Summary of Recommendation and Evidence

The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (Table 1). B recommendation.

Rationale

IMPORTANCE

Depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well.

DETECTION

The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.

BENEFITS OF EARLY DETECTION AND INTERVENTION AND TREATMENT

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 USPSTF found convincing evidence that 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 also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.

HARMS OF EARLY DETECTION AND INTERVENTION AND TREATMENT

The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none.

The USPSTF 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 aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

USPSTF ASSESSMENT

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 USPSTF also concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in pregnant and postpartum women who receive care in clinical practices that have CBT or other evidence-based counseling available after screening.

Clinical Considerations

PATIENT POPULATION UNDER CONSIDERATION

This recommendation applies to adults 18 years and older. It does not apply to children and adolescents, who are addressed in a separate USPSTF recommendation statement (available at http://www.uspreventiveservicestaskforce.org).

ASSESSMENT OF RISK

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.

SCREENING TESTS

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 in postpartum and pregnant women. All positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.

SCREENING TIMING AND INTERVAL

There is little evidence regarding the optimal timing for screening. The optimum interval for screening for depression is also unknown; more evidence for all populations is needed to identify ideal screening intervals. A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.

TREATMENT

Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches (e.g., CBT or brief psychosocial counseling), alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider CBT or other evidence-based counseling interventions when managing depression in pregnant or breastfeeding women.

OTHER APPROACHES TO PREVENTION

The Community Preventive Services Task Force, which makes evidence-based recommendations on preventive services for community populations, recommends collaborative care for the management of depressive disorders as part of a multicomponent, health care system–level intervention that uses case managers to link primary care providers, patients, and mental health specialists. More information about the Community Preventive Services Task Force and its recommendations on depression interventions is available on its website (http://www.thecommunityguide.org).

USEFUL RESOURCES

The USPSTF has made recommendations on screening for depression in children and adolescents and screening for suicide risk in adolescents, adults, and older adults (available at http://www.uspreventiveservicestaskforce.org).

The Substance Abuse and Mental Health Services Administration maintains a national registry of evidence-based programs and practices for substance abuse and mental health interventions (http://nrepp.samhsa.gov/) that may be helpful for clinicians looking for models of how to implement depression screening.

Other Considerations

IMPLEMENTATION

The USPSTF recommends that screening be implemented with adequate systems in place. “Adequate systems in place” refers to having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care. These essential functions can be provided through a wide range of different arrangements of clinician types and settings. In the available evidence, the lowest effective level of support consisted of a designated nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to evidence-based behavioral treatment.¹ At the highest level, support included screening; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for medication adherence; a visit with a trained therapist for CBT; and a reduced copayment for patients referred for psychotherapy.^2,3

Multidisciplinary team–based primary care that includes self-management support and care coordination has been shown to be effective in the management of depression. These components of primary care are detailed in recommendations from the Community Preventive Services Task Force.⁴ It recommends collaborative care for the treatment of major depression in adults 18 years and older on the basis of strong evidence of effectiveness in improving short-term treatment outcomes. As defined, collaborative care and disease management of depressive disorders include a systematic, multicomponent, and team-based approach that “strengthens and supports self-care, while assuring that effective medical, preventive, and health maintenance interventions take place” to improve the quality and outcome of patient care.⁴

COSTS

The economic burden of depression is substantial for individuals as well as society. Costs to an individual may include emotional suffering, reduced quality of personal relationships, possible adverse effects from treatment, cost of mental health and medical visits and medications, time away from work and lost wages, and cost of transportation. Costs to society may include loss of life, reduced productivity (because of both diminished capacity while at work and absenteeism from work), and increased costs of mental health and medical care.

RESEARCH NEEDS AND GAPS

Gaps in the evidence on screening for depression in older adults in primary care include a lack of information from large-scale randomized controlled trials in settings that are applicable to the U.S. population. More research is needed on the accuracy of screening tools in languages other than English and Spanish and to identify the timing and optimal screening interval in all populations. Data are lacking on both the accuracy of screening and the benefits and harms of treatment in pregnant women, as well as for the balance of benefits and harms of treatment with antidepressants in postpartum women. Finally, research is needed to assess barriers to establishing adequate systems of care and how these barriers can be addressed.