US Preventive Services Task Force Recommendations and Rationale on Depression Screening, Page 1

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.

Summary of Recommendation

  • The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.
    Rating: B Recommendation.
    Rationale: The USPSTF found good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity. Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results. Small benefits have been observed in studies that simply feed back screening results to clinicians. Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective followup and treatment. The USPSTF concluded the benefits of screening are likely to outweigh any potential harms.
  • The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression.
    Rating: I Recommendation.
    Rationale: The USPSTF found limited evidence on the accuracy and reliability of screening tests in children and adolescents and limited evidence on the effectiveness of therapy in children and adolescents identified in primary care settings.

Clinical Considerations

  • Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]).2 Asking two simple questions about mood and anhedonia (“Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”) may be as effective as using longer instruments.3 There is little evidence to recommend one screening method over another, so clinicians can choose the method that best fits their personal preference, the patient population served, and the practice setting.
  • All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (i.e., those from the fourth edition of Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) to determine the presence or absence of specific depressive disorders, such as major depression and/or dysthymia.4 The severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse) should be addressed.
  • Many risk factors for depression (e.g., female sex, family history of depression, unemployment, and chronic disease) are common, but the presence of risk factors alone cannot distinguish depressed from nondepressed patients.
  • The optimal interval for screening is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (e.g., panic disorder or generalized anxiety), substance abuse, or chronic pain.
  • Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful followup. Benefits from screening are unlikely to be realized unless such systems are functioning well.
  • Treatment may include antidepressants or specific psychotherapeutic approaches (e.g., cognitive behavioral therapy or brief psychosocial counseling), alone or in combination).
  • The benefits of routinely screening children and adolescents for depression are not known. The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine depression screening has not been studied in pediatric populations in primary care settings. Clinicians should remain alert for possible signs of depression in younger patients. The predictive value of positive screening tests is lower in children and adolescents than in adults, and research on the effectiveness of primary care-based interventions for depression in this age group is limited.

Scientific Evidence

Epidemiology and Clinical Consequences

Depressive disorders are common, chronic and costly. The World Health Organization identified major depression as the fourth leading cause of worldwide disease in 1990, causing more disability than either ischemic heart disease or cerebrovascular disease.5 In primary care settings, the point prevalence of major depression ranges from 5 to 9 percent among adults, and up to 50 percent of depressed patients are not recognized.6,7 Other disabling depressive illnesses include dysthymia (a chronic low-grade depression) and minor depression (an episodic, less severe illness). These two illnesses are as common as major depression in primary care settings. Depressive disorders are also relatively common in younger persons, with estimated prevalence of 0.8 to 2.0 percent in children and 4.5 percent in adolescents.

Accuracy and Reliability of Screening Tests

Several depression screening instruments are available; most instruments have relatively good sensitivity (80 percent to 90 percent) but only fair specificity (70 to 85 percent).2 Most instruments are easy to use and can be administered in less than 5 minutes. Shorter screening tests, including simply asking questions about depressed mood and anhedonia, appear to detect a majority of depressed patients and, in some cases, perform better than the original instrument from which they were derived.3

Assuming optimal test performance and a prevalence of major depression of 5 to 10 percent in primary care settings, about 24 to 40 percent of patients who screen positive will have major depression. Some patients with “false positive” results on screening may have dysthymia or subsyndromal depressive disorders that might benefit from treatment or closer monitoring; others may have comorbid disorders such as anxiety disorder, substance abuse, panic disorder, post-traumatic stress disorder, or grief reactions; still others may have no disorder at all. The finding of a positive screen therefore requires further diagnostic questioning by the clinician to establish an appropriate diagnosis and initiate a plan for treatment and followup.

Screening instruments have been tested in children and adolescents, with sensitivity ranging from 40 to 100 percent and specificity from 49 to 100 percent. Because the underlying prevalence is much lower than in adults, the positive predictive value is low.

Effectiveness of Early Treatment

Effective treatments are available for patients with depressive illnesses detected in primary care settings.1,8 Antidepressant medications for major depression, including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), are clearly more effective than placebo. Most of the data supporting effectiveness come from structured trials with selected populations, although more recent studies using “usual care” comparison groups and real-world settings have produced similar effects. Newer agents perform similarly to older agents.

Psychosocial and psychotherapeutic interventions are probably as effective as antidepressant medications for major depression, but they are clearly more time-intensive.7 The benefits of psychotherapy for other depressive illnesses are less well studied. Few studies have examined the effect of combining medications and psychotherapy.

No studies have examined treatment outcomes for children or adolescents identified by primary care clinicians through screening. Evidence for treating adolescents comes from school and community settings where SSRIs and cognitive-behavioral therapy, but not tricyclic antidepressants, appear to be effective. Whether these results can be generalized to primary care settings or to children is unclear.

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