Screening for Major Depressive Disorder Among Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force
Forman-Hoffman VL, McClure E, McKeeman J, Wood CT, Middleton JC, Skinner AC, Perrin EM, Viswanathan M. Screening for Major Depressive Disorder Among Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 116. AHRQ Publication No. 13-05192-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
- USPSTF Recommendation Statement
- Fox News Health: US Panel Reaffirms Depression Screening for Adolescents
- Huffington Post: Detecting Depression: A Public Health Priority
To evaluate the evidence on screening and treating children and adolescents for major depressive disorder (MDD) for the U.S. Preventive Services Task Force. This update modified the inclusion criteria used in the 2009 review to focus on screening for MDD (i.e., studies reporting that ≥50% of their sample had MDD); thus, we do not address screening or treatment for minor depression or dysthymia. Little is known about the etiological links between subthreshold depression, dysthymia, and MDD or efficacious treatments for less severe forms of depression in children. Focusing on MDD reduces heterogeneity in patient characteristics and targets children and adolescents experiencing more serious symptoms who are most likely to suffer severe functional impairment and suicidality.
PubMed/MEDLINE, the Cochrane Library, PsycINFO, ClinicalTrials.gov, HSRProj, the World Health Organization International Clinical Trials Registry Platform, and reference lists of published literature (through February 2015). We re-reviewed studies identified in the 2009 report against the revised inclusion and exclusion criteria.
Two investigators independently selected studies reporting on benefits and harms of screening; accuracy of screening tools compared with diagnostic evaluations; and benefits or harms of treatment of MDD compared with placebo, usual care, or waitlist interventions.
One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings using predefined criteria.
No trials examine the impact of screening for pediatric MDD in primary care on subsequent improvements in depression and other health-related outcomes. No new screening accuracy studies met our criteria. The limited number of screening accuracy studies from the 2009 review that remain in our synthesis suggest that the Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory (BDI) can identify adolescents who are at risk of MDD (PHQ-A sensitivity, 73%; PHQ-A specificity, 94%; BDI sensitivity, 84% to 90%; BDI specificity, 81% to 86%). We found no eligible studies on screening accuracy in children. Additionally, we found one new collaborative care study but no other new psychotherapy or combined therapy intervention studies. One new placebo-controlled study, an acute escitalopram trial in adolescents ages 12 to 17 years, met our criteria for treatment efficacy trials. One fluoxetine trial (ages 12 to 17 years), one escitalopram trial (ages 6 to 17 years), one citalopram trial (ages 7 to 17 years), and one cognitive behavior therapy trial (ages 14 to 18 years) from the 2009 review continued to meet our inclusion and exclusion criteria. Evidence from individual selective serotonin reuptake inhibitor (SSRI) trials demonstrated the efficacy of fluoxetine but not citalopram; one escitalopram trial demonstrated efficacy but the other did not. One collaborative care study demonstrated improvement in symptoms, response, and remission but not functional status. We found no evidence of harms attributable to treatment.
Our inclusion and exclusion criteria, coupled with our thresholds for quality, resulted in the inclusion of five screening accuracy studies of fewer than 2,900 children and adolescents (none of whom were younger than age 11 years) and six treatment trials that randomized fewer than 1,500 children and adolescents with MDD conducted over the past three decades. As a result, we cannot make definitive statements regarding associated benefits or harms, particularly for rare outcomes such as suicidality. Small sample sizes, high attrition, and potentially biased ascertainment of the reference standard in screening studies constrain the evidence base. Evidence gaps sharply limit conclusions for screening in children younger than age 11 years, screening and treatment differences by sex or race/ethnicity subgroups, and MDD treatment other than SSRIs.
We found no evidence of a direct link between screening for MDD in children and adolescents in primary care or comparable settings and depression or other health-related outcomes. We found evidence that some screening tools are accurate and some treatments have benefit for MDD among adolescents (but not younger children), with no evidence of associated harms. Although no study found statistically significant harms associated with treatment, lack of precision hampers our ability to rule out effects. Evidence gaps sharply limit conclusions for screening in children younger than age 12 years, screening and treatment differences by sex or race/ethnicity subgroups, and efficacy of MDD treatment other than SSRIs.