Screening for Depression: Recommendations and RationaleFREE

The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. This is a grade B recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

The USPSTF found good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results. Small benefits have been observed in studies that simply feed back screening results to clinicians. Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment. The USPSTF concluded the benefits of screening are likely to outweigh any potential harms.

The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression. This is a grade I recommendation.

Many formal screening tools are available (for example, the Zung Self-Depression Scale, Beck Depression Inventory, General Health Questionnaire, and Center for Epidemiologic Study Depression Scale) (1, 2). Asking two simple questions about mood and anhedonia (“Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”) may be as effective as using longer instruments (3). There is little evidence to recommend one screening method over another, so clinicians can choose the method that best fits their personal preference, the patient population served, and the practice setting.

All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (for example, those from the fourth edition of Diagnostic and Statistical Manual of Mental Disorders) to determine the presence or absence of specific depressive disorders, such as major depression or dysthymia (4). The severity of depression and comorbid psychological problems (for example, anxiety, panic attacks, or substance abuse) should be addressed.

Many risk factors for depression (such as female sex, family history of depression, unemployment, and chronic disease) are common, but the presence of risk factors alone cannot distinguish depressed from nondepressed patients.

The optimal interval for screening is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (such as panic disorder or generalized anxiety), substance abuse, or chronic pain.

Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful follow-up. Benefits from screening are unlikely to be realized unless such systems are functioning well.

Treatment may include antidepressants or specific psychotherapeutic approaches (for example, cognitive–behavioral therapy or brief psychosocial counseling), alone or in combination.

The benefits of routinely screening children and adolescents for depression are not known. The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine depression screening has not been studied in pediatric populations in primary care settings. Clinicians should remain alert for possible signs of depression in younger patients. The predictive value of positive screening tests is lower in children and adolescents than in adults, and research on the effectiveness of primary care–based interventions for depression in this age group is limited.

The Canadian Task Force on Preventive Health Care 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 Canadian Task Force 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).

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair (University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair (University of Texas Health Science Center, San Antonio, Texas); Paul S. Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles J. Homer, MD, MPH (National Initiative for Children's Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey)*; Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York)*; Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts); Cynthia D. Mulrow, MD, MSc (University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and Infants' Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount Sinai School of Medicine and The Mount Sinai Medical Center, New York, New York)*; Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University College of Physicians and Surgeons, New York, New York); and Steven H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia).

*These current members were not on the Task Force at the time these recommendations were voted on.