Depression and Suicide Risk in Adults: Screening

Major depressive disorder (MDD) is a common mental disorder in the United States that can have a substantial impact on an individual’s life.^1,2 If left untreated, MDD can be associated with an increased risk of cardiovascular events, exacerbation of comorbid conditions, or increased mortality.^1,3-5 In 2019, 7.8% (19.4 million) of adults experienced at least one major depressive episode; 5.3% of adults (13.1 million) experienced a major depressive episode with severe impairment.^1,6 Depression can be a chronic condition characterized by periods of remission and recurrence, often beginning in adolescence or early adulthood. However, full recovery may occur.¹

Depression is also common in postpartum and pregnant persons and affects both the parent and infant. Depression during pregnancy increases the risk of preterm birth and low birthweight or small-for-gestational age.^7,8 Postpartum depression may interfere with parent-infant bonding.⁹

Data from PRAMS showed an increase in self-reported depression during pregnancy, from 11.6% in 2016 to 14.8% in 2019.¹⁰

Suicide is the 10th-leading cause of death in adults (45,390 deaths; 2017 data).¹² From 2001 to 2017, there was a 31% increase in suicide deaths.¹² Over the last decade there has been an 88% rate increase; however, in recent years suicide rates have declined.¹³ In 2020, provisional suicide deaths numbered 45,855, which was 3% less than in 2019 (47,511 deaths).^14,15 Rates of suicide attempts and deaths vary by sex, age, and race and ethnicity.¹ Psychiatric disorders and previous suicide attempts increase the risk of suicide.¹

The U.S. Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for MDD in adults, including pregnant and postpartum persons as well as older adults, has a moderate net benefit.

The USPSTF concludes that the evidence is insufficient on the benefit and harms of screening for suicide risk in adults, including pregnant and postpartum persons as well as older adults, due to a lack of evidence. As a result, the balance of benefits and harms cannot be determined.

See Tables 1 and 2 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.¹⁶

Patient Population Under Consideration

This recommendation applies to adults age 18 years or older who do not have a diagnosed mental health disorder or are not showing recognized signs or symptoms of depression or suicide risk. Older adults are defined as age 65 years or older. This recommendation focuses on screening for MDD and does not address screening for other depressive disorders, such as minor depression or dysthymia.

Condition Definitions

The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) defines MDD as having at least 2 weeks of mild to severe persistent feelings of sadness or a lack of interest in everyday activities. Depression can also present with irritability, poor concentration, and somatic complaints (e.g., difficulty sleeping, decreased energy, and changes in appetite).¹⁷

Perinatal depression is defined as major and minor depressive episodes that occur during pregnancy and the postpartum period (the first 12 months following delivery).¹⁸ In addition to common symptoms of depressive disorders (e.g., feeling sad or loss of interest in activities), other symptoms during the perinatal period may include difficulty bonding with the infant, experiencing persistent doubt in parenting abilities, and having thoughts of death, suicide, self-harm, or harm of the infant.¹⁹

Suicidal behavior includes suicidal ideation, suicide attempts, and suicide completion. Suicidal ideation refers to thinking about, considering, or planning suicide. Suicide attempts refer to nonfatal, self-directed, and potentially injurious behavior that is intended to result in death. Suicide completion is defined as a death caused by self-inflicted injurious behavior with the intent to result in death because of the behavior.²⁰

Assessment of Risk

The USPSTF recommends screening for depression in all adults regardless of risk factors. Risk factors for depression include a combination of genetic, biological, and environmental factors,^1,21 such as a family history of depression, prior episode of depression, other mental health conditions, a history of trauma or adverse life events, or a history of disease or illness (e.g., cardiovascular disease).^25-31

Prevalence rates vary by sex, age, race, ethnicity, education, marital status, geographic location, poverty level, and employment status.^1,21 Women have double the risk of depression compared with men.^22,23 Young adults, multiracial individuals, and Native American/Alaska Native individuals have higher rates of depression.²⁴

Risk factors for perinatal depression include life stress, low social support, history of depression, marital or partner dissatisfaction, and a history of abuse.³²

Screening Tests

Many brief screening tools have been developed that may screen for depression and are appropriate for use in primary care. All positive screening results should lead to additional assessments to confirm the diagnosis, determine symptom severity, and identify comorbid psychological problems.

Commonly used depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms in adults, the Center for Epidemiologic Studies Depression Scale (CES-D), the Geriatric Depression Scale (GDS) in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant persons.¹

Screening instruments for suicide risk include the Beck Hopelessness Scale, the SAD PERSONS Scale (Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness), and the SAFE-T (Suicide Assessment Five-step Evaluation and Triage).¹

Screening Intervals

There is little evidence regarding the optimal timing for screening for depression; more evidence is needed. In the absence of data, a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of patients at increased risk is warranted.

Treatment or Interventions

Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches (e.g., cognitive behavioral therapy or brief psychosocial counseling), alone or in combination.¹ Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider cognitive behavioral therapy or other evidence-based counseling interventions when managing depression in pregnant or breastfeeding persons.

Implementation

Adequate systems and clinical staff are needed to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care. Inadequate support and followup may result in treatment failures or harms, including those indicated by the U.S. Food and Drug Administration boxed warning for selective serotonin reuptake inhibitors (SSRIs). These essential functions can be provided through a wide range of different arrangements of clinician types and settings, including primary care clinicians, mental health specialists, or collaboratively by both following a collaborative care model.¹ Collaborative care is a multicomponent, healthcare system–level intervention that uses care managers to link primary care providers, patients, and mental health specialists.^1,33 Additional components of support include training and materials to improve clinicians’ knowledge and skills surrounding diagnosis and treatment of depression, facilitation or improvement of the referral process, and patient-specific treatment materials.¹

Racism and structural policies have contributed to wealth inequities in the United States, which also affects mental health in underserved communities.³⁴ For example, wealth inequities may result in barriers, such as treatment costs and lack of insurance, to receiving mental health services, which tend to have a greater impact on Black persons and other racial and ethnic groups than on White persons.³⁵ The misdiagnosis of mental health conditions occurs more in Black and Hispanic/Latino patients compared with White patients.^36-38 Black patients are also less likely to receive mental health services than White or Asian American patients.^39,40

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Suicide is the second-leading cause of death in individuals ages 10 to 34 years.² Eighty-three percent of individuals who died by suicide were seen in primary care in the previous year; 24% of individuals had a mental health diagnosis in their medical records in the month prior to death.⁴¹

Factors resulting in increased risk for suicide attempts include severe psychological distress, major depressive episodes, alcohol use disorder, marital status (i.e., divorced or separated), or being unemployed. Important risk factors for suicide deaths include previous suicide attempts (strongest predictor of future suicide death), mental health disorders and substance abuse, family history of suicide or mental health disorders, life stressors, family violence or abuse, incarceration or legal problems, certain medical conditions, chronic pain, or being a military veteran.¹

Suicide risk varies by age, sex, and race and ethnicity.¹ Men are more than 3 times more likely to die from suicide than women.⁴² The highest suicide rates for women occur between the ages of 45 and 54 years, while for men the highest rates occur after age 65 years.¹² In the United States, the highest suicide rates are among White adults, followed by Native American/Alaska Native adults. Between 2014 and 2019, suicide rates increased in Black individuals by 30% and in Asian or Native Hawaiian/Pacific Islander individuals by 16%.⁴³ 

Potential Harms

Although evidence on harms of screening for suicide risk is limited, potential harms of screening include false-positive screening results that lead to unnecessary referrals and treatment (and associated time and economic burden), labeling, anxiety, and stigma.

Current Practice

Evidence is limited on the implementation of routine mental health screening in the United States. No information on screening rates for depression and suicide risk in the United States was identified. Suicide screening likely primarily occurs as part of depression screening among settings that have implemented suicide screening.

Screening instruments for suicide risk usually include components related to current suicide ideation, self-harm behaviors, and assessments of past attempts and behaviors. It is unknown how often primary care providers detect higher suicide risk in adults. Thirty-six percent of U.S. primary care providers discussed suicide in encounters with patients showing symptoms of major depression or adjustment disorders, or seeking antidepressants.⁴⁴

Additional Tools and Resources

The Community Preventive Services Task Force (CPSTF) has several recommendations related to mental health conditions in adults. The CPSTF recommends collaborative care for managing depressive disorders. The CPSTF recommends both home-based depression care and depression care management in primary care clinics for older adults. The CPSTF also recommends mental health benefits legislation in increasing appropriate utilization of mental health services for persons with mental health conditions. More information about the CPSTF and its recommendations on depression interventions is available on its website (https://www.thecommunityguide.org).

The Substance Abuse and Mental Health Services Administration maintains a national registry of evidence-based programs and practices for substance abuse and mental health interventions (https://www.samhsa.gov/resource-search/ebp) that may be helpful for clinicians looking for models of how to implement depression screening. The Suicide Prevention Resource Center, supported by the Substance Abuse and Mental Health Services Administration, offers various resources on suicide prevention (https://www.sprc.org/).

In 2021, the U.S. Surgeon General released a Call to Action that seeks to progress toward full implementation of the National Strategy for Suicide Prevention (https://www.sprc.org/resources-programs/surgeon-generals-call-action-implement-national-strategy-suicide-prevention).

Other Related USPSTF Recommendations

The USPSTF has recommendations on mental health topics pertaining to adults, including screening for anxiety (in progress), preventive counseling interventions for perinatal depression,⁴⁵ screening for unhealthy drug use,⁴⁶ and screening and behavioral counseling interventions for alcohol use.⁴⁷

This recommendation will replace the 2014 USPSTF recommendation statement on screening for suicide risk in adults⁴⁸ and the 2016 recommendation statement on screening for MDD in adults.⁴⁹ Previously, the USPSTF concluded that there was insufficient evidence to assess the balance of benefits and harms of screening for suicide risk in adults and older adults in primary care (I statement). The USPSTF recommended screening for MDD in in the general adult population, including pregnant and postpartum persons, noting that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate followup (B recommendation). The current draft recommendation statements are consistent with these previous recommendations.

Scope of Review

The USPSTF commissioned a systematic review¹ to evaluate the benefits and harms of screening, accuracy of screening, and benefits and harms of treatment of MDD and suicide risk in asymptomatic adults that would be applicable to primary care settings.

Accuracy of Screening Tests

The USPSTF examined evidence on the most widely used or recommended screening tools for depression: PHQ, any version; CES-D; EPDS for perinatal persons; and GDS for older adults.¹

The USPSTF found 13 primary studies (N=8,706) and eight existing systematic reviews (ESRs) (N≈75,000) on accuracy of screening tests for detecting depression.¹ The ESRs assessed different versions of the PHQ, 2- and 3-item Whooley screening questions, CES-D, and EPDS.¹ One study conducted a series of individual patient data meta-analyses to compare several versions of the PHQ with structured or semistructured interviews. In the individual patient data meta-analyses, the PHQ-9 identified 88% of participants with major depression and 85% of those without major depression, at the standard cutoff of 10 or greater, when compared with a semistructured interview reference standard (sensitivity, 0.88 [95% CI, 0.83 to 0.92]; specificity, 0.85 [95% CI, 0.82 to 0.88]; 29 studies [N=6,725]).¹

At the standard cutoff of 2 or greater and when compared with a semistructured interview, the PHQ-2 was more sensitive than the PHQ-9, identifying 91% of participants with major depression (sensitivity, 0.91 [95% CI, 0.88 to 0.94]; 48 studies [N=11,703]). However, specificity at that cutoff was lower, identifying 67% of participants without depression (specificity, 0.67 [95% CI, 0.64 to 0.71]; 48 studies [N=11,703]). The Whooley screening questions and CES-D demonstrated accuracy comparable with the PHQ-2.¹ The accuracy of the EPDS was also similar to the PHQ-2, with sensitivities ranging from 81% to 90% and specificities ranging from 83% to 88%.¹

The 13 primary studies covered multiple versions of the GDS; the GDS-15 was the most common version. In the studies, participants were age 55 years or older (mean age, 69 to 85 years). Fifty to seventy percent of participants were women. Race and ethnicity was reported in only four studies. When race or ethnicity was reported in studies, patients were primarily White, although one study from the United Kingdom included only Afro-Caribbean participants.¹ The standard cutoff of 5 or greater had an acceptable balance of sensitivity and specificity. In a pooled analysis, the GDS-15 accurately identified participants with major depression (sensitivity, 0.93 [95% CI, 0.83 to 0.97]; I²=85.7%; specificity, 0.81 [95% CI, 0.68 to 0.90]; I²=99.2%) with a cutoff score of 5.¹

Three studies (n=1,801) assessed screening instruments for suicidal ideation.^1,50-52 Two studies evaluated general adult populations and one study evaluated older adults. The study with the most events was limited to older adults.¹ Individual screening tests (GDS-15, GDS-SI, and Symptom Driven Diagnostic System for Primary Care [SDDS-PC]) were not examined in more than one study. Most screening instruments reported sensitivity and specificity above 0.80 for at least one reported cutoff score.¹

Benefits of Early Detection and Treatment

Seventeen screening trials (N=18,437 participants) directly addressed the benefits of screening for depression on health outcomes. Four trials included unscreened control groups. The remaining trials screened all participants but provided the screening results to the intervention groups’ clinicians.¹ Trial participants included adults of all ages and perinatal populations: six studies included general adult populations; four studies were limited to older adults; six studies were limited to postpartum patients (between 2 and 12 weeks postpartum); and one study was limited to pregnant patients.¹

Nine of the studies were conducted in the United States. The remaining studies were conducted in the United Kingdom, Hong Kong, and Northern European countries.¹ All studies took place in primary care, general practice, obstetrics-gynecology, or other maternal or child wellness settings.¹ The average age of trial participants was 38.2 years. Ninety-three percent of all participants were women; a majority were women in studies focused on general adult populations (73% women) and older adults (66% women). Among studies conducted in the United States, Black study participants ranged from 7.1% to 51.2% (6 studies); Hispanic/Latino study participants ranged from 4.5% to 59.3% (4 studies); and White study participants ranged from 29% to 94.1% (6 studies). Only one study reported the percent of participants of Asian descent, and none reported the percent who were Native American/Alaska Native.¹ Depression outcomes included prevalence, remission, and response.

The direct evidence from the 17 screening trials demonstrated increased rates of depression remission or scoring below a specified symptom severity level after 6 to 12 months in general adult and perinatal populations.¹ Screening interventions, most of which also included other care management components, were associated with a lower prevalence of depression or clinically important depressive symptomatology at 6 months postbaseline or postpartum (or the closest followup to 6 months; odds ratio [OR], 0.60 [95% CI, 0.50 to 0.73]; 8 randomized, controlled trials [RCTs] [n=10,244]; I²=0%). Among participants scoring above a predefined symptom level at baseline, screening interventions were associated with a greater likelihood of remission or scoring below a specified level of depression symptomatology (OR, 1.58 [95% CI, 1.23 to 2.02]; 8 RCTs [n=2,302]; I²=0%) after 6 months (or the closest followup to 6 months). However, no benefit in symptom severity measures was found (pooled mean difference in change, -1.0 [95% CI, -2.3 to 0.3]; 9 studies [n=5,543]; I²=74.4%).¹ The evidence in older adult populations demonstrated smaller effects. Four trials examined screening only in older adults and only one trial used a depression measure that was specifically designed for older adults. Trials among general adult populations included older adults; however, none of the trials reported subgroup effects by age.¹

Thirty-eight ESRs evaluated treatment for depression: 29 ESRs (≥346 RCTs; N≈45,078) addressed psychological treatment and nine ESRs addressed pharmacologic treatment (≥522 studies; N≥116,477). One ESR reported both psychological and pharmacotherapy treatment.¹ Psychotherapy treatment improved depression and other health outcomes such as anxiety symptoms, hopelessness, quality of life, and functioning in primary care patients, perinatal populations, and older adults. The broadest analysis, which included any type of psychotherapy compared with any kind of control condition, measuring the depression outcome immediately after treatment (typically 2 to 6 months postbaseline), demonstrated a moderate to large effect on depression (standardized mean difference, -0.72 [95% CI, -0.78 to -0.67]; 385 studies; N not reported but estimated at approximately 33,000). The effect was smaller but still statistically significant when limited to studies in primary care patients (standardized mean difference, -0.42 [95% CI, -0.56 to -0.29]; 59 studies; N not reported).¹ Remission and response to treatment were sporadically reported. Data were limited for populations who were socially or economically disadvantaged or in specific racial or ethnic groups. However, the limited evidence supported benefits of psychological treatment in these populations as well.¹

Pooled analyses of antidepressant medications demonstrated increased rates of remission and response to treatment, and small but statistically significant reductions in depressive symptom severity in the short term (typically 8 weeks).¹ Fluoxetine, which had the largest body of evidence (117 studies), was associated with a small reduction in symptom severity (standardized mean difference, -0.23 [95% CI, -0.28 to -0.19]), an increase in the odds of remission (OR, 1.46 [95% CI, 1.34 to 1.60]), and an increase in the odds treatment response (OR, 1.52 [95% CI, 1.40 to 1.66]).¹ Limited evidence was available on the longer-term impact of antidepressants in the synthesized literature, and information was lacking on the benefits of pharmacologic treatment in specific a priori populations of interest.¹

Only one short-term RCT (n=443) examined screening for suicide risk, which was limited to primary care patients who had screened positive for depression.¹ This trial reported no statistically significant group differences in suicidal ideation at 2 weeks’ followup, with one suicide attempt among all study participants.¹

Eighteen RCTs (N=2,694) of suicide prevention among persons at increased risk of suicide were included.¹ The effectiveness of psychological interventions for suicide prevention on suicide deaths and suicide attempts could not be determined due to the small number of events. One suicide death was reported. Most studies reported five or fewer suicide attempts per study group, and the pooled effect was not statistically significant (OR, 0.78 [95% CI, 0.51 to 1.21]; 9 RCTs [n=1,647]; I²=20.5%).¹ Pooled analyses did not demonstrate improvement over usual care for suicidal ideation, self-harm, or depression symptom severity.¹

Harms of Screening and Treatment

Only one depression screening RCT (N=462) reported on harms. This trial was among postpartum patients and no adverse events were reported in the intervention and placebo groups. Across all other depression screening studies that reported on benefits of screening, there was no pattern of effects indicating that screening might paradoxically worsen any outcomes the interventions were intending to benefit.¹

Four ESRs addressed the harms of psychotherapy (~63 RCTs; N≈8,466) in adults of all ages and perinatal persons. Psychological interventions did not increase the risk of harm, measured as deterioration of depressive symptoms with any psychological treatment, self-guided internet-based cognitive behavioral therapy, and guided internet-based interventions.¹ In three ESRs, the deterioration rates were lower with psychological interventions or did not differ statistically from the control group. In an ESR of older adults, 14 included trials did not report safety data.¹

Twenty-one ESRs (~522 RCTs and 166 observational studies; N≈8,163,814) and one cohort study (N=358,351) addressed the harms of pharmacotherapy in adults of all ages and perinatal persons.¹ Two ESRs assessed perinatal patients, four evaluated older adults, and the remaining reviews included adults of any age.¹ Pharmacologic agents evaluated SSRIs and other second-generation antidepressants. Harm outcomes included any adverse events, dropout due to adverse events, serious adverse events, suicide deaths, suicide attempts, and suicide ideation.¹

Pharmacologic treatment was associated with a higher risk of dropout due to adverse events. There was also an increased risk of serious adverse events with SSRI use compared with placebo (OR, 1.39 [95% CI 1.12 to 1.72]; 44 RCTs; N not reported; I²=0%). The absolute risk of serious adverse events appears to be relatively low, and evidence for specific serious adverse events was very limited. There were too few suicide deaths to determine the association between antidepressant use and suicide death. However, RCT and observational evidence demonstrated a small absolute increase in risk of suicide attempts with second-generation antidepressant use among adults age 65 years or younger (OR, 1.53 [95% CI, 1.09 to 2.15]; N=40,857; 0.7% of antidepressants users vs. 0.3% of placebo users). Evidence on other outcomes (e.g., cardiovascular-related, bleeding, mortality, risk of falls, fractures, or dementia) was limited and mostly included observational evidence, including harms of pharmacotherapy in pregnant or postpartum persons (e.g., preeclampsia, gestational diabetes, postpartum hemorrhage, and spontaneous abortion).¹

A short-term study (2 weeks’ followup) among primary care patients (n=443) who screened positive for depression assessed the harms of suicide risk screening.⁵³ Although absolute scores were higher on two of the three suicidal ideation measures, compared with no screening, the findings were not statistically significant.¹

One RCT of suicide prevention treatment reported on harms. There were no differences between groups at followup on an instrument developed to evaluate the perceived level of coercion experienced by service users during hospital admission.⁵⁴ Treatment trials did not show results indicating harms.

Although the evidence is clear that providing depression screening in adults and pregnant and postpartum patients is beneficial, more research is needed to ensure that all patients receive depression screening equitably. Studies are needed that provide more information on the following.

• Research is needed to assess barriers to establishing adequate systems of care and how these barriers can be addressed; there are also limitations to understanding the direct effect of screening relative to other depression management supports.
• Rigorous examination of implementation programs are needed that report the percent of patients being screened, referred, and treated as well as patient health outcomes.
• More research is needed to understand the effect of depression screening and most accurate screening tools among Black, Hispanic/Latino, Asian American, and Native American/Alaska Native communities and other underrepresented groups.

More evidence on whether and how screening for suicide risk can improve health outcomes is also needed. There are several critical evidence gaps.

• More research on the epidemiology and natural history of suicide risk is needed. Persons who attempt suicide and survive and those who die by suicide are overlapping populations. More research to understand these groups and to determine how primary care can improve health outcomes in these groups is needed.
• Additional evidence is needed to determine whether more individuals with screen-detected suicidal ideation could be helped before they act.
• Studies examining the benefits and potential harms of targeted vs. general screening would also be helpful.
• Treatment studies in populations with screen-detected suicide risk in all age groups are needed.
• Targeting persons at high risk, such as Native American/Alaska Native and Hispanic/Latino persons, may help determine whether tailored therapies are more effective in these populations.
• Foundational research is needed in primary care populations, including determining which tools should be used and how screening should be implemented.

The American College of Physicians recommends depression screening in all adults. It defines adults who are postpartum, have a personal or family history of depression, or have comorbid medical illnesses as being at increased risk.⁵⁵ The American College of Preventive Medicine recommends universal screening for depression for all adults.⁵⁶ The Institute for Clinical Systems Improvement recommends universal screening for suspected depression based on patient presentation, risk factors, and special populations (e.g., pregnant and postpartum persons and individuals with cognitive impairment).⁵⁷ The American College of Obstetricians and Gynecologists recommends that all obstetrician-gynecologists and other obstetric care providers complete an assessment of mood and emotional well-being (including screening for postpartum depression) during postpartum visits. All patients with depression should be evaluated for suicidal thinking and previous suicide attempts and referred to a mental health specialist, if needed.⁵⁸ The U.S. Department of Veterans Affairs recommends universal screening for suicide risk for veterans.⁵⁹

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