Valerie Forman-Hoffman, PhD, MPH; Emily McClure, MSPH; Joni McKeeman, PhD; Charles T. Wood, MD; Jennifer Cook Middleton, PhD; Asheley C. Skinner, PhD; Eliana M. Perrin, MD, MPH; Meera Viswanathan, PhD
Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of the Agency for Healthcare Research and Quality. Therefore, no statement in this report should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Grant Support: By the Agency for Healthcare Research and Quality (contract HHSA290201200015iT02).
Disclosures: Dr. Forman-Hoffman reports other from the Agency for Healthcare Research and Quality and Substance Abuse and Mental Health Services Administration outside the submitted work. Dr. Skinner reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr. Perrin reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr. Viswanathan reports other funding from the U.S. Department of Health and Human Services and grants from the Agency for Healthcare Research and Quality during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2259.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Valerie Forman-Hoffman, PhD, MPH, RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27709; e-mail, email@example.com.
Current Author Addresses: Drs. Forman-Hoffman, McKeeman, Wood, Middleton, Skinner, Perrin, and Viswanathan and Ms. McClure: RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27709.
Author Contributions: Conception and design: V. Forman-Hoffman, E. McClure, C.T. Wood, A.C. Skinner, E.M. Perrin, M. Viswanathan.
Analysis and interpretation of the data: V. Forman-Hoffman, E. McClure, J. McKeeman, C.T. Wood, A.C. Skinner, E.M. Perrin, M. Viswanathan.
Drafting of the article: E. McClure, J. McKeeman, C.T. Wood, A.C. Skinner, E.M. Perrin, M. Viswanathan.
Critical revision of the article for important intellectual content: V. Forman-Hoffman, E. McClure, J. McKeeman, C.T. Wood, A.C. Skinner, E.M. Perrin, M. Viswanathan.
Final approval of the article: V. Forman-Hoffman, E. McClure, J. McKeeman, C.T. Wood, J.C. Middleton, A.C. Skinner, E.M. Perrin, M. Viswanathan.
Provision of study materials or patients: M. Viswanathan.
Statistical expertise: V. Forman-Hoffman, M. Viswanathan.
Obtaining of funding: V. Forman-Hoffman, E.M. Perrin, M. Viswanathan.
Administrative, technical, or logistic support: V. Forman-Hoffman, E. McClure, J.C. Middleton, E.M. Perrin, M. Viswanathan.
Collection and assembly of data: V. Forman-Hoffman, E. McClure, J. McKeeman, C.T. Wood, J.C. Middleton, A.C. Skinner, M. Viswanathan.
Major depressive disorder (MDD) is common among children and adolescents and is associated with functional impairment and suicide.
To update the 2009 U.S. Preventive Services Task Force (USPSTF) systematic review on screening for and treatment of MDD in children and adolescents in primary care settings.
Several electronic searches (May 2007 to February 2015) and searches of reference lists of published literature.
Trials and recent systematic reviews of treatment, test–retest studies of screening, and trials and large cohort studies for harms.
Data were abstracted by 1 investigator and checked by another; 2 investigators independently assessed study quality.
Limited evidence from 5 studies showed that such tools as the Beck Depression Inventory and Patient Health Questionnaire for Adolescents had reasonable accuracy for identifying MDD among adolescents in primary care settings. Six trials evaluated treatment. Several individual fair- and good-quality studies of fluoxetine, combined fluoxetine and cognitive behavioral therapy, escitalopram, and collaborative care demonstrated benefits of treatment among adolescents, with no associated harms.
The review included only English-language studies, narrow inclusion criteria focused only on MDD, high thresholds for quality, potential publication bias, limited data on harms, and sparse evidence on long-term outcomes of screening and treatment among children younger than 12 years.
No evidence was found of a direct link between screening children and adolescents for MDD in primary care or similar settings and depression or other health-related outcomes. Evidence showed that some screening tools are accurate and some treatments are beneficial among adolescents (but not younger children), with no evidence of associated harms.
Agency for Healthcare Research and Quality.
Appendix Table 1. Search Strings*
Appendix Table 2. Key Questions
Analytic framework for screening for childhood depression.
MMD = major depressive disorder.
Summary of evidence search and selection.
Studies were published since May 2007. HSRProj = Health Services Research Projects in Progress; WHO ICTRP = World Health Organization International Clinical Trials Registry Platform.
Table 1. Accuracy of Screening Tests for Childhood Depression
Table 2. Pooled Estimates of Efficacy Outcomes in Randomized, Controlled Trials Among Children and Adolescents With MDD
Appendix Table 3. Summary of Evidence for Benefits and Harms of Screening and Treatment for MDD in Children and Adolescents
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Philippe Binder MD Professor, Benoit V. Tudrej MD PhD, Dagmar M. Haller PD
Université de Poitiers, Université de Genève, Unité de médecine de Premier Recours,
February 20, 2016
Simple ways to detect serious problems!
This literature review confirms the accuracy of two screening tools (PHQ-9 and BDI) as means of identifying major depressive disorders in children and adolescents. As several other authors have done, the authors call upon primary care providers to undertake a central role in this identification. For the general population, this function is essentially fulfilled by general practitioners. However, the latter are usually contacted for somatic or administrative reasons. Little more than 8% of teenagers' visits' to physicians are psychologically motivated. Moreover, general practitioners are reluctant to identify a depressive disorder or an environment that could lead to suicide (1). They tend to wait for either an explicit request or an obvious clinical presentation. And general practitioners will not use the BDI when a youngster comes for treatment of bronchitis! Although they could be incited to include a PHQ-9 or BDI in an annual check-up, the one-time, ad hoc nature of such screening would reduce its interest. Indeed, depressive disorders in adolescents are often transitory, and as the authors emphasize, ad hoc identification is hardly predictive of future major depressive disorders. Finally, these tests are limited to depression, even though half of the deaths by suicide of adolescents occur outside an environment identified as likely to lead to depression.
A more suitable attitude would be constant vigilance rather than precise ad hoc identification. Vigilance-favoring tools could be built to alert primary care providers. They should necessarily include means of sensitization to suicidal risk above and beyond the approach of depression. They should include simple questions that are innocuous enough to be put forward in all consultations involving teenagers and that are likely to alert a professional (2). The BDO or HQ9 grids could subsequently serve as complements. For depression, there have already been suggestions, including a 3-question approach (3). We have also developed a warning test for suicidal risk that can be used at any time during a consultation, and that has been validated in France (4). We have just finalized an updated version pertaining to 4 daily-life disorders: Bullying, Insomnia Tobacco and Stress (in press). Similar initiatives should be encouraged to provide better tools for everyday vigilance; because once a teenager is screened, he is more likely to be treated (5).
1. Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007 Sep-Oct;5(5):412-8
2. Shain BN, American Academy of Pediatrics Committee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics. 2007 Sep;120(3):669-76
3. Haugen W, Haavet OR, Sirpal MK, Christensen KS. Identifying depression among adolescents using three key questions: a validation study in primary care. Br J Gen Pract. 2016 Feb;66(643):e65-70.
4. Haute Autorité de Santé. Recommandations de bonne pratique. Manifestations dépressives à l’adolescence. Repérage, diagnostic et stratégie des soins de premier recours. Paris: HAS; nov 2014
5. Gould MS, Marrocco FA, Hoagwood K, Kleinman M, AmakawaL, Altschuler E. Service use by at-risk youths after school-based suicide screening. J Am Acad Child Adolesc Psychiatry. 2009 Dec ;48(12):1193-201.
Forman-Hoffman V, McClure E, McKeeman J, Wood CT, Middleton JC, Skinner AC, et al. Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. ;164:342–349. doi: 10.7326/M15-2259
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Published: Ann Intern Med. 2016;164(5):342-349.
Published at www.annals.org on 9 February 2016
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