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National Screening for Mental Illness in Teens Inspires Controversy

If mental illness is epidemic among teenagers, why isn't screening for it routine?



¿ Patrick Kociniak/Design Pics/Corbis

When Laurie Flynn's 17-year-old daughter Shannon attempted suicide, it came without warning. "I would have sworn on a stack of Bibles until the attempt that there was nothing wrong with her. I had no clue," Flynn recalls.

The story is disturbingly familiar to many parents. Suicide is currently the third leading killer of teenagers, after accidents and homicide. Each year roughly one in 10 teens ages 15 to 19 attempt suicide at least once, with more than 600,000 injuring themselves badly enough after their attempts to require medical attention.

Past studies have revealed that parents do not know of suicide attempts 90 percent of the time. In fact, roughly one third to two thirds of suicidal teens do not reveal past attempts to anyone.

Teens with mental disorders are at even greater risk—roughly 90 percent of teens who died by suicide had a psychiatric illness at the time of their deaths, according to research by child and adolescent psychiatrist David Shaffer at Columbia University. Nearly two thirds of youth who die by suicide exhibit psychiatric symptoms for more than a year beforehand, which makes this time a significant window for potential intervention.

Flynn is now executive director of TeenScreen, a national mental health and suicide risk screening program based on Shaffer's research. In 2005 the program screened more than 55,000 teens at 460 sites in 42 states and they hope to have exceeded 500 sites by the end of 2006. "The idea is to identify risks early to prevent tragedies," Flynn says. "It's amazing when kids who are really struggling and don't know why then learn what's going on and that there are things that can help."

The program not only helps detect teens at risk for suicide, but also tackles the silent epidemic of mental illness among young people.

"There are people who say, 'Suicide is rare, so why devote such energy to it?' And they're right," Shaffer comments. "The rationale for going ahead is that the disorders predisposing to suicide are very common and extremely disabling. If they can get help, their school attendance can go up, social relationships can improve, grades can get better, and they can feel happier."

Teenage mental illness also has consequences later in life—research from sociologist Ronald Kessler at Harvard Medical School has revealed that more than half of all cases of adult mental illness begin during the teenage years. "Five out of 10 of the leading causes of disability worldwide are significant mental illnesses, and the number one overall cause of disability in the United States is depression," notes Eric Caine, co-director of the Center for the Study of Prevention of Suicide at the University of Rochester, who is not associated with TeenScreen. "If you start to look at their economic impact, the World Bank, which is not exactly a soft-hearted group, found major mental disorders have a huge impact far exceeding infectious diseases and a number of cancers, but there's an inordinate lack of attention toward them."

"The hope is to take away some of the stigma around mental health disorders with the idea of a mental health checkup, as routine and widely available as any other checkup," Flynn explains.

TeenScreen employs a screening process divided into two stages: In the first, teens answer questionnaires with roughly 15 to 50 questions dealing with the most important signs of teen suicide. "For the most part that's depression in girls. Boys are more complicated—often depression with substance or alcohol abuse, or anxiety disorders," Shaffer says.

All teens then go on to a second stage that includes face-to-face discussions. Those that had tested positive by answering yes to a certain number of questions about their mental health meet with clinicians to determine if they are truly at risk. Those teenagers that are deemed so are then offered a referral for a complete mental health evaluation. with negative test results meet with program staff for the chance to ask for help with any problems not covered in the screening.

Screening via TeenScreen is always a voluntary activity, requiring the consent of both teens and parents. All results are confidential and are not shared with teachers or included in academic records. "On average, close to 50 percent of families will give consent for screening," says TeenScreen director Leslie McGuire. About a third of kids test positive on the questionnaire, and roughly half of those get referred for further evaluation after the clinical interview.

Preliminary results suggest TeenScreen has positive effects. In one follow-up survey of parents whose children were identified by the program, 72 percent reported their child was doing very well or showed significant improvement after participating in TeenScreen and seeing a mental health professional.

The U.S. Surgeon General has highlighted screening as an effective means of youth suicide prevention. Furthermore, President Bush's New Freedom Commission on Mental Health has cited TeenScreen as a model screening program. In addition, New York State is planning on implementing a modified version of the program for 400,000 kids.

These accolades do not mean that TeenScreen is without critics. It has come under fire from observers who fear that it could lead to mandatory screening, notably Rep. Ron Paul (R-Tex.), a physician, who tried unsuccessfully in 2005 to block federal funds for screening. (Neither TeenScreen nor the New Freedom Commission on Mental Health endorse mandatory screening.)

Caine points out that there are other techniques for preventing suicide, including gatekeeper approaches in which teachers and others receive training to spot suicidal tendencies.

"We don't think screening is the only way to prevent suicide," McGuire counters. "When a community has the resources and interest to do more than screening, we very much support that."

Shaffer also notes that gatekeeper approaches have their own weaknesses, some of which stem from the fact that "visible manifestations of suicidality are very nonspecific. So they generally try and look for grades going down, or kids seeming more irritable, or losing friends. These are extremely common adolescent behaviors that sometimes can be indicative of an underlying depression, but by no means always."

One concern voiced by Marcia Angell, a senior lecturer at Harvard Medical School, was whether Shaffer or TeenScreen had financial ties to drug companies that make antidepressants. Shaffer stresses he has no ties to drug companies, and TeenScreen has never been affiliated with or funded by any pharmaceutical companies.

Caine wonders what screening programs do with all the kids with problems they turn up. Flynn explains that a key part of the development time TeenScreen spends at each site involves making connections with local mental health service providers and finding out ways to help families find financial support if needed. "We're not just identifying teens at risk and saying good luck to them," she notes.

Flynn's daughter Shannon is now 37. "She finished high school and got a graduate degree, and two years ago she got married. Nothing was easy, but it's a happy outcome," Flynn observes. "I shudder to think what the outcome might have been. It's why I'm so passionate about identifying risks early."

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