USPSTF expands recommendations for depression screening in teens

In updated guidance on screening for major depressive disorder (MDD), the US Preventive Services Task Force (USPSTF) is now expanding its recommendation to include all adolescents aged 12 years and older.

The decision to expand the screening recommendation was based on new knowledge about therapies, as well as evidence that basic screening tools already used in primary care settings were adequate in recognizing the signs of MDD as other more extensive screening and diagnosis tools.

The recent update notes that not only should physicians screen all adolescents over age 12 years for depression, but also recommends that parents be aware of possible depressive symptoms in younger children for whom screening is not recommended.

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The changes are a result of USPSTF’s commission of researchers at RTI International in Research Triangle Park, North Carolina and the University of North Carolina at Chapel Hill for input on the depression screening regulations last year. The teams found there was no evidence that screening for depression would be harmful to teenagers and, in fact, found the Patient Health Questionnaire for Adolescents and the primary care version of the Beck Depression Inventory to be very useful in performing mental health assessments on adolescents.

However, the review did not yield a change in recommendations for younger children, with USPSTF stating there was not enough evidence to recommend depression screening for children under age 12 years.

Previously, for both age groups, USPSTF only recommended depression screening when adequate systems were in place for accurate diagnosis, effective treatment, and appropriate follow-up. Now, the federal task force found evidence that currently available screening tools in primary care are accurate in identifying MDD.

The USPSTF found no evidence that screening for depression in adolescents in the primary care setting actually leads to improved outcomes, but the task force did find moderate benefits in the severity of depression and depressive symptoms, and on global functioning scores.

Medications like selective serotonin reuptake inhibitors (SSRIs), on the other hand, have known harms in all age groups, but USPSTF says the risk of adverse effects or negative side effects are small in relation to the benefit if the patient is closely monitored. Psychotherapy and psychosocial support therapies have been found to be relatively harmless, says USPSTF.

NEXT: Highlighting risk factors

While the updated recommendation states that all adolescents should be screened for depression, USPSTF does highlight some factors that may reveal a higher risk in some patients. Adolescents that could face a higher risk of developing MDD include females, older teenagers, teenagers with a family history of depression, previous depressive episodes, other mental or behavioral health problems, chronic medical illness, obesity, and ethnicity.

Other risk factors include childhood abuse or neglect, traumatic events, loss of a loved one or romantic relationship, family conflict, questioning their sexual orientation, low socioeconomic status, and poor academic performance.

As far as how often screenings should take place, USPSTF found no evidence supporting any particular interval.

“Repeated screening may be most productive in adolescents with risk factors for MDD,” states USPSTF. “Opportunistic screening may be appropriate for adolescents, who may have infrequent health care visits.”

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A number of treatments and interventions are available to treat adolescents with depression, including pharmacology, psychotherapy, psychosocial support, and complementary and alternative therapies. The US Food and Drug Administration previously issued a warning for antidepressants, urging appropriate monitoring for worsening or changing symptoms. As of now, fluoxetine (Prozac) is approved to treat depression in children aged older than 8 years, and escitalopram (Lexapro) is approved to treat depression in adolescents aged 12 to 17 years. The SSRIs, on the other hand, may be risky in children, specifically increasing the risk of suicide or suicidal ideation.

In discussing depression, the USPSTF guidance refers to MDD, not singular episodes. Individuals with MDD suffer from 1 or more depression episodes lasting at least 2 weeks and resulting in significant functional, social, or occupational impairment.

“In some children and adolescents with MDD, these symptoms may present as periods of disruptive mood and irritability rather than as a sad mood and may last for weeks, months, or even years. Major depressive disorder is associated with significant morbidity and mortality,” states USPSTF.

Other symptoms in children and adolescents may also include poor school performance and socialization, underage pregnancy, physical illness, and substance abuse. Adolescents with depressive disorders also have more hospitalizations and an increased risk for suicide-USPSTF says 10% of children aged 5 to 14 years, and 19% of adolescents aged 13 to 18 years with MDD attempts suicide.

NEXT: Taking it case-by-case

Major depressive disorder usually sets in around 14 to 15 years of age, with development occurring earlier in girls. National prevalence of MDD in adolescents in around 8%, according to USPSTF, and 2% of boys and 4% of girls aged 8 to 15 years reporting having MDD in a 2005 report. However, only as estimated 36% of children and 44% of adolescents receive treatment for their depression, according to USPSTF.

Alex Krist, MD, MPH, a USPSTF member and professor at Virginia Commonwealth University in Richmond says the updated recommendations aim to improve the number of MDD cases that are identified and treated early for better long-term outcomes.

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“Major depressive disorder can be a debilitating condition for children and teenagers, one that can impact their lives in a variety of ways. Major depression in adolescence often goes undiagnosed, which can lead to an increased risk for suicide as well as depression in adults,” Krist says. “Primary care clinicians who care for children and teenagers should know that the Task Force recommends screening all adolescents between 12 and 18 years of age for MDD. They also should know that, at the time of this recommendation, the current evidence is insufficient to assess the balance of benefits and harms of screening for depression in children aged 11 years or younger, so we look forward to reassessing this topic as more information becomes available."

While the USPSTF makes recommendations, Krist says pediatricians should approach each case individually and consider the risk factors of the individual patients.

“Clinicians should use their judgment to determine how often screening should occur as well as the best treatment options for individual patients, based on personal risk factors, other behavioral health conditions, and life events. In all, we are hopeful that this recommendation will further inform clinicians on the benefits and harms of screening; the accuracy of screening tests used in primary care; and the benefits and harms of different interventions,” Krist says. “Moreover, we hope this recommendation can help to expand access to care in communities that lack efficient resources-in turn, helping more young people who are affected get the appropriate care and support they need.”