USPSTF Issues Final Recommendation on Screening for Depression in Children and Adolescents

Screening recommended for adolescents, but evidence inconclusive for younger children

The U.S. Preventive Services Task Force (USPSTF) has released a final recommendation statement on screening for depression in children and adolescents. The task force recommended screening for major depressive disorder (MDD) in adolescents 12 to 18 years of age and found that there was not enough evidence to recommend for or against screening in children 11 years of age and younger.

Depression is a leading cause of disability in the U.S., according to the statement. Children and adolescents with MDD 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. MDD in children and adolescents is strongly associated with recurrent depression in adulthood, with other mental disorders, and with an increased risk for suicidal ideation, suicide attempts, and suicide completion.

The USPSTF found adequate evidence that screening instruments for depression can accurately identify MDD in adolescents aged 12 to 18 years in primary care settings. The USPSTF found no studies that directly evaluated whether screening for MDD in children aged 11 years or younger in primary care (or comparable) settings leads to improved health and other outcomes, and found inadequate evidence for the benefits of treatment in children with screen-detected MDD.

The USPSTF found no studies that directly evaluated whether screening for MDD in adolescents in primary care (or comparable) settings leads to improved health and other outcomes. However, the USPSTF found adequate evidence that treatment of MDD detected through screening in adolescents is associated with moderate benefit (for example, improved depression severity, depression symptoms, or global functioning scores).

The USPSTF recommends screening for MDD in all adolescents but notes that several risk factors might help identify patients who are at higher risk. The causes of MDD are not fully known but likely involve a combination of genetic, biological, and environmental factors. Risk factors for MDD in children and adolescents include female sex, older age, family (especially maternal) history of depression, prior episode of depression, other mental health or behavioral problems, chronic medical illness, overweight and obesity, and, in some studies, Hispanic race/ethnicity. Other psychosocial risk factors 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.

Many MDD screening instruments have been developed for use in primary care and have been used in adolescents. Two that have been studied most often are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). Data on the accuracy of MDD screening instruments in younger children are limited.

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

Treatment options for MDD in children and adolescents include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches. Fluoxetine (Prozac, Eli Lilly; Sarafem, Warner Chilcott), a selective serotonin reuptake inhibitor (SSRI), is approved by the FDA for the treatment of MDD in children 8 years of age or older, and escitalopram (Lexapro, Forest Laboratories), another SSRI, is approved for the treatment of MDD in adolescents aged 12 to 17 years. 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. 

The USPSTF concluded, on the basis of a previous review, that the use of SSRIs in children is associated with harms, specifically a risk for suicidality. Evidence on the harms of psychotherapy alone or in combination with SSRIs in children is limited. Newer studies provide little additional evidence on treatment harms in children and adolescents but do not suggest more risks. Only four studies examined the harms of treatment with SSRIs in children and adolescents. These studies found no increased risk for suicidality associated with antidepressant use, but risk for rare events could not be precisely determined because the studies had limited statistical power. No trials of psychotherapy or combined interventions in children examined harms.

Source: USPSTF; February 2016.