Depression is a particularly insidious disorder in the lives of young people and one that schools have good reason to be concerned about. As an internalising disorder, its effects are frequently not recognised by either the sufferer or those around them until the symptoms are quite pronounced. While in the past school administrators may have been inclined to believe that management of mood disorders belonged solely in clinics or hospitals, there are now compelling reasons for schools to be deliberate and proactive in their management of students with depression. The first reason is the concerning prevalence of mood disorders among young people. In Australia, 12-month prevalence of major depressive disorder (MDD) in children and adolescents is 5% (Lawrence et al., Reference Lawrence, Johnson, Hafekost, Boterhoven De Haan, Sawyer, Ainley and Zubrick2015), while a recent study in the United States reported 12-month prevalence of MDD at 7.5% (Avenevoli et al., Reference Avenevoli, Swendsen, He, Burstein and Merikangas2015). Prevalence rates will be higher once other forms of depressive disorders and subthreshold depression difficulties are included. Accordingly, a high school could expect between 5–10% of their student body to meet criteria for a depressive disorder in any given year. In fact, recent research suggests that the prevalence rates of depression in young people are increasing (Lawrence et al., Reference Lawrence, Johnson, Hafekost, Boterhoven De Haan, Sawyer, Ainley and Zubrick2015; Twenge et al., Reference Twenge, Cooper, Joiner, Duffy and Binau2019). The second reason for schools to be intentional and focused in the management of depression is that health and wellbeing are now integral parts of a total school education. To a large degree this was stimulated by the Health Promoting Schools movement (World Health Organization, 1986), which aimed at enabling young people to increase their control over, and to improve, their health. More recently, schools have been heavily influenced by the social and emotional learning movement (Zins & Elias, Reference Zins and Elias2007; Zins et al., Reference Zins, Elias and Greenberg2003). School administrators are genuinely interested in how to promote wellbeing in schools (Konu & Rimpelä, Reference Konu and Rimpelä2002) and establish learning environments that are characterised by care and nurture (Warin, Reference Warin2017). Careful management of students with depression is a natural response within such a context. A third reason for schools to take depression seriously is its influence on a student’s academic performance. It is well documented that depressed students achieve lower academic attainment than their nondepressed peers (Fröjd et al., Reference Fröjd, Nissinen, Pelkonen, Marttunen, Koivisto and Kaltiala-Heino2008; Riglin et al., Reference Riglin, Petrides, Frederickson and Rice2014; Verboom et al., Reference Verboom, Sijtsema, Verhulst, Penninx and Ormel2014; Weidman et al., Reference Weidman, Augustine, Murayama and Elliot2015). The reasons for this are varied and complex. Young people with MDD experience a wide range of neuropsychological deficits, including impaired executive functioning, working memory, processing speed, verbal fluency and visuo-spatial memory (Baune et al., Reference Baune, Fuhr, Air and Hering2014; Marazziti et al., Reference Marazziti, Consoli, Picchetti, Carlini and Faravelli2010). Moreover, depressed young people are more likely to be absent or truant from school (Egger et al., Reference Egger, Costello and Angold2003; Finning et al., Reference Finning, Ukoumunne, Ford, Danielsson-Waters, Shaw, Romero De Jager, Stentiford and Moore2019), with missed class influencing school achievement. Depressed students tend to have a negative academic self-image (Masi et al., Reference Masi, Tomaiuolo, Sbrana, Poli, Baracchini, Pruneti, Favilla, Floriani and Marcheschi2001), which in turn leads to increased risk of school dropout (Quiroga et al., Reference Quiroga, Janosz, Bisset and Morin2013). Indeed, school drop-out becomes the ultimate determinant of underachievement for depressed students (Dupéré et al., Reference Dupéré, Dion, Nault-Brière, Archambault, Leventhal and Lesage2018).
Considering these factors, it is essential that schools are well prepared to care for depressed students — and equally importantly, to take steps to prevent students becoming depressed. The purpose of the current article is to bring together international research on the role of schools in the total management of mood disorders in order to offer a coherent description of what can be considered ‘best practice’ in school-based management of depressive disorders.
Defining Depressive Disorders
The Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM–5; American Psychiatric Association, 2013) defines depressive disorders within eight different categories and considers MDD the ‘classic condition’ within this group. A diagnosis of MDD requires a person have five (or more) of the following symptoms: (1) Depressed mood; (2) Diminished interest or pleasure; (3) Significant weight loss, weight gain, or changes in appetite; (4) Insomnia or hypersomnia; (5) Psychomotor agitation or retardation; (6) Fatigue/loss of energy; (7) Diminished ability to think or concentrate or indecisiveness; (8) Recurrent thoughts of death.
For diagnosis, these symptoms must be present over a two-week period; represent a change from previous functioning; at least one symptom must be depressed mood or loss of interest/pleasure; the symptoms must cause significant distress or impairment; and, they must not be due to the effect of a substance or other medical condition. When MDD persists for one year in children and adolescents (two years in adults) it may fall with the category of persistent depressive disorder (dsythmia). Other DSM-5 depression disorders that school psychologists are less likely to encounter include substance- or medication-induced depressive disorder and premenstrual dysphoric disorder.
Defining Best Practice
It is widely accepted that best practices in psychological intervention — in whatever contexts they are practised — are those that are evidence-based. The APA Presidential Task Force on Evidence-Based Practice has offered the following definition: ‘Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’ (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). This definition offers three key components for school-based practitioners to consider. First, best practice is based on the best available research; second, it requires clinical expertise on behalf of the practitioner; and third, it takes into account the unique features of the patient/client group and their individual characteristics.
Defining Mental Health Intervention
In offering a framework for best practice in the management of depressive disorders in schools, this article adopts the mental health intervention spectrum model first proposed by the Institute of Medicine (Mrazek & Haggerty, Reference Mrazek and Haggerty1994). The model originally divided mental health intervention into three general domains — prevention, treatment and maintenance. Prevention highlighted interventions that occur prior to the initial onset of a disorder and can be offered either universally to a whole cohort, selectively to those considered at-risk, or only to those with indicated signs of the disorder. Treatment interventions are considered both those involved in case identification as well as standard treatments for known disorders. Maintenance refers to those interventions involved in promoting compliance with long-term treatment as well as after-care, including rehabilitation. More recently this model has been adapted to include the role of mental health promotion on the intervention spectrum (National Research Council and Institute of Medicine, 2009). In this adaptation, promotion is seen as distinct from prevention in that it values the promotion of healthy outcomes such as competence and wellbeing, rather than as just a means to prevent illness. Although this model was developed within the context of a health system, these four related approaches to intervention can be very appropriately adapted for consideration within schools and form the basis of our conceptualisation of best practice in the management of depressive disorders. The remainder of this article will expand on the scope and potential of evidence-based practices for the management of depression within schools across these four domains.
Mental Health Promotion
Health promotion has been a widely adopted practice internationally, evidenced by the popularity over some decades of the Health Promoting Schools movement (World Health Organisation, 1986). Core features of mental health promotion programs in schools are that they are delivered universally across entire cohorts and are aimed at enhancing wellbeing, resilience and general social-emotional competence in students rather than trying to prevent the onset of mental health conditions. Accordingly, in relation to depression, the aim of promotion programs is not specifically to prevent depression, but to promote positive coping skills and wellbeing to improve overall emotional health. There is a sound evidence base for the relationship between various ‘physical’ domains in the promotion of mental health, including physical exercise (Ahn & Fedewa, Reference Ahn and Fedewa2011), sleep (Lovato & Gradisar, Reference Lovato and Gradisar2014) and diet (O’Neil et al., Reference O’Neil, Quirk, Housden, Brennan, Williams, Pasco, Berk and Jacka2014). Schools do well to include education in these matters, either within the curriculum or in other school-based methods.
Over some decades, schools have implemented a broad range of proactive programs to enhance student wellbeing, including programs to promote self-esteem (King et al., Reference King, Vidourek, Davis and McClellan2002), social and emotional learning (Greenberg et al., Reference Greenberg, Weissberg, O’Brien, Zins, Fredericks, Resnik and Elias2003), mindfulness (Huppert & Johnson, Reference Huppert and Johnson2010) and positive psychology (Seligman et al., Reference Seligman, Ernst, Gillham, Reivich and Linkins2009). Generally speaking, such programs have been promoted with some enthusiasm by their proponents and embraced by well-intended schools. One large-scale, school-based example is the Social and Emotional Aspects of Learning (SEAL) program, which was developed by the Department for Education and Skills (DfES) in England and rolled out to approximately 80% of primary and 20% of secondary schools across England from 2005 (Humphrey et al., Reference Humphrey, Kalambouka, Bolton, Lendrum, Wigelsworth, Lennie and Farrell2008). Based on Goleman’s model of emotional intelligence, the aim of the program was to promote the social and emotional skills believed to underpin effective learning, positive behaviour, regular attendance and emotional wellbeing. Evaluations carried out a few years later of both the primary school (Hallam, Reference Hallam2009) and secondary school (Humphrey et al., Reference Humphrey, Lendrum and Wigelsworth2010) programs failed to find compelling evidence for the effectiveness of the programs and they were subsequently discontinued. This raises a key question for any school looking to adopt a best-practice approach: Do mental health promotion programs actually work? Numerous systematic reviews and meta-analyses of mental health promotion programs in schools have been carried out over the past 15 years. Unfortunately, the findings of these can be considered ‘mixed’ at best. A Cochrane Review of the World Health Organization’s Health Promoting School (HPS) Framework (Langford et al., Reference Langford, Bonell, Jones, Pouliou, Murphy, Waters, Komro, Gibbs, Magnus and Campbell2015) found no evidence for the effectiveness of HPS initiatives on mental health. Similarly, in their review of universal, school-based mental health promotion interventions in the United Kingdom, Mackenzie and Williams (Reference Mackenzie and Williams2018) concluded that the effectiveness of these programs was neutral or small, with higher quality studies returning fewer positive effects. A common theme is that there are methodological limitations in many of the individual studies. Not all reviews are quite so negative. Reviews of studies on interventions to improve social and emotional functioning in primary schools found some areas of effectiveness (Fenwick-Smith et al., Reference Fenwick-Smith, Dahlberg and Thompson2018; Green et al., Reference Green, Howes, Waters, Maher and Oberklaid2005), as did a review of mental health promotion programs carried out in low- and middle-income countries (Barry et al., Reference Barry, Clarke, Jenkins and Patel2013). Other reviews have considered both promotion and prevention interventions within the same study (Weare & Nind, Reference Weare and Nind2011; Wells et al., Reference Wells, Barlow and Stewart-Brown2003). The themes to emerge across the reviews conducted is that more effective universal mental health programs focus on promotion rather than prevention; they seek to modify the school environment/climate; and, they are delivered over an extended time frame. Schools are encouraged to carefully examine the evidence for the effectiveness of a program before implementing it, paying particular attention to evidence from studies done with samples similar to the school’s own characteristics (e.g., age of student, socio-economic status, cultural mix). One of the core elements of school-based mental health promotion involves the creation of a positive school climate. Often synonymous with school environment, school climate refers to ‘the norms, expectations, and beliefs that contribute to creating a psychosocial environment that determines the extent to which people feel physically, emotionally, and socially safe’ (Aldridge & McChesney, Reference Aldridge and McChesney2018, p. 122). In their review of studies on the relationship between school climate and mental health, Aldridge and McChesney (Reference Aldridge and McChesney2018) conclude that the body of evidence establishing this relationship is ‘sizeable’ and they draw particular attention to the evidence for the positive role on a student’s mental health played by positive relationships with teachers and peers, a positive perception of school safety and positive perceptions of school connectedness. Positive school climate has not only been found to be protective against mental illness generally, but depression specifically (Langille et al., Reference Langille, Rasic, Kisely, Flowerdew and Cobbett2012; Millings et al., Reference Millings, Buck, Montgomery, Spears and Stallard2012; Ross et al., Reference Ross, Shochet and Bellair2010; Shochet et al., Reference Shochet, Homel, Cockshaw and Montgomery2008). Moreover, school connectedness is associated with reduced reports of suicidal thoughts and behaviours (Marraccini & Brier, Reference Marraccini and Brier2017). Accordingly, a strong case exists for schools seeking to promote positive mental health to pay careful attention to managing their school climate. Strategies for promoting positive school climate have been well described elsewhere (e.g., Cohen, Reference Cohen, Goldstein and Brooks2013).
Practitioner Checklist — Promotion
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Our school implements activities and interventions that promote physical exercise, healthy diet, good sleep hygiene and social connectedness.
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Our school implements social and emotional learning programs that are evidence based.
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Our school implements school climate enhancement programs grounded in regular measurement of school climate.
Prevention
Unlike mental health promotion programs, depression prevention programs specifically focus on trying to stop the onset of the disorder. Schools can adopt interventions that are universal (i.e., targeting a whole group or population, regardless of risk status), selective (i.e., targeting students who are experiencing risk factors that make them more vulnerable than others), or indicated (i.e., programs for students who are already showing signs or symptoms of depression). Universal programs have some distinct advantages over selective or indicated programs, including avoiding the possibility of stigmatising any individuals in selective/indicated programs, having lower dropout rates and ensuring that no student with depressive symptoms is overlooked due to inadequate case-identification processes (Offord et al., Reference Offord, Kraemer, Kazdin, Jensen and Harrington1998). Several depression-specific universal group programs have been developed or trialled for use in schools, including the Resourceful Adolescent Program (Shochet et al., Reference Shochet, Dadds, Holland, Whitefield, Harnett and Osgarby2001) and the Penn Resiliency Program (Gillham et al., Reference Gillham, Reivich, Freres, Chaplin, Shatté, Samuels, Elkon, Litzinger, Lascher, Gallop and Seligman2007). Others target anxiety and depression symptoms together, such as the Friends Program (Barrett et al., Reference Barrett, Farrell, Ollendick and Dadds2006) and the Feelings Club (Manassis et al., Reference Manassis, Wilansky-Traynor, Farzan, Kleiman, Parker and Sanford2010). Numerous meta-analyses and systematic reviews have been undertaken to evaluate the effectiveness of preventive programs for depression and there is now considerable consensus that prevention programs do return reductions in depressive symptoms. Most (e.g., Merry et al., Reference Merry, Hetrick, Cox, Brudevold-Iversen, Bir and McDowell2012; Werner-Seidler et al., Reference Werner-Seidler, Perry, Calear, Newby and Christensen2017) find evidence of sustained improvement over time, but that the effect size remains relatively small. Most also find that universal programs return less favourable effect sizes than selective or indicated programs (Calear & Christensen, Reference Calear and Christensen2010; Cowan, Reference Cowan2014; Stice et al., Reference Stice, Shaw, Bohon, Marti and Rohde2009; Werner-Seidler et al., Reference Werner-Seidler, Perry, Calear, Newby and Christensen2017). In light of this, and in accordance with other commentators (Mazza & Reynolds, Reference Mazza, Reynolds, Doll and Cummings2008; Spence & Shortt, Reference Spence and Shortt2007), schools are better served to focus on running selective/indicated preventative programs in favour of universal programs. Importantly, interventions based on cognitive behaviour therapy (CBT) have the strongest evidence of efficacy (Hilt-Panahon et al., Reference Hilt-Panahon, Kern, Divatia and Gresham2008).
A central depression prevention activity that all schools must implement is a strong antibullying program. Students who experience bullying have been shown to be a greater risk of developing depression both while at school (Brunstein Klomek et al., Reference Brunstein Klomek, Marrocco, Kleinman, Schonfeld and Gould2007) and in the years beyond school (Lund et al., Reference Lund, Nielsen, Hansen, Kriegbaum, Molbo, Due and Christensen2009; Ttofi et al., Reference Ttofi, Farrington, Lösel and Loeber2011). Many systematic reviews on the effectiveness of antibullying programs have now been done (e.g., Evans et al., Reference Evans, Fraser and Cotter2014; Jiménez-Barbero et al., Reference Jiménez-Barbero, Ruiz-Hernández, Llor-Zaragoza, Pérez-García and Llor-Esteban2016; Lee et al., Reference Lee, Kim and Kim2015; Ttofi & Farrington, Reference Ttofi and Farrington2011), with results suggesting that antibullying programs are effective, but with a low to moderate effect size. Programs that have been found to return more effective outcomes are those that involve parent meetings, improved playground supervision, those implemented on more heterogenous samples, and those that target younger children.
Practitioner Checklist — Prevention
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Our school implements evidence-based depression prevention programs.
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Our school prioritises selective and indicated programs over universal programs.
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Our school has a clearly articulated and effective anti-bullying program.
Treatment
The Institute of Medicine model highlights two areas of ‘treatment’ for mental health difficulties — case identification and standard treatment for known disorders.
Case Identification
A core component of case identification of students with depressive disorders in a school is having staff who are capable of recognising signs of depression in students. To some degree this task requires mental health staff in schools (e.g., psychologists, social workers, counsellors, nurses) to be adequately trained and proficient in the recognition and management of depression. However, it remains the case that in most schools only a small percentage of students have regular contact with these staff. It is therefore important that classroom and wellbeing teachers have some familiarity with the signs of depression in students and are informed on how to respond with students of concern. This has been best articulated within the suicide-prevention model of teachers being ‘gatekeepers’ who can identify at-risk students and then ensure these young people are linked with appropriate follow-up. Providing training to increase teachers’ mental health literacy has had some positive effects on teachers’ knowledge and attitudes towards students with mental health difficulties (Jorm et al., Reference Jorm, Kitchener, Sawyer, Scales and Cvetkovski2010), but it remains the case that teachers alone are not sufficient to identify all at-risk students (Cunningham & Suldo, Reference Cunningham and Suldo2014; Moor et al., Reference Moor, Maguire, McQueen, Wells, Elton, Wrate and Blair2007; Scott et al., Reference Scott, Wilcox, Schonfeld, Davies, Hick, Turner and Shaffer2009). This theme also arises in research on teachers as gatekeepers for suicidal students, where the results suggest that although the concept is sound, it is yet to produce convincing attitudes of efficacy (Mo et al., Reference Mo, Ko and Xin2018).
Considering this, best practice schools will have additional strategies in place to identify at-risk students. Most important among these are mental health screening programs. The science and practice of school-based screening is now well developed and articulated (Stiffler & Dever, Reference Stiffler and Dever2015). Systematic screening has been shown to be superior at identifying at-risk students compared to the more traditional approach of teacher identification and referral (Eklund & Dowdy, Reference Eklund and Dowdy2014; Scott et al., Reference Scott, Wilcox, Schonfeld, Davies, Hick, Turner and Shaffer2009). A range of suitable screeners are available for schools to directly screen for symptoms of depression, such as the Centre for Epidemiological Studies Depression Scale for Children (Faulstich et al., Reference Faulstich, Carey, Ruggiero, Enyart and Gresham1986) or the Mood and Feelings Questionnaire (Angold et al., Reference Angold, Costello, Messer, Pickles, Winder and Silver1995). Alternatively, schools can use measures that screen for broader emotional distress, such as the Strengths and Difficulties Questionnaire (Goodman et al., Reference Goodman, Meltzer and Bailey1998) or the Behavioral and Emotional Screening System (Kamphaus & Reynolds, Reference Kamphaus and Reynolds2015). Best practice in school-based screening always involves a tiered system, whereby those identified by the screening process as being at-risk receive follow-up assessment and, if required, referral to a suitable mental health service in the community.
School-Based Treatment for Depressive Disorders
The most suitable place for depressed young people to receive treatment is in a community-based mental health clinic. Accordingly, best-practice schools will ensure that any student identified with a mood disorder is swiftly referred for external treatment. However, given that only about half of all young people with a mental health disorder are accessing mental health service providers (Green et al., Reference Green, McLaughlin, Alegría, Costello, Gruber, Hoagwood, Leaf, Olin, Sampson and Kessler2013; Lawrence et al., Reference Lawrence, Johnson, Hafekost, Boterhoven De Haan, Sawyer, Ainley and Zubrick2015), there is a strong argument for schools to be proactive in ensuring that depressed students access treatment. In line with the Expanded School Mental Health approach (Weist, Reference Weist, Ollendick and Prinz1997; Weist et al., Reference Weist, Sander, Lowie and Christodulu2002) best practice involves schools developing strong collaborative relationships with mental health services within their own community. There are likely to be unique considerations regarding treatment of depressive disorders for students in rural areas compared to urban areas, particularly in countries like Australia, where some students live in very remote communities. Rural adolescents face a range of logistical problems that are barriers to seeking help, primarily a lack of specialist local services and a need to organise transport to travel to services (Francis et al., Reference Francis, Boyd, Aisbett, Newnham and Newnham2006). In fact, rural adolescents may have a preference to seek help for mental health problems from a school-based service rather than other community-based mental health services (Boyd et al., Reference Boyd, Hayes, Nurse, Aisbett, Francis, Newnham and Sewell2011). In light of this, best practice in rural or remote schools may require some school psychologists to take a more ‘hands-on’ role with some depressed students. In these situations, school psychologists are advised, as far as is logistically possible, to share treatment responsibility with whatever community-based services are available and to be particularly diligent when monitoring a student’s mood. Moreover, best practice would dictate that school-based professionals be guided in their treatment by available ‘best practice guidelines’ for the treatment of depression that have been developed and published around the world (e.g., Malhi et al., Reference Malhi, Bassett, Boyce, Bryant, Fitzgerald, Fritz, Hopwood, Lyndon, Mulder, Murray, Porter and Singh2015; McDermott et al., 2010). Cognitive behavioural therapy and interpersonal therapy are consistently recognised as the best evidence-based treatment approaches for adolescent depression (David-Ferdon & Kaslow, Reference David-Ferdon and Kaslow2008; Weersing et al., Reference Weersing, Jeffreys, Do, Schwartz and Bolano2017). Finally, schools may be able to offer computer-based ‘treatment’ programs for students already identified as depressed (Pennant et al., Reference Pennant, Loucas, Whittington, Creswell, Fonagy, Fuggle, Kelvin, Naqvi, Stockton and Kendall2015; Stasiak et al., Reference Stasiak, Fleming, Lucassen, Shepherd, Whittaker and Merry2016).
Practitioner Checklist — Treatment
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Teachers at our school can recognise the signs of depression in students and know when and how to refer students to the school mental health service.
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Our school has a mental health screening program to identify students with depressive symptoms.
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Our school collaborates closely with mental health services available within our local community, including referring depressed students for suitable community-based intervention.
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Our school mental health service can provide evidence-based treatment (individual, group or computer-based) for students who cannot access community-based services.
Maintenance
Within the Institute of Medicine model, the aim of maintenance interventions is to decrease the long-term disability related to the disorder through compliance with long-term treatment and aftercare, including rehabilitation (Mrazek & Haggerty, Reference Mrazek and Haggerty1994). In translating this to best practice in schools for depressed students, there are a range of ongoing ‘care’ interventions that are likely to reduce the impact of the diagnosis, as well as ultimately the severity and duration of the disorder. These practical school-based responses fall into the domain of day-to-day adjustments and accommodations. While such adjustments may not have a strong evidence base to support them, nonetheless they are a vital component of school-based intervention that require careful attention by school staff. These practical maintenance interventions can be divided into four broad domains.
1. Support team management
School management of mood disorders requires a team-based approach, consisting of a network of school staff working in concert with the young person, his/her family and with community-based practitioners in ongoing care. The school team extends beyond the school mental health practitioners (psychologists, counsellors, social workers) to include Year Coordinators, Pastoral Care/Wellbeing coordinators, school nurse and every staff member with an area of responsibility for the young person. This includes not only classroom teachers, but extra-curricular staff (e.g., sports coaches, music or dance teachers), before- and after-school care staff, all staff supervising excursions or camps, and replacement, casual and student teachers. Although there will be key staff involved in developing the school management plan, this plan will need to be communicated to all relevant staff members in a clear, timely and respectful way. To the degree that all staff members may be required to help manage students with mental health difficulties, mental health literacy for all teaching staff is critical (Whitley et al., Reference Whitley, Smith and Vaillancourt2013).
2. Symptom management
Any student with a major depressive disorder requires a clearly articulated plan for how depressive symptoms and risk will be managed at school. Such a plan should consider how the individual student’s expected core symptoms (e.g., low mood, lethargy, low self-esteem, irritability, diminished concentration and motivation) may present across the school day and how these will be managed. Moreover, the plan should articulate where and how the student can access support or time out at school. Such a plan is only effective to the degree that it is communicated to people within the school who will have a role to play with the student. The most effective plans are developed collaboratively between the student, the school mental health/wellbeing staff, key teachers, the student’s family and the community-based practitioner. Further, any depressed student with elevated suicide risk should not attend school until a management plan is in place that is agreed to by the student, school, family and the community-based practitioners.
3. Academic management
Classroom teachers should expect that depressed students will have impaired ability to apply themselves to their academic tasks. Best practice will require classroom teachers and school systems to make suitable adjustments and accommodations to the academic program that allow the depressed student to fully access the curriculum and demonstrate their learning during assessments. Most students with MDD will require an Individualised Education Plan (IEP). Teachers generally find IEPs to be helpful (Lee-Tarver, Reference Lee-Tarver2006), and the more health information they have about a student, the better able they are to make classroom modifications (Cunningham & Wodrich, Reference Cunningham and Wodrich2006). Writing an effective IEP for a depressed student should adopt the best practice guidelines of any other student IEP (Pierangelo & Giuliani, Reference Pierangelo and Giuliani2007).
4. Medication management
Medication is an important and common aspect of treatment for many young people with MDD. Most young people on medication for depression will only take medicine once per day, usually at the start of the day or immediately before bed. However, some young people may be required to take medicine during the day. The American Academy of Pediatrics has published a policy statement that outlines recommended guidelines for the administration of medication at school (American Academy of Pediatrics, 2009). This policy articulates the risks of untrained school staff administering medication and endorses all schools having a full-time registered nurse to be responsible, among other duties, for the delivery of all medication. While this recommendation is beyond the resources of many schools, all schools should have a clearly articulated medication policy that outlines when and how schools obtain authority to administer medication; who will administer the medication and how this will be logged; the conditions under which students can self-administer medication; how medication is to be stored on school premises; and, first aid in the event of a medication error. Schools should also pay particular attention to the medication needs of depressed students on school camps and excursions.
Practitioner Checklist — Maintenance
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Our school identifies a support team for each student with depression.
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Our school develops an IEP for each student with depression that identifies the nature of their difficulty and what accommodations can be made in the classroom and during assessments.
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Our school ensures the IEP is communicated to each staff member who has a role with the student.
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Depressed students in our school know when, where and how to get help at school at times of particular distress.
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Our school has a clear and practical medication policy.
Discussion
The purpose of this article is to encourage schools to adopt policies and procedures that move them towards best practice in the management of students with depressive disorders. The paper has been titled Towards Best Practice with an understanding that there is no single nor universal description of best practice that will be applicable in all schools. However, as far as possible, best practice will always be evidence-based practice. One of the challenges for school-based practitioners is to integrate this knowledge with the specific context of their school in relation to the characteristics, culture and preferences of their student body. Moreover, all schools operate with a range of practical and logistical limitations, such as the personnel they have on staff, the financial and practical resources available at their disposal, and the support available more broadly both from the parent body and wider community-based mental health agencies. In considering management of depressed students, schools must be alert to specific population groups that are at greater risk. This will include girls (Mojtabai et al., Reference Mojtabai, Olfson and Han2016), students from lower socio-economic backgrounds (Shore et al., Reference Shore, Toumbourou, Lewis and Kremer2018), students with learning difficulties (Francis et al., Reference Francis, Caruana, Hudson and McArthur2019; Maag & Reid, Reference Maag and Reid2006) and refugee students (Hodes, Reference Hodes2019).
School-based mental health professionals are encouraged to read this article, with two important caveats. First, this paper does not discuss in any depth school management of students who are self-harming or suicidal. Schools should expect students with a depressive disorder to be more likely to exhibit such behaviours (Fliege et al., Reference Fliege, Lee, Grimm and Klapp2009; Jacobson et al., Reference Jacobson, Muehlenkamp, Miller and Turner2008). School management of self-harm and suicide has been discussed in detail elsewhere (e.g., Katz et al., Reference Katz, Bolton, Katz, Isaak, Tilston-Jones and Sareen2013; Miller & Brock, Reference Miller and Brock2010). Second, depressive symptoms are frequently accompanied by a range of comorbid conditions, most notably substance abuse (Kaminer et al., Reference Kaminer, Connor and Curry2007), anxiety (Cummings et al., Reference Cummings, Caporino and Kendall2014), conduct disorders (Wolff & Ollendick, Reference Wolff and Ollendick2006) and eating disorders (Santos et al., Reference Santos, Richards and Bleckley2007). In fact, any student with another diagnosed mental health difficulty should also be considered to be at-risk of having, or developing depression (Avenevoli et al., Reference Avenevoli, Swendsen, He, Burstein and Merikangas2015). Accordingly, school mental health staff should be alerted to these comorbidities and their management. Similarly, this article has not considered the specific management of bipolar disorder in young people and the unique management challenges of students during a manic phase (Hart et al., Reference Hart, Brock and Jeltova2014).
A final consideration concerns an important but often overlooked component of school wellbeing — that is, the relationship between student wellbeing and staff wellbeing. Teaching is a particularly stressful occupation within which to work (Johnson, Reference Johnson2005; Stansfeld et al., Reference Stansfeld, Rasul, Head and Singleton2011). Recent research has established a relationship between teacher wellbeing and student wellbeing — specifically, that better teacher wellbeing is associated with better student wellbeing and lower psychological distress (Harding et al., Reference Harding, Morris, Gunnell, Ford, Hollingworth, Tilling, Bell, Grey, Brockman, Campbell, Araya, Murphy and Kidger2019). Harding and colleagues (Reference Harding, Morris, Gunnell, Ford, Hollingworth, Tilling, Bell, Grey, Brockman, Campbell, Araya, Murphy and Kidger2019) conclude that one pathway from teacher wellbeing to student psychological distress is, in part, a decline in student-teacher relationship. This is consistent with research by Way et al. (Reference Way, Reddy and Rhodes2007), which found that a decline in positive teacher support over time led to an increase in depressive symptoms in students. The implication for best practice is clear: better teacher-student relationships, facilitated by higher teacher wellbeing, becomes a key component to reducing the likelihood of student depression. School executives are encouraged to not only consider student wellbeing, but also staff wellbeing.
Conclusion
Students with a depressive disorder present a significant challenge for schools. Depression will affect not only a student’s mood, but also their behaviour and academic outcomes. If well prepared, schools are in an excellent place to be part of the solution rather than part of the problem for these young people. This article argues that ‘best practice’ for schools is not a reactive response after a student has been diagnosed. Rather, schools can work across the intervention spectrum to promote emotional health and prevent the onset of depression, as well as intervening with students once they have been diagnosed with a depressive disorder. Best practice across these situations will always be guided by the growing body of evidence.
