Bring in universal mental health checks in schoolsBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5478 (Published 24 September 2013) Cite this as: BMJ 2013;347:f5478
- Simon Nicholas Williams, academic clinical fellow in public health, Institute of Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK; , visiting scholar, Feinberg School of Medicine, Northwestern University, Chicago, USA
A recent BMJ study suggested that school based cognitive behavioural therapy programmes may not be effective in reducing depressive symptoms.1 I agree with the authors that further research and evaluation of such programmes are necessary. However, although school might not be the most appropriate setting for the treatment of childhood and adolescent mental health problems, it is the most appropriate setting for the identification of mental health problems in this population.
There are great benefits to be had from the provision of routine mental health checks for all schoolchildren, not only those who have traditionally been deemed most at risk. The UK government’s current mental health outcomes strategy focuses on “prevention of mental illness and early identification and intervention,” emphasising a more “localised approach.”2 However, when it comes to prevention and early identification, a more standardised approach would be more equitable and effective. Physical health checks have been done in schools for more than a century, so why not mental health checks?
Mental health problems cost the UK an estimated £105bn (€125bn; $166bn) annually. Of this, £21.3 billion is spent on health and social care,3 more than double the total annual cost of cancer diagnosis and treatment in the UK (£9.4 billion).4 About three quarters of adult mental disorders are extensions of juvenile disorders (50% of which could be diagnosed before the age of 15).5 If left untreated, these can lead to more serious social and economic problems in adolescence and adulthood, related to crime, unemployment, and suicide, for example.6 7 Therefore, early intervention and prevention should be aimed at youths.8 Introducing mental health screening in schools could enable early diagnosis and treatment of childhood mental health problems and therefore reduce many of the costs associated with adolescent and adult mental health problems.
A recent systematic review concluded that screening and early intervention at schools may be an effective strategy to reduce the burden of disease from depression in children and adolescents.9 Furthermore, research shows how early interventions for children can have beneficial effects in the areas of depression, anxiety, post-traumatic stress disorder, and suicide prevention, as well as for subclinical disorders.10 11 12 13 14 Of course, before intervention can occur mental health problems must be identified.
Evidence indicates that early identification of, and intervention for, mental health problems can be cost effective, even for some of the most costly mental health disorders such as conduct disorder and depression.15 For example, early intervention for conduct disorders could save an estimated £115 000 to £150 000 a case.16 Also, early intervention for the treatment of childhood and adolescent depression (using fluoxetine) has been shown to be cost effective, at approximately £15 000 per quality adjusted life year.17
Why then, despite this mounting evidence, and in a time where other types of screening (including bowel, breast, cervical, and prostate screens) are becoming more common in the UK, do we not already have school based mental health checks? The stigma associated with a mental health diagnosis is likely a deterrent, particularly for parents. The cost of implementing mental health checks is likely another stumbling block, particularly for government and health authorities.
However, a programme in which all children are screened, rather than just those who are traditionally deemed at risk, would likely have a destigmatising effect. That is, children from some socioeconomic groups or family backgrounds would not be singled out. Although many mental health disorders are more common among children from lower socioeconomic groups, others, such as anxiety disorders, are just as common, if not more common, among children from higher socioeconomic groups.18 Furthermore, a universal screening programme would allow health services to identify those children who are experiencing early signs of developing mental health problems. The children could be monitored and recommended for referral for treatment where appropriate. As noted, early intervention could help to provide much needed emotional and therapeutic support for children and subsequently reduce future lost work hours and the costs of adult mental healthcare.
A brief, well validated, diagnostic aide, like the Beck Youth Inventories (BYI), could be administered in the school by either a counsellor or a trained specialist and could identify those children who are in need of in-depth investigation, diagnosis, and potentially treatment. The BYI can help identify signs of depression, anxiety, anger problems, and disruptive behaviour.19 Parents could be informed as to the purposes and nature of the examination and could be given the opportunity to “opt-out” their child.
The BYI can be administered from age 7, and so this would be an appropriate age for a first screening. In an ideal scenario, the checks would occur several times in the child’s schooling; mental health, like physical health, is not static. Because the costs of administering checks are relatively low, the idea of having multiple checks is far from impossible.
By using a validated tool, by administering it at multiple points during a child’s school years, and 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 programs.
Assessment could be accomplished cheaply and in a group format. The five inventories (for depression, anxiety, anger, disruptive behaviour, and self concept) can be administered by a qualified health professional to a group (for example, a class of 25 children) in approximately 30 minutes. The inventories are then scored individually. I estimate that the total basic costs of screening would amount to only £27 a child. As such, a health screening programme for all children in the UK aged 7 would cost less than £18.5m (see box).
Although I commend the government’s commitment to prevention and early diagnosis of mental health problems, a local approach is neither effective nor equitable. One of the problems with localised healthcare, including mental healthcare, is that it can perpetuate existing inequalities or create new disparities. Offering routine mental health checks in schools is one way to ensure that all children get equal access to resources for the prevention or early diagnosis of mental health problems. The next step should be a trial to pilot and evaluate the short term outcomes of a routine mental health check in UK schools.
Costs of mental health screening for all UK schoolchildren
The combined Beck Youth Inventories booklet costs £115 for 25 (www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8014-197)
The hourly rate of a qualified health professional is £51 (www.pssru.ac.uk/archive/pdf/uc/uc2011/section1.pdf)
The Office of National Statistics gives the population of 7 year olds in the UK as 685 000
The total cost per child is for the combined BYI booklet (£115/25 = £4.60) + health professional’s administration time within group (30 minutes at £51 per hour / 25 = £1.02) + health professional’s individual scoring time (25 minutes at £51 per hour = £21.25) = £26.87
Total cost of a UK-wide screening programme would be £26.87 × 685 000 = £18m
Cite this as: BMJ 2013;347:f5478
I thank Kimberly Dienes, whose research, insight, and suggestions were instrumental in formulating this argument.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.