Screening For Depression In Adults

Estimate Of Magnitude Of Net Benefit

General Adult Population and Older Adults

The evidence from 5 RCTS, in addition to indirect evidence reviewed for the 2009 recommendation, supports moderate certainty that screening for depression in general adults is of moderate net benefit. The evidence for older adults is less clear, because the trials that assessed the direct effect of screening found no benefit and possibly even harm. However, given the strength of the indirect evidence , the inclusion of adults older than 65 years in the studies of all adults, and the weakness of the direct evidence on screening in older adults, the USPSTF concludes that the weight of evidence still favors a net benefit. However, more research on optimal screening approaches in older adults is imperative.

Pregnant and Postpartum Women

Assessing Newly Diagnosed Patients

These tools include:

• Patient Health Questionnaire : this is a nine-item questionnaire which helps both to diagnose depression and to assess severity. It is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual – Fourth Edition . It takes about three minutes to complete. Scores are categorised as minimal , mild , moderate , moderately severe and severe depression . It can be downloaded free from the internet.
• Hospital Anxiety and Depression Scale: despite its name, this has been validated for use in primary care. It is designed to assess both anxiety and depression. It takes about five minutes to complete. The anxiety and depression scales each have seven questions, and scores are categorised as normal , mild , moderate and severe .
• Beck Depression Inventory® – Second Edition : this also uses DSM criteria. it takes about five minutes to complete. It is an assessment of the severity of depression and is graded as minimal , mild , moderate and severe . It consists of 21 items to assess the intensity of depression in clinical and normal patients. Each item is a list of four statements arranged in increasing severity about a particular symptom of depression. It is also not free but can be purchased from the supplier’s website.

Other screening tests may be useful in particular situations. They include:

Effectiveness Of Screening And Treatment

General Adult Population and Older Adults

Nine good- or fair-quality trials addressed screening in general adults and older adults . Seven studies were conducted in the United States, and 2 were conducted in the Netherlands. Most studies were published in the 1990s and early 2000s only 1 of the 9 trials was published since the previous systematic review. One study in general adults directly compared screening with usual care case-finding,9 while the other studies screened all patients for depression, enrolled only those screening positive, and returned results of screening to clinicians in the intervention group only.6 Studies included a range of additional treatment components along with providing screening result feedback to clinicians.

Improvements in remission, response rates, or both in the general adult population ranged from 17% to 87%. Other outcomes were sparsely reported. The effect of screening on remission, response rates, or both in the trials of older adults was minimal. However, both of the trials in older adults that showed a paradoxical effect were conducted in the Netherlands, and the trial with the worst outcomes had a number of features that may have affected its reliability, including external referrals for depression treatment, very low uptake of treatment , and high mortality and morbidity in the intervention group, suggesting that the control and intervention groups may have been different at baseline.

Pregnant and Postpartum Women

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Benefits Of Early Detection And Intervention And Treatment

The USPSTF found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes in adults, including pregnant and postpartum women.

The USPSTF found convincing evidence that treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.

The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy improves clinical outcomes in pregnant and postpartum women with depression.

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Summary Of Recommendations For Clinicians And Policy

Recommendations on screening for depression in primary care settings are provided for people 18 years of age or older who present at a primary care setting with no apparent symptoms of depression. These recommendations do not apply to people with known depression, with a history of depression or who are receiving treatment for depression.

• For adults at average risk of depression,* we recommend not routinely screening for depression.

• For adults in subgroups of the population who may be at increased risk of depression,â we recommend not routinely screening for depression.â¡

• âµ* The average-risk population includes all individuals 18 years of age or older with no apparent symptoms of depression who are not considered to be at increased risk.

• âµâ Subgroups of the population who may be at increased risk of depression include people with a family history of depression, traumatic experiences as a child, recent traumatic life events, chronic health problems, substance misuse, perinatal and postpartum status, or Aboriginal origin.

• âµâ¡ Clinicians should be alert to the possibility of depression, especially in patients with characteristics that may increase the risk of depression, and should look for it when there are clinical clues, such as insomnia, low mood, anhedonia and suicidal thoughts.

Quick Inventory Of Depressive Symptomatology

The QIDS-SR measures the severity of depressive symptoms in adults 18 and older. There are 16 measures, selected from the Inventory of Depressive Symptomology . These symptoms correspond to the diagnostic criteria from the DSM-IV. Respondents use a 4-point Likert-type scale to assess their behaviors and mood over the course of the past week. It takes five to seven minutes to complete the report.

Rush, A.J., Trivedi, M.H., Ibrahim, H.M., Carmody, T.J., Arnow, B., Klein, D.N., . . . Keller, M.B. . The 16-item Quick Inventory of Depressive Symptomatology , clinician rating , and self-report : A psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54, 573-583.

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• Pricing varies and can be purchased through ePROVIDE Mapi Research TrustTM.
• An electronic version is also available through MD+CALC.

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Short Form Health Survey

As part of the Medical Outcomes Study , a multi-year, multi-site study that investigated variations in patient outcomes, the RAND Corporation developed the 36-item Short Form Health Survey as a set of easily administered quality-of-life measures. These measures rely on patient self-reports and are widely used for routine monitoring and assessment of care outcomes in the adult population. The survey can be completed in 10 minutes or less.

Ware, J.E., & Sherbourne, C.D. . The MOS 36-item short-form health survey : I. Conceptual framework and item selection. Medical Care, 30, 473-483.

McHorney, C.A., Ware Jr, J.E., Lu, J.R., & Sherbourne, C.D. . The MOS 36-item Short-Form Health Survey : III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care, 32, 40-66. Retrieved from

More Information

• 36-Item Short Form Survey Instrument

Do I Need Health Insurance To Receive This Service

The referral service is free of charge. If you have no insurance or are underinsured, we will refer you to your state office, which is responsible for state-funded treatment programs. In addition, we can often refer you to facilities that charge on a sliding fee scale or accept Medicare or Medicaid. If you have health insurance, you are encouraged to contact your insurer for a list of participating health care providers and facilities.

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Depression Screening And Follow

The percentage of members 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care.

• Depression Screening. The percentage of members who were screened for clinical depression using a standardized instrument.
• Follow-Up on Positive Screen. The percentage of members who received follow-up care within 30 days of a positive depression screen finding.

Patients With Clinical Clues To Depression

Screening for depression refers to the detection of depression among patients with no apparent symptoms. Yet, clinicians can use symptoms of depression to identify patients with potential depression. Evidence suggests that detecting depression based on clinical symptoms tends to identify patients with more severe depression, who may be more likely to benefit from treatment. Clinicians should be alert to the possibility of depression in patients with clinical clues, especially those at increased risk of depression, and implement treatment as appropriate when depression is diagnosed.

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Interventions To Treat Depression

There are many available treatments for depression, including psychotherapy and pharmacotherapy, both of which are widely available either directly in primary care or through referral from primary care. More than half of patients treated for MDD receive treatment in general medicine settings, with the remaining patients receiving care in mental health specialty settings.

FDA-Approved Pharmacotherapy for Depression in Adults.

Recent efforts to improve depression outcomes in primary care settings often include collaborative care interventions. These interventions apply a chronic disease care model to depression and utilize care or case managers to support the primary care clinician, facilitate patients’ treatment engagement, and monitor symptoms. Care managers may provide patient education arrange appointments with specialty providers monitor treatment adherence, depressive symptoms, and adverse effects notify providers when patients fail to improve or experience side effects and provide supportive or psychotherapeutic counseling in some cases. Collaborative care interventions have been recommended by the Community Preventive Services Task Force.

Complementary and alternative therapies include yoga, exercise, and dietary supplements such as St. John’s wort, and some interventions are appropriate second-line treatments for severe depression when first-line treatments are not effective, such as polypharmacy, transcranial stimulation, and electroconvulsive therapy.

Accuracy Of Screening Tests

General Adult Population and Older Adults

The accuracy of screening tests in the general adult population was established in the 2002 and 2009 USPSTF reviews and found to be convincing.

Pregnant and Postpartum Women

Twenty-three studies , including 8 studies of the English-language version, compared the accuracy of the EPDS with a diagnostic interview.6 Sensitivity of the English-language EPDS with a cutoff score of 13 ranged from 0.67 to 1.00 , and specificity for detecting MDD was consistently at least 0.90. In the 2 trials conducted in the United States,7, 8 including a recent study in low-income African American women, sensitivity for detecting MDD ranged from 0.78 to 0.81. This suggests that the average sensitivity of the EPDS with a cutoff score of 13 in the United States is approximately 0.80, and the positive predictive value for detecting MDD would be 47% to 64% in a population with a 10% prevalence of MDD. The Spanish-language version also showed acceptable performance characteristics. No studies of screening in pregnant and postpartum women with the 9-item PHQ or other versions met inclusion criteria.

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Cornell Scale For Depression In Dementia

The Cornell Scale for Depression in Dementia is designed for use in elderly patients with underlying cognitive deficits. Because this patient population may give unreliable answers, the CSDD additionally uses information from a patient informant, someone who knows and has frequent contact with the patient, and can include family members or care staff.

The CSDD takes approximately 20 minutes to administer. The CSDD is a 19-item scale, with scores of 0 for absent, 1 for mild or intermittent, and 2 for severe symptoms. A total score of 10 indicate probable major depression and greater than 18 indicate definite major depression. However, a recent study found a score of 6 or more has a sensitivity of 93% and specificity of 97%. The same questions are asked of both the patient and the informant and include mood-related signs of anxiety, sadness, lack of reactivity to pleasant events, and irritability behavioral disturbance including psychomotor agitation and retardation, physical complaints, acute loss of interest physical signs such as appetite loss, weight loss, and lack of energy cyclic functions including diurnal variations and sleep difficulties and ideation disturbance including suicide, self-deprecation, pessimism, and mood congruent delusions .

Initial Screening In Patients Who May Have Depression

NICE recommends that any patient who may have depression should be asked the following two questions:

• During the last month have you often been feeling down, depressed or hopeless?
• During the last month have you often been bothered by having little interest or pleasure in doing things?

A ‘yes’ response to one of the two questions has high specificity for depression but low sensitivity . The following questions should then be asked:

During the last month, have you often been bothered by:

• Feeling bad about yourself or that you are a failure or have let yourself or your family down?
• Poor concentration?

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Response To Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from July 28, 2015, to August 24, 2015. A number of comments requested a more detailed definition of what constitutes an adequate system for screening. The USPSTF revised the Implementation section to clarify that a range of staff types, organizational arrangements, and settings can be used to support the goals of depression screening and provided a link to the Substance Abuse and Mental Health Services Administration registry of evidence-based mental health interventions as a resource. Comments suggested that access to depression screening and management resources would be useful. The USPSTF has now provided links to evidence-based depression screening and management toolkits for primary care settings. There were several requests to clarify the potential harms of SSRIs in response, the USPSTF added information to the Discussion section. Finally, many concerns were expressed about barriers to effectively implementing screening within adequate systems of care the USPSTF noted this as a research need.

For a list of current USPSTF members, go to .

This article was first published in JAMA on January 26, 2016 :380-7).

Current Us Initiatives And Recommendations Of Other Organizations

The Healthy People 2020 initiative has published 12 objectives related to mental health and mental disorders, including major depression, as listed below:

• MHMD-4: Reduce the proportion of persons who experience major depression episodes
• MHMD-10: Increase depression screening by primary care providers

The recommendations for depression screening in clinical practice from other health organizations are listed in .

Recommendations of Other Organizations for Depression Screening in Adults.

In addition, some states have passed legislation to mandate screening in women who are pregnant , postpartum , or both . Other states have passed legislation to guarantee reimbursement for screening, initiate programs to train providers, or raise awareness about depression in pregnant and postpartum women.

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Harms Of Early Detection And Intervention And Treatment

The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none.

The USPSTF found adequate evidence that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none.

The USPSTF found that second-generation antidepressants are associated with some harms, such as an increase in suicidal behaviors in adults aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age however, the magnitude of these risks is, on average, small. The USPSTF found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

Depression In Adults: Screening

The Healthy People 2020 evidence-based resources identified have been selected by subject matter experts at the U.S. Department of Health and Human Services. Each of the selected evidence-based resources has been rated and classified according to a set of specific criteria based, in part, on publication status, publication type, and number of studies. This classification scheme does no necessarily consider all dimensions of quality, such as statistical significance, effect size , meaningfulness of effect, additional effect over control, and study design .

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Hamilton Depression Rating Scale

The Hamilton Rating Scale for Depression, abbreviated HDRS, HRSD or HAM-D, measures depression in individuals before, during and after treatment. The scale is administered by a health care professionals and contains 21 items, but is scored based on the first 17 items, which are measured either on 5-point or 3-point scales. It takes 15 to 20 minutes to complete and score.

Hamilton, M. . A rating scale for depression. Journal of Neurology, Neurosurgery & Psychiatry, 23, 56-61.

Trajkovi, G., Starevi, V., Latas, M., Letarevi, M., Ille, T., Bukumiri, Z., & Marinkovi, J. . Reliability of the Hamilton Rating Scale for Depression: A meta-analysis over a period of 49 years. Psychiatry Research, 189, 1-9.

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