This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for depression, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition1.
Summary of Recommendation
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Depressive disorders are common, chronic and costly. The World Health Organization identified major depression as the fourth leading cause of worldwide disease in 1990, causing more disability than either ischemic heart disease or cerebrovascular disease (5). In primary care settings, the point prevalence of major depression ranges from 5 percent to 9 percent among adults, and up to 50 percent of depressed patients are not recognized (6,7). Other disabling depressive illnesses include dysthymia (a chronic low-grade depression) and minor depression (an episodic, less severe illness). These two illnesses are as common as major depression in primary care settings. Depressive disorders are also relatively common in younger persons, with estimated prevalence of 0.8 percent to 2.0 percent in children and 4.5 percent in adolescents.
Several depression screening instruments are available; most instruments have relatively good sensitivity (80 percent to 90 percent) but only fair specificity (70 percent to 85 percent) (2). Most instruments are easy to use and can be administered in less than 5 minutes. Shorter screening tests, including simply asking questions about depressed mood and anhedonia, appear to detect a majority of depressed patients and, in some cases, perform better than the original instrument from which they were derived (3).
Assuming optimal test performance and a prevalence of major depression of 5 percent to 10 percent in primary care settings, about 24 percent to 40 percent of patients who screen positive will have major depression. Some patients with "false positive" results on screening may have dysthymia or subsyndromal depressive disorders that might benefit from treatment or closer monitoring; others may have comorbid disorders such as anxiety disorder, substance abuse, panic disorder, post-traumatic stress disorder, or grief reactions; still others may have no disorder at all. The finding of a positive screen therefore requires further diagnostic questioning by the clinician to establish an appropriate diagnosis and initiate a plan for treatment and followup.
Screening instruments have been tested in children and adolescents, with sensitivity ranging from 40 percent to 100 percent and specificity from 49 percent to 100 percent. Because the underlying prevalence is much lower than in adults, the positive predictive value is low.
Effective treatments are available for patients with depressive illnesses detected in primary care settings (1,8). Antidepressant medications for major depression, including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), are clearly more effective than placebo. Most of the data supporting effectiveness come from structured trials with selected populations, although more recent studies using "usual care" comparison groups and real-world settings have produced similar effects. Newer agents perform similarly to older agents.
Psychosocial and psychotherapeutic interventions are probably as effective as antidepressant medications for major depression, but they are clearly more time-intensive (7). The benefits of psychotherapy for other depressive illnesses are less well studied. Few studies have examined the effect of combining medications and psychotherapy.
No studies have examined treatment outcomes for children or adolescents identified by primary care clinicians through screening. Evidence for treating adolescents comes from school and community settings where SSRIs and cognitive-behavioral therapy, but not tricyclic antidepressants, appear to be effective. Whether these results can be generalized to primary care settings or to children is unclear.
The review for the USPSTF identified 14 randomized, controlled trials that have examined the effectiveness of screening for depression in primary care settings (9). In eight studies, the only intervention was feedback of screening results to clinicians; remaining studies combined feedback with other interventions for patients or clinicians. The trials reported various outcomes, including recognition of depression, rates of treatment, and clinical improvement among patients with depression. In seven trials, routine depression screening with feedback of screening results to providers generally increased recognition of depression, especially major depression, by a factor of 2 to 3 compared with usual care. Trials that examined the effect of feedback of screening results on the proportion of depressed patients who received treatment showed mixed results: in four fair-to-good quality trials that used feedback alone, there was no significant effect on treatment rates, but four of the five trials that combined feedback with treatment advice or other system supports reported increased treatment rates in the intervention group compared with usual care. Ten trials measured the effect of screening and feedback on depression outcomes from 1 month to 2 years after the intervention. Five of these 10 studies reported significant improvements in the clinical outcomes of depressed patients, and three others reported improvements that did not reach statistical significance.
All three trials that compared the effects of integrated recognition and management programs with usual care in community primary care practices showed significantly improved patient outcomes. Integrated programs included feedback, provider and/or patient education, access to case management and/or mental health care, telephone followup, and institutional commitment to quality improvement. One trial, which included both newly detected cases of depression and patients already under treatment, showed improvement in patient symptoms at 6 months only among patients beginning a new treatment episode. No improvement was noted among patients who had recently been treated (that is, those who would have been identified without specific screening). Two trials showed improved symptoms at 12 months; one of these also showed more employment retention in intervention compared with usual care patients. All three trials required allocation of clinic resources to detection and management programs.
On the basis of estimates from the above-mentioned trials, approximately 11 patients identified as depressed as a result of screening would need to be treated to produce one additional remission (9). If depression (including major depression, dysthymia, and minor depression) is present in 10 percent of primary care patients, then 110 patients would need to be screened to produce one additional remission after 6 to 12 months of treatment. The number needed to treat for benefit would be smaller for patients with major depression only, but a larger group would need to be screened to identify them.
The potential harms of screening include false-positive screening results, the inconvenience of further diagnostic work-up, the adverse effects and costs of treatment for patients who are incorrectly identified as being depressed, and potential adverse effects of labeling. None of the research reviewed provided useful empirical data regarding these potential adverse effects.
The Canadian Task Force on Preventive Health Care (CTFPHC) found fair evidence to exclude routine screening of asymptomatic individuals for depression in 1994 but suggested that clinicians maintain a high degree of clinical suspicion for depression among their patients (10). The CTFPHC is currently revisiting this recommendation. The American College of Obstetricians and Gynecologists recommends that clinicians should be alert to symptoms of depression and question patients about psychosocial stressors and family history of depression when taking their history (11). The American Academy of Pediatrics recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence (12). The American Medical Association recommends screening for depression among adolescents who may be at risk owing to family problems, drug or alcohol use, or other indicators of risk (13).
1. Pignone M, Gaynes BN, Rushton JL, et al. Screening for Depression. Systematic Evidence Review No. 6 (Prepared by the Research Triangle Institute—University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011) AHRQ Publication. No. 02-S002. Rockville, MD: Agency for Healthcare Research and Quality, May 2002.
2. Williams JW, Hitchcock Noel P, Cordes JA, Ramirez G, Pignone M. Rational clinical examination. Is this patient clinically depressed? JAMA 2002;287:1160-7.
3. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are as good as many. J Gen Intern Med 1997;12:439-45.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.
5. Murray CJ, Lopez AD. Global Burden of Disease. Cambridge, MA: Harvard University Press; 1996.
6. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD: U.S. Department of Health and Human Services; 1993. AHCPR Publication No. 93-0550.
7. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.
8. Mulrow CD, Williams JW Jr, Chiquette E, et al. Efficacy of newer pharmacotherapies for treating depression in primary care patients. Am J Med 2000;108:54-64.
9. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002.
10. Canadian Task Force on the Periodic Health Examination. The Canadian Guide to Clinical Health Care. Ottawa, Ontario: Health Canada;1994:450-4.
11. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 2002:126-33, 235-6,79.
12. Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics. Pediatrics 2000;105;871-4.
13. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph. Chicago: American Medical Association; 1997.
Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX), Paul S. Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); *Mark S. Johnson, M.D., M.P.H. (Associate Professor of Clinical Family Medicine and Chairman Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); *Jonathan D. Klein, M.D., M.P.H. (Associate Professor of Pediatrics and of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Professor of Medicine, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N. (Professor and Associate Dean for Research, School of Nursing, University of Michigan, Ann Arbor, MI); *Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, and Medical Director of the Primary Care and Medical Services Care Center, Mount Sinai School of Medicine and The Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Associate Professor of Obstetrics, Gynecology and Public Health, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor of Family Medicine, Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).
*These current members were not on the Task Force at the time this recommendation was voted.
Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: uspstf@ahrq.gov.
This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.preventiveservices.ahrq.gov.
Individual copies of this statement are available online through the National Guideline Clearinghouse™ at: http://www.guideline.gov; or may be obtained in print from the AHRQ Publications Clearinghouse: Phone Toll-Free 1-800-358-9295; E-mail ahrqpubs@ahrq.gov.
The summary of the evidence and the recommendation statement are also available in print by subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. Select for order form: PDF Version (230 KB), Text Version. The cost of a subscription is $60 and can be ordered through the AHRQ Publications Clearinghouse (call 1 800 358 9295 or E-mail ahrqpubs@ahrq.gov).
Current as of May 2002
Internet Citation:
U.S. Preventive Services Task Force. Screening for Depression: Recommendations and Rationale. May 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/depressrr.htm
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