FROM PEDIATRICS AND ANNALS OF INTERNAL MEDICINE
Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.
Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.
“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”
Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).
The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.
Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.
Here are the key recommendations:
• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”
As stated in the recommendations, the phrase “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.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”
The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”
• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”
The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.
In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.
In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”
Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”
The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.
The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.
On Twitter @dougbrunk
