Task Force Issues Final Recommendation on Screening for Depression in Adults

Experts see benefit in primary care screening

The U.S. Preventive Services Task Force (USPSTF) has released a final recommendation statement on screening for depression in adults. The task force found evidence that screening in the primary care setting is beneficial and recommends that clinicians screen all adults for depression. The recommendation statement was published online in the Journal of the American Medical Association.

In 2009, the USPSTF recommended screening all adults when staff-assisted depression care supports are in place, and selective screening based on professional judgment and patient preferences when such support is not available. In recognition that such support is now much more widely available and accepted as part of mental health care, the new recommendation statement has omitted the recommendation regarding selective screening, as it no longer represents current clinical practice. The current statement also specifically recommends screening for depression in pregnant and postpartum women, subpopulations that were not specifically reviewed for the 2009 recommendation.

The USPSTF found “adequate evidence” that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women. The task force also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression. The task force found “convincing evidence” that the treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.

The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none. The task force also found adequate evidence that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none.

The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors) are associated with some harms, such as an increase in suicidal behaviors in adults ages 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with the risk increasing with age; however, the task force determined that the magnitude of these risks is, on average, small. The task force found evidence of potential serious fetal harms from pharmacological treatment of depression in pregnant women, but the likelihood of these serious harms is low.

The USPSTF recommends screening in all adults regardless of risk factors. However, a number of factors are associated with an increased risk of depression. Among general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment status. Women, young and middle-aged adults, and nonwhite persons have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, or unemployed. Other groups who are at increased risk of developing depression include persons with chronic illnesses (e.g., cancer or cardiovascular disease), other mental health disorders (including substance misuse), or a family history of psychiatric disorders.

Among older adults, risk factors for depression include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and a history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from those without depression.

Risk factors for depression during pregnancy and postpartum include poor self-esteem, child-care stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, previous postpartum depression, lower socioeconomic status, and unintended pregnancy.

Commonly used depression screening instruments include the Patient Health Questionnaire (in various forms) and the Hospital Anxiety and Depression Scales in adults; the Geriatric Depression Scale in older adults; and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women. All positive screening results should lead to additional assessment that considers the severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.

Source: USPSTF; January 2016.

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