US Preventive Services Task Force Recommendations and Rationale on Depression Screening, Page 2
This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for depression, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition1. For more on depression screening, see our main psychological tests and quizzes.
Effectiveness of Screening
The review for the USPSTF identified 14 randomized, controlled trials that have examined the effectiveness of screening for depression in primary care settings.9 In eight studies, the only intervention was feedback of screening results to clinicians; remaining studies combined feedback with other interventions for patients or clinicians. The trials reported various outcomes, including recognition of depression, rates of treatment, and clinical improvement among patients with depression. In seven trials, routine depression screening with feedback of screening results to providers generally increased recognition of depression, especially major depression, by a factor of 2 to 3 compared with usual care. Trials that examined the effect of feedback of screening results on the proportion of depressed patients who received treatment showed mixed results: in four fair-to-good quality trials that used feedback alone, there was no significant effect on treatment rates, but four of the five trials that combined feedback with treatment advice or other system supports reported increased treatment rates in the intervention group compared with usual care. Ten trials measured the effect of screening and feedback on depression outcomes from 1 month to 2 years after the intervention. Five of these 10 studies reported significant improvements in the clinical outcomes of depressed patients, and three others reported improvements that did not reach statistical significance.
All three trials that compared the effects of integrated recognition and management programs with usual care in community primary care practices showed significantly improved patient outcomes. Integrated programs included feedback, provider and/or patient education, access to case management and/or mental health care, telephone followup, and institutional commitment to quality improvement. One trial, which included both newly detected cases of depression and patients already under treatment, showed improvement in patient symptoms at 6 months only among patients beginning a new treatment episode. No improvement was noted among patients who had recently been treated (that is, those who would have been identified without specific screening). Two trials showed improved symptoms at 12 months; one of these also showed more employment retention in intervention compared with usual care patients. All three trials required allocation of clinic resources to detection and management programs.
On the basis of estimates from the above-mentioned trials, approximately 11 patients identified as depressed as a result of screening would need to be treated to produce one additional remission.9 If depression (including major depression, dysthymia, and minor depression) is present in 10 percent of primary care patients, then 110 patients would need to be screened to produce one additional remission after 6 to 12 months of treatment. The number needed to treat for benefit would be smaller for patients with major depression only, but a larger group would need to be screened to identify them.
Potential Harms of Screening and Treatment
The potential harms of screening include false-positive screening results, the inconvenience of further diagnostic work-up, the adverse effects and costs of treatment for patients who are incorrectly identified as being depressed, and potential adverse effects of labeling. None of the research reviewed provided useful empirical data regarding these potential adverse effects.
Recommendations of Others
The Canadian Task Force on Preventive Health Care (CTFPHC) found fair evidence to exclude routine screening of asymptomatic individuals for depression in 1994 but suggested that clinicians maintain a high degree of clinical suspicion for depression among their patients.10 The CTFPHC is currently revisiting this recommendation. The American College of Obstetricians and Gynecologists recommends that clinicians should be alert to symptoms of depression and question patients about psychosocial stressors and family history of depression when taking their history.11 The American Academy of Pediatrics recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence.12 The American Medical Association recommends screening for depression among adolescents who may be at risk owing to family problems, drug or alcohol use, or other indicators of risk.13
References
1. Pignone M, Gaynes BN, Rushton JL, et al. Screening for Depression. Systematic Evidence Review No. 6 (Prepared by the Research Triangle Institute–University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011) AHRQ Publication. No. 02-S002. Rockville, MD: Agency for Healthcare Research and Quality, May 2002.
2. Williams JW, Hitchcock Noel P, Cordes JA, Ramirez G, Pignone M. Rational clinical examination. Is this patient clinically depressed? JAMA 2002;287:1160-7.
3. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are as good as many. J Gen Intern Med 1997;12:439-45.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.
5. Murray CJ, Lopez AD. Global Burden of Disease. Cambridge, MA: Harvard University Press; 1996.
6. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD: U.S. Department of Health and Human Services; 1993. AHCPR Publication No. 93-0550.
7. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.
8. Mulrow CD, Williams JW Jr, Chiquette E, et al. Efficacy of newer pharmacotherapies for treating depression in primary care patients. Am J Med 2000;108:54-64.
9. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002.
10. Canadian Task Force on the Periodic Health Examination. The Canadian Guide to Clinical Health Care. Ottawa, Ontario: Health Canada;1994:450-4.
11. American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 2002:126-33, 235-6,79.
12. Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics. Pediatrics 2000;105;871-4.
13. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph. Chicago: American Medical Association; 1997.
Members of the Task Force
Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX), Paul S. Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children’s Healthcare Quality, Boston, MA); *Mark S. Johnson, M.D., M.P.H. (Associate Professor of Clinical Family Medicine and Chairman Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); *Jonathan D. Klein, M.D., M.P.H. (Associate Professor of Pediatrics and of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Professor of Medicine, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants’ Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N. (Professor and Associate Dean for Research, School of Nursing, University of Michigan, Ann Arbor, MI); *Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, and Medical Director of the Primary Care and Medical Services Care Center, Mount Sinai School of Medicine and The Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Associate Professor of Obstetrics, Gynecology and Public Health, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor of Family Medicine, Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).
*These current members were not on the Task Force at the time this recommendation was voted.
Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
Source: This recommendation first appeared in Ann Intern Med 2002;136(10):760-4.
Current as of May 2002
Citation:
U.S. Preventive Services Task Force. Screening for Depression: Recommendations and Rationale. May 2002. Agency for Healthcare Research and Quality, Rockville, MD.
Task Force Ratings
Strength of Recommendations
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A. — The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B. — The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C. — The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D. — The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I. — The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
Quality of Evidence
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
