Screening for Depression--A Tale of Two Questions.

The US Preventive Services Task Force (USPSTF)1 has issued new recommendations on Screening for Depression in which they concluded, “The USPSTF 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 accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation).” Grade B indicates high certainty that the net benefit is moderate or moderate certainty that the net benefit 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, appropriately diagnosed and treated with evidence-based stepped care or referred to a setting that can provide the necessary care. The new guidelines are similar to the 2002 and 2009 USPSTF depression screening recommendations except for 1 major change: neither the 2002 nor the 2009 recommendations mentioned pregnant or postpartum women.2,3 The recent USPSTF recommendations are largely based on a systematic review evaluating the potential benefits of depression screening in pregnant or postpartum women.4No new 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) to a depression screening intervention vs usual care.5 Intervention group participants completed the 10-item Edinburgh Postnatal Depression Scale (EPDS); control group participants completed a general self-efficacy scale (similar in length and format) but did not complete the EPDS. All participants underwent a clinical assessment by a nurse who was blinded to their group allocation; patients (from either 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). Based on this and other studies, the USPSTF concluded 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, American College of Obstetricians and Gynecologists) do recommend routine screening for depression, especially for subgroups of patients who are at high risk, such as persons with low socioeconomic status, limited social support, chronic pain, disability, unintended pregnancy, comorbid mental health issues, or chronic medical conditions. Moreover, most US insurance providers, including the Center for Medicare and Medicaid Services, cover annual screening for depression in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. Therefore, primary care clinicians must be familiar with how to implement a depression screening program.