A recent BMJ article by one of the authors of this post (SW), argued the need for universal mental health checks in schools. This personal view stemmed from a wider collaborative research project (SW and KD), which explores the school as an effective site for early identification and intervention in mental health. The response to the BMJ article has been considerable. Here we would like to take the opportunity to reply to some of the more critical responses we have received. However, it is worth pointing out that many of the arguments in these responses, though they have critical intent, actually agree with rather than contradict our own arguments as expressed in the BMJ article. We use a recent blog by James Coyne as the basis for our response, since it nicely articulates some of the challenges we have received.
Coyne writes: “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.”
Our response: We agree. In fact, the concluding sentence of the BMJ article was: “The next step should be a trial to pilot and evaluate the short term outcomes of a routine mental health check in UK schools.” Skepticism is easy. Finding fault in existing proposals to the solution of a given problem is far less challenging than proposing new ways which remedy the faults in these existing proposals. When it comes to early identification of mental health issues, what are the alternatives and where is the evidence that they are effective? But let’s also not forget that evidence of the effectiveness of universal school based screening does exist.
Coyne writes: “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 labelled as having a mental health problem…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.”
Again, we agree. As argued in the BMJ paper, diagnosis does not happen as a result of the screening tests. Rather, the screening tests can enable monitoring, further investigation, and “watchful waiting.” Also it is emphasized that referral only happens for those children where screening has identified the need: “The children could be monitored and recommended for referral for treatment where appropriate.” The issue of false positives is also already addressed in the BMJ piece: “by carefully following up or referring children with potential mental health problems for further monitoring, we can reduce the potential risks of false positives, which are characteristic of a number of other routine screening programmes.” To reiterate, screening identifies those at risk of abnormal emotional, behavioral, and mental wellbeing and can lead to further monitoring, investigation, and follow-up. Although it was beyond the scope of the BMJ paper, we also feel that having mental health professionals, child psychologists, or counsellors, stationed in schools is a great idea. There are organizations that already use this approach—see Place2Be as an example. Secondly, two-stage screening is also an idea we support. Using a freely available tool like the Strengths and Difficulties Questionnaire (SDQ) as an initial screen would narrow down the number of children recommended for further assessment, thus addressing concerns over the cost of a screening programme as calculated in the BMJ paper.
Coyne writes: “[instead of screening] 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.”
Here, we disagree. Treatment for children who already have a serious mental health problem is of course essential, but we know that once a mental problem develops, it is much harder to “cure.” Recurrence rates for childhood depression are incredibly high at approximately 70%, not to mention comorbidity with other disorders. You do not only handle a crisis once it develops, you try to prevent it from happening. The ever increasing rates of childhood depression is a crisis and further treatment of those already in treatment does not appear to be stopping this crisis.
Simon Williams PhD FRSPH is a research associate at the Feinberg School of Medicine in Northwestern University, Chicago in the United States. He was formerly a research fellow at the Institute of Public Health at the University of Cambridge in the UK, and is a fellow of the Royal Society of Public Health. His research interests include public mental health policy and the effectiveness of early diagnosis.
Kimberly Dienes PhD is an assistant professor in the Department of Psychology at Roosevelt University. She is a licensed clinical psychologist and completed her internship and postdoctoral fellowship at Northwestern University’s Feinberg School of Medicine. She received her PhD in clinical psychology from the University of California, Los Angeles. Her research interests are stress sensitivity, depression, and HPA axis functioning.
Competing interests statement: All authors declare that that we have read and understood the BMJ Group policy on declaration of interests and we have no relevant interests to declare.