Draft Recommendation Statement
Depression in Adults: Screening
July 27, 2015
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.
The USPSTF makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Depression is among the leading causes of disability in persons age 15 years or older. It affects individuals, families, businesses, and society. It is common in primary care patients. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well.
The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings.
Benefits of Early Detection and Intervention/Treatment
The USPSTF found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women.
The USPSTF found convincing evidence that treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.
The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.
Harms of Early Detection and Intervention/Treatment
The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none.
The USPSTF found adequate evidence that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none.
The USPSTF found evidence that there is a potential for serious harms from pharmacological treatment of depression in pregnant women but that the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.
The USPSTF concludes that for adults who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate followup, there is at least moderate certainty that the net benefit of screening for depression is moderate. For pregnant and postpartum women, there is at least moderate certainty that the net benefit of screening for depression is moderate based on the evidence of benefits and harms when CBT or other evidence-based counseling is available.
Patient Population Under Consideration
This recommendation applies to adults older than age 18 years. It does not apply to children and adolescents, who are addressed in a separate USPSTF recommendation statement (available at www.uspreventiveservicestaskforce.org).
Assessment of Risk
The USPSTF recommends screening in all adults regardless of risk factors. However, there are a number of factors that are associated with an increased risk of depression. Among general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment. Women, young and middle-aged adults, and nonwhite individuals have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, and unemployed. Other groups at increased risk of developing depression include persons with chronic illnesses (e.g., cancer or cardiovascular disease), other mental health disorders (including substance misuse), and a family history of psychiatric disorders.
Risk factors for depression during pregnancy and postpartum include prenatal depression, poor self-esteem, childcare stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, maternity “blues,” lower socioeconomic status, and unintended pregnancy.
Among older adults, risk factors for depression include disability and poor health status related to medical illness–complicated grief, chronic sleep disturbance, loneliness, and a personal history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from patients without depression.
The Patient Health Questionnaire (PHQ) is the most commonly used depression screening instrument in the United States. Other commonly used depression screening instruments include the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women. All positive screening tests should trigger additional assessment that considers severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.
The optimum interval for screening for depression is unknown; more evidence for all populations is needed to identify ideal screening intervals.
Treatment of depression generally includes antidepressants or specific psychotherapy approaches (e.g., CBT or brief psychosocial counseling), alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacological agents, clinicians are encouraged to refer to recent treatment guidelines and consider the severity of depression and the benefits and harms of different treatments when managing depression in individual pregnant or breastfeeding women.
Other Approaches to Prevention
The Community Preventive Services Task Force recommends collaborative care for the management of depressive disorders as part of a multicomponent, health care system–level intervention that uses case managers to link primary care providers, patients, and mental health specialists. More information about the Community Preventive Services Task Force and its recommendations on depression interventions is available on its Web site (www.thecommunityguide.org).
The 2009 USPSTF recommendation on screening for depression in children and adolescents is currently being updated. The USPSTF has also has made a recommendation on screening for suicide risk in adolescents, adults, and older adults. The full recommendation statements and evidence reviews are available on the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Adequate Systems in Place to Ensure Accurate Diagnosis, Effective Treatment, and Appropriate Followup
“Adequate systems in place” refers to having systems and clinical staff that support the primary care clinician by providing some direct depression care, such as administration of questionnaires, care support or coordination, case management, or mental health treatment. In the available evidence, the lowest effective level of support consisted of a designated nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to behavioral treatment.1 At the highest level, support included screening; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for followup assessment and ongoing support for adherence to medication for patients who are prescribed antidepressant medications; a visit with a trained therapist for CBT; and a reduced copay for patients referred for psychotherapy.2, 3
In a successful study designed for practices without ready access to mental health specialty care, office staff recruited, screened, and enrolled participants who screened positive for depression before a clinic visit.4 If the physician confirmed the depression diagnosis, the participant was scheduled for a return visit with the physician and nurse specialist in 1 week. The nurse specialist reassessed the patient’s level of depression, discussed treatment options and preferences, and asked the participant to complete a homework assignment. Participants completed up to eight additional sessions that followed the same pattern, either by phone or in person. Multidisciplinary team-based primary care that includes self-management support and care coordination has been shown to be effective in management of depression. These components of primary care are detailed in recommendations from the Community Preventive Services Task Force.5 It recommends collaborative care for the treatment of major depression in adults age 18 years or older on the basis of strong evidence of effectiveness in improving short-term treatment outcomes. As defined, collaborative care and disease management of depressive disorders includes a systematic, multicomponent, and team-based approach that “strengthens and supports self-care, while assuring that effective medical, preventive and health maintenance interventions take place” to improve the quality and outcome of patient care.5
The economic burden of depression is substantial for individuals as well as society. Costs to an individual may include suffering, possible side effects from treatment, fees for mental health and medical visits and medications, time away from work and lost wages, transportation, and reduced quality of personal relationships. Costs to society may include loss of life, reduced productivity (because of both diminished capacity while at work and absenteeism from work), and increased costs of mental health and medical care.
Research Needs and Gaps
Data are lacking on both the accuracy of screening and the benefits and harms of treatment in pregnant women, as well as for the balance of benefits and harms of treatment with antidepressants in postpartum women. Gaps in the evidence on screening for depression in older adults in primary care include a lack of information from large-scale randomized, controlled trials (RCTs) in settings that are applicable to the U.S. population. More research is needed to identify the optimal screening interval in all populations.
Burden of Disease
Major depressive disorder (MDD) is a common and significant health care problem. It is the leading cause of disability among adults in high-income countries and is associated with increased mortality due to suicide and impaired ability to manage other health issues. Depression has a major impact on quality of life for the patient and affects family members, especially children. Depression also imposes a significant economic burden through direct and indirect costs. In the United States, an estimated $22.8 billion was spent on depression treatment in 2009, and lost productivity cost an additional estimated $23 billion in 2011.6
Scope of Review
The commissioned systematic review to update this recommendation focused on direct evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women. The USPSTF also reviewed the evidence on the accuracy of depression screening instruments and the benefits and harms of depression treatment in these populations.
Accuracy of Screening Tests
General Adult Population and Older Adults
The accuracy of screening tests in the general adult population was established in the 2002 and 2009 USPSTF reviews and found to be convincing.
Pregnant and Postpartum Women
Twenty-one studies (n=6,325), including seven studies of the English-language version, compared the accuracy of the EPDS with a diagnostic interview.7 Sensitivity of the English-language EPDS with a cutoff of 13 ranged from 0.67 (95% confidence interval [CI], 0.18 to 0.96) to 0.95 (95% CI, 0.81 to 1.00), and specificity for detecting MDD was consistently at least 0.90. In the two trials conducted in the United States,8, 9 including a recent study in low-income African American women, sensitivity for detecting MDD ranged from 0.78 to 0.81. This suggests that the average sensitivity of the EPDS with a cutoff of 13 in the United States is approximately 0.80, and the positive predictive value for detecting MDD would be 47% to 64% in a population with a 10% prevalence of MDD. The Spanish-language version also showed acceptable performance characteristics. No studies of screening in pregnant and postpartum women with the 9-item PHQ or other versions met inclusion criteria.
Effectiveness of Screening and Treatment
General Adult Population and Older Adults
Nine good- or fair-quality trials addressed screening in general adults (five trials; n=2,924) and older adults (four trials; n=890). Seven studies were conducted in the United States and two (in older adults) were conducted in the Netherlands. Most studies were published in the 1990s and early 2000s; only one (in older adults) of the nine trials was published since the previous systematic review. One study in general adults directly compared screening with usual care case-finding,10 while the other studies screened all patients for depression, enrolled only those screening positive, and returned results of screening to providers in the intervention group only.7 Studies included a range of additional treatment components along with providing screening result feedback to clinicians.
Improvements in remission and/or response rates in the general adult population ranged from 17% to 87%. Other outcomes were sparsely reported. The effect of screening on remission and/or response rates in the trials of older adults was minimal. However, both of the trials in older adults that showed a paradoxical effect were conducted in the Netherlands, and the one with the worst outcomes had a number of features that may have affected its reliability, including external referrals for depression treatment that may have disrupted established doctor-patient relationships, very low uptake of treatment (19%), and high mortality and morbidity in the intervention group suggesting that the control and intervention groups may have been different at baseline.
The 2009 USPSTF recommendation concluded that the evidence is sufficient to establish the benefits of treatment of depression in general adult populations, including older adults.11 A systematic review of intention-to-treat trials comparing three groups of adult patients who received antidepressants, psychotherapy, or a control condition reported a 46% remission rate with antidepressants and a 48% remission rate with psychotherapy after 10 to 16 weeks.12 Two systematic reviews concluded that antidepressants were effective in treating depression in older adults. In one reviews, older adults who received antidepressants were twice as likely to have remission from major or minor depression as older adults who received placebo (odds ratio [OR], 2.03 [95% CI, 1.67 to 2.46]).13 The other review indicated that among community-dwelling older adults, 36% of those who received antidepressants were in remission at the end of the study compared with 21% of those who received placebo (OR, 2.13 [95% CI, 1.61 to 2.86]).14 In addition, two good-quality systematic reviews on the efficacy of psychotherapy in older adults found that older adults who received psychotherapy were more than twice as likely to have remission as those who received no treatment (OR, 2.47 [95% CI, 1.76 to 3.47] vs. 2.63 [95% CI, 1.96 to 3.53]).13, 15
Pregnant and Postpartum Women
The USPSTF identified six fair- or good-quality trials (n=11,869) (five in postpartum women and one in pregnant women) that assessed the effect of screening for depression in pregnant and postpartum women.7 Trial participants were identified through primary care settings using the EPDS (cutoff scores varied), and included both women with and without depression. None of the trials simply compared usual care with screening plus usual care. Two trials assessed minimal additional intervention beyond screening or feedback of screening results in postpartum16 and pregnant17 women, two trials assessed the effects of screening plus provider supports in postpartum women,17, 18 and two trials assessed feedback of screening results plus adjunctive counseling by home health visitors in postpartum women.19, 20 Studies varied by geographical location (United States, northern Europe, United Kingdom, and Hong Kong), length of followup (11 weeks to 16 months), and baseline depression rates (10% to 28%).
Despite the variation in trial design and population, results were reasonably consistent across the range of designs. Trials in postpartum women showed 28% to 59% reductions in risk of depression at followup compared with usual care. The reported effect was smaller (18%) and did not reach statistical significance in the trial of pregnant women but was in the same direction.17 The four studies that reported remission or response rates reported statistically significant improvements in both postpartum and pregnant women. The most applicable trial (U.S. trial of screening plus provider supports) found that 45% of intervention participants reported a 5-point or greater reduction in 9-item PHQ score (an improvement considered to be clinically important) compared with 35% percent of usual care participants (OR, 1.74 [95% CI, 1.05 to 5.86]; adjusted for depression history, marital status, income, education, age, and degree of parenting stress).18
Seventeen trials examined the benefits of treatment interventions in women who screened positive for depression in primary care or community settings. Fifteen trials were in postpartum women (usually 6 to 12 weeks postpartum) and two were in pregnant women,21, 22 but all reported outcomes during the postpartum period. Only one small short-term trial of screen-detected depression in postpartum women included antidepressants as an intervention.23 The most commonly studied approach was CBT or related interventions that included CBT components. All nine trials of CBT or CBT-related interventions, including the two trials in pregnant women, showed an increased likelihood of remission with treatment in the short term (≤7.8 months). The magnitude of effect in pregnant women was similar to that in postpartum women. Pooled results that used only the longest followup period within 1 year showed a 35% increase in the likelihood of remission with CBT (DerSimonian and Laird pooled relative risk, 1.35 [95% CI, 1.19 to 1.53]; k=9; I2=18.7%) compared with usual care. The other eight non-CBT studies examined a diverse range of interventions but did not provide sufficient evidence to draw conclusions for any one approach. There was also insufficient evidence to assess differences in effectiveness for patient subgroups.
Potential Harms of Screening and Treatment
General Adult Population and Older Adults
One trial in general adults reported no adverse events attributable to screening in a subset of participants with newly-identified depression;24 none of the other effectiveness trials in general adults reported on harms. One trial in older adults reported paradoxical effects from screening, as previously discussed. No additional studies addressing harms of screening were identified in the review.
The 2009 USPSTF review found seven studies that compared suicide-related events in adults who received selective serotonin reuptake inhibitors (SSRIs) and other second-generation antidepressants versus placebo. No studies reported a significant increase in completed suicide rates in adults who received antidepressants compared with those who received placebo, although completed suicides were rare and, as a result, the power to detect a significant difference was limited.25 For adults older than age 65 years, antidepressant use seemed to be protective against suicidal behavior (OR, 0.06 [95% CI, 0.01 to 0.58]).26 In addition, the 2009 USPSTF evidence review identified one fair-quality study on bleeding risk in older adults who received SSRIs. Although patients age 16 years or older were at increased risk of upper gastrointestinal bleeding during SSRI use, the risk increased significantly with age, from 4.1 hospitalizations per 1,000 adults ages 65 to 70 years to 12.3 hospitalizations per 1,000 octogenarians. The odds of upper gastrointestinal bleeding in adults ages 40 to 79 years who were currently taking SSRIs (adjusted OR, 3.0 [95% CI, 2.1 to 4.4]) was much higher when they were also taking a nonsteroidal anti-inflammatory drug (adjusted OR, 15.6 [95% CI, 6.6 to 36.6]).27
Pregnant and Postpartum Women
Only one trial, which focused on the effects of screening alone in postpartum women, specifically reported on adverse effects of screening, and found none.16 None of the other screening trials showed any signals of concern. The literature search did not identify additional trials addressing harms of screening.
None of the trials addressing the benefits of behaviorally-based interventions reported on harms of treatment. In addition, none of the trials showed paradoxical effects of concern. The review found no additional trials addressing the harms of behaviorally-based interventions beyond those that were included for the benefits of treatment. The majority of the evidence on the harms of antidepressants was drawn from a good-quality comprehensive systematic review on the comparative effectiveness and safety of antidepressant treatment for depression in pregnant and postpartum women sponsored by the Agency for Healthcare Research and Quality.28 This review included studies published between 1996 and 2013 and was supplemented with 12 additional fair- to good-quality observational studies (n=4,759,435) published after the review.7 The review included 15 observational studies that provided evidence on the harms of antidepressants at unknown dosages in pregnant women with depression and an additional 109 observational studies that provided evidence on the harms of antidepressants in pregnant women whose depression status in either or both treatment arms was unknown. This observational evidence shows that second-generation antidepressant use during pregnancy may be associated with small increases in risk of preeclampsia, postpartum hemorrhage, miscarriage, perinatal death, preterm birth, serotonin withdrawal syndrome, respiratory distress, pulmonary hypertension, major malformations, cardiac malformations, and being small for gestational age.
Estimate of Magnitude of Net Benefit
General Adult Population and Older Adults
The evidence from five RCTS, in addition to indirect evidence reviewed for the 2009 recommendation, supports moderate certainty that screening for depression in general adults is of moderate net benefit. The evidence for older adults is less clear, since the trials that assessed the direct impact of screening found no benefit and possibly even harm. However, given the strength of the indirect evidence (the accuracy of screening in older adults and the effectiveness of treatment in older adults), the inclusion of adults older than age 65 years in the studies of all adults, and the weakness of the direct evidence on screening in older adults, the USPSTF concludes that the weight of evidence still favors a net benefit. However, more research on optimal screening approaches in older adults is imperative.
Pregnant and Postpartum Women
Direct and indirect evidence support moderate certainty that screening for depression in pregnant and postpartum women is of moderate net benefit. Six RCTs with varying degrees of additional support found direct benefit of screening, 21 studies confirmed the accuracy of the EPDS for identifying MDD, and nine RCTs found benefit of treatment with CBT.7 Although most of the evidence (except for harms of SSRIs) is in postpartum women, the direction and magnitude of effect in pregnant women was consistent with the outcomes for postpartum women and for adults in general. It is important to note that the evidence on treatment benefit is primarily for nonpharmacological interventions (i.e., CBT), there is evidence of a small risk of harm to fetal health with SSRI use in pregnant women, and there is a lack of evidence on harms of SSRI use in postpartum women. Therefore, it is important that a range of treatment options are available for pregnant and postpartum women with depression who are identified through screening, and that treatment choices are made through a shared decisionmaking process.
In 2009, the USPSTF recommended screening all adults when staff-assisted depression care supports are in place, and selective screening based on professional judgment and patient preferences when such support is not available. In recognition that such support is now much more widely available and accepted as part of mental health care, the current recommendation statement has omitted the recommendation regarding selective screening, as it is no longer representative of current clinical practice. The current statement also specifically recommends screening for depression in pregnant and postpartum women, subpopulations that were not specifically reviewed for the 2009 recommendation.
The American Academy of Family Physicians recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and followup. It recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. These recommendations are based on the 2009 USPSTF recommendation.29 The American Academy of Pediatrics recommends that pediatricians screen mothers for postpartum depression at the infant’s 1-, 2-, and 4-month visits.30 The American College of Physicians recommends that primary care providers screen all adults for depression and that all primary care providers should have systems in place, either within the primary care setting itself or through collaborations with mental health professionals, to ensure the accurate diagnosis and treatment of this condition. It supports the 2009 USPSTF recommendation.31 The American Congress of Obstetricians and Gynecologists concludes that there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening; however, since screening for depression has the potential to benefit a woman and her family, it should be strongly considered.32 The Canadian Task Force on Preventive Health Care does not recommend routinely screening for depression in adults at average risk of depression or in subgroups of the population who may be at increased risk of depression.33 The Institute for Clinical Systems Improvement recommends that clinicians use a standardized instrument to screen for depression if it is suspected based on risk factors or presentation. The Community Preventive Services Task Force recommends collaborative care for the management of depressive disorders based on strong evidence of effectiveness in improving depression symptoms, adherence to treatment, response to treatment, and remission and recovery from depression. This collaboration is designed to improve the routine screening and diagnosis of depressive disorders, as well as the management of diagnosed depression.5
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