high prevalence estimates of child and adolescent mental illness. The New Freedom Committee and the Child Mental Health Screening and Prevention Act, with the support of the Garrett Lee Smith Memorial Act, stimulated some attention and funding to screening for mental illness (Friedman, 2006; Gould et al., 2005). As a result, screening programs have cropped up in schools across the country. Described below are four different secondary school-based depression screening models. Figure 1 is a schematic depicting the differing levels of concern and intervention that are intrinsic to the screening models.

Figure 1. Schematic of differences in school-based depression screening models.

Figure 1

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Reynolds' Multi-stage Depression Screening

Because of the episodic nature of depressive illness and often transient nature of depressive symptoms, Reynolds (1986) introduced a multiple-stage screening model. The multiple assessment model addresses the potential of having a high number of false positives in initial screens. In this model, the first round of screening is universal. The second round is a rescreening of those who screened high the first time, roughly 3-6 weeks after original assessment. The third and final round is a clinical evaluation of all the students who screened high in the second round. At no point in the process were the screens intended to function as formal diagnosis of depression. Rather, the program sought to identify those at risk of depression and those in need of intervention. Although this program was described in the scientific literature, no evaluation reports have been published. Recent school-based models, in particular Teen Screen and Signs of Suicide (SOS), have built on and modified Reynolds' early screening model.

TeenScreen

Columbia University's TeenScreen Program is a voluntary mental health check-up program that assists both students and parents in understanding the changes of adolescence. Since its inception, the program has spread from its original location in New York City to over 500 local sites (schools and community-based settings) in 43 states and Washington, D.C. TeenScreen's program, which assesses children age 9-18, consists of two parts: administration of a questionnaire that takes 10 minutes to complete and assesses depressive symptoms, suicidal ideation and attempts, anxiety, substance use, and general health problems and follow-up of positive screens by a mental health professional. The follow-up interview functions as a verification process, to confirm whether the questionnaire's result is clinically significant. If deemed necessary, students and parents are offered free referrals for further evaluation. In 2005, the program screened roughly 55,000 students across the U.S. 33% of TeenScreen participants screened positive, and 17% positive screens required further evaluation (Friedman, 2006). Recently, Scott et al. (2009) evaluated the effectiveness of the TeenScreen Program. In that study, the research staff tested TeenScreen's effectiveness at identifying distressed students. Although TeenScreen aims to identify students at risk, its effort would be redundant if the program only identified students already recognized as at-risk by school officials. The research staff recruited study participants from seven high schools in the New York City metropolitan area. In total, 1729 students participated in the screening, and 489 students screened positive. The principal nominated staff to serve as identifiers of troubled youth, and each staff member was blinded to the student's screen status. Staff members were asked to assess level of concern about each student's emotional health. Ultimately, the research staff determined that roughly 34% of students who had screened positive with TeenScreen were not identified as at-risk by faculty. These findings support the idea that screening captures manifestations of adolescent distress that are otherwise overlooked by involved adults. (Scott et al., 2009).

Signs of Suicide

Signs of Suicide (SOS) is a school-based prevention program that includes both an educational and a screening element. The SOS program includes a short curriculum to increase awareness of suicide and the risks leading to suicide. A unique feature of this education component is the emphasis on peer intervention. The program outlines a response plan entitled ACT that stands for Ask, Care, and Tell. When they suspect a peer is suicidal, students are instructed to ask how the peer how s/he is doing, to remind the peer that they care and to tell their concerns about the student to an adult. According to developmental theory, peers serve as the primary sphere of social involvement during adolescence; therefore, SOS's peer focused intervention appears developmentally appropriate for this age group (Aseltine & DeMartino, 2004). The screening portion of this project varies from TeenScreen's model. In the SOS program, students voluntarily complete a screening questionnaire that taps depressive symptoms and suicidal thoughts; then students are responsible for scoring their own questionnaires. SOS program staff informs students of what constitutes a positive screen, and the onus to follow-up with appropriate services is on the students. In an outcome evaluation conducted by Aseltine and DeMartino (2004), SOS demonstrated a short-term impact on students' attitudes and behavior towards suicide. In the study, 2100 students in five schools (3 in Hartford, CT and 2 in Columbus, GA) participated in a randomized control study. These students represented a racially and economically diverse sample. Students in the intervention group were administered the 2-day SOS program in either health or social studies class. Students in the control group were not exposed to the SOS program until the evaluation was complete. Three months after implementation of this program to the intervention group, the entire study sample was surveyed about their attitudes and behaviors in terms of suicide. The results of this assessment illustrated that the intervention group maintained lower rates of suicide attempts, greater knowledge about suicide prevention as well as a nuanced attitude about depression and suicide. Evaluation of the long-term effects of this program has not been conducted (Ibid).

As evidenced above, a number of program models incorporating mental health screening in school settings have been implemented and evaluated. Two extend the reach of early identification by making straight forward screening approaches available within the school setting and providing resources for (TeenScreen) or encouragement of (SOS) a follow-up response to a positive screen. None of the models coupled the multiple-stage screening model with a systematic on-site follow-up that actively facilitates student linkage to supportive services.

Developmental Pathways Screening Program

The Developmental Pathways Screening Program (DPSP) was designed to identify students experiencing emotional distress as they transition to middle school, to determine the source of their distress, and to link these students to supports to enhance their chances for a healthy, successful start to middle school. The program targets a developmental transition from elementary school to middle school, a time of vulnerability that can adversely affect a child's self-esteem, social engagement, and scholastic performance. DPSP identifies students early in the transition period when the risk of emotional distress is heightened and when even those with distress levels below diagnostic thresholds face adverse long-term outcomes, if their distress is not addressed. The screening program is implemented universally, as some manifestations of distress remain invisible and thus are frequently overlooked. Child mental health professionals visit schools to conduct follow-up evaluations of students who screen positive. Need for support is determined and linkages to school and community-based academic, social, and mental health supports are facilitated.

Theoretical Model Underlying DPSP

DPSP retains important components of prior mental health screening models. Firstly, the project is implemented in the school setting. All participating students initially complete a brief, valid confidential screening questionnaire assessing their depressive and conduct problem symptoms. Child mental health professionals provide on-site follow-up evaluations for positive screens and contact parents of all students who undergo evaluation to deliver recommendations for support. The model extends previous screening models in several important ways. DPSP targets children prior to the high school years when a precipitous increase is observed in the incidence of depressive disorders. Because the normative transition to middle school is stressful to most students and can trigger previously latent emotional distress in vulnerable students, the initial round of screening is universal in nature. In the middle phase of program implementation, students are considered positive screens if they show early signs of distress, scoring below a cut off score threshold that is set below the clinical range established for the screening measures. Child mental health professionals (CMHP) offer on-site follow-up evaluation to all positive screens. During and after this evaluation, the CMHP facilitates the student's connection to appropriate academic, social and mental health services by using motivational interviewing techniques in conversations with students and their caregivers. DPSP seeks to shorten the typical 6-8 year delay between the onset of a mood disorder and treatment seeking (Friedman, 2006) and to improve 6th graders' adjustment to middle school through early identification of distress as well as active linkage with appropriate services. Table 1 describes some of the specific features of the DPSP screening program.

Table 1. Components of Developmental Pathways Screening Program.

DPS Program Component Specific Features
Confidential Screening Questionnaire 3rd grade reading level; administered in classroom during one class period by university staff
Onsite Follow-up Evaluation Conducted by master's level child mental health professionals hired by university; 30-45-minute structured session with student and 15-minute semi-structured phone call to parent

  • Confirms presence of emotional distress

  • Determines source of distress (academic, social, emotional)

  • Develops plan for additional support: academic, social, emotional health

  • Incorporates elements of motivational interviewing (menu of options; decisional balance, feedback, OARS, open-ended questions, affirmations, reflections, summaries; Miller & Rollnick, 2002) to promote successful linkage
Accommodations for Special Populations

  • Informational materials are translated into major non-English languages of enrolled students

  • Administration of questionnaire can be verbal or one-on-one due to language, behavioral, reading, sensory challenges

  • Translation services used to deliver feedback via telephone to parents with limited English proficiency
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Evaluation of the DPSP

Over the years, a series of evaluations of the Developmental Pathways Screening Program have been carried out to address questions of whether:

  • implementation of school-based mental health screening was feasible,

  • screening was acceptable to families from a variety of racial and ethnic backgrounds,

  • the DPSP was cost effective,

  • active or passive parental consent matters,

  • screening generated an unacceptable number of false positives,

  • linkages to needed supports were successfully facilitated, and

  • the DSPS screening model was associated with a better school adjustment, linkage to supports, and parent satisfaction than a streamlined screening model.

Evaluation study methods and results are summarized below.

Feasibility

Initially, our concern was whether we could successfully inform families about the program and encourage them to participate, implement confidential screening in classrooms, and finally train and deploy part time clinicians to conduct onsite follow-ups. The DPSP was initially implemented in 2002 in four Seattle area middle schools (Vander Stoep et al., 2005) as part of a NIMH-funded epidemiological study of children's mental health. A total of 861 6th grade students, or 81% of enrollees at the four schools participated. Of the participating students, 15% screened positive and received an onsite structured follow-up assessment with a child mental health professional. Out of these students, 59% were determined to need additional support, including academic tutoring, referral to the school counselor, or community mental health services. Successful implementation of in-class screening was facilitated by strong collaborative relationships between DPSP and school staff. Confidentiality was maintained. High participation in 2002 screening was due in part to conditions of “passive” parental consent.

Acceptability

Public school systems in urban areas of the U.S. serve diverse populations. In the Seattle Public Schools, 23% of students are African American, 23% are Asian American, and 11% are of Hispanic origin. Thirty-nine percent meet eligibility requirements to receive free or reduced price lunches. A high percentage of students have at least one immigrant parent. Foundation funding obtained in 2004 was used to focus on questions of racial and ethnic differences in DSPS participation and outcomes. Parents were telephoned six weeks after screening and follow-up to collect information on three areas: linkage, barriers to linkage, and program satisfaction. Racial differences in participation rates were noted, with 49% African American, and 51% of Asian American students screened, compared to 67% of Hispanic, and 71% of European American students. No racial/ethnic differences were found in the percentage of children who screened positive, however, following evaluation by a child mental health professional, significantly more children of African American, Asian American, and Hispanic origin were determined to be in need of additional support. No racial or ethnic differences were found in the proportion that were successfully linked. The top six barriers to successful linkage as reported by parents included transportation, limited time availability, child discomfort with recommended plan, difficulty contacting provider, cost, and stigma. Significantly more Asian American, African American, and Hispanic parents than European American parents reported transportation and limited time as barriers. Significantly more European American parents reported child discomfort with recommended plan as a barrier. Overall, 94% of participating parents reported high program satisfaction.

Cost-effectiveness

Considerations of program costs and effectiveness enter into decisions as to whether to implement school-based mental health screening. Kuo et al. (2009) enumerated costs for DPSP screening and clinical evaluation in terms of labor and overhead and summarized program cost per enrolled student, per positive screen, and per referral. Cost-effectiveness was reported in terms of cost per student successfully linked to services. School demographics were used to generate a predictive formula for estimating the proportion of students likely to screen positive in a particular school, and this proportion can be used to estimate program cost. Program costs ranged from $8.88 to $13.64 per enrolled student, depending on the prevalence of positive screens in a school. Of students who were referred for services, 72% were linked to supportive services within six weeks. Cost-effectiveness was estimated to be $416.90 per successful linkage when 5% of students screened positive, and $106.09 when 20% screened positive. A formula for estimating the proportion of students who will screen positive was derived from information on a school's student population, including % male gender, % receiving reduced fee lunch, % English Language Learner, % Special Education, % single parent households, and % suspended in the past year proved accurate to within 5%.

Parental Permission

As mentioned previously, the Seattle Public School District's parental consent requirements were changed from passive to active between the 2002-3 and 2003-4 school years. The change in permission conditions provided a natural experiment to examine the differences in DPSP participation under active vs. passive consent (Chartier, 2008). When children were required to have written parental permission (active consent), participation declined dramatically from 85% to 66%, compared to when parents were provided with written information and then had to actively decline in order for their child not to participate (passive consent). The decline in participation was disproportionately higher among subgroups of students who were at greater risk for depression. Thus, the requirement of active parental consent was associated with the unwanted effect of reinforcing existing disparities in access to mental health services.

Positive Predictive Value

A recurring concern in the arena of depression screening is the “false positive.” When children who are not truly suffering from emotional distress screen positive, they and their parents can be subjected to undue apprehension and possibly stigmatization. Therefore, a screening program must choose a validated screening tool and must set a cut off level that optimizes the “yield” while reducing the number of false positives. During its eight years of implementation, DPSP has maintained a very steady positive predictive value of ∼60%. With a positive screen prevalence of 20 per 100, when the program screens 100 children, 8 will screen positive falsely and 12 will be “true positives.” DPSP staff takes steps such to reduce students' anxiety around screening by ensuring confidential and up beat follow-up evaluations, by using non-stigmatizing language (distress, rather than depression), and by communicating in parent phone calls about the student's assets.

Linkage Success

A concern held by schools or communities is that universal screening will yield a need that is larger than the available resources. At the level of the individual child and family, this problem translates into the risk of identifying a problem, but not resolving it. There are many barriers to obtaining mental health services, including lack of mental health coverage by healthcare insurance plans, a large proportion of the population that is uninsured, and a lack of access to evidence-based treatments. As a result, communities are not ensured positive outcomes for persons experiencing emotional distress or even serious psychiatric disability, especially in the face of other pressing health, educational, or social concerns. Since 2005, DPSP has embedded a motivational interviewing component into the clinical evaluation, added a second follow-up phone call to parents who received recommendation for supports, and then tracked whether students were successfully linked to recommended supports through a call from a research assistant 5-weeks post-screening. Over the most recent four years of program implementation, research assistants make a 5-week post-screening phone call to parents to track the proportion of recommendations that result in successful linkage.

Pilot RCT

The 2008 iteration of DPSP included implementation of a small-scale randomized control trial (McCormick, 2009). The trial investigated the impact of giving feedback to parents via telephone conversation with motivational interviewing (MI) versus giving feedback to parents via a mailed letter. Investigators hypothesized that parents in the telephone MI feedback condition would experience greater sense of urgency and empowerment and that as a result students of parents in this condition would:

  1. be more likely to link to recommended services

  2. experience lower levels of emotional distress by the 2nd semester of 6th grade

  3. experience a more positive middle school adjustment.

To assess emotional health outcomes (changes in depression and conduct problem scores), students who had screened positive in the fall received a second screening four months post-intervention, during the 2nd semester of 6th grade. School record data were used to ascertain GPA, attendance, and disciplinary actions. The previously described 5-week follow-up phone call was made to ascertain linkage status. After the second round of screening, staff surveyed parents and teachers to assess their satisfaction with the screening program.

Results showed that a higher proportion of students in the telephone MI feedback group (78%) were linked to recommended support services compared to the control group (36%) (1-tailed Fisher exact test, p=.06). In general, regardless of how parent feedback was delivered, students who screened positive and underwent the clinical evaluation reported significant declines in levels of depression symptoms, as well as conduct problems. Consistently better, but not statistically significant adjustment across three school indicators (GPA, attendance, disciplinary actions) was noted for students in the phone MI feedback condition. DPSP received high marks of satisfaction with students, parents, and teachers. Differences in parent reactions to the program were apparent in written comments. From a telephone MI feedback parent: “I got good follow-up on the phone call. [The CMHP] recommended talking to the teacher, which was great. [My daughter] formed a bond, and it's been really good for her to have support.” From a parent who received feedback via mail: “Not sure what the program does. Just got the letter - not really sure what she got out of the meetings.” Several parents in the control condition reported a desire for better communication during program implementation. In general, parents and teachers maintained high levels of agreement that mental illness adversely effects school performance and that students' mental health should be addressed in schools.

Of note is that each year that the DPSP has been implemented, a new evaluation question has been formulated and addressed. Implementation and evaluation costs have ranged from $10,000/year in one school to $30,000 in four schools. Originally funded as part of a larger National Institute of Health-sponsored epidemiological study, since 2005 DSPS has been supported by private foundations and individual donors. DPSP integrates program development, implementation, and evaluation at a low cost and provides a model for performing continuous quality improvement. Next steps are to design a larger randomized controlled trial.

Conclusions

In the past 20 years, school-based mental health programs have been created and modified, which has led to increased identification of at-risk students, connection of those students to appropriate services, and promotion of positive mental health at the individual and population levels (Cassano & Fava, 2002). Successful implementation of school-based mental health programs warrants a careful consideration and examination of potential costs and benefits. This paper reports on the growing base of empirical evidence that addresses questions regarding the costs and effects of school-based depression screening.

Although we have presented some encouraging evaluation findings to support the implementation of school-based screening, the evidence base warrants considerable strengthening through application of rigorous research methods. Studies are needed that can make appropriate attributions of improvement in linkage to supportive services, decreases in emotional distress and increases in academic success. Randomized controlled trials of screening programs, while ideal for generating findings about program effectiveness, are challenging to implement. Three factors, in particular land scientists in a methodological quagmire. First, it is difficult to apply random assignment at the individual student level within a universal screening framework, and at the school level, it is difficult to ensure adequate comparability and power. Next, it is difficult to measure outcomes because it is difficult to know whether children's mental health status is improving without screening them. And finally, it is difficult to establish a strong comparison condition because it is unethical to refrain from following up with children who screen positive.

Besides the micro-level questions of whether program benefits can be studied, implementation of universal screening programs also warrants as a careful assessment of community readiness and interest among target groups within the community. While a recent study published in the American Journal of Preventive Medicine ranked depression screening among the top 25 preventive services offering the most health benefit for the health care dollar (Johnson, 2006), implementation of universal screening of children remains controversial. Considerable public backlash was generated by recommendations from the New Freedom Commission to implement universal mental health screening in public schools. In 2004, the U.S. Congress proposed an amendment to an appropriations bill which would have prohibited funding for such programs (Paul, 2004). Although the bill did not pass, some members of the media, the public, and Congress decried universal screening as coercive and potentially stigmatizing. Ultimately, critics accused screening programs of furthering the shadowy agenda of the pharmaceutical industry (Conservative Caucus, 2004; Eakman, 2004). Fueling public apprehension about screening are reports of the recent upsurge in use of psychotropic medications such as Ritalin among school-aged children (Dunn, 2002) and of drug companies and even the FDA failing to make public evidence of harmful side-effects of antidepressants for treating adolescents (Shetty, R., 2004; Elias, 2004; Harris, 2004). Questions regarding the voluntary or mandatory nature of screening programs, the dissemination and use of screening results, and the interests and agendas of proponents and funders raise legitimate concerns that community stakeholders must address openly.

Meanwhile, depression and other mental health problems are taking a critical toll on school performance. An estimated 50% of failure to complete secondary school in U.S. population can be attributed to unaddressed mental health problems (Vander Stoep et al., 2003). A legacy of school-based screening and treatment for health conditions, a surge in the development of promising school-based programs addressing mental health concerns, and a focus among policy-makers on preventing childhood depression (Hoagwood, 2003) and “leaving no child behind” (U.S. Department of Education, 2002) indicate that the public interest and technological expertise needed to address mental health concerns in the school setting are increasing. As Hoagwood has written, “Given the serious risks that children with mental health problems face in remaining intellectually and emotionally engaged in learning, the integration of mental health and educational perspectives are needed.” With further evaluation and refinement, universal school-based depression screening may prove an effective means of detecting early precursors to mental health problems that can be readily addressed but if left unattended can escalate and seriously interfere with the cognitive, emotional and social development, reducing students' chances of academic success.

Contributor Information

Erin McCormick, University of Washington, Seattle.

Kelly Thompson, University of Washington, Seattle.

Ann Vander Stoep, University of Washington, Seattle.

Elizabeth McCauley, University of Washington, Seattle, Seattle Children's Hospital.

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