Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.
Frequency of Service
No information available.
Risk Factor Information
No information available.
Patient Population Under Consideration
This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD. This recommendation focuses on screening for MDD and does not address screening for other depressive disorders, such as minor depression or dysthymia.
Assessment of Risk
The USPSTF recommends screening for MDD in all adolescents but notes that several risk factors might help identify patients who are at higher risk. The causes of MDD are not fully known and likely involve a combination of genetic, biological, and environmental factors. Risk factors for MDD in children and adolescents include female sex; older age; family (especially maternal) history of depression; prior episode of depression; other mental health or behavioral problems; chronic medical illness; overweight and obesity; and, in some studies, Hispanic race/ethnicity. Other psychosocial risk factors include childhood abuse or neglect, exposure to traumatic events (including natural disasters), loss of a loved one or romantic relationship, family conflict, uncertainty about sexual orientation, low socioeconomic status, and poor academic performance.
Many MDD screening instruments have been developed for use in primary care and have been used in adolescents. Two that have been most often studied are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). Data on the accuracy of MDD screening instruments in younger children are limited.
The USPSTF found no evidence on appropriate or recommended screening intervals, and the optimal interval is unknown. Repeated screening may be most productive in adolescents with risk factors for MDD. Opportunistic screening may be appropriate for adolescents, who may have infrequent health care visits.
Treatment or Interventions
Treatment options for MDD in children and adolescents include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches. Fluoxetine is approved by the FDA for treatment of MDD in children aged 8 years or older, and escitalopram is approved for treatment of MDD in adolescents aged 12 to 17 years. The FDA has issued a boxed warning for antidepressants, recommending that patients of all ages who start antidepressant therapy be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior.1 Collaborative care is a multicomponent, health care system–level intervention that uses care managers to link primary care providers, patients, and mental health specialists.
Suggestions for Practice Regarding the I Statement
In deciding whether to screen for MDD in children aged 11 years or younger, primary care providers should consider the following issues.
Potential Preventable Burden
Little is known about the prevalence of MDD in children aged 11 years or younger. The mean age of onset of MDD is about 14 to 15 years. Early onset is associated with worse outcomes. The average duration of a depressive episode in childhood varies widely, from 2 to 17 months.
The USPSTF found inadequate evidence on the harms of screening for MDD in children. The USPSTF concluded that screening itself is unlikely to be associated with significant harms, aside from opportunity costs, labeling and potential stigma associated with a positive result, and referral for further evaluation and treatment.
The USPSTF concluded, on the basis of a previous review, that the use of SSRIs in children is associated with harms, specifically risk for suicidality. Evidence on the harms of psychotherapy alone or in combination with SSRIs in children is limited. Newer studies provide little additional evidence on treatment harms in children and adolescents but do not suggest more risks. Only 4 studies examined the harms of treatment with SSRIs in children and adolescents. These studies found no increased risk for suicidality associated with antidepressant use, but risk for rare events could not be precisely determined because the studies had limited statistical power. No trials of psychotherapy or combined interventions in children examined harms.
The USPSTF found no evidence on the current frequency of or methods used in primary care for screening for MDD in children.
Additional Approaches to Prevention
The Community Preventive Services Task Force recommends collaborative care for the management of depressive disorders, based on strong evidence of effectiveness in improving depression symptoms, adherence and response to treatment, and remission and recovery from depression. For this and related recommendations from the Community Preventive Services Task Force, go to www.thecommunityguide.org/mentalhealth/index.html.
In a separate recommendation statement, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in primary care settings, including among adolescents (I statement). Other USPSTF recommendations on mental health topics pertaining to children and adolescents, including illicit drug and alcohol use, can be found on the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Many screening tools are available to identify depression in children and adolescents, and some have been used in primary care. The number of items in each tool, the administrative time required to complete them, and the appropriate ages for screening vary. A positive result on an initial screening test does not necessarily indicate the need for treatment. Screening is usually done in 2 phases: the initial screening is followed by a second phase in which skilled clinicians take into account contextual factors surrounding the patient’s current situation, through either additional probing or a formal diagnostic interview. In instances where treatment is recommended, it can be initiated by the screening provider or through referral to another set of treatment providers. A negative result on a screening test, however, does not always preclude referral when clinical judgment or parental concerns suggest it is warranted.
The USPSTF recommends that screening be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Depression can be managed in the primary care or specialist setting or collaboratively in both settings. Treatment options for depression include pharmacologic, behavioral, multimodal, and collaborative care models, some of which require coordination. Finally, inadequate support and follow-up may result in treatment failures or harms, as indicated by the FDA boxed warning. “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 arrangements of clinician types and settings.
Research Needs and Gaps
The systematic evidence review identified several critical research gaps, including the need for studies of screening for and treatment of MDD in children younger than 11 years. Large, good-quality randomized, controlled trials (RCTs) are also needed to better understand the overarching effects of screening for MDD on intermediate and long-term health outcomes. It would be helpful to quantify the proportion of persons with screen-detected MDD who are treated or referred as well as their willingness and ability to be assessed and treated.
The systematic review excluded studies with participants who had comorbid disorders. Children and adolescents with MDD more often have comorbid conditions than those without MDD, particularly in primary care settings. This underscores the importance of additional research in child and adolescent populations that are similar to those found in primary care settings to study the effects of comorbid conditions on screening accuracy, type of MDD treatment selected, and benefits and harms.
For treatment of MDD, research needs include well-designed studies of psychotherapy and combined treatments, as well as studies of the benefits and harms of other treatments (such as non-SSRI medications and complementary or alternative approaches). For rare events, meta-analyses are needed that include only children and adolescents with MDD and focus on current FDA-approved medications. Studies with long-term follow-up are also needed.
Update of Previous USPSTF Recommendation
In 2009, the USPSTF recommended screening for MDD in adolescents (aged 12 to 18 years) when systems are in place to ensure accurate diagnosis, psychotherapy (CBT or interpersonal), and follow-up and concluded that the evidence was insufficient to make a recommendation for children (aged 7 to 11 years). The current recommendation reaffirms these positions but removes the mention of specific therapies in recognition of decreased concern over the harms of pharmacotherapy in adolescents when they are adequately monitored.
Depression is a leading cause of disability in the United States. Children and adolescents with MDD typically have functional impairments in their performance at school or work, as well as in their interactions with their families and peers. Depression can also negatively affect the developmental trajectories of affected youth. Major depressive disorder in children and adolescents is strongly associated with recurrent depression in adulthood; other mental disorders; and increased risk for suicidal ideation, suicide attempts, and suicide completion.
In nationally representative U.S. surveys, about 8% of adolescents reported having major depression in the past year. Little is known about the prevalence of MDD in children. Among children and adolescents aged 8 to 15 years, 2% of males and 4% of females reported having MDD in the past year.
The USPSTF found adequate evidence that screening instruments for depression can accurately identify MDD in adolescents aged 12 to 18 years in primary care settings. The USPSTF found no studies of screening instruments for depression in children aged 11 years or younger in primary care (or comparable) settings and concluded that the evidence is inadequate.
Benefits of Early Detection and Intervention and Treatment
The USPSTF found no studies that directly evaluated whether screening for MDD in adolescents in primary care (or comparable) settings leads to improved health and other outcomes. However, the USPSTF found adequate evidence that treatment of MDD detected through screening in adolescents is associated with moderate benefit (for example, improved depression severity, depression symptoms, or global functioning scores).
The USPSTF found no studies that directly evaluated whether screening for MDD in children aged 11 years or younger in primary care (or comparable) settings leads to improved health and other outcomes and found inadequate evidence on the benefits of treatment in children with screen-detected MDD.
Harms of Early Detection and Intervention and Treatment
The USPSTF found no direct evidence on the harms of screening for MDD in adolescents. Medications for the treatment of depression, such as selective serotonin reuptake inhibitors (SSRIs), have known harms. However, the magnitude of the harms of pharmacotherapy is small if patients are closely monitored, as recommended by the U.S. Food and Drug Administration (FDA). The USPSTF found adequate evidence on the harms of psychotherapy and psychosocial support in adolescents and estimates that the magnitude of these harms is small to none.
The USPSTF found inadequate evidence on the harms of screening for or treatment of MDD in children aged 11 years or younger.
The USPSTF concludes with moderate certainty that screening for MDD in adolescents aged 12 to 18 years has a moderate net benefit.
The USPSTF concludes that the evidence on screening for MDD in children aged 11 years or younger is insufficient. Evidence is lacking, and the balance of benefits and harms cannot be determined.
Recommendations of OthersThe American Academy of Pediatrics’ Bright Futures program recommends annual screening in child and adolescent patients for emotional and behavioral problems.18 Medicaid’s child health component, the Early and Periodic Screening, Diagnosis, and Treatment program, recommends screening to detect physical and mental conditions at periodic, age-appropriate intervals and, if risk is identified, follow-up with diagnostic and treatment coverage.19 The Canadian Task Force on Preventive Health Care states that there is insufficient evidence to recommend for or against screening for depression in children or adolescents in primary care settings.20