Screening for Depression in Adults: U.S. Preventive Services Task Force Recommendation Statement FREE

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.

It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.

The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. This is a B recommendation.

The USPTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. This is a C recommendation.

See the Clinical Considerations section for the definition of staff-assisted depression care supports and additional information.

The Figure summarizes the recommendation and suggestions for clinical practice.

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit.

Depression is among the leading causes of disability in persons 15 years or older. It affects individuals, families, businesses, and society. It is common in primary care patients.

The USPSTF found good evidence that screening improves the accurate identification of depressed patients in primary care settings.

The USPSTF found good evidence that treating depressed adults and older adults identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.

The USPSTF found good evidence that programs combining depression screening and feedback with staff-assisted depression care supports improve clinical outcomes in adults and older adults.

The USPSTF found fair evidence that screening and feedback alone without staff-assisted care supports do not improve clinical outcomes in adults and older adults.

The USPSTF found no evidence of harms of screening for depression in adults or older adults.

The USPSTF found at least fair-quality evidence that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) increase suicidal behaviors in adults aged 18 to 29 years, especially those with major depressive disorder (MDD) and those who receive paroxetine. The USPSTF found at least fair-quality evidence that SSRI use is associated with an increased risk for upper gastrointestinal (UGI) bleeding in adults older than 70 years, with risk increasing with age.

The USPSTF concludes that for adults who receive care in clinical practices that have staff-assisted depression care supports in place, there is at least moderate certainty that the net benefit of screening for depression is at least moderate.

The USPSTF concludes that for adults who receive care in clinical practices without staff-assisted depression care supports in place, there is at least moderate certainty that the net benefit of screening adults for depression is small.

This recommendation applies to nonpregnant adults, including older adults. It does not apply to children and adolescents, who are considered a separate population.

Individuals at increased risk for depression are considered at risk throughout their lifetime. Groups at increased risk include persons with other psychiatric disorders, including substance misuse; persons with a family history of depression; persons with chronic medical diseases; and persons who are unemployed or of lower socioeconomic status. Also, women are at increased risk compared with men. Significant depressive symptoms are associated with common life events in older adults, including medical illness, cognitive decline, bereavement, and institutional placement in residential or inpatient settings. However, the presence of risk factors alone cannot distinguish depressed patients from nondepressed patients.

The USPSTF reviewed evidence about the accuracy of screening instruments in identifying depressed adults in 2002 (1). Many formal screening tools are available, including instruments designed specifically for older adults. Asking 2 simple questions about mood and anhedonia (“Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”) may be as effective as using more formal instruments (2). There is little evidence to recommend 1 screening method over another; therefore, clinicians may choose the method most consistent with their personal preference, the patient population being served, and the practice setting.

All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (that is, those from the updated Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) to determine the presence or absence of specific depressive disorders, such as MDD or dysthymia. The severity of depression and comorbid psychological problems (for example, anxiety, panic attacks, or substance abuse) should be addressed.

The reviews of evidence on which this recommendation is based cover treatment of adults with antidepressants or psychotherapy (1) and updated evidence on the efficacy of depression treatment in older adults (3). Treatment may include antidepressants or specific psychotherapeutic approaches (for example, cognitive behavioral therapy or brief psychosocial counseling) alone or in combination. Both are effective in treating adults and older adults.

In treating patients aged 18 to 29 years, clinicians may want to select a psychotherapeutic approach or medications other than SSRIs because of the increased risk for suicidal behavior associated with the use of SSRIs. Similarly, for adults 65 years or older, clinicians may want to select a psychotherapeutic approach or medications other than SSRIs because of the increased risk for UGI bleeding associated with the use of SSRIs. In addition, the concurrent use of SSRIs with a nonsteroidal anti-inflammatory drug (NSAID) or low-dose aspirin increases the risk for UGI bleeding in adults (aged 40 to 79 years), although the increase in risk is less with aspirin. The risk for UGI bleeding is greater for medications that feature a moderate to high degree of serotonin reuptake inhibition.

“Staff-assisted depression care supports” refers to clinical staff that assist the primary care clinician by providing some direct depression care, such as care support or coordination, case management, or mental health treatment.

In the available evidence, the lowest effective level of staff-assisted depression care supports consisted of a screening nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to behavioral treatment (4). At the highest level, staff-assisted depression care supports included screening; institutional monetary commitment; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; many materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for adherence to medication for those prescribed antidepressant medications; a visit with a trained therapist for cognitive behavioral therapy; and a reduced copay for patients referred for psychotherapy (5 - 6). In a successful study designed for practices without ready access to mental health specialty care, office staff recruited, screened, and enrolled participants who screened positive for depression before a clinic visit (7). If the physician confirmed the depression diagnosis, the participant was scheduled for a return visit with the physician and to meet with the nurse specialist in 1 week. The nurse specialist reassessed the patient's level of depression, discussed treatment options and preferences, and asked the participant to complete a homework assignment. Participants completed up to 8 additional sessions that followed the same pattern, either by phone or in person.

Multidisciplinary team-based primary care that includes self-management support and care coordination has been shown to be effective in management of depression. These components of primary care are detailed in recent recommendations from the Task Force on Community Preventive Services (8). It recommends collaborative care for treatment of adults 18 years or older with major depression on the basis of strong evidence of effectiveness in improving short-term treatment outcomes. As defined, collaborative care and disease management of depressive disorders includes a systematic, multicomponent, team-based approach that “strengthens and supports self-care, while assuring that effective medical, preventive and health maintenance interventions take place” to improve the quality and outcome of patient care for treatment of major depressive disorders (8).

The optimum interval for screening for depression is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (for example, panic disorder or generalized anxiety), substance abuse, or chronic pain.

The Task Force on Community Preventive Services also has made several recommendations about depression care in older adults. It recommends clinic-based depression care management to reduce depression in older adults on the basis of sufficient evidence and home-based depression care management on the basis of strong evidence. The Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of community-based exercise interventions for reducing depression in older adults.

The Task Force on Community Preventive Services makes recommendations on population-based interventions appropriate for use by communities and health care systems to promote health and to prevent disease, injury, disability, and premature death. More information about the Task Force on Community Preventive Services and its recommendations on depression interventions is available on their Web site (www.thecommunityguide.org).

The USPSTF recently updated its recommendation on screening for depression in children and adolescents. The USPSTF recommends screening adolescents (aged 12 to 18 years) for MDD when systems are in place to assure accurate diagnosis, psychotherapy (cognitive behavioral or interpersonal), and follow-up (Grade B recommendation). In addition, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (aged 7 to 11 years) for MDD (I statement).

In 2004, the USPSTF concluded that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population (I statement). At that time, the USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. The USPSTF also found limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk, and found no evidence that directly addressed the harms of screening and treatment of suicide risk. In addition, the USPSTF found insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality.

For the full recommendation statements and evidence reviews, please go to the Agency for Healthcare Research and Quality Web site (www.preventiveservices.ahrq.gov).

The proper diagnosis, treatment, and follow-up of adults with depression require substantial institutional investment and coordination.

The economic burden of depression is substantial for individuals as well as society. Costs to an individual may include suffering, possible side effects from treatment, fees for mental health and medical visits and medications, time away from work and lost wages, transportation, and reduced quality of personal relationships. Costs to society may include loss of life, reduced productivity (because of both diminished capacity while at work and absenteeism from work), and increased costs of mental health and medical care. In 2000, the United States spent an estimated $83.1 billion in direct and indirect costs of depression (3).

Gaps in the evidence on depression screening in adults in primary care include a lack of information from large-scale randomized, controlled trials (or other well-controlled trials) on the specific role of depression screening in improving depression care management. Useful information that could be derived from studies of depression screening that ascertain health outcomes includes response and remission rates and health risks.

Other research needs and gaps include updated information about the frequency with which depression cases are missed in primary care and the level of severity of these cases. This information would help determine the need for active case finding. Also, information on the possible adverse effects and harms of depression care management programs is needed to determine the net benefits of these approaches. In addition, more information is needed about approaches to preventing risk for bleeding in patients who receive SSRIs, including monitoring, dosage or medication adjustments, and cotherapies. Finally, additional information is needed about the efficacy, tolerability, and safety of antidepressants, including pharmacogenetic studies, studies of the effects of genetic variability, and studies of medication interactions. This information could be used to target depression treatments more effectively to increase benefits and reduce adverse effects.

Depressive disorders include MDD, dysthymia, and minor depression. Other conditions that include depressive features (for example, bipolar disorder) are not considered depressive disorders. Depression is often associated with loss of productivity at work and impairment in relationships and social functioning. It is a major risk factor for suicide.

In primary care settings, the prevalence of MDD ranges from 5% to 13% in adults and from 6% to 9% in older adults. The prevalence of dysthymia in adults in primary care settings is estimated to range from 2% to 4%. One third to one half of adults and nearly two thirds of older adults who receive treatment for depression receive it in a primary care setting (3). Large-scale studies of patients initiating treatment of depression show that approximately two thirds achieve remission within 1 year. Older patients have similar or slightly lower recovery rates than other adults, possibly because of a higher rate of comorbid medical conditions. Despite fairly high rates of recovery from particular episodes, depression is highly recurrent. A large-scale community care based study of depression treatment found that about half of patients who achieved remission had relapse during the subsequent year (3).

This recommendation statement updates the 2002 USPSTF recommendation statement on screening for depression in adults. Evidence gathered for this recommendation focused on areas identified as gaps in the evidence in the 2002 review; issues that the USPSTF judged in the previous review to have strong evidence were not addressed. The current evidence review examined direct evidence that primary care depression screening programs improve health outcomes. It also examined the available evidence on the efficacy of depression treatment in older adults and the harms of screening and adverse events from antidepressant treatment in all adults.

Several depression screening instruments are available, including the Zung Self-Depression Scale, Beck Depression Inventory, General Health Questionnaire, Center for Epidemiologic Study Depression Scale, SelfCARE (D), and the Geriatric Depression Scale; the latter 2 were developed specifically for older adults. Most of these instruments have relatively good sensitivity (80% to 90%) but only fair specificity (70% to 85%). Most are easy to use and can be administered in less than 5 minutes. Shorter screening tests, including simply asking questions about depressed mood and anhedonia, seem to detect most depressed patients and, in some cases, do better than the original instrument from which they were derived (3).

No new relevant evidence was found that supports screening for depression in primary care settings without feedback or follow-up (9). A fair-quality randomized, controlled trial (10) studied the health benefits of screening for depression by comparing a group that received screening with a group that received usual care. Williams and colleagues (10) randomly assigned 969 patients at 2 primary care practices to either receive standard care or complete a depression screening before a scheduled visit. Results, both positive and negative, were recorded in the patient's chart. Patients who were depressed on initial screening were more likely to have normal depression scores 3 months after their initial visit than patients who had not had screening (48% vs. 27%; P < 0.05). However, the apparent benefit was no longer seen when the comparison included patients who were screened and not depressed at the initial visit.

Two good-quality and 6 fair-quality randomized, controlled trials were identified that examined the effectiveness of depression screening programs with varying levels of care support on health outcomes. Four included general adult populations, and 4 focused on older adults. Four of these studies had been included in the previous review. All of the studies randomly assigned or enrolled adults who screened positive for depression; most administered the screening instrument in the clinic waiting room. Screening test results were given only to clinicians whose patients screened positive (9).

Because of the nature of the evidence, the effects of screening cannot be separated from the effects of staff-assisted depression care. Of the 4 trials that were conducted in the general adult population, 3 reported effectiveness in improving depression outcomes, particularly among adults with newly detected depression. The 1 study that did not demonstrate effectiveness in improving depression outcomes offered only simple feedback of screening results, with no other support.

All 3 of the studies that found effectiveness in improving depressive symptoms included some level of staff-assisted depression care support in addition to screening. One fair-quality study that featured staff support for scheduling follow-up visits and facilitating referrals demonstrated an improvement in depressive symptoms, but only among adults with newly identified depression who were not seeking treatment (4). The other 2 studies were large-scale trials that featured higher-intensity interventions involving depression care by staff other than the primary care provider. The higher-intensity interventions included such elements as intensive clinician and office support staff training, support staff or specialty mental health provider participation in ongoing depression care, and several follow-up contacts (5,7).

The trial that provided the highest-intensity depression care found significantly fewer patients in either of the 2 intervention groups who screened positive for depression after the intervention (based on a 2-item instrument) compared with patients who received usual care (6-month follow-up, 40% vs. 50% [P = 0.001]; 12-month follow-up, 42% vs. 51% [P = 0.005]) (5). After 5 years, 36% of patients in 1 intervention group screened positive for depression on a 2-item instrument compared with 44% of patients who received usual care (P = 0.05) (6).

Given the number of components to this program, the degree to which the screening components contributed to the improvement in depression cannot be measured. Furthermore, although this study demonstrated the feasibility of delivering a multicomponent program in a primary care setting, the program required substantial institutional investments.

Of the 4 studies conducted in older adults, only 1 found improved depression outcomes in an intervention group beyond usual care; it was also the only study that expanded the role of other clinical or office staff to assist with depression care (11). This trial involved the assistance of a case manager, who interviewed and referred patients to primary or specialty care or to a multidisciplinary geriatric assessment team. The case manager also provided patient education and follow-up. The generalizability of this trial to general primary care screening of older adults may be limited because the study population consisted of patients who were at high risk for several conditions. It is not clear whether older adults who screened positive only for depression were eligible for the study.

Effective treatments are available for patients with depressive illnesses detected in primary care settings. Psychotherapy and antidepressant medications for MDD, delivered singly or in combination, are effective in treating adults. A systematic review of intention-to-treat trials comparing 3 groups of patients who received antidepressants, psychotherapy, or a control condition reported a 46% remission rate with antidepressants and a 48% remission rate with psychotherapy after 10 to 16 weeks (12). Both treatments are widely available from primary care providers or by referral.

Three good-quality systematic reviews included meta-analyses on the effectiveness of treatments for older adults. Two reviews concluded that antidepressants were effective in treating depressed older adults. In the most recent review, older adults who received antidepressants were twice as likely to have remission from major or minor depression as older adults who received placebo (odds ratio [OR], 2.03 [95% CI, 1.67 to 2.46]) (13). A Cochrane review indicated that among community-dwelling older adults, 36% of those who received antidepressants were in remission at the end of the study compared with 21% of those who received placebo (OR, 2.13 [CI, 1.61 to 2.86]) (14).

Psychotherapy is also an effective treatment of depression in older adults. Two good-quality systematic reviews on the efficacy of psychotherapy in older adults found that depressed older adults treated with psychotherapy were more than twice as likely to have remission as those who received no treatment (OR, 2.47 [CI, 1.76 to 3.47] vs. 2.63 [CI, 1.96 to 3.53]) (13,15).

The potential harms of screening include false-positive results, the inconvenience of additional diagnostic workup, the costs and adverse effects of treatment of patients who are incorrectly identified as being depressed, and potential adverse effects of labeling. The evidence review found no evidence on any of these potential harms of screening (9).

Harms of treatment include serious adverse effects of antidepressants, such as suicide-related events and psychiatric events, as well as minor side effects, including nausea, dizziness, diarrhea, headache, sexual dysfunction, and insomnia. For older adults, harms of treatment also include serious medical events, such as UGI bleeding.

The evidence review found 7 studies that compared suicide-related events among adults who received SSRIs and other second-generation antidepressants with adults who received placebo. No studies reported a significant increase in completed suicide rates in adults who received antidepressants compared with those who received placebo, although completed suicides were rare and, as a result, the power to detect a significant difference was limited (3).

Results from 5 meta-analyses indicated that the odds of suicidal behavior, generally defined as suicide attempts, preparatory acts, or serious self harm, nearly doubled for 2 groups: adults aged 18 to 24 years with MDD or other psychiatric indications who received second-generation antidepressants (OR, 2.31 [CI, 1.02 to 5.64]) (16) and adults who received treatment with SSRIs for any indication (OR, 2.70 [CI, 1.22 to 6.97]) (17). The highest odds of nonfatal suicidal behavior were found in adults with MDD who received paroxetine (OR, 6.70 [CI, 1.1 to 149.4]) (18), with such behaviors mostly exhibited by those aged 18 to 29 years (risk difference for suicidal behavior, 2.7 per 1000 patients treated with paroxetine; number needed to treat, 370 [CI, 208 to 1667]). For all ages, the risk for suicidal behaviors was highest in the first month of treatment (19).

For adults older than 65 years, antidepressant use seemed to be protective against suicidal behavior (OR, 0.06 [CI, 0.01 to 0.58]) (20).

The evidence review identified 1 fair-quality study on bleeding risk in older adults who received SSRIs. Although patients 16 years or older were at increased risk for UGI bleeding during periods of SSRI use, the risk increased significantly with age, from 4.1 hospitalizations per 1000 adults aged 65 to 70 years to 12.3 hospitalizations per 1000 octogenarians. The odds of UGI bleeding in adults aged 40 to 79 years who currently receive SSRIs (adjusted OR, 3.0 [CI, 2.1 to 4.4]) was much higher when they also received an NSAID (adjusted OR, 15.6 [CI, 6.6 to 36.6]) (21).

For adults who receive care in clinical practices that have staff-assisted depression care supports in place, there is at least moderate certainty that the net benefit of screening for depression is at least moderate.

For adults who receive care in clinical practices that do not have staff-assisted depression care supports in place, there is at least moderate certainty that the net benefit of screening adults for depression is small.

In 2002, the USPSTF recommended screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up (B recommendation). The current recommendation adds some specificity by stipulating that staff-assisted depression care supports need to be in place. If such supports are not in place, the USPSTF does not recommend routine screening of adults (C recommendation).

The 2002 recommendation concluded that the evidence was insufficient to recommend for or against routine screening of children or adolescents for depression. Given the availability of new evidence about screening for depression in children and adolescents, the USPSTF has made separate recommendations for these populations (the current USPTF recommendation on screening for depression in children and adolescents is available at www.preventiveservices.ahrq.gov).

The Canadian Task Force on Preventive Health Care recommends that adults in the general population be screened for depression in primary care settings with integrated feedback to patients and access to follow-up and treatment. The Canadian Task Force found insufficient evidence to recommend for or against screening adults in the general population for depression in settings without effective follow-up and treatment (22). The American College of Obstetricians and Gynecologists recommends that clinicians be alert to symptoms of depression and provide follow-up care or a referral if depression is recognized (23).

Members of the U.S. Preventive Services Task Force at the time this recommendation was finalized† are Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B. Petitti, MD, MPH, Vice-Chair (Arizona State University, Phoenix, Arizona); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio); Allen J. Dietrich, MD‡ (Dartmouth Medical School, Hanover, New Hampshire); Leon Gordis, MD, DrPH (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland); Kimberly D. Gregory, MD, MPH (Cedars-Sinai Medical Center, Los Angeles, California); Russell Harris, MD, MPH (University of North Carolina School of Medicine, Chapel Hill, North Carolina); George Isham, MD, MS (HealthPartners, Minneapolis, Minnesota); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York); Carol Loveland-Cherry, RN, PhD (University of Michigan School of Nursing, Ann Arbor, Michigan); Lucy Marion, PhD, RN (Medical College of Georgia School of Nursing, Augusta, Georgia); Virginia Moyer, MD, MPH (Baylor College of Medicine, Houston, Texas); Judith Ockene, MEd, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); George Sawaya, MD (University of California San Francisco, San Francisco, California); and Barbara Yawn, MD, MS (Olmsted Medical Center, Rochester, Minnesota).

† For a list of current Task Force members, go to www.ahrq.gov/clinic/uspstfab.htm.

‡ Recused from voting.