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Screening for Child and Adolescent Depression In Primary Care Settings: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet].

Source

Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Apr. Report No.: 09-05130-EF-1.
U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews.

Excerpt

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.

PMID:
20722167
[PubMed]
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