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Draft Research Plan

Depression in Children and Adolescents: Screening

May 15, 2013

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

1a. Does screening for depression in children and adolescents in the primary care setting lead to improved health and other related outcomes?
1b. Does screening for depression in children and adolescents lead to improved health and other related outcomes for subgroups defined by age, sex, or race/ethnicity?
2a. Are screening instruments for depression in children and adolescents accurate in identifying depression in primary care or comparable (e.g., school-based clinic) settings?
2b. What is the proportion of children and adolescents who are accurately identified with depression by screening in subgroups defined by age, sex, or race/ethnicity?
3a. Does screening increase the proportion of patients identified with or treated for depression?
3b. Does screening increase the proportion of patients identified with or treated for depression in subgroups defined by age, sex, or race/ethnicity?
4a. What are the harms of screening for depression in children and adolescents?
4b. What are the harms of screening for depression in subgroups defined by age, sex, or race/ethnicity?
5a. Does treatment of depression in screen-detected children and adolescents identified in primary care or comparable settings improve health and other related outcomes?
5b. What are the benefits of treatment of depression in subgroups defined by age, sex, or race/ethnicity?
6a. What are the harms of depression treatment for children and adolescents?
6b. What are the harms of depression treatment for subgroups defined by age, sex, or race/ethnicity?

These key questions (KQs) reflect important changes since the 2009 systematic review. All KQs now explicitly incorporate a subquestion on subgroups. In addition to the subgroup of primary interest in the 2009 review (age), the KQs also ask about sex and race/ethnicity.

Contextual questions are not systematically reviewed and are not shown in the Analytic Framework.

Valid and reliable risk stratification tools may enhance the U.S. Preventive Services Task Force's (USPSTF's) ability to provide targeted recommendations for risk groups. Contextual information on uptake of existing recommendations may help tailor updated recommendations. The issues of risk factors and uptake of USPSTF recommendations will be addressed through the following contextual questions.

  1. What proportion of primary care providers assess, treat, and refer child and adolescent patients with depression (i.e., major depressive disorder [MDD], dysthymia, and minor depression)? What proportion of primary care providers have access to collaborative systems of care for these patients?
  2. What are the most common types of treatments for MDD in children and adolescents that can be initiated in or referred from primary care, school clinics, or comparable settings? Is there evidence of valid and reliable risk stratification tools to identify children and adolescents at highest risk for depression?
  3. Are children and adolescents with depression and comorbid mental health (e.g., attention deficit hyperactivity disorder, anxiety disorders) or chronic physical health conditions (e.g., diabetes, asthma) in primary care, school clinics, or comparable settings more likely to be screened, treated, or referred for treatment than children or adolescents with depression only? Do these patients receive different treatments from children and adolescents without comorbidities?
  4. Is there evidence of other types of effective treatments for depression in children and adolescents, such as other types of pharmacotherapy (e.g., serotonin–norepinephrine reuptake inhibitors, norepinephrine–dopamine reuptake inhibitors) or complementary and alternative medicine therapy?

The Proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Report. Criteria are overarching as well as specific to each of the KQs.

  Inclusion Exclusion
Populations Children and adolescents ages 7–18 years screened or treated for depression
  • Populations in which a majority of the sample is not ages 7–18 years, such as adults (≥18 years) or children ages 0–6 years only
  • Mixed populations of adults and children without a separate analysis of pediatric outcomes (ages 7–18 years)
  • Severe medical (e.g., cancer) and psychiatric illnesses (e.g., psychotic disorders)
  • Perinatal or parental depression
  • Minor depression or dysthymia
  • Populations that include diagnoses other than MDD without a separate analysis of MDD
Interventions: Screening
  • Screening instruments that are feasible for primary care settings; that is, screening takes ≤15 minutes to complete if delivered prior to clinician and patient face-to-face contact (e.g., in the waiting or exam room before clinician entrance), ≤5 minutes or ≤5 questions if done during the face-to-face visit, and feasible to score in primary care settings
  • More general mental health screening tools, if they have a depression module or are being used to identify depressive illness and related outcomes
  • Screening instruments that are not feasible for primary care settings; that is, screening takes >15 minutes to complete if delivered prior to clinician and patient face-to-face contact (e.g., in the waiting or exam room before clinician entrance), >5 minutes or >5 questions if done during the face-to-face visit, or not feasible to score in primary care settings
  • More general mental health screening tools, if they do not have a depression module and are not being used to identify depressive illness
Interventions: Treatment Pharmacological interventions:
  • Selective serotonin reuptake inhibitors: fluoxetine, fluvoxamine, sertraline, citalopram, and escitalopram

Psychotherapy interventions:

  • Cognitive-behavioral therapy
  • Interpersonal psychotherapy
  • Pure or guided self-help
  • Family support
  • Parental education
  • Peer support

System-level interventions:

  • Collaborative care interventions

Combined interventions:

  • Combinations of pharmacological or psychotherapy interventions
Pharmacological interventions:
  • Tricyclic antidepressants
  • Monoamine oxidase inhibitors
  • Paroxetine
  • Serotonin–norepinephrine reuptake inhibitors, norepinephrine–dopamine reuptake inhibitors, other types of off-label pharmacological interventions

Other therapy:

  • Electroconvulsive therapy
  • Other interventions that are not primary care feasible or referable
  • Complementary and alternative medicine
Comparisons KQs 1, 3, 4:
  • Screened versus unscreened

KQ 2:

  • Screening instrument versus gold standard diagnostic instrument

KQ 5:

  • Medications versus placebo
  • Psychotherapy versus wait-list control, usual care, or supportive counseling
  • Intervention versus sham

KQ 6:

  • Medications versus placebo
  • Intervention versus wait-list control
  • Intervention versus usual care
  • Intervention versus sham
KQs 1, 3–6:
  • Single-group design with no comparator
  • Active comparator of screening instrument (KQs 1–4) or treatment (KQs 5, 6)
Outcomes KQs 1, 5:

Primary outcomes of interest:

  • Remission from depression
  • Depressive symptoms
  • Recurrence of depression

Additional outcomes of interest:

  • Quality of life
  • Academic, psychosocial, and global functioning
  • Delinquency, unplanned pregnancy, substance abuse
  • Improvement in comorbid mental disorders, including conduct disorder, attention deficit hyperactivity disorder, and anxiety disorders
  • Health status, physical health symptoms
  • Suicidality or death from untreated depression

KQ 2:

  • Sensitivity
  • Specificity
  • Positive predictive value
  • Receiver operator curve characteristics (area under the curve)

KQ 3:

  • MDD diagnosis

KQ 4:

  • False-positive results leading to unnecessary treatment
  • Stigma
  • Opportunity costs
  • Resources (staff needed to perform screening, training staff on use of screening instruments)

KQ 6:

  • Death
  • Other serious psychiatric events (such as hospitalization, suicidal ideation, and suicide attempts)
  • Triggering symptoms of mania
  • Discontinuation of medication due to adverse events
  • Side effects of medications
KQs 1, 3–6:
  • All other outcomes not listed in inclusion criteria
Timing KQs 1, 3–6:
  • Outcomes reported at 6-week followup or later

KQ 2:

  • Diagnostic accuracy compared with an independent standard, assessed at ≤2 months after the screening test
KQs 1, 3–6:
  • Outcomes reported earlier than 6 weeks following screening or treatment

KQ 2:

  • Diagnostic accuracy compared with an independent standard, assessed at >2 months after the screening test
Settings KQs 1–4:
  • Primary care or comparable settings, such as school clinics; nonclinic-based settings (e.g., church or after-school programs)
  • United States and other countries with very high Human Development Index

KQs 5, 6:

  • Primary care or comparable setting or school-based clinic setting; nonclinic-based settings (e.g., church or after-school programs)
  • Outpatient settings that receive referrals from primary care or comparable settings, school-based clinics, or nonclinic-based settings
  • United States and other countries with a Human Development Index of "very high"
KQs 1–4:
  • Settings not comparable with a primary care or comparable setting (e.g., high-risk conditions not prevalent in primary care populations)
  • Inpatients or those in residential treatment or drug treatment programs; incarcerated populations
  • Countries with a Human Development Index of low to high

KQs 5, 6:

  • Inpatients or those in residential treatment or drug treatment programs; incarcerated populations
  • Countries with a Human Development Index of "low" to "high"
Study Designs KQs 1, 3–6:
  • Randomized, controlled trials
  • Controlled clinical trials
  • Systematic reviews

KQ 2:

  • Test/retest studies (test compared with gold standard) that are stand-alone or incorporated within other study designs

KQs 4, 6:

  • Prospective cohort studies with sample size ≥1,000
  • Retrospective cohort studies with sample size ≥1,000
KQs 1, 3–6:
  • Letters to the editor without primary data
  • Commentaries
  • Editorials
  • Case reports
  • Case series

KQs 1, 3:

  • Prospective or retrospective cohort studies

KQ 2:

  • Does not report sensitivity and specificity compared with an independently assessed criterion standard for MDD

KQs 4, 6:

  • Prospective cohort studies with sample size <1,000
  • Retrospective cohort studies with sample size <1,000
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