USPSTF: Screen for Major Depressive Disorder at Age 12

Megan Brooks

September 09, 2015

In newly released draft recommendations, the US Preventive Services Task Force (USPSTF) continues to recommend screening children for major depressive disorder (MDD) starting at age 12 years, provided that adequate systems are in place for diagnosis, treatment, and monitoring.

"This is a B recommendation" and is the same recommendation made in 2009, task force member Alex Kemper, MD, from Duke University Medical School, Durham, North Carolina, told Medscape Medical News.

As in 2009, the USPSTF concludes that there is insufficient evidence to weigh the balance of benefits and harms of screening for MDD in children aged 11 years and younger, issuing an "I" statement. They call for more research into whether screening children younger than 12 would result in the same benefits.

"The task force regularly looks at recommendations that it has made in the past as new evidence becomes available. There have been some new studies out around both screening and treatment and that prompted the task force to go back and look at this," Dr Kemper explained.

The new USPSTF draft recommendations were released September 7. The draft recommendation statement and draft evidence review have been posted for public comment on the USPSTF website.

Debilitating, Often Overlooked

"The task force continues to recommend that adolescents between 12 and 18 be screened for MDD. Unfortunately, there is still not enough evidence for the children under 12 years of age to know what benefits or harms of screening are," Dr Kemper said.

MDD can be a "debilitating condition for adolescents and their families. Screening in a primary care setting can help to identify youth with depression who might not otherwise be identified," he added in a news release.

David Fassler, MD, member of the American Academy of Child and Adolescent Psychiatry, who did not participate in the task force review, agrees.

"Depression is a very real illness which affects approximately 5% of all children and adolescents. Fortunately, it is also quite treatable. But treatment is most helpful when the signs and symptoms are recognized as soon as possible," Dr Fassler, professor of psychiatry, University of Vermont, Burlington, told Medscape Medical News. "Enhanced public and professional education and access to appropriate school-based screening programs improve early identification and increase access to timely and effective intervention."

According to the task force, evidence shows that adolescents aged 12 to 18 years who are identified in primary care as having MDD and who are treated experience improvement in depression symptoms and daily functioning.

"By screening for MDD, doctors and other primary care clinicians can have a meaningful discussion with young patients and their parents or guardians about treatment options and supports that can improve health, life, and relationships," task force member Alexander Krist, MD, of Virginia Commonwealth University, Richmond, said in the release.

The average age of onset of MDD in childhood and adolescence is 14 to 15 years, the task force notes, and onset is earlier in girls than boys. Yet only 36% to 44% of children and adolescents with depression receive treatment, suggesting that for most youth with depression, their conditions are not diagnosed or treated.

There is "adequate" evidence that available screening instruments for depression can accurately identify MDD in adolescents aged 12 to 18 years in primary care settings, the task force said. Two of the most often used instruments are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). The task force found no studies of screening instruments for depression in children aged 11 years and younger in primary care (or comparable) settings.

Dr Kemper told Medscape Medical News that in his community, "adolescents are regularly screened for depression as part of well child care and when they come in for sick visits, simply because many adolescents don't come in for regular routine care. It's important to have plans set up for what to do if a child tests positive on a depression screen."

"The tool that we use is the PHQ-A, but there are a number of different tools that are out there. What's nice is that the screening instruments for MDD have low rates of false positives and do a really good job of identifying those children that need to have further evaluation," Dr Kemper said.

Comments Sought Until October 5

Although the USPSTF recommends MDD screening for all adolescents starting at age 12, it notes that several risk factors might help identify those at higher risk for MDD. These factors include female sex, older age, family history of depression (especially maternal), prior episode of depression, other mental health/behavioral problems, chronic medical illness, overweight/obesity, and Hispanic race/ethnicity.

"Other psychosocial risk factors for MDD include childhood abuse or neglect, exposure to traumatic events (including natural disasters), loss of a loved one or romantic relationship, family conflict, uncertainty about sexual orientation, low socioeconomic status, and poor academic performance," the task force said.

Currently, the optimal screening interval for MDD in adolescents is unknown, although repeat screening may be "most productive" in adolescents with MDD risk factors, the task force said.

The task force's draft recommendations align with recommendations from several other organizations, including the American Academy of Family Physicians, which recommends screening for MDD in adolescents aged 12 to 18 years when systems are accessible to ensure accurate diagnosis, treatment (psychotherapy), and follow-up.

The American Academy of Pediatrics' Bright Futures program recommends screening annually in children and adolescents for emotional and behavioral problems. Medicaid's child health component, the Early and Periodic Screening, Diagnosis, and Treatment program, recommends screening to detect physical and mental conditions at periodic, age-appropriate intervals; if risk is identified, it recommends follow-up with diagnostic and treatment coverage.

Comments can be submitted from September 8 to October 5, 2015.

The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

A separate USPSTF recommendation on screening for depression in adults is in progress.


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