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Cover of Screening for Child and Adolescent Depression In Primary Care Settings

Screening for Child and Adolescent Depression In Primary Care Settings

A Systematic Evidence Review for the U.S. Preventive Services Task Force

Evidence Syntheses, No. 69

Investigators: , MD, MPH, , PhD, , PhD, and , MD, MPH.

Oregon Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 09-05130-EF-1

Structured Abstract

Background:

Depression among youth is a relatively common, disabling condition that is associated with serious long-term morbidities and risk of suicide. The majority of depressed youth, however, are undiagnosed and untreated, despite opportunities for identification in settings such as primary care.

Purpose:

We sought to assess the health effects of routine primary care screening for Major Depressive Disorder (MDD) among children and adolescents ages 7 to 18 years, including evaluating the accuracy of screening tests and the risks and benefits of treatment with psychotherapy and/or SSRIs.

Methods:

We developed an analytic framework and five key questions to represent the logical evidence connecting primary care screening to improved health outcomes. We conducted a series of literature searches for each key question in Medline, the Cochrane Central Registry of Controlled Trials, PsycInfo, and the Cochrane Database of Systematic Reviews through May 2007. We also reviewed studies included in recent systematic evidence reviews and meta-analyses, contacted experts, and reviewed bibliographies from relevant studies. We examined 5,737 abstracts and 480 full text articles. One reviewer abstracted relevant information from each included article into standardized evidence tables. A second reviewer checked key elements. Two reviewers quality graded each article using US Preventive Services Task Force criteria. Due to heterogeneity among studies, we conducted qualitative syntheses for studies of screening test accuracy and for the benefits and harms of psychotherapeutic treatment interventions. For SSRI trials, we quantitatively pooled results for absolute risk differences for response rates and suicide-related adverse effects, using random effects models, and describe findings of other systematic reviews.

Results:

No controlled trials compared health outcomes in screened and unscreened pediatric populations. Data from six fair-quality studies evaluating the accuracy of screening instruments among 2,781 adolescents in primary care or school settings report sensitivity of 73 to 100 percent and specificity of 65 to 94 percent. Three studies including participants less than 12 years old yielded sensitivities of 53 to 90 percent and specificities of 49 to 96 percent. Pooled risk difference (RD) for response rates among nine fair- or good-quality, double-blinded, placebo-controlled RCTs evaluating short-term efficacy of SSRIs among 1,972 children and adolescents yielded a higher response rate among treated youth (RD 12 percent, 95 percent confidence interval (CI) 7, 16). Ten fair- or good-quality RCTs evaluated short-term efficacy of psychotherapy among 757 children or adolescents aged 9 to 18 years. Most psychotherapy trials demonstrated an improvement in depression symptoms based on proportion achieving remission, change in mean depression score, or improved global functioning. Treatment with SSRIs was associated with a small increased risk of suicidality (RD 1 percent, 95 percent CI 0, 2). Suicidality includes suicidal ideation, preparatory acts, or attempts. No suicide deaths have occurred in controlled trials of SSRIs. Observational data are inconclusive.

Conclusions:

Although no trials of screening for pediatric MDD were identified, limited available data suggest that primary care feasible screening tools may be accurate in identifying depressed adolescents, and treatment can improve depression outcomes. Treating depressed youth with SSRIs may be associated with a small increased risk of suicidality and therefore should only be considered if judicious clinical monitoring is possible. Specific treatment should be based on the individual's needs and mental health treatment guidelines.

Contents

Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227.

U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC)1 under contract to the Agency for Healthcare Research and Quality (AHRQ),2 Rockville, MD (Contract No. 290-02-0024, Task Order Number 1).

Suggested citation:

Williams SB, O'Connor, E, Eder M, Whitlock E. Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 69. AHRQ Publication No. 09-05130-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, April 2009.

The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

1

Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227.

2

U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

Bookshelf ID: NBK35127PMID: 20722167
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