Updated Depression Screening Recommendations for Adults

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Screening of all adults is recommended regardless of risk factors.
Screening of all adults is recommended regardless of risk factors.

Major depressive disorder (MDD) affects an estimated 6.7% of US adults annually, and the World Health Organization (WHO) identifies it as the source of the heaviest disability burden among all mental and behavioral disorders.1 As the leading cause of disability in individuals aged 15 and older, depression negatively affects not only the person suffering from the disorder, but also families, businesses, and society at large. Effective screening efforts can help prevent the development or worsening of these issues for at-risk individuals.

Earlier this year, the US Preventive Services Task Force (USPSTF) published an update to their 2009 recommendations for depression screening in US adults.2 Based on a systematic review of recent evidence, the task force concluded  “with at least moderate certainty that there is a moderate net benefit to screening for depression in adults, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening.” A similar benefit level was determined for the screening of pregnant and postpartum women whose healthcare settings offer cognitive behavioral therapy (CBT) or other evidence-based counseling approaches to follow positive screening results. The new recommendations differ from the previous one with the addition of these specific guidelines for pregnant and postpartum women, and with the omission of selective screening recommendations based on certain practice limitations.

Screening of all adults is recommended regardless of risk factors, as “the presence or absence of risk factors alone cannot distinguish patients with depression from those without depression,” wrote the authors. However, the authors note a variety of factors associated with increased risk in the general adult population, such as female sex, young and middle adulthood, non-white race, medical or psychiatric comorbidities, and family history of mental illness. In addition, certain risk factors more frequently pertain to specific adult populations–for example, complicated grief and chronic sleep disturbance in older adults, and child-care stress and decreased social support in pregnant and postpartum women.

The USPSTF recommends that positive screening results from commonly used instruments such as the Patient Health Questionnaire (PHQ), the Hospital Anxiety and Depression Scales (HADS), the Geriatric Depression Scale, or the Edinburgh Postnatal Depression Scale (EPDS) should be followed with more in-depth assessment to determine the severity of symptoms, psychological and medical comorbidities, and alternate diagnoses. Their specification that “adequate systems” should be in place means that there should be sufficient staff and systems to facilitate appropriate screening, diagnosis, and evidence-based treatment or referral to a qualified care setting. “These essential functions can be provided through a wide range of different arrangements of clinician types and settings,” they stated.

While effective depression treatment typically consists of antidepressant medication, psychotherapy, or both, clinicians are advised to consider CBT or other evidence-based approaches for pregnant or lactating patients due to potential medication-related risks to the fetus or infant. Additionally, the Community Preventive Services Task Force recommends a collaborative care model for depression management that utilizes case managers to connect patients, primary care providers, and mental health clinicians, and the  registry of evidence-based programs and practices offered by Substance Abuse and Mental Health Services Administration contains information on implementing depression screening systems.

References 

1. National Institute of Health: National Institutes of Mental Health. Major depression among adults. Retrieved on 6/22/16.

2. Siu AL and the US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016; 315(4):380-7.

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