Major Depressive Disorder, Major Depressive Episode
Conditions
Keywords
adolescent; mental health; depression; suicide
Brief summary
The primary goal of the proposed study is to compare the effectiveness of universal school based screening for adolescent major depressive disorder to the current school process of targeted screening based on concerning behavior.
Detailed description
The prevalence of annual major depressive disorder (MDD) episodes has increased by greater than 50% from 2008 to 2015 among US adolescents. Paralleling the rise in MDD, suicide is now the 2nd leading cause of adolescent deaths. Despite the US Preventive Services Task Force (USPSTF) 2009 endorsement of universal screening for adolescent MDD in primary care, MDD screening occurs in less than 2% of office visits. The primary goal of the proposed study is to compare the effectiveness of universal versus targeted adolescent MDD screening in a school setting. Universal screening was chosen to be conducted in schools because, compared to medical settings; schools are more likely to regularly engage with adolescents. The hypothesis is that universal school-based screening with the validated Patient Health Questionnaire (PHQ) will result in increased rates of MDD screening, identification and treatment engagement. The Penn State team brings a breadth of experience in pediatrics, community-engaged research, adolescent health, psychiatry and engagement with minority populations.
Interventions
OTHERUniversal Screening Arm
Students with PHQ-9 score \>10, corresponding to a positive MDD screen, will proceed through the same SAP triage process as students referred by traditional means. SAP triage will determine MDD identification. As SAP triage is not diagnostic, MDD identification is based on SAP recommendations for MDD related school or community services. Treatment engagement will be tracked per current SAP processes. To immediately identify and address suicidal intent, the survey will flag a positive response to PHQ-9 question 9 in real time. A suicidal student would proceed directly to management through the school crisis plan. Students in the intervention arm will also be tracked for behavior concerning for MDD at any point in the school year prompting SAP triage referral.
Sponsors
Health Resources and Services Administration (HRSA)
Patient-Centered Outcomes Research Institute
Milton S. Hershey Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SCREENING
Masking
NONE
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Students in grades 9-12 at 14 public schools in Pennsylvania. This is a change from the originally anticipated 16 schools, as 2 were unable to continue participation. Anticipated enrollment numbers will be updated once the data are finalized. HRSA funding for primarily rural school districts (only one is urban). PCORI funding for urban school districts.
Exclusion criteria
* Students whose parents complete the opt-out consent * Students not enrolled in one of the participating schools * Students not in grades 9-12 * Students with disabilities that are deemed unable to participate by the school district
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Major Depressive Disorder (MDD) Composite: Positive Patient Health Questionnaire-9 (PHQ-9; Universal Arm) or MDD Concern Prompting Student Assistance Program (SAP) Referral, Confirmed MDD Symptoms by SAP, Engage With One SAP Recommended Service/Treatment | up to 9 months | Universal 1) Adolescents with PHQ-9 score \>10 or who at any point in the year exhibit behavior concerning for MDD prompting a SAP triage request (PHQ-9 score: min 0, max 27, higher scores=greater depression symptoms), 2) Adolescents identified with MDD by SAP triage, and 3) Adolescents who successfully engage with at least one SAP recommendation. Prior Sept-Nov screening adjusted per school preference. Targeted 1\) Adolescents with behavior concerning for MDD prompting a SAP triage request, 2) Adolescents identified with MDD by SAP triage, and 3) Adolescents who successfully engage with at least one SAP recommendation Concern for MDD based on a primary or secondary potentially MDD related SAP incoming referral reason SAP triage is not diagnostic, so MDD identified based on recommendations for MDD related school or community services (e.g. mental health treatment services) HRSA funds mostly rural schools (all rural but one school) and PCORI funds urban schools |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| MDD Screen Positive/Concern: Adolescents Who Screen Positive for MDD Either by PHQ-9 (Universal Screening Arm Only) or by Concern for MDD Prompting a Request for SAP Triage | up to 9 months | Universal screening arm: Adolescents with PHQ-9 score \>10 or who at any point in the year exhibit behavior concerning for MDD prompting a self or collateral request for SAP triage (PHQ-9 score: min 0, max 27, higher scores=greater depression symptoms) Targeted screening arm: Adolescents with behavior concerning for MDD which prompts self or collateral request for SAP triage at any point during the school year. Concern for MDD is based on a primary or secondary potentially MDD related SAP incoming referral reason. |
| Suicidal Adolescent | up to 9 months | Universal screening arm: PHQ-9 positive response to question #9 re: suicidal thoughts, which requires management by the state-mandated school crisis plan or student self or collateral report of suicidal thoughts, which requires management by the state-mandated school crisis plan (source school district). Targeted screening arm: Student self or collateral report of suicidal thoughts, which requires management by the state-mandated school crisis plan (source school district). Any student suicide attempts or completed suicides shared with the school district will also be included. |
| MDD Identification: Adolescents Confirmed With MDD Symptoms in Need of Follow-up Based on Triage by the School SAP Team | up to 9 months | Universal and targeted screening arms: Adolescents who are identified as having MDD symptoms in need of follow-up based on triage by the school SAP team. As SAP triage is not diagnostic, MDD identified will be based on SAP recommendations for school or community services which are MDD related (e.g. mental health treatment services). |
| MDD Treatment Engagement: Successful Engagement With at Least One SAP Recommendation | up to 9 months | Universal and targeted screening arms: Adolescents who successfully engage with at least one SAP recommendation. This may be fulfilled by parental report that an appointment was successfully scheduled. |
| Missed School Days | up to 9 months | data aggregate by grade level only |
| Grade Point Average (Gpa) | up to 9 months | data aggregate by grade level only |
| Grade Advancement/Graduation: This Measure Represents the Percent of Students Promoted in Each Grade for the School (Grades 9-12, School District Data) | up to 9 months | data aggregate by grade level only Note: The clinical trials record previously included additional secondary outcome measures for the Keystone testing and SAT/ACT testing. However, as these data were only received from one school, and these tests are only given in specific grades, reporting these outcomes would require disclosure of the number of students in specific grades at this school. This level of detail could allow specific school identification, and the variables were removed. |
| Student School Policy Violations and Suspensions Based on School District Data | up to 9 months | data aggregate by grade level only schools currently track the number of student policy violations (e.g. for drug and alcohol, violence) and student suspensions |
Other
| Measure | Time frame | Description |
|---|---|---|
| Subgroup Analyses Based on School District Demographic Data | up to 9 months | Sex (Male, Female), Ethnicity, Race, Rural/Urban |
Countries
United States
Participant flow
Recruitment details
Letters sent to parents or guardians before screening detailed the project and screening instrument, the Patient Health Questionnaire-9 (PHQ-9), and offered the opportunity to opt their student out of the study. Out of 13,171 students, 262 opted out.
Participants by arm
| Arm | Count |
|---|---|
| Targeted Screening Arm (Current Process) Students randomized to the targeted screening arm will complete their routine school-based health screenings. Students will be followed through the academic year for referrals to the Student Assistance Program (SAP). SAP currently exists in all Pennsylvania (PA) schools and functions like a triage service. If a student exhibits behavior concerning for MDD (raised by any contact, e.g. teachers, nurse, parent, peer, or even self-referral), SAP will triage the student and based on the initial assessment provide recommendations for school or community-based services. | 6,436 |
| Universal Screening Arm (Intervention) Students randomized to the universal screening arm will complete the Patient Health Questionnaire (PHQ-9) during the academic year. This screening tool includes nine close-ended questions with a scoring system ranging from 0 to 27. Scores \>10 are considered a positive screen. Students with a positive PHQ-9 result will then proceed to SAP triage as per the current process for those referred via the targeted screening arm.
Universal Screening Arm: Students with PHQ-9 score \>10, corresponding to a positive MDD screen, will proceed through the same SAP triage process as students referred by traditional means.
SAP triage will determine MDD identification. As SAP triage is not diagnostic, MDD identification is based on SAP recommendations for MDD related school or community services.
Treatment engagement will be tracked per current SAP processes.
To immediately identify and address suicidal intent, the survey will flag a positive response to PHQ-9 question 9 in real time. A suicidal student would proceed directly to management through the school crisis plan.
Students in the intervention arm will also be tracked for behavior concerning for MDD at any point in the school year prompting SAP triage referral. | 6,473 |
| Total | 12,909 |
Baseline characteristics
| Characteristic | Total | Targeted Screening Arm (Current Process) | Universal Screening Arm (Intervention) |
|---|---|---|---|
| Age, Continuous | 16 years | 16 years | 16 years |
| Grade 10th | 3154 Participants | 1048 Participants | 2106 Participants |
| Grade 11th | 2983 Participants | 1932 Participants | 1051 Participants |
| Grade 12th | 2811 Participants | 1026 Participants | 1785 Participants |
| Grade 9th | 3961 Participants | 2430 Participants | 1531 Participants |
| Race/Ethnicity, Customized Hispanic (any race) | 2687 Participants | 1266 Participants | 1421 Participants |
| Race/Ethnicity, Customized Non-Hispanic Black | 2891 Participants | 1571 Participants | 1320 Participants |
| Race/Ethnicity, Customized Non-Hispanic White | 5842 Participants | 2857 Participants | 2985 Participants |
| Race/Ethnicity, Customized Other or multiple races | 1489 Participants | 742 Participants | 747 Participants |
| Region of Enrollment United States | 12909 participants | 6436 participants | 6473 participants |
| Sex: Female, Male Female | 5946 Participants | 2941 Participants | 3005 Participants |
| Sex: Female, Male Male | 6963 Participants | 3495 Participants | 3468 Participants |
| Urban/rural Rural | 1446 Participants | 708 Participants | 738 Participants |
| Urban/rural Urban | 11463 Participants | 5728 Participants | 5735 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 6,436 | 0 / 6,473 |
| other Total, other adverse events | 0 / 6,436 | 0 / 6,473 |
| serious Total, serious adverse events | 0 / 6,436 | 0 / 6,473 |
Outcome results
Primary
Major Depressive Disorder (MDD) Composite: Positive Patient Health Questionnaire-9 (PHQ-9; Universal Arm) or MDD Concern Prompting Student Assistance Program (SAP) Referral, Confirmed MDD Symptoms by SAP, Engage With One SAP Recommended Service/Treatment
Universal 1) Adolescents with PHQ-9 score \>10 or who at any point in the year exhibit behavior concerning for MDD prompting a SAP triage request (PHQ-9 score: min 0, max 27, higher scores=greater depression symptoms), 2) Adolescents identified with MDD by SAP triage, and 3) Adolescents who successfully engage with at least one SAP recommendation. Prior Sept-Nov screening adjusted per school preference. Targeted 1\) Adolescents with behavior concerning for MDD prompting a SAP triage request, 2) Adolescents identified with MDD by SAP triage, and 3) Adolescents who successfully engage with at least one SAP recommendation Concern for MDD based on a primary or secondary potentially MDD related SAP incoming referral reason SAP triage is not diagnostic, so MDD identified based on recommendations for MDD related school or community services (e.g. mental health treatment services) HRSA funds mostly rural schools (all rural but one school) and PCORI funds urban schools
Time frame: up to 9 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Major Depressive Disorder (MDD) Composite: Positive Patient Health Questionnaire-9 (PHQ-9; Universal Arm) or MDD Concern Prompting Student Assistance Program (SAP) Referral, Confirmed MDD Symptoms by SAP, Engage With One SAP Recommended Service/Treatment | 35 Participants |
| Universal Screening Arm (Intervention) | Major Depressive Disorder (MDD) Composite: Positive Patient Health Questionnaire-9 (PHQ-9; Universal Arm) or MDD Concern Prompting Student Assistance Program (SAP) Referral, Confirmed MDD Symptoms by SAP, Engage With One SAP Recommended Service/Treatment | 80 Participants |
Comparison: Statistical analysis was conducted using the intent-to-treat principle. Analysis for primary and secondary outcomes that compared universal to targeted screening was conducted using mixed effects logistic regression.p-value: <0.00195% CI: [1.39, 3.1]Regression, Logistic
Secondary
Grade Advancement/Graduation: This Measure Represents the Percent of Students Promoted in Each Grade for the School (Grades 9-12, School District Data)
data aggregate by grade level only Note: The clinical trials record previously included additional secondary outcome measures for the Keystone testing and SAT/ACT testing. However, as these data were only received from one school, and these tests are only given in specific grades, reporting these outcomes would require disclosure of the number of students in specific grades at this school. This level of detail could allow specific school identification, and the variables were removed.
Time frame: up to 9 months
Population: Information obtained from one school in the 2018-2019 school year. The following year was the COVID-19 pandemic (2019-2020). It was decided obtaining this secondary, grade level information was a lower priority versus the primary outcome.~For this single school all students advanced to the next grade level. Cell counts are low and reporting raw numbers would allow identification of the school, so the information is provided as a percentage.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Grade Advancement/Graduation: This Measure Represents the Percent of Students Promoted in Each Grade for the School (Grades 9-12, School District Data) | 100 % of students |
| Universal Screening Arm (Intervention) | Grade Advancement/Graduation: This Measure Represents the Percent of Students Promoted in Each Grade for the School (Grades 9-12, School District Data) | 100 % of students |
Secondary
Grade Point Average (Gpa)
data aggregate by grade level only
Time frame: up to 9 months
Population: Information was obtained from one of the participating schools in the 2018-2019 school year. The following year saw the start of the COVID-19 pandemic (2019-2020). It was ultimately decided obtaining this secondary, grade level information was a lower priority compared to the primary outcome.~Data from this one school is reported as summed gpa by grades randomized to each arm, but no further analysis was conducted.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Grade Point Average (Gpa) | 6.2 total summed gpa per grade in each arm |
| Universal Screening Arm (Intervention) | Grade Point Average (Gpa) | 5.2 total summed gpa per grade in each arm |
Secondary
MDD Identification: Adolescents Confirmed With MDD Symptoms in Need of Follow-up Based on Triage by the School SAP Team
Universal and targeted screening arms: Adolescents who are identified as having MDD symptoms in need of follow-up based on triage by the school SAP team. As SAP triage is not diagnostic, MDD identified will be based on SAP recommendations for school or community services which are MDD related (e.g. mental health treatment services).
Time frame: up to 9 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | MDD Identification: Adolescents Confirmed With MDD Symptoms in Need of Follow-up Based on Triage by the School SAP Team | 64 Participants |
| Universal Screening Arm (Intervention) | MDD Identification: Adolescents Confirmed With MDD Symptoms in Need of Follow-up Based on Triage by the School SAP Team | 233 Participants |
p-value: <0.00195% CI: [2.49, 4.38]Regression, Logistic
Secondary
MDD Screen Positive/Concern: Adolescents Who Screen Positive for MDD Either by PHQ-9 (Universal Screening Arm Only) or by Concern for MDD Prompting a Request for SAP Triage
Universal screening arm: Adolescents with PHQ-9 score \>10 or who at any point in the year exhibit behavior concerning for MDD prompting a self or collateral request for SAP triage (PHQ-9 score: min 0, max 27, higher scores=greater depression symptoms) Targeted screening arm: Adolescents with behavior concerning for MDD which prompts self or collateral request for SAP triage at any point during the school year. Concern for MDD is based on a primary or secondary potentially MDD related SAP incoming referral reason.
Time frame: up to 9 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | MDD Screen Positive/Concern: Adolescents Who Screen Positive for MDD Either by PHQ-9 (Universal Screening Arm Only) or by Concern for MDD Prompting a Request for SAP Triage | 200 Participants |
| Universal Screening Arm (Intervention) | MDD Screen Positive/Concern: Adolescents Who Screen Positive for MDD Either by PHQ-9 (Universal Screening Arm Only) or by Concern for MDD Prompting a Request for SAP Triage | 1026 Participants |
p-value: <0.00195% CI: [5.07, 6.93]Regression, Logistic
Secondary
MDD Treatment Engagement: Successful Engagement With at Least One SAP Recommendation
Universal and targeted screening arms: Adolescents who successfully engage with at least one SAP recommendation. This may be fulfilled by parental report that an appointment was successfully scheduled.
Time frame: up to 9 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | MDD Treatment Engagement: Successful Engagement With at Least One SAP Recommendation | 35 Participants |
| Universal Screening Arm (Intervention) | MDD Treatment Engagement: Successful Engagement With at Least One SAP Recommendation | 80 Participants |
Secondary
Missed School Days
data aggregate by grade level only
Time frame: up to 9 months
Population: Information was obtained from one of the participating schools in the 2018-2019 school year. The following year saw the start of the COVID-19 pandemic (2019-2020). It was ultimately decided obtaining this secondary, grade level information was a lower priority compared to the primary outcome.~Data from this one school is reported, but no further analysis was conducted.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Missed School Days | 495 absences |
| Universal Screening Arm (Intervention) | Missed School Days | 358 absences |
Secondary
Student School Policy Violations and Suspensions Based on School District Data
data aggregate by grade level only schools currently track the number of student policy violations (e.g. for drug and alcohol, violence) and student suspensions
Time frame: up to 9 months
Population: Information was obtained from one of the participating schools in the 2018-2019 school year. The following year saw the start of the COVID-19 pandemic (2019-2020). It was ultimately decided obtaining this secondary, grade level information was a lower priority compared to the primary outcome.~Data from this one school is reported, but no further analysis was conducted.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Student School Policy Violations and Suspensions Based on School District Data | 3 Participants |
| Universal Screening Arm (Intervention) | Student School Policy Violations and Suspensions Based on School District Data | 1 Participants |
Secondary
Suicidal Adolescent
Universal screening arm: PHQ-9 positive response to question #9 re: suicidal thoughts, which requires management by the state-mandated school crisis plan or student self or collateral report of suicidal thoughts, which requires management by the state-mandated school crisis plan (source school district). Targeted screening arm: Student self or collateral report of suicidal thoughts, which requires management by the state-mandated school crisis plan (source school district). Any student suicide attempts or completed suicides shared with the school district will also be included.
Time frame: up to 9 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Targeted Screening Arm (Current Process) | Suicidal Adolescent | 96 Participants |
| Universal Screening Arm (Intervention) | Suicidal Adolescent | 622 Participants |
Other Pre-specified
Subgroup Analyses Based on School District Demographic Data
Sex (Male, Female), Ethnicity, Race, Rural/Urban
Time frame: up to 9 months
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Targeted Screening Arm (Current Process) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 20 Participants |
| Targeted Screening Arm (Current Process) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 90 Participants |
| Targeted Screening Arm (Current Process) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 31 Participants |
| Universal Screening Arm (Intervention) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 153 Participants |
| Universal Screening Arm (Intervention) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 52 Participants |
| Universal Screening Arm (Intervention) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 626 Participants |
| Male (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 110 Participants |
| Male (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 15 Participants |
| Male (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 33 Participants |
| Male (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 80 Participants |
| Male (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 28 Participants |
| Male (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 400 Participants |
| Non-Hispanic White (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 61 Participants |
| Non-Hispanic White (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 27 Participants |
| Non-Hispanic White (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 48 Participants |
| Non-Hispanic White (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 474 Participants |
| Non-Hispanic White (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 42 Participants |
| Non-Hispanic White (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 115 Participants |
| Non-Hispanic Black (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 6 Participants |
| Non-Hispanic Black (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 10 Participants |
| Non-Hispanic Black (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 95 Participants |
| Non-Hispanic Black (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 37 Participants |
| Non-Hispanic Black (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 187 Participants |
| Non-Hispanic Black (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 13 Participants |
| Hispanic (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 5 Participants |
| Hispanic (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 2 Participants |
| Hispanic (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 28 Participants |
| Hispanic (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 204 Participants |
| Hispanic (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 16 Participants |
| Hispanic (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 67 Participants |
| Other (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 0 Participants |
| Other (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 1 Participants |
| Other (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 16 Participants |
| Other (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 9 Participants |
| Other (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 14 Participants |
| Other (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 161 Participants |
| Urban (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 55 Participants |
| Urban (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 28 Participants |
| Urban (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 189 Participants |
| Urban (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 69 Participants |
| Urban (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 212 Participants |
| Urban (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 893 Participants |
| Rural (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 7 Participants |
| Rural (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 11 Participants |
| Rural (Targeted Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 9 Participants |
| Rural (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | SAP confirmed depressive symptoms in need of follow-up | 21 Participants |
| Rural (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Initiated treatment | 11 Participants |
| Rural (Universal Screening) | Subgroup Analyses Based on School District Demographic Data | Identified via PHQ-9 or behaviors of concern | 133 Participants |
p-value: <0.00195% CI: [6.71, 10.58]Regression, Logistic
p-value: <0.00195% CI: [6.58, 11.35]Regression, Logistic
p-value: 0.00695% CI: [4.65, 6.44]Regression, Logistic