Multi-tiered Systems of Support for School-Based Mental Health: A Systematic Review of Depression Interventions

Help-seeking processes related to targeted school-based mental health services: systematic review

BACKGROUND

One in seven adolescents globally are affected by mental health conditions, yet only a minority receive professional help. School-based mental health services have been endorsed as an effective way to increase access to mental health support for people at risk, or currently presenting with mental health conditions, throughout adolescence. Despite this, low treatment utilisation prevails, therefore the aim of this review is to contribute insights into the processes related to adolescents' accessing and engaging with essential targeted mental health support within schools.

METHODS

This systematic review extracted qualitative, quantitative and mixed-methods data to determine what processes affect adolescents seeking help from targeted school-based mental health services (TSMS). Searches were conducted in EMBASE, Medline, PsycINFO, CINAHL, ERIC, Web of Science, in addition to manual searching and expert consultations. Data were synthesised following guidelines for thematic synthesis and narrative style synthesis.

RESULTS

The search resulted in 22 articles reflecting 16 studies with participant sample sizes ranging from n = 7 to n = 122. Three main themes were identified: 'access-related factors', 'concerns related to stigma', and 'the school setting'. These findings elucidate how help-seeking processes are variable and can be facilitated or hindered depending on the circumstance. We identified disparities with certain groups, such as those from low-socio economic or ethnic minority backgrounds, facing more acute challenges in seeking help. Help-seeking behaviours were notably influenced by concerns related to peers; an influence further accentuated by minority groups given the importance of social recognition. Conflicting academic schedules significantly contribute to characterising treatment barriers.

CONCLUSIONS

The findings of this review ought to guide the delivery and development of TSMS to facilitate access and promote help-seeking behaviours. Particularly, given the evidence gaps identified in the field, future studies should prioritise investigating TSMS in low- and middle-income settings and through quantitative methodologies.

REGISTRATION

The protocol for this systematic review was registered on PROSPERO (ID CRD42023406824).

Mental Health Screenings: Practices and Patterns of These and Other Health Screenings in U.S. School Districts

Schools' health screenings can identify students' missed health concerns. Data from the 2016 School Health Policies and Practices Study were used to determine the proportion of U.S. school districts with physical and mental health screening policies and the proportion that arrange off-campus mental health services. We also examined differences between districts with and without mental health screening policies regarding having physical health screening policies, patterns of these policies, and off-campus mental health service arrangements. Eleven percent of districts had no policies on any of the four physical health screenings assessed, and 87% lacked policies on mental health screenings, the latter especially concerning considering the impact of COVID-19. Districts with policies on mental health screenings were significantly more likely to have body mass index (p < .01) and oral health (p < .001) screening policies, and to arrange for off-campus case management (p < .001), family counseling (p < .05), group counseling (p < .01), self-help (p < .05) and intake evaluation (p < .05).

School-based universal mental health promotion intervention for adolescents in Vietnam: Two-arm, parallel, controlled trial

The aim of this study was to evaluate the effects of Happy House, a universal school-based programme, in reducing adolescents' depressive symptoms and improving their mental well-being, coping self-efficacy and school connectedness. This was a school-based, two-arm parallel controlled trial. Depressive symptoms were measured using the Centre for Epidemiologic Studies Depression Scale. Data were collected at recruitment, and at 2 weeks and 6 months post-intervention. Mixed-effect models were conducted to estimate the effects of the intervention on the outcomes. A total of 1,084 students were recruited. At 2 weeks post-intervention, the effect size on depressive symptoms was 0.11 (p = 0.011) and the odds of having clinically significant depressive symptoms were lower in the intervention compared to the control (0.56, p = 0.027). Both of these were no longer significant at 6 months post-intervention. Psychological well-being mean scores in the intervention were significantly higher than in the control at 2 weeks post-intervention (effect size 0.13). Coping self-efficacy mean scores were significantly higher in the intervention group at both 2-week and 6-month post-intervention (effect sizes from 0.17 to 0.26). Data support the potential of Happy House to reduce the prevalence of adolescent mental health problems and to promote positive mental health in the school context in Vietnam.

Adolescent, parent, and provider perspectives on school-related influences of mental health in adolescents with suicide-related thoughts and behaviors

Previous research supports a link between school-related factors, such as bullying and school connectedness, and suicidal thoughts and behaviors. To deepen understanding of how school experiences may function as both protective and risk factors for youth struggling with suicidal thoughts and behaviors, this qualitative study explored multiple perspectives. Specifically, in-depth interviews were conducted with adolescents previously hospitalized for a suicidal crisis (n = 19), their parents (n = 19), and the professionals they may interact with in schools and hospitals (i.e., school professionals [n = 19] and hospital providers [n = 7]). Data were analyzed using applied thematic analysis revealing three main themes related to perceptions of how school experiences can positively or negatively impact mental health, including (a) school activities, (b) school social experiences, and (c) school interventions. An emergent theme related to the complexity of suicide-related risk identified the ways in which school experiences may intersect with other environmental, biological, and psychological factors. Findings underscore the need for school-based approaches to address the unique academic, social, and emotional needs of students with suicide-related risk that complement the supports and services provided in their home and community.

Associations Between School Mental Health Team Membership and Impact on Service Provision

Schools are the most common venue in which children and youth receive mental health services. To organize delivery of mental health care to such a large number of children, use of school teams is often recommended. Yet, there is limited empirical literature about the composition of school mental health teams or teams’ relations to service provision. This study investigated team composition, including team multidisciplinarity (number of different types of professionals) and the presence of a community provider, and the relations of these two variables to service provision at Tier 1 (mental health promotion), Tier 2 (early intervention) and Tier 3 (intensive treatment) for 386 schools representing different school sizes, locations, and urbanicity. Results suggested team multidisciplinarity and the presence of a community provider were related to more frequent endorsement of service provision at schools. Practice and research implications are discussed including possible application to hiring decisions and further research with longitudinal data and information on service quality.

Community-Based Prevalence of Externalizing and Internalizing Disorders among School-Aged Children and Adolescents in Four Geographically Dispersed School Districts in the United States

The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

A multi-tiered systems of support blueprint for re-opening schools following COVID-19 shutdown

The COVID-19 pandemic will create enormous disruptions for youth and families with respect to economic and health status, social relationships, and education for years to come. The process of closing and intermittently reopening schools adds to this disruption and creates confusion for parents and school officials who must balance student educational progress with health and safety concerns. One framework that may serve as a roadmap in this regard is a multi-tiered systems of support (MTSS) model. This article briefly addresses four main domains of functioning (adjustment, traumatic stress, academic status, health and safety) across three tiers of support (universal, targeted, intensive). Each section draws on existing literature bases to provide specific recommendations for school officials who must address various and changing logistical, academic, and health-based challenges. The recommendations are designed to be flexible given fluctuations in the current crisis as well as focused on maximum-value targets. An MTSS approach adapted for contemporary circumstances can also be used to help address longstanding disparities that have been laid bare by the pandemic.

Effects of Mass Shootings on the Mental Health of Children and Adolescents

PURPOSE OF REVIEW

To examine mass shootings in youth including mass shooting trends, risk and protective factors for emotional sequelae, mental health, prevention of mass shootings, and the assessment and treatment of survivors.

RECENT FINDINGS

Many youth are exposed to gun violence, with a smaller subset exposed to mass shootings. While youth have varying responses to mass shootings, possibly due to risk and protective factors as well as level of exposure, the mental health outcomes are significant and include posttraumatic stress, suicide, depression, substance abuse, and anxiety. Efforts at developing effective prevention and treatment programs are still underway but generally take a tiered public health approach. Mass shootings have significant mental health outcomes for youth survivors, particularly those with direct exposure or risk factors. Continued efforts are needed to better understand the effects of mass shootings and how to prevent them from occurring as well as how to best address the needs of survivors.

Confirmatory Factor Structure and Predictive Validity of the Early Identification System-Student Report in a Community Sample of High School Students

The purpose of this paper is to confirm the factor structure, examine the invariance, and investigate the predictive validity using disciplinary data for 5262 high school students who completed the Early Identification System-Student Response (EIS-SR). The development and theory of the EIS-SR is discussed along with prior work. Building off of prior factor analytic work with a separate sample, it was hypothesized the items of the EIS-SR would coalesce into seven factors representing Externalizing Behavior, Internalizing Behavior, Peer Relationship Problems, School Disengagement, Emotional Dysregulation, Attention and Academic Issues, and Relational Aggression. Furthermore, it was hypothesized that EIS-SR scores would be invariant with regard to gender and grade level. Lastly, it was hypothesized that students with high EIS-SR subscale scores would be predictive of school discipline events. Our analyses indicated the EIS-SR did fit the previously observed factor structure with the items loading on seven distinct scales. Tests for measurement invariance indicated support that the EIS-SR measured the seven factors equally well regardless of both gender and grade level. Lastly, EIS-SR subscale scores predicted spring office disciplinary referrals, both in and out of school suspensions, and attendance.

The effectiveness, feasibility and scalability of the school platform in adolescent mental healthcare

PURPOSE OF REVIEW

Schools are increasingly at the forefront of mental healthcare for young people internationally. This review aims to describe recent developments in school-based mental health activities to respond to mental health needs in adolescents, with a focus on empirical studies aimed at preventing, ameliorating or treating mental disorders.

RECENT FINDINGS

The field is characterized by substantial heterogeneity in program design and research methods. Evidence for effectiveness of single-faceted school-based mental health programs is equivocal. Recent systematic reviews and meta-analyses have reported mixed findings across a variety of single-faceted universal and targeted programs at post-intervention, short-term and long-term follow-up. The largest and most recent review and network meta-analyses conclude there is limited evidence in support of these forms of school-based anxiety and depression prevention programs. Feasibility studies, which include consideration of appropriate service providers, suggest a need to consider schools as complex systems when designing interventions. Recent models adopting whole-school approaches appear feasible, effective and potentially sustainable with modest levels of resourcing.

SUMMARY

Greater evidence is needed regarding long-term impact and sustainability of interventions. Recent trials of multifaceted and multilevel interventions show particular promise. Future research should further explore strategies embedded within school systems and processes.

Interpersonal Counseling in the Treatment of Adolescent Depression: A Randomized Controlled Effectiveness and Feasibility Study in School Health and Welfare Services

In order to offer early and accessible treatment for adolescents with depression, brief and effective treatments in adolescents’ everyday surroundings are needed. This randomized controlled trial studied the preliminary effectiveness, feasibility, and acceptability of interpersonal counseling (IPC) and brief psychosocial support (BPS) in school health and welfare services. The study was conducted in the 28 lower secondary schools of a large city in Southern Finland, randomized to provide either IPC or BPS. Help-seeking 12–16-year-old adolescents with mild-to-moderate depression, with and without comorbid anxiety, were included in the study. Fifty-five adolescents received either 6 weekly sessions of IPC or BPS and two follow-up sessions. Outcome measures included self- and clinician-rated measures of depression, global functioning, and psychological distress/well-being. To assess feasibility and acceptability of the treatments, adolescents’ and counselors’ treatment compliance and satisfaction with treatment were assessed. Both treatments were effective in reducing depressive disorders and improving adolescents’ overall functioning and well-being. At post-treatment, in both groups, over 50% of adolescents achieved recovery based on self-report and over 70% based on observer report. Effect sizes for change were medium or large in both groups at post-treatment and increased at 6-month follow-up. A trend indicating greater baseline symptom severity among adolescents treated in the IPC-providing schools was observed. Adolescents and counselors in both groups were satisfied with the treatment, and 89% of the adolescents completed the treatments and follow-ups. This trial suggests that both IPC and BPS are feasible, acceptable, and effective treatments for mild-to-moderate depression in the school setting. In addition, IPC seems effective even if comorbid anxiety exists. Our study shows that brief, structured interventions, such as IPC and BPS, are beneficial in treating mild-to-moderate depression in school settings and can be administered by professionals working at school.

Trial registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT03001245.

Culturally informed gatekeeper training for youth suicide prevention in Guyana: A pilot examination

Adolescent suicide is a pressing concern in Guyana, a low-to middle-income country in South America with the highest adolescent suicide rate globally. Gatekeeper trainings for suicide prevention conducted in high-income countries have been found to increase knowledge of suicide prevention, increase referrals of at-risk youth, and reduce stigma toward help-seeking for suicidality. The current study sought to engage in a pilot examination of the effectiveness, acceptability, and feasibility of a culturally informed gatekeeper training suicide prevention program for Guyanese youth. Secondary school teachers and staff ( N = 16) were trained in a culturally informed, evidence-based gatekeeper suicide prevention program. Mixed methods analyses revealed significant increases in knowledge of suicide prevention, as well as decreases in rigid or judgmental attitudes toward suicide post-training among secondary school teachers and staff. Further, results indicated that participants deemed the program culturally acceptable and feasible for use in the school setting. Findings have implications for the delivery and implementation of culturally informed gatekeeper training programs for suicide prevention in low-to middle-income countries.

A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents

Given the recent rise in adolescent mental health issues, many researchers have turned to school-based mental health programs as a way to reduce stress, anxiety, and depressive symptoms among large groups of adolescents. The purpose of the current systematic review and meta-analysis is to identify and evaluate the efficacy of school-based programming aimed at reducing internalizing mental health problems of adolescents. A total of 42 articles, including a total of 7310 adolescents, ages 11-18, met inclusion for the meta-analyses. Meta-analyses were completed for each of the three mental health outcomes (stress, depression, and anxiety) and meta-regression was used to determine the influence of type of program, program dose, sex, race, and age on program effectiveness. Overall, stress interventions did not reduce stress symptoms, although targeted interventions showed greater reductions in stress than universal programs. Overall, anxiety interventions significantly reduced anxiety symptoms, however higher doses may be necessary for universal programs. Lastly, depression interventions significantly reduced depressive symptoms, but this reduction was moderated by a combination of program type, dose, race, and age group. Although, school-based programs aimed at decreasing anxiety and depression were effective, these effects are not long-lasting. Interventions aimed at reducing stress were not effective, however very few programs targeted or included stress as an outcome variable. Implications for practice, policy and research are discussed.