Screening for Depression—A Tale of Two Questions

Abstract

The US Preventive Services Task Force (USPSTF)1 has issued new recommendations on Screening for Depression inwhich they concluded, “TheUSPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accuratediagnosis, effective treatment, andappropriate follow-up (B recommendation).”GradeB indicateshighcertainty that the netbenefit ismoderateormoderate certainty that thenetbenefit is moderate to substantial. An “adequate system” includes a depression care manager who ensures that patients are screened and, if they screen positive for depression, appropriatelydiagnosedandtreatedwithevidence-basedstepped careor referred toa setting that canprovide thenecessarycare. The newguidelines are similar to the 2002 and 2009USPSTF depression screening recommendations except for 1 major change:neither the2002nor the2009recommendationsmentioned pregnant or postpartumwomen.2,3 The recentUSPSTF recommendations are largelybasedon a systematic review evaluating the potential benefits of depressionscreening inpregnantorpostpartumwomen.4Nonew randomized trials of depression screening in (nonpregnant or postpartum) adults have been added since the 2009 guidelines. One example of the new studies included in the USPSTF systematic review was a trial that randomized 462 postpartum women (who were not already receiving psychiatric treatment) toadepressionscreening interventionvsusual care.5 Intervention groupparticipants completed the 10-item Edinburgh Postnatal Depression Scale (EPDS); control group participants completed a general self-efficacy scale (similar in length and format) but didnot complete theEPDS.All participants underwent a clinical assessment by a nurse who was blinded to their group allocation; patients (fromeither group) who were assessed by this nurse as having probable postnatal depression were referred for further evaluation and treatment. Intervention patients with an EDPS score of at least 10 (or any suicidal ideation)were referred for further evaluation and treatment (regardless of the clinical assessment). In an intention to treat analysis, 13% of the intervention group and 22.1% of the control group had EDPS scores of at least 10 at 6 months (risk ratio, 0.59; 95% CI, 0.39-0.89; number needed to screen, 11). Basedon this andother studies, theUSPSTFconcluded that screening results in the reduction or remission of depression symptoms and that the magnitude of harms of screening for depression in adults is small to none. Whether the available evidence justifies routine screening of unselected adults for depression is debatable. Notably, the Canadian Task Force on Preventive Health Care does not recommend routine screening for depression in adults at average risk.6 However, multiple other organizations (eg, American Academy of Family Physicians, American College of Physicians,AmericanCollegeofObstetriciansandGynecologists)do recommendroutinescreeningfordepression,especially forsubgroupsofpatientswhoareathighrisk, suchaspersonswith low socioeconomic status, limitedsocial support, chronicpain,disability, unintended pregnancy, comorbid mental health issues, or chronicmedical conditions.Moreover,most US insuranceproviders, including theCenter forMedicareandMedicaid Services, coverannual screening fordepression inprimarycare settingsthathavestaff-assisteddepressioncaresupports inplace to assure accurate diagnosis, effective treatment, and followup.Therefore,primarycarecliniciansmustbefamiliarwithhow to implement a depression screening program.