Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force

Major depressive disorder (MDD) is relatively common in childhood and adolescence and is associated with functional impairment and suicide. Nationally representative samples have indicated a past-year prevalence of approximately 8% for adolescents (1, 2) and roughly 3% in younger children (aged 8 to 15 years) (3). The prevalence of depression in primary care settings may be twice that of community samples of children and adolescents (4) and seems to be increasing (5). In addition, nationally representative studies have indicated that fewer than one half of children and adolescents with major depression receive treatment for mental health issues (2, 3, 6). Primary care providers can play a critical role in identifying depression among children and adolescents, particularly because youth with mental health issues frequently use primary care services. Because primary care providers are often the first point of professional contact for children and their families during times of distress, they can facilitate early identification of mental health issues; begin initial management; and refer children, as necessary, for further mental health assessment and treatment. They also serve vital roles in collaborative care and practice networks that include mental health specialists. Schools are also important in identifying and treating depression in children and adolescents. In 2011, 12% of adolescents aged 12 to 17 years reported receiving mental health care at school (2). Early identification and treatment may be particularly important because of the long-term and recurrent nature of MDD (7) and its myriad negative sequelae. Associated functional impairment; decreased academic performance; and troubled relationships with parents, siblings, and peers are common and can affect developmental trajectories (8, 9). In addition, children and adolescents with depression are likely to have other comorbid mental health problems (7, 10); somatic symptoms, such as headache and migraine, stomach aches, and musculoskeletal pain; and chronic medical conditions, such as asthma and diabetes (11). Childhood and adolescent MDD is associated with increased risk for suicidal thoughts, attempts, and completions (12). In 2009, the U.S. Preventive Services Task Force (USPSTF) guidelines recommended routine screening for depression in children and adolescents aged 12 to 18 years in primary care settings when resources are available for additional evaluation and care (13, 14). Although most experts from family medicine, pediatrics, nursing, psychology, and child psychiatry endorse routine surveillance for youth at high risk for depression (15), routine universal screening is still debated. Some pediatricians report discomfort with screening for and diagnosing depression, citing lack of self-efficacy, training, or experience specific to delivering mental health care (16). Some providers are also concerned about access to mental health services for patients with positive screening results. The objective of this report is to update the recommendations released in 2009 for screening adolescents and children for MDD in primary care and similar settings (such as school-based clinics). Methods Scope of the Review We searched for evidence on the benefits and harms of screening; accuracy of feasible screening tests; and potential benefits and risks of treating MDD using collaborative care, psychotherapy, or selective serotonin reuptake inhibitors (SSRIs) among children and adolescents seen in primary care or similar settings, such as school-based clinics. We also wanted to determine whether the benefits and harms differed by age, sex, or race/ethnicity. Appendix Tables 1 and 2 and Appendix Figures 1 and 2 show key questions; search strings; analytic framework; and numbers of identified articles, screened articles, eligible articles for full-text review, and included articles organized as a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) tree (for studies published since May 2007, the end date for the 2009 review's searches). Appendix Table 1. Search Strings* Appendix Table 2. Key Questions Appendix Figure 1. Analytic framework for screening for childhood depression. MMD = major depressive disorder. Appendix Figure 2. 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. Data Sources and Searches We searched PubMed (MEDLINE), the Cochrane Library, and PsychInfo for English-language articles published from May 2007 to 4 February 2015. Unpublished literature was identified via searches of ClinicalTrials.gov, Health Services Research Projects in Progress, and the World Health Organization's International Clinical Trials Registry Platform. We also reviewed and included, as appropriate, studies from reference lists of pertinent review articles and all literature suggested by peer reviewers or public comment respondents. Appendix Table 1 and the full evidence report (available at www.uspreventiveservicestaskforce.org) include all of the search strategies used for each key question and the databases searched. Two investigators independently reviewed titles and abstracts. We dually and independently reviewed the full text of studies that at least 1 reviewer indicated as potentially meeting our prespecified criteria for each key question, according to initial abstract review. To reduce heterogeneity and ensure focus on children and adolescents with more serious symptoms because they are more likely to have severe functional impairment and suicidality, we restricted inclusion of efficacy and harms studies to those in which at least 50% of participants had an MDD diagnosis. Screening accuracy studies had to be done in primary care or similar settings, be of feasible length and format to administer in a setting similar to primary care, and include a comparison against a gold-standard assessment tool. We included randomized and nonrandomized trials published between May 2007 and 4 February 2015 and systematic reviews published between January 2011 and 4 February 2015 of MDD treatment efficacy and harms, testretest studies of screening for MDD, and cohort studies with at least 1000 participants for studies of screening and treatment harms. In addition to the new literature searches, we also applied, dually and independently, the inclusion and exclusion criteria described previously to all studies from the 2009 review (17), which included articles published from 1990 to May 2007 that focused on screening for and treatment of depression, but not specifically MDD, in children and adolescents. The exact differences between the inclusion and exclusion criteria applied in the current and former reviews are documented in the full evidence report at www.uspreventive servicestaskforce.org. Data Extraction and Quality Assessment Using predefined criteria developed by the USPSTF and others for additional criteria for diagnostic accuracy studies, 2 investigators independently assessed the quality of each study as good, fair, or poor (18). We resolved disagreements by discussion and consensus. For screening accuracy studies, flaws that resulted in poor-quality ratings included use of an inappropriate reference standard, improper administration of the screening test, biased ascertainment of the reference standard, very small sample size, or very narrowly selected spectrum of patients. For treatment efficacy and harms studies, flaws that resulted in poor-quality ratings included high overall attrition (at least 20%) or differential attrition (at least 15%) between study groups, unreliable or invalid measurement instruments or unequal application across study groups (including not masking outcome assessment), and little or no attention given to key confounders; and, for randomized, controlled trials, the lack of an intention-to-treat analysis. We excluded all studies dually determined to be of poor quality. We rated the overall body of evidence for each key question using the system developed by the USPSTF (18). Data Synthesis and Analysis We organized our findings according to the key questions. We used Comprehensive Meta Analysis, version 3 (Biostat), to calculate effect sizes and 95% CIs. We planned to use meta-analysis to pool the efficacy outcomes by drug (such as escitalopram trials) and drug family (such as all SSRIs), but heterogeneity across studies limited the number of combinable interventions and outcomes, which precluded the calculation of pooled estimates. Role of the Funding Source The Agency for Healthcare Research and Quality funded this study under a contract to support the work of the USPSTF. Members of the USPSTF and the Agency medical officer assisted in the development of the review's scope, key questions, and analytic framework. The Agency for Healthcare Research and Quality reviewed and approved this manuscript before publication, but the authors are solely responsible for its content and the decision to submit it for publication. Results Only 2 new treatment efficacy studies met our criteria (19, 20). The studies included in the 2009 review, when re-reviewed against our criteria, yielded 5 studies on screening accuracy (2124) and 4 trials in 6 publications on treatment efficacy (3 publications on 1 trial [2527] and 1 publication each on the other 3 trials [2830]). Benefits, Yield, and Harms of Screening We found no trials that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings. We also did not find studies that addressed whether screening increases the proportion of children or adolescents identified with MDD or results in harms. No meta-analyses or retrospective cohort studies met our inclusion criteria. We excluded studies if less than half of the sample of children and adolescents had MDD or did not repo