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Guideline Summary
Guideline Title
Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement.
Bibliographic Source(s)
U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Dec 1;151(11):784-92. PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med 2002 May 21;136(10):760-4. [13 references]

Scope

Disease/Condition(s)

Depression

Guideline Category
Prevention
Screening
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Preventive Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
  • To update the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults
  • To summarize the current USPSTF recommendations and supporting scientific evidence on screening for depression in adults
Target Population

Non-pregnant adults 18 years or older, including older adults, seen in primary care

Note: The guideline does not apply to children and adolescents, who are considered a separate population.

Interventions and Practices Considered
  1. Screening for depression using:
    • Simple questions about mood and anhedonia
    • Formal screening tools
  2. Assessing risk of depression
  3. Timing of screening
  4. Use of staff-assisted depression care supports
Major Outcomes Considered

Key Question 1: Is there direct evidence that screening for depression among adults and older adults in primary care reduces morbidity and/or mortality?

Key Question 1a: What is the impact of clinician feedback of screening test results (with or without additional care management support) on depression response and remission in screen-detected depressed patients receiving primary care?

Key Question 2: What are the harms of screening for depressive disorders in adults and older adults?

Key Question 3: Is antidepressant and/or psychotherapy treatment of older depressed adults effective in improving health outcomes?

Key Question 4: What are the adverse effects of antidepressant treatment (particularly selective serotonin reuptake inhibitors [SSRIs] and other second-generation drugs) for depression in adults and older adults?

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): A systematic evidence review was prepared by the Oregon Evidence-based Practice Center (EPC) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Availability of Companion Documents" field).

Data Sources and Searches

EPC investigators used the Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, and PsycINFO to search for relevant systematic reviews, meta-analyses, and primary studies published in English from January 1998 to December 2007. The full evidence report provides the search strategies (see the "Availability of Companion Documents" field).

Study Selection

Two investigators reviewed 4088 abstracts published in English and 412 full-text articles against key question–specific inclusion and exclusion criteria (see the "Major Outcomes Considered" field for a list of the key questions). Articles for key questions 1 and 1a were limited to randomized and controlled clinical trials that were conducted in primary care or similar settings. Key question 1 trials compared outcomes in screened and unscreened patients. Trials for key question 1a were required to have used the screening results for care decisions for intervention recipients and not for the control participants. Outcomes for these 2 questions were focused on depression response and remission.

EPC investigators focused their review of harms of treatment (key question 4) on already-synthesized evidence, supplemented by large observational studies. Methods for incorporating systematic reviews and meta-analyses are detailed elsewhere (Appendix Table 2 of the systematic evidence review [see "Availability of Companion Documents" field]). The EPC examined serious adverse effects associated with antidepressant treatment, including suicide-related events (completed suicide, serious self-harm or attempted suicide, suicidal ideation, or suicidal behavior [usually defined to include suicide attempts, preparatory acts, or nonfatal serious self-harm]), and serious psychiatric events, including hospitalization. For older adults, the EPC also considered evidence of serious medical events (for example, upper gastrointestinal bleeding) that were associated with selective serotonin reuptake inhibitors (SSRIs) and other second-generation antidepressant use. The EPC examined rates of early discontinuation as a proxy for less serious adverse effects, particularly discontinuation due to adverse effects as a measure of tolerability. EPC investigators focused on second-generation antidepressants (SSRIs in particular) because of their preponderance of use in the United States.

Updated Searching and Study Examination

Because of the delay between completion of the systematic review and publication, EPC investigators repeated their search strategy through February 2009. They reviewed 800 abstracts against inclusion and exclusion criteria, and 21 seemed to meet criteria for this systematic review. After examining results of each of these new studies (as described in the abstracts), EPC investigators determined that they would be unlikely to change their conclusions. Appendix Table 3 of the systematic evidence review (see "Availability of Companion Documents" field) lists these studies.

Number of Source Documents

Evidence-based Practice Center (EPC) investigators reviewed a total of 4088 abstracts and 412 complete articles for all Key Questions (KQs). A total of 33 articles met inclusion criteria and were selected for abstraction, synthesis, and critical appraisal. (Appendix Figure 2 in the systematic evidence review [see the "Availability of Companion Documents" field] lists the search results and article flow by key question).

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): A systematic evidence review was prepared by the Oregon Evidence-based Practice Center (EPC) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Availability of Companion Documents" field).

Data Extraction and Quality Assessment

Two investigators rated articles for quality by using design-specific quality criteria on the basis of the USPSTF methods. The National Institute for Health and Clinical Excellence criteria (for all study designs) and the Oxman criteria (for systematic reviews) supplemented these methods. One investigator abstracted data from included studies into evidence tables and another verified it. The full evidence report shows complete quality criteria (see "Availability of Companion Documents" field).

Regulatory reviews provided unique challenges and could not be evaluated by using typical quality criteria. For example, their search approach was different because they can mandate that manufacturers supply requested data. Because of the large number of trials (often in the hundreds) and proprietary information involved, they did not provide detailed information about individual trials.

Data Synthesis and Analysis

Data synthesis was primarily qualitative because of clinical heterogeneity. For cohort studies included for key question 4, EPC investigators calculated absolute event rates and confidence intervals (CIs) for suicide-related events on the basis of reported data if this information was not provided. The 95% CIs were calculated on the basis of a Poisson distribution by using the GENMOD procedure (SAS software, version 8.2, SAS Institute, Cary, North Carolina) with the RISK option. Similarly, for the meta-analyses of antidepressant trials included for key question 4, EPC investigators calculated missing CIs by using the FREQ procedure.

Methods Used to Formulate the Recommendations
Balance Sheets
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The U.S. Preventive Services Task Force (USPSTF) systematically reviews the evidence concerning both the benefits and harms of widespread implementation of a preventive service. It then assesses the certainty of the evidence and the magnitude of the benefits and harms. On the basis of this assessment, the USPSTF assigns a letter grade to each preventive service signifying its recommendation about provision of the service (see Table below). An important, but often challenging, step is determining the balance between benefits and harms to estimate "net benefit" (that is, benefits minus harms).

Table 1. U.S. Preventive Services Task Force Recommendation Grid*

Certainty of Net Benefit Magnitude of Net Benefit
Substantial Moderate Small Zero/Negative
High A B C D
Moderate B B C D
Low Insufficient

*A, B, C, D, and I (Insufficient) represent the letter grades of recommendation or statement of insufficient evidence assigned by the U.S. Preventive Services Task Force after assessing certainty and magnitude of net benefit of the service (see the "Rating Scheme for the Strength of the Recommendations" field).

The overarching question that the Task Force seeks to answer for every preventive service is whether evidence suggests that provision of the service would improve health outcomes if implemented in a general primary care population. For screening topics, this standard could be met by a large randomized, controlled trial (RCT) in a representative asymptomatic population with follow-up of all members of both the group "invited for screening" and the group "not invited for screening."

Direct RCT evidence about screening is often unavailable, so the Task Force considers indirect evidence. To guide its selection of indirect evidence, the Task Force constructs a "chain of evidence" within an analytic framework. For each key question, the body of pertinent literature is critically appraised, focusing on the following 6 questions:

  1. Do the studies have the appropriate research design to answer the key question(s)?
  2. To what extent are the existing studies of high quality? (i.e., what is the internal validity?)
  3. To what extent are the results of the studies generalizable to the general U.S. primary care population and situation? (i.e., what is the external validity?)
  4. How many studies have been conducted that address the key question(s)? How large are the studies? (i.e., what is the precision of the evidence?)
  5. How consistent are the results of the studies?
  6. Are there additional factors that assist the Task Force in drawing conclusions (e.g., presence or absence of dose–response effects, fit within a biologic model)?

The next step in the Task Force process is to use the evidence from the key questions to assess whether there would be net benefit if the service were implemented. In 2001, the USPSTF published an article that documented its systematic processes of evidence evaluation and recommendation development. At that time, the Task Force's overall assessment of evidence was described as good, fair, or poor. The Task Force realized that this rating seemed to apply only to how well studies were conducted and did not fully capture all of the issues that go into an overall assessment of the evidence about net benefit. To avoid confusion, the USPSTF has changed its terminology. Whereas individual study quality will continue to be characterized as good, fair, or poor, the term certainty will now be used to describe the Task Force's assessment of the overall body of evidence about net benefit of a preventive service and the likelihood that the assessment is correct. Certainty will be determined by considering all 6 questions listed above; the judgment about certainty will be described as high, moderate, or low.

In making its assessment of certainty about net benefit, the evaluation of the evidence from each key question plays a primary role. It is important to note that the Task Force makes recommendations for real-world medical practice in the United States and must determine to what extent the evidence for each key question—even evidence from screening RCTs or treatment RCTs—can be applied to the general primary care population. Frequently, studies are conducted in highly selected populations under special conditions. The Task Force must consider differences between the general primary care population and the populations studied in RCTs and make judgments about the likelihood of observing the same effect in actual practice.

It is also important to note that 1 of the key questions in the analytic framework refers to the potential harms of the preventive service. The Task Force considers the evidence about the benefits and harms of preventive services separately and equally. Data about harms are often obtained from observational studies because harms observed in RCTs may not be representative of those found in usual practice and because some harms are not completely measured and reported in RCTs.

Putting the body of evidence for all key questions together as a chain, the Task Force assesses the certainty of net benefit of a preventive service by asking the 6 major questions listed above. The Task Force would rate a body of convincing evidence about the benefits of a service that, for example, derives from several RCTs of screening in which the estimate of benefits can be generalized to the general primary care population as "high" certainty (see the "Rating Scheme for the Strength of Recommendations" field). The Task Force would rate a body of evidence that was not clearly applicable to general practice or has other defects in quality, research design, or consistency of studies as "moderate" certainty. Certainty is "low" when, for example, there are gaps in the evidence linking parts of the analytic framework, when evidence to determine the harms of treatment is unavailable, or when evidence about the benefits of treatment is insufficient. Table 4 in the methodology document listed below (see "Availability of Companion Documents" field) summarizes the current terminology used by the Task Force to describe the critical assessment of evidence at all 3 levels: individual studies, key questions, and overall certainty of net benefit of the preventive service.

Sawaya GF et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med. 2007;147:871-875 [5 references].

Rating Scheme for the Strength of the Recommendations

What the U.S. Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice

Grade Grade Definitions Suggestions for Practice
A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.
C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small. Offer or provide this service only if other considerations support offering or providing the service in an individual patient.
D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.
I
Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read "Clinical Considerations" section of USPSTF Recommendation Statement (see "Major Recommendations" field). If this service is offered, patients should understand the uncertainty about the balance of benefits and harms.

USPSTF Levels of Certainty Regarding Net Benefit

Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Level of Certainty Description
High The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
  • The number, size, or quality of individual studies
  • Inconsistency of findings across individual studies
  • Limited generalizability of findings to routine primary care practice
  • Lack of coherence in the chain of evidence
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
  • The limited number or size of studies
  • Important flaws in study design or methods
  • Inconsistency of findings across individual studies
  • Gaps in the chain of evidence
  • Findings not generalizable to routine primary care practice
  • A lack of information on important health outcomes
More information may allow an estimation of effects on health outcomes.
Cost Analysis

Evidence-based Practice Center (EPC) investigators retrieved and reviewed articles on cost and cost-effectiveness relevant to depression screening in primary care.

A cost-effectiveness study of a primary care depression care management intervention including a one-time screening component (which was included in the review) found that the intervention was cost-effective in patients who had not been previously identified as depressed. The authors estimated the incremental cost-effectiveness ratio for enhanced care compared to usual care ranged from $9,592 to $14,306 per quality-adjusted life year (QALY) over the course of two years. However, this intervention was not continued after the trial ended, despite its promising results, raising doubts about the feasibility of this program without other facilitating factors that were present when the study was conducted.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Peer Review. Before the U.S. Preventive Services Task Force makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft evidence review to 4 to 6 external experts and to federal agencies and professional and disease-based health organizations with interests in the topic. The experts are asked to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the Task Force in memo form. In this way, the Task Force can consider these external comments before it votes on its recommendations about the service. Draft recommendation statements are then circulated for comment from reviewers representing professional societies, voluntary organizations, and Federal agencies. These comments are discussed before the final recommendations are confirmed.

Comparison with Guidelines from Other Groups. Recommendations for screening from the following groups were discussed: the Canadian Task Force on Preventive Health Care (CTFPHC) and the American College of Obstetricians and Gynecologists (ACOG).

Recommendations

Major Recommendations

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the Levels of Certainty regarding Net Benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.

Summary of Recommendations and Evidence

  • The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. This is a B recommendation.
  • The USPSTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. This is a C recommendation.

Clinical Considerations

Patient Population Under Consideration

This recommendation applies to nonpregnant adults, including older adults. It does not apply to children and adolescents, who are considered a separate population.

Assessment of Risk

Individuals at increased risk for depression are considered at risk throughout their lifetime. Groups at increased risk include persons with other psychiatric disorders, including substance misuse; persons with a family history of depression; persons with chronic medical diseases; and persons who are unemployed or of lower socioeconomic status. Also, women are at increased risk compared with men. Significant depressive symptoms are associated with common life events in older adults, including medical illness, cognitive decline, bereavement, and institutional placement in residential or inpatient settings. However, the presence of risk factors alone cannot distinguish depressed patients from nondepressed patients.

Screening Tests

The USPSTF reviewed evidence about the accuracy of screening instruments in identifying depressed adults in 2002. Many formal screening tools are available, including instruments designed specifically for older adults. Asking 2 simple questions about mood and anhedonia ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") may be as effective as using more formal instruments. There is little evidence to recommend 1 screening method over another; therefore, clinicians may choose the method most consistent with their personal preference, the patient population being served, and the practice setting.

All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (that is, those from the updated Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) to determine the presence or absence of specific depressive disorders, such as major depressive disorder (MDD) or dysthymia. The severity of depression and comorbid psychological problems (for example, anxiety, panic attacks, or substance abuse) should be addressed.

Treatment

The reviews of evidence on which this recommendation is based cover treatment of adults with antidepressants or psychotherapy and updated evidence on the efficacy of depression treatment in older adults. Treatment may include antidepressants or specific psychotherapeutic approaches (for example, cognitive behavioral therapy or brief psychosocial counseling) alone or in combination. Both are effective in treating adults and older adults.

In treating patients aged 18 to 29 years, clinicians may want to select a psychotherapeutic approach or medications other than selective serotonin reuptake inhibitors (SSRIs) because of the increased risk for suicidal behavior associated with the use of SSRIs. Similarly, for adults 65 years or older, clinicians may want to select a psychotherapeutic approach or medications other than SSRIs because of the increased risk for upper gastrointestinal (UGI) bleeding associated with the use of SSRIs. In addition, the concurrent use of SSRIs with a nonsteroidal anti-inflammatory drug (NSAID) or low-dose aspirin increases the risk for UGI bleeding in adults (aged 40 to 79 years), although the increase in risk is less with aspirin. The risk for UGI bleeding is greater for medications that feature a moderate to high degree of serotonin reuptake inhibition.

Staff-Assisted Depression Care Supports

"Staff-assisted depression care supports" refers to clinical staff that assist the primary care clinician by providing some direct depression care, such as care support or coordination, case management, or mental health treatment.

In the available evidence, the lowest effective level of staff-assisted depression care supports consisted of a screening nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to behavioral treatment. At the highest level, staff-assisted depression care supports included screening; institutional monetary commitment; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; many materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for adherence to medication for those prescribed antidepressant medications; a visit with a trained therapist for cognitive behavioral therapy; and a reduced copay for patients referred for psychotherapy. In a successful study designed for practices without ready access to mental health specialty care, office staff recruited, screened, and enrolled participants who screened positive for depression before a clinic visit. If the physician confirmed the depression diagnosis, the participant was scheduled for a return visit with the physician and to meet with the nurse specialist in 1 week. The nurse specialist reassessed the patient’s level of depression, discussed treatment options and preferences, and asked the participant to complete a homework assignment. Participants completed up to 8 additional sessions that followed the same pattern, either by phone or in person.

Multidisciplinary team-based primary care that includes self-management support and care coordination has been shown to be effective in management of depression. These components of primary care are detailed in recent recommendations from the Task Force on Community Preventive Services. It recommends collaborative care for treatment of adults 18 years or older with major depression on the basis of strong evidence of effectiveness in improving short-term treatment outcomes. As defined, collaborative care and disease management of depressive disorders includes a systematic, multicomponent, team-based approach that "strengthens and supports self-care, while assuring that effective medical, preventive and health maintenance interventions take place" to improve the quality and outcome of patient care for treatment of major depressive disorders.

Screening Intervals

The optimum interval for screening for depression is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (for example, panic disorder or generalized anxiety), substance abuse, or chronic pain.

Other Approaches to Prevention

The Task Force on Community Preventive Services also has made several recommendations about depression care in older adults. It recommends clinic-based depression care management to reduce depression in older adults on the basis of sufficient evidence and home-based depression care management on the basis of strong evidence. The Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of community-based exercise interventions for reducing depression in older adults.

The Task Force on Community Preventive Services makes recommendations on population-based interventions appropriate for use by communities and health care systems to promote health and to prevent disease, injury, disability, and premature death. More information about the Task Force on Community Preventive Services and its recommendations on depression interventions is available on its Web site (www.thecommunityguide.org External Web Site Policy).

Useful Resources

The USPSTF recently updated its recommendation on screening for depression in children and adolescents. The USPSTF recommends screening adolescents (aged 12 to 18 years) for MDD when systems are in place to assure accurate diagnosis, psychotherapy (cognitive behavioral or interpersonal), and follow-up (Grade B recommendation). In addition, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (aged 7 to 11 years) for MDD (I statement).

In 2004, the USPSTF concluded that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population (I statement). At that time, the USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. The USPSTF also found limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk, and found no evidence that directly addressed the harms of screening and treatment of suicide risk. In addition, the USPSTF found insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality.

For the full recommendation statements and evidence reviews, please go to the Agency for Healthcare Research and Quality Web site (www.preventiveservices.ahrq.gov External Web Site Policy).

Definitions:

What the U.S. Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice

Grade Grade Definitions Suggestions for Practice
A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.
C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small. Offer or provide this service only if other considerations support offering or providing the service in an individual patient.
D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.
I
Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read "Clinical Considerations" section of USPSTF Recommendation Statement (see "Major Recommendations" field). If this service is offered, patients should understand the uncertainty about the balance of benefits and harms.

USPSTF Levels of Certainty Regarding Net Benefit

Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Level of Certainty Description
High The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
  • The number, size, or quality of individual studies
  • Inconsistency of findings across individual studies
  • Limited generalizability of findings to routine primary care practice
  • Lack of coherence in the chain of evidence
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
  • The limited number or size of studies
  • Important flaws in study design or methods
  • Inconsistency of findings across individual studies
  • Gaps in the chain of evidence
  • Findings not generalizable to routine primary care practice
  • A lack of information on important health outcomes
More information may allow an estimation of effects on health outcomes.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Benefits of Detection and Early Intervention

  • The U.S. Preventive Services Task Force (USPSTF) found good evidence that treating depressed adults and older adults identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.
  • The USPSTF found good evidence that programs combining depression screening and feedback with staff-assisted depression care supports improve clinical outcomes in adults and older adults.
  • The USPSTF found fair evidence that screening and feedback alone without staff-assisted care supports do not improve clinical outcomes in adults and older adults.
Potential Harms

Harms of Detection and Early Intervention

  • The U.S. Preventive Services Task Force found no evidence of harms of screening for depression in adults or older adults.
  • The USPSTF found at least fair-quality evidence that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) increase suicidal behaviors in adults aged 18 to 29 years, especially those with major depressive disorder (MDD) and those who receive paroxetine.
  • The USPSTF found at least fair-quality evidence that SSRI use is associated with an increased risk for upper gastrointestinal (UGI) bleeding in adults older than 70 years, with risk increasing with age.

Qualifying Statements

Qualifying Statements
  • The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.
  • Recommendations are based on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.
  • The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

Implementation of the Guideline

Description of Implementation Strategy

The experiences of the first and second U.S. Preventive Services Task Force (USPSTF), as well as that of other evidence-based guideline efforts, have highlighted the importance of identifying effective ways to implement clinical recommendations. Practice guidelines are relatively weak tools for changing clinical practice when used in isolation. To effect change, guidelines must be coupled with strategies to improve their acceptance and feasibility. Such strategies include enlisting the support of local opinion leaders, using reminder systems for clinicians and patients, adopting standing orders, and audit and feedback of information to clinicians about their compliance with recommended practice.

In the case of preventive services guidelines, implementation needs to go beyond traditional dissemination and promotion efforts to recognize the added patient and clinician barriers that affect preventive care. These include clinicians' ambivalence about whether preventive medicine is part of their job, the psychological and practical challenges that patients face in changing behaviors, lack of access to health care or of insurance coverage for preventive services for some patients, competing pressures within the context of shorter office visits, and the lack of organized systems in most practices to ensure the delivery of recommended preventive care.

Dissemination strategies have changed dramatically in this age of electronic information. While recognizing the continuing value of journals and other print formats for dissemination, the Agency for Healthcare Research and Quality will make all USPSTF products available through its Web site External Web Site Policy. The combination of electronic access and extensive material in the public domain should make it easier for a broad audience of users to access USPSTF materials and adapt them for their local needs. Online access to USPSTF products also opens up new possibilities for the appearance of the annual, pocket-size Guide to Clinical Preventive Services.

To be successful, approaches for implementing prevention have to be tailored to the local level and deal with the specific barriers at a given site, typically requiring the redesign of systems of care. Such a systems approach to prevention has had notable success in established staff-model health maintenance organizations, by addressing organization of care, emphasizing a philosophy of prevention, and altering the training and incentives for clinicians. Staff-model plans also benefit from integrated information systems that can track the use of needed services and generate automatic reminders aimed at patients and clinicians, some of the most consistently successful interventions. Information systems remain a major challenge for individual clinicians' offices, however, as well as for looser affiliations of practices in network-model managed care and independent practice associations, where data on patient visits, referrals, and test results are not always centralized.

Implementation Tools
Foreign Language Translations
Mobile Device Resources
Patient Resources
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Dec 1;151(11):784-92. PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1996 (revised 2009 Dec 1)
Guideline Developer(s)
U.S. Preventive Services Task Force - Independent Expert Panel
Guideline Developer Comment

The U.S. Preventive Services Task Force (USPSTF) is a Federally-appointed panel of independent experts. Conclusions of the USPSTF do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or DHHS agencies.

Source(s) of Funding

United States Government

Guideline Committee

U.S. Preventive Services Task Force (USPSTF)

Composition of Group That Authored the Guideline

Task Force Members*: Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B. Petitti, MD, MPH, Vice-Chair (Arizona State University, Phoenix, Arizona); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio); Allen J. Dietrich, MD** (Dartmouth Medical School, Hanover, New Hampshire); Leon Gordis, MD, DrPH (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland); Kimberly D. Gregory, MD, MPH (Cedars-Sinai Medical Center, Los Angeles, California); Russell Harris, MD, MPH (University of North Carolina School of Medicine, Chapel Hill, North Carolina); George Isham, MD, MS (HealthPartners, Minneapolis, Minnesota); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York); Carol Loveland-Cherry, RN, PhD (University of Michigan School of Nursing, Ann Arbor, Michigan); Lucy Marion, PhD, RN (Medical College of Georgia School of Nursing, Augusta, Georgia); Virginia Moyer, MD, MPH (Baylor College of Medicine, Houston, Texas); Judith Ockene, MEd, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); George Sawaya, MD (University of California San Francisco, San Francisco, California); and Barbara Yawn, MD, MS (Olmsted Medical Center, Rochester, Minnesota).

*Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to www.ahrq.gov/clinic/uspstfab.htm External Web Site Policy.

**Recused from voting.

Financial Disclosures/Conflicts of Interest

The U.S. Preventive Services Task Force has an explicit policy concerning conflict of interest. All members disclose at each meeting if they have a significant financial, professional/business, or intellectual conflict for each topic being discussed. Task Force members with conflicts may be recused from discussing or voting on recommendations about the topic in question.

Guideline Status

This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med 2002 May 21;136(10):760-4. [13 references]

Guideline Availability

Electronic copies: Available from the U.S. Preventive Services Task Force (USPSTF) Web site External Web Site Policy. Also available from Annals of Internal Medicine Online External Web Site Policy.

Print copies: Available from the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse. For more information, go to http://www.ahrq.gov/research/publications/index.html External Web Site Policy or call 1-800-358-9295. (Outside the United States: 1-410-381-3150; Toll-free TDD service, hearing impaired only: 888-586-6340.)

Availability of Companion Documents

The following are available:

Evidence Reviews:

  • O'Connor EA, Whitlock EP, Gaynes B, Beil TL. Screening for depression in adults and older adults in primary care: an updated systematic review. Evidence Synthesis No. 75. AHRQ Publication No. 10-05143-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, 2009 Dec. 167 p. Electronic copies: Available from the U.S. Preventive Services Task Force (USPSTF) Web site External Web Site Policy.
  • O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med 2009;151:793-803. Electronic copies: Available from the Annals of Internal Medicine Web site External Web Site Policy.

The following is also available:

  • Screening for depression in adults: clinical summary of U.S. preventive services task force recommendation. Rockville (MD): Agency for Healthcare Research and Quality, 2009. 1 p. Electronic copies: Available from the U.S. Preventive Services Task Force (USPSTF) Web site External Web Site Policy.

Background Articles:

  • Barton M et al. How to read the new recommendation statement: methods update from the U.S. Preventive Services Task Force. Ann Intern Med. 2007;147:123-127. [8 references]
  • Guirguis-Blake J et al. Current processes of the U.S. Preventive Services Task Force: refining evidence-based recommendation development. Ann Intern Med. 2007;147:117-122. [4 references]
  • Sawaya GF et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med. 2007;147:871-875. [5 references]

Electronic copies: Available from U.S. Preventive Services Task Force (USPSTF) Web site External Web Site Policy.

The following is also available:

  • The guide to clinical preventive services, 2009. Recommendations of the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ), 2009. 228 p. Electronic copies available from the AHRQ Web site External Web Site Policy.

Print copies: Available from the Agency for Healthcare Research and Quality Publications Clearinghouse. For more information, go to http://www.ahrq.gov/research/publications/index.html External Web Site Policy or call 1-800-358-9295 (U.S. only).

The Electronic Preventive Services Selector (ePSS) External Web Site Policy, available as a PDA application and a web-based tool, is a quick hands-on tool designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. It is based on current recommendations of the USPSTF and can be searched by specific patient characteristics such as age, sex, and selected behavioral risk factors.

Patient Resources

The following are available:

  • Summaries for patients. Screening for depression in adults: U.S. Preventive Services Task Force recommendations. Ann Intern Med 2009 151:I-56. Available from the Annals of Internal Medicine Web site External Web Site Policy.
  • Men: stay healthy at any age. Your checklist for health. Rockville (MD): Agency for Healthcare Research and Quality. AHRQ Pub. No. 07-IP006-A. February 2007. Electronic copies: Available in English External Web Site Policy and Spanish External Web Site Policy from the USPSTF Web site. See the related QualityTool summary on the Health Care Innovations Exchange Web site External Web Site Policy.
  • Women: stay healthy at any age. Your checklist for health. Rockville (MD): Agency for Healthcare Research and Quality. AHRQ Pub. No. 07-IP005-A. February 2007. Electronic copies: Available in English External Web Site Policy and Spanish External Web Site Policy from the USPSTF Web site. See the related QualityTool summary on the Health Care Innovations Exchange Web site External Web Site Policy.

Print copies: Available in English and Spanish from the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse. For more information, go to http://www.ahrq.gov/research/publications/index.html External Web Site Policy or call 1-800-358-9295 (U.S. only).

Myhealthfinder is a new tool that provides personalized recommendations for clinical preventive services specific to the user's age, gender, and pregnancy status. It features evidence-based recommendations from the USPSTF and is available at www.healthfinder.gov External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on May 7, 2002. The updated information was verified by the guideline developer as of May 14, 2002. This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on January 25, 2010. The information was verified by the guideline developer on February 22, 2010.

Copyright Statement

Requests regarding copyright should be sent to: Randie A. Siegel, Electronic Dissemination Advisor, Division of Print and Electronic Publishing, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. Facsimile: 301-427-1873. E-mail: Randie.siegel@ahrq.hhs.gov.

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