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Guideline Summary
Guideline Title
Best evidence statement (BESt). Screening of children and adolescents for major depressive disorder (MDD).
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Screening of children and adolescents for major depressive disorder (MDD). Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Mar 12. 8 p. [21 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Major depressive disorder (MDD)

Guideline Category
Assessment of Therapeutic Effectiveness
Diagnosis
Screening
Clinical Specialty
Family Practice
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To evaluate if rating scales/surveys with semi-structured assessment interviews compared to a clinical assessment alone improve accurate diagnosis, including subtype, identification of comorbidities, and assessment of functionality and severity, among children age 6 to 17 years being referred for major depression screening

Target Population

Children and adolescents 6 to 17 years of age being screened for major depression

Interventions and Practices Considered

Diagnosis/Treatment

  1. Assessment interview
  2. Use of multiple rating scales/surveys:
    • Achenbach Child Behavior Checklist - CBCL
    • Achenbach Youth Self Report - YSR
    • Kiddie Schedule for Affective Disorders - K-SADS
    • Clinical Global Impression - CGI
      • CGI-Severity
      • CGI-Improvement
    • Clinical Global Assessment of Functioning - C-GAF
    • History and Physical
    • Mental Status Exam - MSE
    • Quick Inventory of Depressive Symptomatology - QIDS-17
    • Parenting Stress Index - PSI
    • Pediatric Quality of Life Inventory - PedsQL
    • Children's Interview for Psychiatric Syndromes - ChIPS
  3. Quantification and comparison of symptoms over time
Major Outcomes Considered

Accuracy of diagnosis, including subtype, identification of comorbidities, and assessment of functionality and severity

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

Search Strategy

Database: Ovid MEDLINE(R) <1996 to May Week 2 2009>

  1. exp Bipolar Disorder/ (11370)
  2. limit 1 to English language (10493)
  3. limit 2 to ("all infant (birth to 23 months)" or "all child (0 to 18 years)" or "newborn infant (birth to 1 month)" or "infant (1 to 23 months)" or "preschool child (2 to 5 years)" or "child (6 to 12 years)" or "adolescent (13 to 18 years)") (2323)
  4. (guideline or meta analysis or practice guidelines or systematic review).pt. or "the cochrane library".jn. or "cochrane database of systematic reviews".jn. (31882)
  5. 3 and 4 (24)
  6. exp Depressive Disorder, Major/ (9500)
  7. limit 6 to English language (8985)
  8. limit 7 to ("all infant (birth to 23 months)" or "all child (0 to 18 years)" or "newborn infant (birth to 1 month)" or "infant (1 to 23 months)" or "preschool child (2 to 5 years)" or "child (6 to 12 years)" or "adolescent (13 to 18 years)") (2100)
  9. 8 and 4 (28)
  10. from 9 keep 1-28 (28)

Database: EBM Reviews - Cochrane Database of Systematic Reviews <1st Quarter 2009>

Search Strategy

  1. [exp Bipolar Disorder/] (0)
  2. limit 1 to English language [Limit not valid; records were retained] (0)
  3. limit 2 to ("all infant (birth to 23 months)" or "all child (0 to 18 years)" or "newborn infant (birth to 1 month)" or "infant (1 to 23 months)" or "preschool child (2 to 5 years)" or "child (6 to 12 years)" or "adolescent (13 to 18 years)") [Limit not valid; records were retained] (0)
  4. (guideline or meta analysis or practice guidelines or systematic review).pt. or "the cochrane library".jn. or "cochrane database of systematic reviews".jn. (5726)
  5. 3 and 4 (0)
  6. [from 5 keep 1-24] (0)
  7. bipolar disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text] (75)
  8. 7 not protocols.mp. [mp=title, short title, abstract, full text, keywords, caption text] (66)
  9. from 8 keep 1-66 (66)
  10. depression.mp. [mp=title, short title, abstract, full text, keywords, caption text] (1036)
  11. 10 not protocols.mp. [mp=title, short title, abstract, full text, keywords, caption text] (889)
  12. major depression.mp. [mp=title, short title, abstract, full text, keywords, caption text] (107)
  13. 12 not protocols.mp. [mp=title, short title, abstract, full text, keywords, caption text] (92)
  14. from 13 keep 1-92 (92)

Additional articles identified from reference lists and clinicians

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

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

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

The guideline was reviewed by the Cincinnati Children's Hospital Medical Center Evidence Federation.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a-5) are defined at the end of the "Major Recommendations" field.

  1. It is recommended, for patients with a suspected primary diagnosis of major depressive disorder, that a semi-structured assessment interview be conducted using rating scales/surveys in conjunction with the clinical assessment during the initial visit(s) (see Table 1 below). Use of the appropriate survey instruments (rating scales) aid in comprehensive diagnosing and future treatment planning (US Preventive Services Task Force, 2009 [5a]; Birmaher et al., 2007 [5a]). (See attachment 1 in the original guideline document for suggested schedule of use by visit for screening and long term treatment).

    Note 1: Rating scales/surveys assist in the assessment interview and treatment of children and adolescents with psychopathology allowing for quantification and comparison of symptoms over time, across individuals and situations. Patient developmental appropriateness for the patient, psychometrics, and utility are several factors to consider when selecting one or more appropriate scales/surveys for use. Using multiple scales may minimize the limitations of a single scale (Myers & Winters, 2002 [5a]).

    Table 1: Rating Scales/Survey Instruments for Diagnosis of Major Depressive Disorder

    Scale/Survey Function Age Evidence
    Achenbach Child Behavior Checklist - CBCL Differentiate diagnosis 6 to 18 See Note 2
    Achenbach Youth Self Report - YSR Differentiate diagnosis 11 to 18
    Kiddie Schedule for Affective Disorders - K-SADS Suicidality evaluation Child to Adolescent See Note 3
    Clinical Global Impression
    CGI-Severity CGI-Improvement
    Categorize severity   See Note 4
    Clinical Global Assessment of Functioning - C-GAF Determine level of functioning
    5 minutes to interpret
      See Note 5
    History and Physical Identify contributing/risk factors   See Note 6
    Mental Status Exam - MSE Diagnostic and treatment accuracy 6 to 17 See Note 7
    Quick Inventory of Depressive Symptomatology - QIDS-17 Diagnosis and severity
    10 to 15 minutes
    12 to 17 See Note 8
    Parenting Stress Index - PSI Identify Stress factors Parent See Note 9
    Pediatric Quality of Life Inventory - PedsQL Measure change in functionality 2 to 18 See Note 10
    Children's Interview for Psychiatric Syndromes – ChIPS Diagnostic and identify comorbidities (ADHD, GAD, ODD, SUD)*
    Minutes: 49 inpatient/30 outpatient
    6 to 18 See Note 11

    *ADHD = attention deficit hyperactivity disorder; GAD = generalized anxiety disorder; ODD = oppositional defiant disorder; SUD = substance abuse disorders

    Note 2: The Child Behavior Checklist is a well-established survey originally developed and tested in 1987. The use of this survey more recently demonstrated utility for identifying children at high risk for subsequent psychiatric disorders within a population of children already at high risk by virtue of parental psychopathology (Aebi, Metzke, & Steinhausen, 2009 [3a]; Petty et al., 2008 [4a]).

    Note 3: Because depression is closely related with suicidal thoughts and behavior it is strategic to evaluate these symptoms at the initial and subsequent assessments (Birmaher et al., 2007 [5a]). The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) survey demonstrated higher reliable detection of adolescent suicidality when compared to clinician interview alone (Holi et al., 2008 [2a]).

    Note 4: An advantage of global assessment scales is that the total situation of the patient and not just one particular symptom is evaluated (Schorre & Vandvik, 2004 [5a]). Global scales measuring functional impairment can clarify the impact of the illness, target treatments, determine services needed, and monitor treatment effectiveness (Winters, Collett, & Myers, 2005 [5a]).

    Note 5: Screening for the presence of family psychopathology assists in both the diagnosis and treatment. Parental psychopathology can affect the child's ability and willingness to participate in treatment, may be predictive of course progression, and may influence treatment response (Birmaher et al., 2007 [5a]).

    Note 6: Clinical areas for inclusion when screening for Major Depressive Disorder include medical illnesses, physical examinations and laboratory tests as indicated (Birmaher et al., 2007 [5a]).

    Note 7: The child interview may be conceptualized under two broad categories; that which serves for history taking and the other for the mental status examination (MSE). The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state and consists of an assessment and description of the child's appearance and functioning as revealed in the interview situation (King & American Academy of Child and Adolescent Psychiatry, 1997 [5a]). When combined with the historical information the MSE allows the clinician to formulate an accurate diagnosis and reasoned treatment plan.

    Note 8: Measuring depression severity aids in the screening, measurement of treatment effect, and determining symptom remission (Moore et al., 2007 [2b]).

    Note 9: The Parent Stress Index is one of the most common tools used to provide a valid way for mental health professionals to gain confidence in decisions made on the basis of parents’ level of distress (Haskett et al., 2006 [2a]; Reitman, Currier, & Stickle, 2002 [2a])

    Note 10: Clinical applications of quality of life measures include: assessment of functioning in children and adolescents with chronic medical conditions, responsiveness of patients to psychological interventions, and evaluation of significant changes in health status and impact on clinical decision making (Palermo et al., 2008 [1a]; Varni et al., 2002 [4a]). The PedsQL survey has been demonstrated to be an adequate assessment instrument regarding depressive symptoms (Reinfjell et al., 2008 [2a]).

    Note 11: Areas for inclusion when screening for Major Depressive Disorder include subtypes of depressive disorders, and comorbidities (Birmaher et al., 2007 [5a]). The Child Interview for Psychiatric Syndromes (ChIPS) is used to maximize clinician efficiency and as a diagnostic instrument in training and research (Weller et al., 2000 [1b]; Swenson et al., 2007 [2a]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Accurate diagnoses were made when a scale/survey tool was used in the interview evaluation in adolescents. There were no studies that demonstrated an improvement in health outcome between the uses of a screening tool versus clinical interview; however, depressed youth are at an increased risk of suicide. It is therefore considered reasonable that early identification may lead to earlier decrease in major depressive disorder (MDD) symptoms if prompt treatment follows.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
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
Getting Better
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Screening of children and adolescents for major depressive disorder (MDD). Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Mar 12. 8 p. [21 references]
Adaptation

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

Date Released
2010 Mar 12
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Development Group: Robert Kowatch, MD, Division of Child & Adolescent Psychiatry; Michael Sorter, MD, Director Division of Child & Adolescent Psychiatry; Sergio Delgado, MD, Division of Child & Adolescent Psychiatry; Carol Engel, MD, Division of Child & Adolescent Psychiatry; Mary Matias-Akhtar, MD, Division of Child & Adolescent Psychiatry

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Also, the original guideline document External Web Site Policy contains an applicability issue to measure a potential outcome and Attachment 1 which is a schedule for screening tools.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 8, 2010.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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