BMJ Open. 2025 Nov 23;15(11):e104620. doi: 10.1136/bmjopen-2025-104620.
ABSTRACT
OBJECTIVES: To examine state-level variation in mental health screening practices for high school athletes in the USA and evaluate associations between screening protocols and adolescent depression-related and suicide-related outcomes.
DESIGN: Cross-sectional study of preparticipation examination (PPE) forms and Youth Risk Behaviour Surveillance System (YRBSS) data.
SETTING: High school athletics across all 50 US states and the District of Columbia.
PARTICIPANTS: 732 676 high school students who completed the 2021 YRBSS survey (grades 9-12).
PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of depressive symptoms and suicide-related behaviours, measured using YRBSS items on sadness/hopelessness, suicide ideation, planning, attempts and suicide attempts resulting in injury. State-level PPE forms were reviewed for presence and depth of mental health screening, including Patient Health Questionnaire-4 (PHQ-4) and eating disorder (ED) risk questions.
RESULTS: Screening practices varied widely, ranging from no mention of mental health in some states to required evaluations with formal referral protocols in others. Of 732 676 students, 503 861 (68.7%) reported feeling sad or hopeless, 608 416 (83.0%) seriously considered suicide and 64 072 (8.8%) attempted suicide in the past year. States with required screening protocols had higher reported rates of depressive symptoms (71.0% vs 68.7%, p<0.001) but lower suicide attempt rates (8.0% vs 8.8%, p<0.001) compared with states with no screening. Use of PHQ-4 and ED risk questions was associated with lower suicide attempt prevalence (8.4% vs 8.8%, p<0.001).
CONCLUSIONS: High school athletes represent a vulnerable group in need of structured and standardised mental health screening. State-level screening policies were associated with lower suicide attempt rates, though causal inference is limited by the cross-sectional design. Standardised use of validated mental health tools may support early identification and intervention for at-risk adolescents.
PMID:41285503 | DOI:10.1136/bmjopen-2025-104620
