A new report by the U.S. Preventive Services Task Force (USPSTF) recommends that primary care providers screen the general adult population for depression, including pregnant and postpartum women.
The task force also advises that the screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The report appears in the Journal of the American Medical Association (JAMA).
Technically, this recommendation is a grade B recommendation, meaning that there is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
Currently, depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting, and also common in postpartum and pregnant women.
The U.S. Preventive Services Task Force (USPSTF) reviewed the evidence in the medical literature on the benefits and harms of screening for depression in adult populations.
The task force specifically looked at the effects on special populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations.
The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications. This report is an update of a 2009 USPSTF recommendation statement. The USPSTF continues to recommend that adults 18 and older be screened for depression.
The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.
They also found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women.
Moreover, 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 improves outcomes.
They also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.
A current issue for many public health initiatives is whether a screen is helpful or potentially harmful if false negatives result — that is, if a screen incorrectly suggests a person may have a disease or illness.
In this case, the USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none and that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none.
Researchers also found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms. For example, an increase in suicidal behaviors in adults age 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 also 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.
The next issue is knowing when to perform the screen.
The optimal timing and interval for screening for depression is not known. A pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, medical issues, and life events to determine if additional screening of high-risk patients is warranted.
Positive screening results should lead to additional assessment that considers severity of depression, review of associated psychological problems, alternate diagnoses, and medical conditions.
Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches, alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider evidence-based counseling interventions when managing depression in pregnant or breastfeeding women.