New Depression Screening Guidelines Released

Nancy A. Melville

January 26, 2016

The US Preventive Services Task Force (USPSTF) has updated its recommendation on the screening of depression in the general adult population aged 18 years and older, endorsing its previous call for screening of all individuals at the primary care level and adding screening of pregnant and postpartum women, regardless of risk factors.

Following a systemic review of evidence on the issue, "the USPSTF concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in adults, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening," the recommendation states.

The update of the task force's 2009 depression screening recommendations reflects stronger evidence of the importance of screening for depression during and after pregnancy, task force member Karina Davidson, PhD, professor at Columbia University Medical Center, New York City, told Medscape Medical News.

"The addition of the subpopulation of pregnant women and postpartum women is new for this 2015 recommendation. At the time of the previous recommendation, there was not enough evidence to recommend for or against screening pregnant women and postpartum women, but now there is," she said.

The recommendation level is "B," which indicates a moderate net benefit, whereas the highest level, an "A" grade, would indicate a high benefit, she added.

"In the future, there may be additional evidence that shows that there is high net benefit. Additionally, the task force identifies a number of areas in this recommendation where additional research is needed."

The recommendations, which were published online January 26 in JAMA, call for primary care practitioners to offer or provide the screening for all patients, using effective screening tests such as the Patient Health Questionnaire, the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale in postpartum and pregnant women.

Applause for Proactive Approach

In an accompanying editorial, Michael E. Thase, MD, of the University of Pennsylvania, in Philadelphia, noted that the grade B recommendation underscores the broad variations in depression, and hence the challenges in treatment.

"In part, the B grade reflects the nature of major depression disorder, ie, a clinically heterogeneous group of conditions that respond variably to a diverse group of interventions," Dr Thase writes.

"Until there are better methods to match patients with specific forms of treatment, the best hope to improve on a B grade for patients with depression may be to adapt care systems to respond more flexibly and decisively to key events that are associated with nonadherence or treatment failure."

The inclusion of pregnancy and postpartum depression screening in the recommendations is a development that is "long overdue," Richard K. Silver, MD, chairman and chief academic officer of the Department of Obstetrics and Gynecology at NorthShore University Health System, in Evanston, Illinois, told Medscape Medical News.

"I think that's a wonderful development," he said. "Proactive screening is, quite honestly, long overdue because people are still not inclined to have a conversation about this, particularly in pregnancy, and I'm very glad the task force has included that.

"It's also part of the primary care mandate in terms of what the federal government programs expect. There are barriers in terms of people seeking mental health service, so screening is one way of getting around that."

Not Far Enough

However, not all believe the recommendations go far enough. In another accompanying editorial, Charles F. Reynolds III, MD, and Ellen Frank, PhD, both from the University of Pittsburgh Medical Center, praise the task force's recommendations in general but take issue with the failure to specify ideal screening intervals and follow-up.

"While the USPSTF recommendation statement uses words like 'effective treatment and appropriate follow-up," it does not in our view place adequate emphasis on major depression as a recurring, chronic condition in the majority of patients," they write.

"Simply stated, it is not enough to get well — staying well is also important, vitally so, because with each recurrent episode, the risk for chronicity and treatment resistance increases."

Dr Reynolds underscored to Medscape Medical News the need to better address annual screening for depression.

"I do think that annual screening is appropriate from a clinical and public health perspective," said Dr Reynolds, of the Department of Psychiatry at Western Psychiatric Institute and the Clinic of the University of Pittsburgh Medical Center, in Pennsylvania.

Seek and Ye Shall Find

Dr Davidson, of the USPTF, replied that the issue of how often patients should be screened could not be conclusively determined by the evidence, but she agreed that clinicians should be attentive to the need for follow-up.

"Clinicians should use their clinical judgement to determine how often an individual patient should be screened, based on his or her personal risk factors, other behavioral health and health conditions, and life events," she said.

"The task force is calling for more research to determine when depression screening should begin and how often screening should occur."

Aside from the issue of annual screenings, Dr Reynolds underscored the recommendations' important strengths, including the recommendation for screening instruments.

"This [screening process] is analogous to screening for hypertension in diabetes," he said. "If we don't look, we fail to identify people with clinically actionable conditions."

The task force's recommendations are consistent with the guidelines on depression screening of other prominent organizations, including the American Academy of Family Physicians and the American College of Preventive Medicine.

The American College of Obstetricians and Gynecologists recommends screening for depression and anxiety at least once during the perinatal period, and it recommends that screening be coupled with appropriate follow-up and treatment when indicated.

The American Academy of Pediatrics recommends that pediatricians screen mothers for postpartum depression at the infant's 1-, 2-, and 4-month visits.

The USPTF authors and Dr Silver have disclosed no relevant financial relationships. Dr Reynolds and Dr Frank have disclosed a number of relationships with industry, which are listed in the original article.

JAMA. Published online January 26, 2016. Full article, Editorial 1, Editorial 2

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