New USPSTF Guidelines Recommend Depression Screening, but Only When Staff Supports Are in Place

Pauline Anderson

December 03, 2009

December 3, 2009 — Two new clinical guidelines recommend screening adults for depression, but only when supports are in place to help physicians ensure accurate diagnosis and provide effective treatment and follow-up.

The first guideline was developed by the US Preventive Services Task Force (USPSTF). The second, developed to support the USPSTF statement and aimed at the primary care practice, was prepared by researchers led by Elizabeth A O'Connor, PhD, at Kaiser Permanente Center for Health Research, Portland, Oregon, and colleagues at the University of North Carolina, Chapel Hill.

Both guidelines are published in the December issue of the Annals of Internal Medicine.

The new USPSTF guideline updates a previous statement released in 2002 that recommended screening adults for depression in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up. The new recommendation stipulates that staff-assisted depression care supports need to be in place. Such depression care supports could assist with providing direct depression care such as case management.

In its published statement, the USPSTF determined that with such staff-assisted supports in place, there is at least moderate certainty that the net benefit of screening for depression is at least moderate, whereas without these supports, there is at least moderate certainly that the net benefit of screening adults for depression is small.

For Adults Only

The new recommendation applies only to nonpregnant adults, including older adults. A recently updated USPSTF recommendation calls for screening adolescents aged 12 to 18 years for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up. The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening of children aged 7 to 11 years for MDD.

Screening tests for depression include the Zung Self Depression Scale, Beck Depression Inventory, General Health Questionnaire, Center for Epidemiologic Study Depression Scale, SelfCARE (D), and Geriatric Depression Scale. Most of these tests have relatively good sensitivity (80% - 90%), but only fair specificity (70% - 85%); are easy to use; and can be administered in less than 5 minutes, said the authors.

Screening can also involve asking patients 2 simple questions: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

"There is little evidence to recommend 1 screening method over another; therefore clinicians may choose the method most consistent with their personal preference, the patient population being served, and the practice setting," the authors conclude.

The optimum interval for screening for depression is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (eg, panic disorder), substance abuse, or chronic pain, said the authors.

The task force found no evidence of potential harms of screening, such as false-positive results and the inconvenience and costs and adverse effects of treatment of patients incorrectly identified as being depressed.

Suicidal Risks

In reviewing the literature, the task force found at least fair-quality evidence that second-generation antidepressants (mostly selective serotonin reuptake inhibitors, or SSRIs) increase suicidal behaviors, including suicide attempts, preparatory acts, or serious self harm, in those aged 18 to 29 years, especially those with MDD and those taking paroxetine.

Results of 5 meta-analyses indicated that the odds of suicidal behavior nearly doubled for young adults with MDD or other psychiatric indications who received second-generation antidepressants. In this patient population, clinicians may want to select a medication other than SSRIs, the authors write.

The task force also found the same quality of evidence that SSRI use is associated with an increased risk for upper gastrointestinal bleeding in those older than 70 years, with risk increasing with age. They noted that the concurrent use of SSRIs with a nonsteroidal anti-inflammatory drug or low-dose aspirin may increase the risk for upper gastrointestinal bleeding in older adults. Clinicians may want to select a medication other than SSRIs for these patients, said the authors.

Depression in Primary Care

The second clinical guideline focused on screening for depression in primary care. After reviewing the literature, this group also found that screening programs were likely to be effective when other staff members provided part of the depression care, such as assessment and monitoring.

"The most comprehensive programs included clinician training and treatment protocols provided at the point of care, patient educational materials, office staff training and participation in providing post visit follow-up, and available mental health referral," write the authors.

The group developing these guidelines also found no data that identified harms of depression screening.

This group emphasized the importance of close monitoring of adult patients on antidepressant therapy, especially those younger than 30 years.

Depression Statistics

Depression is among the leading causes of disability in patients aged 15 years and older. In primary care settings, the prevalence of MDD ranges from 5% to 13% in adults and from 6% to 9% in older adults. Up to one half of adults and nearly two thirds of older adults who receive treatment for depression receive it in a primary care setting.

About two thirds of patients achieve remission within 1 year. However, depression is highly recurrent; one study found that about half of patients who achieved remission relapsed during the subsequent year.

The economic burden of depression is substantial in terms of suffering and reduced quality of life for individual patients and in terms of costs to society in the form of lost productivity.

Patients at increased risk for depression include those with a family history of depression or a chronic medical disease and those who are unemployed or of a lower socioeconomic status. Women are also at increased risk compared with men.

The authors have disclosed no relevant financial relationships.

Ann Intern Med. 2009;151:784-792, 793-803. Abstract Abstract

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