Include

Exclude

General Adult Population, Including Older Adults

Condition definition

Focus on major depressive disorder, persistent depressive disorder/dysthymia, and depression not otherwise specified, or “depression” with no further diagnostic specificity

Trials with a primary focus on bipolar disorder, schizoaffective disorder, seasonal affective disorder, cyclothymia, substance-induced mood disorder, minor depression, or adjustment disorder with depressed mood

Aim

Studies targeting depression screening

Studies targeting screening or treatment of suicidality, bipolar disorder, or treatment-resistant depression

Population

Adults, including older adults, age 18 years and older

• Nonhuman populations
• Children and adolescents (age <18 years), except when related to harms of antidepressants in pregnant women
• Institutionalized individuals (e.g., psychiatric inpatients or prison inmates)
• Individuals in long-term care (e.g., nursing homes)
• Limited to persons with comorbid conditions
• Trials within closed preexisting social networks (e.g., church, worksite programs)

Intervention

Brief standardized instrument designed to identify persons with depression (no more than 15 minutes if completed prior to visit, no more than 5 minutes if completed during visit); self-report, clinician-administered, or electronically delivered

Trials primarily using treatment modalities other than psychotherapy or FDA-approved antidepressants (e.g., exercise, electroshock treatment, St. John’s wort, social marketing, policy, system-level interventions, or adjunctive agents to enhance the effects of antidepressants)

Comparator

Usual care, no screening, screening with no feedback of results to providers

Outcomes

Benefits of screening (KQ 1):

Primary health outcomes

• Depression symptoms
• Depression remission

Other health outcomes

• Depression response
• Suicide deaths, attempts, or ideation
• All-cause mortality
• Quality of life
• Functioning
• Change in health status (e.g., improvement in comorbid conditions or reduction in physical complaints)
• Child/infant outcomes in postpartum women

Harms of screening (KQ 3):

• Treatment avoidance
• Deterioration in patient-provider relationship
• Others reported by screening trials
• Labeling or stigma
• Inappropriate/unnecessary treatment

Timing of outcome assessment

6 weeks after baseline

Setting

• Primary care settings (e.g., internal medicine, family medicine, obstetrics/gynecology, family planning, military health clinics, university-based health clinics)
• Virtual (e.g., online screening tools), if patients are identified through screening in primary care or other population-based screening
• Psychotherapy: Mental health clinic setting acceptable only if patients are identified through screening in primary care or other population-based screening

• Community/university research laboratories or other nonmedical centers
• Mental health clinics (unless recruitment is through primary care screening)
• Correctional facilities
• School classrooms
• Worksites
• Inpatient/residential facilities
• Emergency departments

Study design

RCT, CCT

All other study designs

Country

Countries categorized as “Very High” on the Human Development Index (as defined by the World Health Organization)

Countries not categorized as “Very High” on the Human Development Index

Language

English

Languages other than English

Study quality

Fair or good

Poor, according to design-specific USPSTF criteria

Pregnant and Postpartum Women

Condition definition

Focus on major depressive disorder, persistent depressive disorder/dysthymia, and depression not otherwise specified, or “depression” with no further diagnostic specificity

Trials with a primary focus on bipolar disorder, schizoaffective disorder, seasonal affective disorder, cyclothymia, substance-induced mood disorder, minor depression, or adjustment disorder with depressed mood

Aim

Screening (KQs 1, 3) and treatment (KQs 4, 5): Studies targeting depression screening and treatment

Diagnostic accuracy of screening (KQ 2): Studies addressing accuracy of depression screening instruments

Harms of antidepressants (KQ 5): Studies addressing harms of antidepressants

Studies targeting screening or treatment of suicidality, bipolar disorder, or resistant depression

Population

Screening (KQs 1, 3): Adult pregnant and postpartum women, age 18 years and older

Treatment (KQs 4, 5): Pregnant and postpartum women screening positive for depression in a primary care setting or identified through other population-based screening

• Nonhuman populations
• Children and adolescents (age <18 years), except when related to harms of antidepressants in pregnant women
• Institutionalized individuals (e.g., psychiatric inpatients or prison inmates)
• Individuals in long-term care (e.g., nursing homes)
• Limited to persons with comorbid conditions
• Trials within closed preexisting social networks (e.g., church, worksite programs)

Intervention

Screening (KQs 1, 3): Brief standardized instrument designed to identify persons with depression (no more than 15 minutes if completed prior to visit, no more than 5 minutes if completed during visit); self-report, clinician-administered, or electronically delivered

Instrument accuracy (KQ 2): Limit to most widely used screening tools in this population, the Patient Health Questionnaire (PHQ) in any form, including the related Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD, depression section) and the Edinburgh Postpartum Depression Scale (EPDS)

Treatment (KQs 4, 5): Primary care–relevant interventions, including psychotherapy, FDA-approved antidepressants, and collaborative care

Treatment modalities other than psychotherapy or FDA-approved antidepressants (e.g., exercise, electroshock treatment, St. John’s wort, social marketing, policy, system-level interventions, or adjunctive agents to enhance the effects of antidepressants)

Comparator

Screening (KQs 1, 3): Usual care, no screening, screening with no feedback of results to providers

Treatment (KQs 4, 5):

Psychotherapy

• No intervention
• Usual care
• Waitlist
• Attention control
• Minimal intervention (e.g., usual care limited to no more than 15 minutes of information)

Antidepressants

• No intervention
• Placebo
• Waitlist

Collaborative care

• Usual care

Treatment (KQs 4, 5 ): Active intervention (i.e., comparative effectiveness)

Outcomes

Benefits of screening (KQ 1) and treatment (KQ 4):

Primary health outcomes

• Depression symptoms
• Depression remission

Other health outcomes

• Depression response
• Suicide deaths, attempts, or ideation
• All-cause mortality
• Quality of life
• Functioning
• Change in health status (e.g., improvement in comorbid conditions or reduction in physical complaints)
• Child/infant outcomes in postpartum women

Diagnostic accuracy of screening (KQ 2):

• Sensitivity
• Specificity
• Positive predictive value
• Negative predictive value
• Equivalent data to make such calculations (i.e., 2 x 2 table)

Harms of screening (KQ 3):

• Treatment avoidance
• Deterioration in patient-provider relationship
• Others reported by screening trials
• Labeling or stigma
• Inappropriate/unnecessary treatment

Harms of antidepressant treatment (KQ 5):

• Suicidality
• Serotonin syndrome
• Cardiac effects
• Seizures (bupropion only)
• Fetal/infant harms: Neonatal death, major malformations, small for gestational age/birthweight

Timing of outcome assessment

Screening (KQs 1, 3): 6 weeks after baseline

Diagnostic accuracy of screening (KQ 2): Maximum 2 weeks between screening and reference standard

Treatment (KQs 4, 5):

• 6 weeks after baseline for treatment and harms of psychotherapy or collaborative care
• No minimum followup for harms of antidepressants

Setting

• Primary care settings (e.g., internal medicine, family medicine, obstetrics/gynecology, pediatrics [for postpartum screening], family planning, military health clinics, university-based health clinics)
• Virtual (e.g., online screening tools), if patients are identified through screening in primary care or other population-based screening
• Psychotherapy: Mental health clinic setting acceptable only if patients are identified through screening in primary care or other population-based screening

Harms of antidepressants (KQ 5): Any outpatient clinical setting

• Community/university research laboratories or other nonmedical centers
• Mental health clinics (unless recruitment is through primary care screening)
• Correctional facilities
• School classrooms
• Worksites
• Inpatient/residential facilities
• Emergency departments

Study design

Benefits of screening (KQ 1), harms of screening (KQ 3), and benefits of treatment (KQ 4): RCT, CCT

Diagnostic accuracy (KQ 2): Comparison with gold standard (structured or semistructured diagnostic interview or a nonbrief [>5 minutes] unstructured interview with mental health clinician) within 2 weeks of screening in populations that include full spectrum of patient severity for the given setting (i.e., cannot limit patient pool to only nondepressed and known/highly likely depressed patients)

Harms of antidepressant treatment (KQ 5): Systematic reviews; large comparative cohort or case-control observational studies published after identified systematic reviews that include observational studies. “Large” is operationalized as:

• n ≥10,000 with at least 6 months of followup for suicide attempts and deaths
• n ≥1,000 with at least 3 months of followup for other outcomes

All other study designs

Country

Countries categorized as “Very High” on the Human Development Index (as defined by the World Health Organization)

Countries not categorized as “Very High” on the Human Development Index

Language

English

Languages other than English

Study quality

Fair or good

Poor, according to design-specific USPSTF criteria