Universal Depression Education in High Schools

A 24-year-old program developed at Johns Hopkins University School of Medicine shows promising results among teenage students willing to seek professional help

After the deaths of three high school students from suicide in the Baltimore area in a two-month period, educators and parents were stunned and seeking guidance. When I first went to several schools to teach the parents and faculty about warning signs, the educators urged me also to create a program to educate high school students about depression.

The work led me to oversee a team of psychiatrists and psychiatric nurses as we developed the Adolescent Depression Awareness Program. Our clinical team at the Johns Hopkins University School of Medicine collaborated with health educators to develop a curriculum they would be comfortable teaching.

After two decades of working to create and refine the curriculum and then the training program for educators, we were focusing on developing web-based training to facilitate broader distribution of the curriculum when COVID-19 emerged. Concerning trends in adolescent depression and suicide began well before the COVID crisis first emerged in 2020, but the need for depression education has grown since.

Doubled Incidence

For more than a decade, the Centers for Disease Control and Prevention has reported increasing rates of depressive symptoms, suicidal thoughts and suicide attempts among high school students. In 2021, the CDC’s Youth Risk Behavior Survey estimated 42 percent of high school students had experienced persistent feelings of sadness or hopelessness, 18 percent made a suicide plan and 10 percent attempted suicide.

Since the pandemic, the adolescent mental health crisis has worsened. Nicole Racine and colleagues at the University of Calgary published a meta-analysis of depressive and anxiety symptoms during the pandemic in JAMA Pediatrics in 2021 that combined data from 29 studies of over 80,000 participants under 18. They estimated 25 percent of children and adolescents had clinically elevated levels of depression and 20 percent had anxiety.

These estimates double the pre-pandemic rates. With the explosion of social media, teens face other triggers for depression, notably cyberbullying. In a meta-analysis published in December 2022 in European Child & Adolescent Psychiatry, Chao Li and colleagues found cyberbullying was strongly associated with increased risk of depression, self-harm, suicidal ideation and suicide attempts.

Multiple other studies have demonstrated a strong link between cyberbullying and depression. Various factors are leading to unprecedented rates of depression among teens.

Schools’ Readiness

School districts do not feel prepared to face this crisis. In a 2022 survey conducted by the U.S. Department of Education’s Institute of Educational Sciences, seven of 10 schools reported increases in the number of students seeking mental health services since the beginning of the pandemic.

Also, 76 percent of schools reported an increase in staff expressing concerns about students having symptoms of depression, anxiety and trauma. Only 12 percent of public schools strongly agreed they could effectively provide mental health services to all students in need.

The U.S. Surgeon General issued an advisory in 2021, “Protecting Youth Mental Health,” which carried summary recommendations for educators for creating positive, safe and affirming school environments. These included learning to recognize signs of changes in mental and physical health among students, and providing a continuum of supports to meet student mental health needs, such as expanding the school-based mental health workforce.

Additionally, the Surgeon General recommended expanding social and emotional learning programs and other evidence-based approaches.

Identifying Depression

Unfortunately, many adolescents with depression are not identified and do not receive appropriate treatment. Depression typically emerges during teenage years, and it is common to misunderstand symptoms of sadness, irritability, social withdrawal and lack of confidence as a normal part of adolescence.

Because mood disorders have a slow and often insidious onset, it can be hard to recognize this as a medical problem needing specific treatment. Because the typical episode of depression in teenagers lasts 6 to 9 months, it can significantly change the trajectory of a high school student’s life. As shown in studies done by the National Institute of Mental Health, 50 percent of youth 8-15 did not receive needed mental health services in the previous year.

An ongoing cohort study of New Zealand youth in JAMA Psychiatry by David Fergusson and Lianne Woodward demonstrated outcomes of adolescent depression. Those depressed as teenagers were more likely as young adults to have recurrent depression, anxiety disorders, substance use issues and suicide attempts. They also were more likely to have educational underachievement, early parenthood and unemployment.

Other significant consequences of untreated mental health issues include dropping out of school and being in trouble with the law. The National Institute of Mental Health reported 37 percent of students with a mental health condition who are 14 and older dropped out of school. This is the highest dropout rate of any disability group. The agency also estimated 70 percent of adolescents involved in the juvenile justice system have a mental illness.

Challenging Stigma

As outlined in the Surgeon General’s advisory, schools should take multiple approaches to address this growing mental health crisis among their students. Without question, increasing the scope of mental health services provided by schools as well as facilitating connection to community resources are critical. Educational programs can contribute to earlier identification and referral for those with adolescent depression.

David Shaffer and Leslie Craft introduced a model for suicide prevention in the Journal of Clinical Psychiatry in 1999 where early identification and treatment of underlying psychiatric disorders were a primary target. Depression education is a method for suicide prevention because most teenagers do not get appropriately assessed or treated in a timely fashion. Combating stigma necessitates more intensive educational efforts to help students identify when they are having serious issues. Depression education can lead to a change in attitude about depression and potentially a change in health-seeking behavior.

Our Mission

The Adolescent Depression Awareness Program, or ADAP, educates high school students, teachers and parents about teenage depression through a school-based curriculum. Our group of mental health professionals taught students for the program’s first six years. With the core curriculum developed, our team piloted training programs to turn over teaching to school-based professionals.

ADAP’s core focus includes recognizing the symptoms of depression, understanding the process of medical decision making, comparing depression to other medical illnesses, recognizing suicidal thoughts as the most serious symptom of depression and understanding that no one is to blame. The program has a hopeful message: Depression is a treatable medical illness.

The three-hour curriculum is designed for school health classes. Some schools implement ADAP using advisory time or other classroom settings. The curriculum involves a combination of discussions, group activities and videos, including one where teenagers talk about their own experiences with mood disorders. The curriculum can be implemented as either three 50-minute classes or two 90-minute classes.

We developed ADAP while working in a variety of schools, including a large public school district in Maryland with 90-minute health classes. Frequent changes in activities keep the students engaged. The program has been implemented in a wide range of schools including public, private and parochial schools. We have had both districtwide implementation and collaborations with individual schools. The ADAP team has collected pre-test and post-test data from more than 135,000 students at 257 schools in 21 states.

Favorable Results

The program’s effectiveness has been rigorously tested. The Adolescent Depression Knowledge Questionnaire, or ADKQ, was developed by our team to assess students’ knowledge about mood disorders and attitudes about seeking help. The program does not include depression screening of students.

In early studies of the program, ADAP was shown to triple the number of students achieving depression literacy when taught by the psychiatrists and psychiatric nurses who developed the program. Depression literacy was defined as answering 80 percent or more of the ADKQ questions correctly. Similar results emerged when the instruction was taught by school-based professionals trained in the curriculum.

The ADAP team published results of a randomized controlled trial of more than 6,600 students in 2017. This study showed significant improvement in the percent of students achieving depression literacy among those who received the ADAP curriculum six weeks after the program. The improvement was sustained at a four-month follow-up.

Within the randomized controlled trial, there was a follow-up study of teachers who were trained to teach ADAP. They completed the same ADKQ at baseline and after the training. A higher level of depression literacy in the teachers was significantly associated with the students’ improvement at post-test assessment.

Importantly, 46 percent of teachers reported at least one student approached them with concerns about themselves or others. This rigorous study showed that ADAP improved knowledge about depression and led to help-seeking.

Initially all training of school-based personnel was done in person, typically during a one-day in-service training. This limited the number of schools that could participate. The development of a web-based training program has allowed for broader dissemination of ADAP. High school educators now can complete the same content in an online, asynchronous training program training at their own pace and at convenient times. Once teachers and counselors have completed the training, they have access to the curriculum materials through the training website.

There is no cost to the teachers or schools for either the training or teaching materials. Continuing education credits are available for the training.

Looking Forward

The Adolescent Depression Awareness Program team is working to expand the dissemination of the high school curriculum and to develop a middle school curriculum focusing on anxiety and depression. ADAP Junior High, which we hope to launch in the fall semester of 2026, will focus on anxiety as well as depression because many students develop anxiety symptoms at a younger age than mood symptoms.

ADAP Junior High will include nine 15-minute modules with each module including teacher-led discussion, animated videos illustrating key points and skill-building activities related to the content for each module. ADAP Junior High also will train school-based educators to provide this content through a web-based training for instructors. n

Karen Swartz is the Myra S. Meyer Professor in Mood Disorders and director of clinical programs at the Johns Hopkins Hospital Mood Disorders Center in Baltimore, Md.