{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T10:12:59Z","timestamp":1777630379944,"version":"3.51.4"},"reference-count":35,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T00:00:00Z","timestamp":1763683200000},"content-version":"unspecified","delay-in-days":20,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,14]]},"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross-sectional study of preparticipation examination (PPE) forms and Youth Risk Behaviour Surveillance System (YRBSS) data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>High school athletics across all 50 US states and the District of Columbia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>732\u2009676 high school students who completed the 2021 YRBSS survey (grades 9\u201312).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u2009676 students, 503\u2009861 (68.7%) reported feeling sad or hopeless, 608\u2009416 (83.0%) seriously considered suicide and 64\u2009072 (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&lt;0.001) but lower suicide attempt rates (8.0% vs 8.8%, p&lt;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&lt;0.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104620","type":"journal-article","created":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T05:45:18Z","timestamp":1763963118000},"page":"e104620","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Epidemiological assessment of mental health screening protocols for high school athlete participation in the USA, 2021"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-2320-3428","authenticated-orcid":false,"given":"Rica A","family":"Generoso","sequence":"first","affiliation":[{"name":"Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vishrudh","family":"Vasudevan","sequence":"additional","affiliation":[{"name":"Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hussein","family":"Hamade","sequence":"additional","affiliation":[{"name":"Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Presley","family":"Sylvester-Omorodion","sequence":"additional","affiliation":[{"name":"Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Wolohan","sequence":"additional","affiliation":[{"name":"Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,11,23]]},"reference":[{"key":"2025112321451371000_15.11.e104620.1","unstructured":"Pappas S . 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