in progress

Draft Recommendation Statement

Depression and Suicide Risk in Children and Adolescents: Screening

April 12, 2022

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.

This topic is being updated. Please use the link(s) below to see the latest documents available.
  • Update in Progress for Depression and Suicide Risk in Children and Adolescents: Screening

Recommendation Summary

Population Recommendation Grade
Asymptomatic adolescents ages 12 to 18 years The USPSTF recommends screening for major depressive disorder (MDD) in adolescents ages 12 to 18 years. B
Asymptomatic children age 11 years or younger The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children age 11 years or younger. I
Asymptomatic children and adolescents The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in children and adolescents. I

Additional Information

Tools
Related Resources
  • Screening for Anxiety, Depression, and Suicide Risk in Children and Adolescents (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

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.

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Depression is a leading cause of disability in the United States. Children and adolescents with depression typically have functional impairments in their performance at school or work, as well as in their interactions with their families and peers. Depression can also negatively affect the developmental trajectories of affected youth. Major depressive disorder (MDD) in children and adolescents is strongly associated with recurrent depression in adulthood; other mental disorders; and increased risk for suicidal ideation, suicide attempts, and suicide completion.1

Suicide is the second-leading cause of death among youth ages 10 to 19 years.2 Psychiatric disorders and previous suicide attempts increase suicide risk. Rates of suicide attempts and deaths vary by sex, age, and race and ethnicity.1

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The U.S. Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for MDD in asymptomatic adolescents ages 12 to 18 years has a moderate net benefit.

The USPSTF concludes that the evidence is insufficient on screening for MDD in asymptomatic children age 11 years or younger. Evidence is lacking, and the balance of benefits and harms cannot be determined.

The USPSTF concludes that the evidence is insufficient on the benefit and harms of screening for suicide risk in asymptomatic children and adolescents due to a lack of evidence. As a result, the balance of benefits and harms cannot be determined.

See Table 1 and Table 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.3

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Patient Population Under Consideration

This recommendation applies to children and adolescents who have no signs or symptoms of depression or suicide risk. 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).4

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.5-7

Assessment of Risk

The USPSTF recommends screening for MDD in all adolescents but notes that several risk factors might help identify patients at higher risk. Risk factors for depression include a combination of genetic, biological, and environmental factors such as a family history of depression, prior episode of depression, and other mental health or behavioral problems. Other psychosocial risk factors include childhood abuse or neglect, exposure to traumatic events, bullying (either as perpetrators or as victims), adverse life events, early exposure to stress, maltreatment, and an insecure parental relationship.1

The prevalence of mental health disorders in racial and ethnic groups may be evolving over time. Previously, studies demonstrated that Black youth had lower rates of mental health disorders compared with White youth. However, more recent cohorts of Black children and adolescents have reported a higher prevalence of suicide rates, increase in suicide attempts, and greater increases in the prevalence of depression than in the past.8-10 Reasons for this increase may be due to multiple factors such as socioeconomic status, family structure, neighborhood effects, and childhood adversity. Adverse childhood experiences influence the likelihood of suffering from mental health conditions such as depression. Adverse childhood experiences may result from a complex interaction of familial, peer, or societal factors. Individual factors (e.g., age, sex, gender identity, sexual orientation, or genetic predisposition) also may serve as risk factors across mental health conditions.1 These adverse childhood experiences may be blatant or subtle (e.g., microaggressions) but are potentially traumatic events that, in the context of historic trauma, structural racism, and biopsychological vulnerability, can worsen mental health outcomes.11 Combined with lower engagement with mental health services, adverse childhood experiences can result in high levels of unmet need in Black youth.12-16 Similar patterns of historic trauma, adverse childhood experiences, and substance abuse may also explain higher rates of mental health disorders in American Indian/Alaska Native youth.17

Screening Tests

Screening instruments for depression are based on either patient or caregiver reporting. Depression screening instruments typically assess common symptoms related to depression. Many instruments also include at least one item related to suicide ideation. The most commonly used screening instrument in clinical practice is the nine-item Patient Health Questionnaire (PHQ-9).

Instruments designed to screen across mental health conditions may be more efficient than instruments targeting a single condition. However, these instruments take longer to administer, thereby reducing feasibility in primary care settings. They also may be less accurate for specific conditions.1

Screening Intervals

The USPSTF found no evidence on appropriate or recommended screening intervals for depression, and the optimal interval is unknown. Repeated screening may be most productive in adolescents with risk factors for depression. Opportunistic screening may be appropriate for adolescents, who may have infrequent health care visits.

Treatment or Interventions

Treatment options for MDD in children and adolescents include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches.1,18,19 Different types of psychotherapy are used in treating children and adolescents with depression, but cognitive behavioral therapy and interpersonal therapy have the most evidence supporting their effectiveness.20-22 Pharmacologic agents are fluoxetine and escitalopram, and pharmacotherapy is sometimes combined with psychotherapy. Fluoxetine is the only medication approved by the U.S. Food and Drug Administration (FDA) has approved for use in treating MDD in children age 8 years or older; escitalopram is approved to treat MDD in adolescents ages 12 to 17 years.18,19 The FDA has issued a boxed warning for antidepressants, recommending that patients of all ages who start antidepressant therapy be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Collaborative care is a multicomponent, health care system–level intervention that uses care managers to link primary care providers, patients, and mental health specialists.23

Implementation

Many screening tools are available to identify depression in children and adolescents, and some have been used in primary care. The number of items in each tool, the administrative time required to complete them, and the appropriate ages for screening vary. An initial screening may be followed by additional probing or a formal diagnostic interview. In instances where treatment is recommended, it can be initiated by the screening provider or through referral to another set of treatment providers.

Depression can be managed in the primary care or specialist setting or collaboratively in both settings. Treatment options for depression include pharmacologic, behavioral, multimodal, and collaborative care models, some of which require coordination. 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. These essential functions can be provided through a wide range of arrangements of clinician types and settings. Inadequate support and followup may result in treatment failures or harms, as indicated by the FDA boxed warning.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Little is known about the prevalence of MDD in children age 11 years or younger. Early onset is associated with worse outcomes.

Suicide is the second-leading cause of death among youth ages 10 to 19 years.2 The rate of suicide deaths is highest among American Indian/Alaska Native youth and lowest among Black youth compared with White youth.24,25 American Indian/Alaska Native youth die by suicide at a rate of 2.5 deaths per 100,000 persons (younger) and 16.1 deaths per 100,000 persons (older).1 White children and adolescents have a similar rate of dying by suicide compared with Black children and adolescents of the same age (1.3 vs. 1.4 deaths per 100,000 persons for White and Black children, respectively); however, the suicide rate among White adolescents is nearly double the rate among Black adolescents (8.4 deaths per 100,000 persons and 4.2 deaths per 100,000 persons, respectively).1,24,25 Important risk factors for suicide are mental health disorders and adverse childhood experiences (e.g., family history of suicide or mental health disorders, previous suicide attempts, life stressors, history of trauma, parent-child conflict, or legal problems).26 Suicide risk varies by gender or sex and type of behavior. Male youth had a higher rate of suicide completion (17.9 deaths per 100,000 persons) than female youth (5.4 deaths per 100,000 persons); however, the risk of suicide attempts was greater in female youth than male youth.27 Lesbian, gay, bisexual, transgender, and queer adolescents demonstrate higher rates of suicide ideation and attempts compared with heterosexual adolescents.28 Treatments to reduce risk for suicide attempt include psychotherapy and pharmacotherapy (e.g., antidepressants, antipsychotics, and mood stabilizers). However, it’s unclear how effective these therapies are in reducing suicide attempts in children and adolescents who do not have signs or symptoms of being suicidal.

Potential Harms

Potential harms of screening for MDD in young children or for suicide risk in children and adolescents of any age include false-positive screening results that lead to unnecessary referrals (and associated time and economic burden), treatment, labeling, anxiety, and stigma. Psychological interventions are likely to have minimal harms.1 The use of selective serotonin reuptake inhibitors in children is associated with harms, specifically risk for suicidality.

Current Practice

Evidence is limited on the implementation of routine mental health screening in the United States. A survey of primary care physicians found that 76% believe in the importance of talking to adolescent patients about their mental health; however, only 46% said that they always asked their patients about their mental health.29

Screening instruments for suicide risk usually include components related to current suicide ideation, self-harm behaviors, and assessments of past attempts and behaviors. Data on how often primary care providers screen for suicide risk in children and adolescents are lacking.

Additional Tools and Resources

The Community Preventive Services Task force recommends targeted school-based cognitive behavioral therapy programs to reduce depression and anxiety symptoms (available at https://www.thecommunityguide.org/findings/mental-health-targeted-school-based-cognitive-behavioral-therapy-programs-reduce-depression-anxiety-symptoms).

The Centers for Disease Control and Prevention also has additional information on depression in childhood (available at https://www.cdc.gov/childrensmentalhealth/depression.html).

The Community Preventive Services Task Force recommends individual cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events based on strong evidence of effectiveness in reducing psychological harm (available at https://www.thecommunityguide.org/findings/violence-psychological-harm-traumatic-events-among-children-and-adolescents-cognitive-individual).

The Community Preventive Services Task Force recommends group cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events based on strong evidence of effectiveness in reducing psychological harm (available at https://www.thecommunityguide.org/findings/violence-psychological-harm-traumatic-events-among-children-and-adolescents-cognitive-group).

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 (available at  https://www.sprc.org/resources-programs/surgeon-generals-call-action-implement-national-strategy-suicide-prevention)

The Suicide Prevention Resource Center, supported by the Substance Abuse and Mental Health Services Administration, offers various resources on suicide prevention (available at https://www.sprc.org/).

Other Related USPSTF Recommendations

The USPSTF has recommendations on mental health topics pertaining to children and adolescents, including screening for anxiety (in progress) and screening for illicit drug30 and alcohol use.31

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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 children and adolescents that would be applicable to primary care settings. Studies conducted in inpatient or psychiatric residential facilities or psychiatric emergency departments were excluded. 

Accuracy of Screening Tests

The USPSTF found seven fair-quality studies on accuracy for detecting depression (n=3,316). There were no studies of depression screening accuracy in children only; one study included children and adolescents younger than age 12 years. The other six studies were in children and adolescents age 12 years or older. Most of the seven screening instruments assessed are not widely used in clinical practice. The USPSTF did not identify any studies that used the most common screening instrument in clinical practice, the PHQ-9.1 The Center for Epidemiologic Studies Depression Scale (two included studies) is also used for screening in practice but does not include items that assess suicidality.1. Each screening instrument was only assessed in one or two studies, and results varied by screening instrument and threshold. The USPSTF found seven fair-quality studies on depression (n=3,316). For studies assessing accuracy of depression screening instruments, sensitivity ranged from 0.59 to 0.94; specificity ranged from 0.38 to 0.97.1

One study of the full PHQ modified for adolescents (PHQ-A) demonstrated a sensitivity of 0.73 (95% CI, 0.58 to 0.85) and a specificity of 0.94 (95% CI, 0.91 to 0.96). Based on the accuracy characteristics of the PHQ-A, 58 false-positive results and 8 false-negative results per 1,000 screening tests conducted would result at the low end of MDD prevalence (3%), and 53 false-positive results and 30 false-negative results would result at the high end of MDD prevalence (11%).34-36 Two studies using the Center for Epidemiologic Studies Depression Scale used different thresholds, with sensitivity ranging from 0.59 to 0.85 and specificity ranging from 0.38 to 0.83.1

Only one fair-quality study assessing the accuracy of screening for suicide risk in adolescents was found (n=580), and none were identified in younger age groups. Sensitivity ranged from 0.87 to 0.91 (depending on reference standard used) and specificity was 0.60.1

Benefits of Early Detection and Treatment

The USPSTF found no studies that directly evaluated the benefits of screening for depression or suicide risk on health outcomes in screened vs. unscreened participants.

Thirteen randomized, controlled trials (RCTs) (n=2,156) addressed the benefits of depression treatment. Of these 13 RCTs, nine were on psychotherapy; two on pharmacotherapy; one on cognitive behavioral therapy, fluoxetine, and their combination; and one on collaborative care. Cognitive behavioral therapy was the most common type of psychotherapy evaluated. The mean age of participants was age 13 years or older in 10 of the studies; only three studies included participants younger than age 12 years. Most studies recruited participants through general advertisements or from health systems and clinics; only one study specifically targeted recruitment from mental health clinics.1 For pharmacotherapy interventions, the evidence is largely limited to short-term benefits (typically up to 12 weeks).

Pooled estimates demonstrated that psychotherapy was associated with improved symptoms (Beck Depression Inventory or Beck Depression Inventory-II standardized mean difference, -0.58 [95% CI, -0.83 to -0.34]; n=471; 4 trials; I2=0%; and Hamilton Depression Scale mean difference, -2.25 [95% CI, -4.09 to -0.41]; n=262; 3 trials; I2=0%) and treatment response (relative risk [RR], 1.73 [95% CI, 1.00 to 3.00]; n=395; 4 trials; I2=0%). There were no statistically significant differences for other measures.1

Pharmacotherapy was statistically significant for improved symptoms (Children’s Depression Rating Scale-Revised [CDRS-R] pooled mean difference, -3.76 [95% CI, 5.95 to -1.57]; n=793; 3 trials, I2=49%). Pharmacotherapy also demonstrated benefit for loss of diagnosis (pooled RR, 1.20 [95% CI, 1.00 to 1.45]; n=793; 3 trials; I2=0%) and a benefit for functional status (Children’s Global Assessment Scale pooled mean difference, 2.60 [95% CI, 0.78 to 4.42]; n=793; 3 trials; I2=0% ). Pharmacotherapy was associated with improvement for remission, but the pooled differences were not statistically significant.1

One study of collaborative care was shown to be statistically significant for improved symptoms at 6 months (CDRS-R change, 8.5 [95% CI, 13.4 to -3.6]; p=0.001), response by 12 months (odds ratio for ≥50% reduction in CDRS-R score from baseline, 3.3 [95% CI, 1.4 to 8.2]), and remission (odds ratio for PHQ-9 score <5 at 6 months, 5.2 [95% CI, 1.6 to 17.3]). The study reported no statistically significant benefits on measures of functioning.1

Sixteen trials (n=3,034) addressed the benefits of treatment of suicide risk. Suicidal ideation, an intermediate outcome, was measured by the Beck Hopelessness Scale, and a statistically significant difference favoring intervention was found (pooled mean difference, 2.35 [95% CI, -4.06 to -0.65]; n=644; 4 trials; I2=46%) compared with the control.1 However, the clinical significance of how this change on the Beck Hopelessness Scale translates to fewer suicide attempts or completed suicides is not well understood. The 12 remaining trials focused on health outcomes but were underpowered.1 Findings for the health outcomes (e.g., suicide deaths, hospitalization or emergency department visits, number of self-harm events, proportion with self-harm events, or functioning) were mixed or not statistically significantly different.1

Harms of Screening and Treatment

The USPSTF found no studies that directly evaluated the evidence on the harms of screening for depression or suicide risk on health outcomes in children or adolescents in primary care or primary care–relevant settings.

Six trials (n=1,352) and one network meta-analysis assessed the harms of depression treatment: three evaluated pharmacotherapy; two evaluated psychotherapy; one evaluated cognitive behavioral therapy, fluoxetine, and their combination; and one evaluated collaborative care. Only one study included children younger than age 12 years.1

The results for pharmacotherapy suggest a higher rate of suicide-related outcomes and withdrawal as a result of adverse events and serious adverse events compared with placebo; the differences were not statistically significant, likely because of a small number of events due to poor reporting. One collaborative care study that looked at harms had inconsistent results for psychiatric hospitalizations and emergency department visits. The two trials of psychotherapy reported inconsistent findings on harms, as did the single trial on collaborative care.1

Two trials (n=885) reported on suicide risk interventions. There were no significant differences in adverse events reported.1

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There are several critical evidence gaps. Studies are needed that provide more information on the following.

Screening for MDD:

  • More RCTs are needed on the benefits and harms of screening for and treatment of MDD in children younger than age 11 years.
  • Large, good-quality RCTs are needed to better understand the overarching effects of screening for MDD on long-term health outcomes.
  • Additional research is needed in child and adolescent populations that are similar to those found in primary care settings to study the effects of comorbid conditions on screening accuracy, type of MDD treatment selected, and benefits and harms.
  • Evidence on collaborative care and integrated behavioral health is lacking in children and adolescents.
  • Evidence on screening and treatment is lacking in populations defined by sex, race and ethnicity, sexual orientation, and gender identity.

Screening for suicide risk:

  • More RCTs are needed on the benefits and harms of screening for suicide risk among children and adolescents in primary care settings compared with no screening or usual care.
  • More information is needed on the performance characteristics of screening tests for suicide risk.
  • Treatment studies are needed in populations with screen-detected suicide risk, in all age groups.
  • Evidence on screening and treatment is lacking in populations defined by sex, race and ethnicity, sexual orientation, and gender identity, such as American Indian/Alaska Native youth (who are at increased risk for suicide).
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The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) recommend routine screening for depression.37 GLAD-PC is supported by the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association. The Canadian Task Force on Preventive Health Care states that there is insufficient evidence to recommend for or against screening for depression in children or adolescents in primary care settings.38 The Canadian Task Force is currently updating its guidelines.38 The American Academy of Pediatrics, the American Foundation for Suicide Prevention, and experts from National Institute of Mental Health released a “Blueprint for Youth Suicide Prevention” that recommends universal screening for suicide risk in youth age 12 years or older; children ages 8 to 11 years should be screened as clinically indicated.39 The American Academy of Child and Adolescent Psychiatry recommends screening for suicide risk across physical and mental health settings.40 The Joint Commission recommends that organizations screen all individuals for suicidal ideation using a validated screening tool.41

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1. Viswanathan M, Wallace I, Middleton JC, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 221. Rockville, MD: Agency for Healthcare Research and Quality; 2022. AHRQ Publication No. 22-05293-EF-1.
2. Heron M. Deaths: leading causes for 2019. Natl Vital Stat Rep. 2021;70(9):1-114.
3. US Preventive Services Task Force. US Preventive Services Task Force Procedure Manual. Accessed March 29, 2022. https://uspreventiveservicestaskforce.org/uspstf/procedure-manual
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
5. Crosby AE, Ortega L, Melanson C. Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2011.
6. Ivey-Stephenson AZ, Demissie Z, Crosby AE, et al. Suicidal ideation and behaviors among high school students - Youth Risk Behavior Survey, United States, 2019. MMWR Suppl. 2020;69(1):47-55.
7. National Institute of Mental Health. Suicide. Accessed March 29, 2022. https://www.nimh.nih.gov/health/statistics/suicide.shtml  
8. Bridge JA, Horowitz LM, Fontanella CA, et al. Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatr. 2018;172(7):697-699.
9. Bridge JA, Asti L, Horowitz LM, et al. Suicide trends among elementary school–aged children in the United States from 1993 to 2012. JAMA Pediatr. 2015;169(7):673-677.
10. Lindsey MA, Sheftall AH, Xiao Y, et al. Trends of suicidal behaviors among high school students in the United States: 1991–2017. Pediatrics. 2019;144(5):e20191187.
11. Bernard DL, Calhoun CD, Banks DE, Halliday CA, Hughes-Halbert C, Danielson CK. Making the "C-ACE" for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on Black youth. J Child Adolesc Trauma. 2021;14(2):233-247.
12. Lu W. Treatment for adolescent depression: national patterns, temporal trends, and factors related to service use across settings. J Adolesc Health. 2020;67(3):401-408.
13. Lu W. Child and adolescent mental disorders and health care disparities: results from the National Survey of Children's Health, 2011-2012. J Health Care Poor Underserved. 2017;28(3):988-1011.
14. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45.
15. Howell E, McFeeters J. Children's mental health care: differences by race/ethnicity in urban/rural areas. J Health Care Poor Underserved. 2008;19(1):237-247.
16. Emergency Task Force on Black Youth Suicide and Mental Health. Ring the Alarm: The Crisis of Black Youth Suicide in America. Accessed March 29, 2022. https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
17. Garcia JL. Historical trauma and American Indian/Alaska Native youth mental health development and delinquency. New Dir Child Adolesc Dev. 2020;2020(169):41-58.
18. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescent With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-20.
19. Pampallona S, Bollini P, Tibaldi G, et al. Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry. 2004;61(7):714-719.
20. David-Ferdon C, Kaslow NJ. Evidence-based psychosocial treatments for child and adolescent depression. J Clin Child Adolesc Psychol. 2008;37(1):62-104.
21. Merry SN, Stasiak K, Shepherd M, et al. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ. 2012;344:e2598.
22. Mufson L, Sills R. Interpersonal psychotherapy for depressed adolescents (IPT-A): an overview. Nord J Psychiatry. 2006;60(6):431-437.
23. U.S. Food and Drug Administration. Antidepressant Use in Children, Adolescents, and Adults: Revisions to Product Labeling. Accessed March 29, 2022. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM173233.pdf
24. Centers for Disease Control and Prevention. WISQARS. Accessed March 29, 2022. https://wisqars.cdc.gov/data/explore-data/home
25. Jack SP, Petrosky E, Lyons BH, et al. Surveillance for violent deaths—National Violent Death Reporting System, 27 states, 2015. MMWR Surveill Summ. 2018;67(11):1.
26. Sheftall AH, Vakil F, Ruch DA, et al. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry. 2021;S0890-8567(21)01365-4.
27. Kessler RC, Avenevoli S, Costello EJ, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69(4):372-380.
28. Ream GL. What's unique about lesbian, gay, bisexual, and transgender (LGBT) youth and young adult suicides? Findings from the National Violent Death Reporting System. J Adolesc Health. 2019;64(5):602-607.
29. Romer D, McIntosh M. Chapter 31. The role of primary care physicians in detection and treatment of adolescent mental health problems. In: Evans DL, Foa EB, Gur RE, et al, eds. Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don't Know: A Research Agenda for Improving the Mental Health of Our Youth. 2nd ed. New York, NY: Oxford University Press; 2012.
30. US Preventive Services Task Force. Primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(20):2060-2066.
31. US Preventive Services Task Force. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(18):1899-1909.
32. LeFevre ML, U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-726.
33. Siu AL, U.S. Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.
34. Johnson JG, Harris ES, Spitzer RL, et al. The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30(3):196-204.
35. Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales. J Am Acad Child Adolesc Psychiatry. 1991;30(1):58-66.
36. Garrison CZ, Addy CL, Jackson KL, et al. The CES-D as a screen for depression and other psychiatric disorders in adolescents. J Am Acad Child Adolesc Psychiatry. 1991;30(4):636-641.
37. Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081.
38. MacMillan HL, Patterson CJ, Wathen CN, et al. Screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ. 2005;172(1):33-35.
39. American Academy of Pediatrics, American Foundation for Suicide Prevention, National Institute of Mental Health. Blueprint for Youth Suicide Prevention. 2022. Accessed April 8, 2022. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/
40. Walter HJ, Bukstein OG, Abright AR, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124.
41. The Joint Commission. National Patient Safety Goal for Suicide Prevention. Accessed March 29, 2022. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_18_suicide_prevention_hap_bhc_cah_11_4_19_final1.pdf

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Rationale Children (age ≤11 years) Adolescents (ages 12 to 18 years)
Detection Inadequate evidence on screening instruments for depression in children age 11 years or younger in primary care Adequate evidence that screening instruments for depression can accurately identify MDD in adolescents ages 12 to 18 years in primary care settings
Benefits of early detection and intervention
  • No direct evidence on the benefits of screening for MDD in children age 11 years or younger in primary care (or comparable) settings on health outcomes
  • Inadequate evidence on the benefits of treatment in children with screen-detected MDD
  • No direct evidence on the benefits of screening for MDD in adolescents in primary care (or comparable) settings on health outcomes
  • Adequate evidence that treatment of MDD detected through screening in adolescents is associated with moderate magnitude of benefit (e.g., improved depression symptoms or response)
  • Adequate evidence to link screening and early treatment of MDD in adolescents to improved outcomes
Harms of early detection and intervention Inadequate evidence on the harms of screening for or treatment of MDD in children age 11 years or younger
  • No direct evidence on the harms of screening for MDD in adolescents
  • Adequate evidence to bound the magnitude of harms of screening and psychotherapy as no greater than small, based on the likely minimal harms of using screening tools, limited evidence of harms, and the noninvasive nature of the interventions. (When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.)
USPSTF Assessment The benefits and harms of screening for MDD in children age 11 years or younger is uncertain, and the balance of benefits and harms cannot be determined Moderate certainty that screening for MDD in adolescents ages 12 to 18 years has a moderate net benefit (e.g., improved depression symptoms or response

Abbreviations: MDD=Major Depressive Disorder; USPSTF=U.S. Preventive Services Task Force.

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Rationale Children and Adolescents
Detection Inadequate evidence on the accuracy of screening for suicide risk in asymptomatic children and adolescents due to a lack of studies.
Benefits of early detection and intervention
  • No direct evidence on the benefits of screening for suicide risk on health outcomes due to an absence of studies.
  • Inadequate evidence on the effectiveness of treatment (psychotherapy, pharmacotherapy, or collaborative care) of suicide risk in improving health outcomes in children and adolescents. Evidence was limited and findings were inconsistent.
Harms of early detection and intervention
  • Inadequate evidence to assess the potential harms of screening for suicide risk in children and adolescents due to an absence of studies.
  • Inadequate evidence to assess the potential harms of psychotherapy, pharmacotherapy, or collaborative care for treatment of suicide risk in children and adolescents due to a lack of studies.
USPSTF Assessment The benefits and harms of screening for suicide risk in children and adolescents are uncertain, and the balance of benefits and harms cannot be determined.
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