Depression: Screening and Diagnosis
Am Fam Physician. 2018 Oct 15;98(8):508-515.
Author disclosure: No relevant financial affiliations.
Depression affects an estimated 8% of persons in the United States and accounts for more than $210 billion in health care costs annually. The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians recommend screening for depression in the general adult population. Additionally, the USPSTF recommends screening children and adolescents 12 to 18 years of age for major depressive disorder. All screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The two-item and nine-item Patient Health Questionnaires (PHQs) are commonly used validated screening tools. The PHQ-2 has sensitivity comparable with the PHQ-9 in most populations; however, the specificity of the PHQ-9 ranges from 91% to 94%, compared with 78% to 92% for the PHQ-2. If the PHQ-2 is positive for depression, the PHQ-9 or a clinical interview should be administered. Screening all postpartum women for depression is recommended by the USPSTF, American Academy of Family Physicians, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Women should be screened for depression at least once during the perinatal period using the PHQ-2, PHQ-9, or Edinburgh Postnatal Depression Scale. In older adults, the Geriatric Depression Scale is also an appropriate screening tool for depression. If screening is positive for possible depression, the diagnosis should be confirmed using Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria.
Major depression is one of the most common mental health disorders in the United States. Prevalence is estimated at 8% in persons 12 years and older.1 In 2015, an estimated 16.1 million adults 18 years and older had at least one major depressive episode in the previous year, and the condition accounted for 3.7% of all U.S. disability-adjusted life years.2 Globally, more than 300 million persons of all ages have depression, which is the leading cause of disability worldwide.3
WHAT IS NEW ON THIS TOPIC
Depression is a major risk factor for suicide in older men, with suicide rates increasing with age in this population. A recent study showed that men older than 75 years had the highest annual incidence of suicide.
The U.S. Preventive Services Task Force, American Academy of Family Physicians, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists recommend screening all postpartum women for depression. Evidence supports the use of the two- or nine-item Patient Health Questionnaire or the Edinburgh Postnatal Depression Scale.
A 2016 systematic review including three randomized trials with more than 6,500 women found a lower prevalence of postpartum depression at follow-up for those screened four to eight weeks after delivery.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
The USPSTF recommends screening for depression in the general adult population. Screening must be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
The PHQ-2 is accepted as an initial screening instrument for depression in all age groups. If depression is identified by the PHQ-2, completion of the PHQ-9 or a clinical interview is recommended.
The USPSTF recommends screening adolescents 12 to 18 years of age for major depressive disorder in the primary care setting. Screening must be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Pregnant women should be screened for depression at least once during the perinatal period using a validated screening instrument such as the Edinburgh Postnatal Depression Scale or the PHQ-9. Consider screening at least once during pregnancy and again four to eight weeks after delivery.
Older adults can be screened for depression using an instrument such as the PHQ-2, PHQ-9, Cornell Scale for Depression in Dementia, or Geriatric Depression Scale.
When screening is positive for possible depression, the diagnosis should be confirmed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
PHQ = Patient Health Questionnaire; USPSTF = U.S. Preventive Services Task Force.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
The USPSTF recommends screening for depression in the general adult population. Screening must be implemented with adequate systems in place to ensure accurate diagnosis, effective
Referencesshow all references
1. Centers for Disease Control and Prevention. National Center for Health Statistics. Depression. Updated October 6, 2016. https://www.cdc.gov/nchs/fastats/depression.htm. Accessed September 9, 2017....
2. National Institute of Mental Health. Major depression. https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml. Accessed September 9, 2017.
3. World Health Organization. Depression fact sheet. Updated March 22, 2018. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed June 15, 2018.
4. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry. 2000;157(12):1925–1932.
5. Greenberg PE, Fournier AA, Sisitsky T, Pike CT, Kessler RC. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). J Clin Psychiatry. 2015;76(2):155–162.
6. Akincigil A, Matthews EB. National rates and patterns of depression screening in primary care: results from 2012 and 2013. Psychiatr Serv. 2017;68(7):660–666.
7. Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in women. Am J Psychiatry. 2002;159(7):1133–1145.
8. Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in men. Am J Psychiatry. 2006;163(1):115–124.
9. Barlow DH, Ellard KK, Sauer-Zavala S, Bullis JR, Carl JR. The origins of neuroticism. Perspect Psychol Sci. 2014;9(5):481–496.
10. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. Am J Psychiatry. 2003;160(6):1147–1156.
11. Hoover DR, Siegel M, Lucas J, et al. Depression in the first year of stay for elderly long-term nursing home residents in the USA. Int Psychogeriatr. 2010;22(7):1161–1171.
12. Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999–2014. NCHS Data Brief no. 241. April 2016. https://www.cdc.gov/nchs/data/databriefs/db241.pdf. Accessed June 15, 2018.
13. Li M, Rodin G. Depression. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill. 2nd ed. Washington DC: American Psychiatric Publishing; 2011.
14. Dekker J, Koelen JA, Peen J, Schoevers RA, Gijsbers-van Wijk C. Gender differences in clinical features of depressed outpatients: preliminary evidence for subtyping of depression? Women Health. 2007;46(4):19–38.
15. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication. JAMA Psychiatry. 2013;70(10):1100–1106.
16. U.S. Preventive Services Task Force. Depression in adults: screening. 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1. Accessed June 12, 2018.
17. American Academy of Family Physicians. Clinical preventive service recommendation. Depression. https://www.aafp.org/patient-care/clinical-recommendations/all/depression.html. Accessed June 12, 2018.
18. VA/DoD essentials for depression screening and assessment in primary care. June 6, 2010. https://www.healthquality.va.gov/guidelines/MH/mdd/MDDTool1VADoDEssentialsQuadFoldFinalHiRes.pdf. Accessed June 18, 2018.
19. Crowley RA, Kirschner N; Health and Public Policy Committee of the American College of Physicians. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med. 2015;163(4):298–299.
20. Patient Health Questionnaire (PHQ) screeners. http://www.phqscreeners.com. Accessed February 8, 2018.
21. Dominguez-Rafer C, Lin S. HDAs HelpDesk Answers. What are the sensitivity and specificity of the PHQ-2 and the PHQ-9 in screening for depression?. Evid Based Pract. 2011;14(3):8.
22. American Academy of Pediatrics. Bright Futures. Engaging patients and families. Periodicity schedule. http://www.aap.org/en-us/professional-resources/practice-support/Pages/PeriodicitySchedule.aspx. Accessed September 9, 2017.
23. O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and post-partum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(4):388–406.
24. U.S. Preventive Services Task Force. Final recommendation statement. Depression in children and adolescents: screening. November 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-children-and-adolescents-screening1. Accessed June 12, 2018.
25. Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics. 2010;125(5):e1097–e1103.
26. Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65(7):805–815.
27. O'Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):3–12.
28. Fisher SD, Wisner KL, Clark CT, Sit DK, Luther JF, Wisniewski S. Factors associated with onset timing, symptoms, and severity of depression identified in the postpartum period. J Affect Disord. 2016;203:111–120.
29. Altemus M, Neeb CC, Davis A, Occhiogrosso M, Nguyen T, Bleiberg KL. Phenotypic differences between pregnancy-onset and postpartum-onset major depressive disorder. J Clin Psychiatry. 2012;73(12):e1485–e1491.
30. Stewart DE. Clinical practice. Depression during pregnancy. N Engl J Med. 2011;365(17):1605–1611.
31. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
32. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380–387.
33. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125(5):1268–1271.
34. Cox JL, Holden J, Henshaw C. Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual. 2nd ed. London, United Kingdom: RCPsych Publications; 2014.
35. Agency for Healthcare Research and Quality. Effective Health Care Program. Comparative Effectiveness Review no. 106. Efficacy and safety of screening for postpartum depression. April 2013. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/depression-postpartum-screening_research.pdf. Accessed June 12, 2018.
36. Monson S, Rollins V. Which self-report measure is most useful for post-partum depression screening in a primary care setting? Evid Based Pract. 2008;11(8):9–10.
37. Trost MJ, Molas-Torreblanca K, Man C, Casillas E, Sapir H, Schrager SM. Screening for maternal postpartum depression during infant hospitalizations. J Hosp Med. 2016;11(12):840–846.
38. Kørner A, Lauritzen L, Abelskov K, et al. The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity study. Nord J Psychiatry. 2006;60(5):360–364.
39. Maurer DM. Screening for depression [published correction appears in Am Fam Physician. 2013;87(7):464]. Am Fam Physician. 2012;85(2):139–144.
40. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. In: Brink TL, ed. Clinical Gerontology: A Guide to Assessment and Intervention. New York, NY: Haworth Press; 1986.
41. Li C, Friedman B, Conwell Y, Fiscella K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depression in older people. J Am Geriatr Soc. 2007;55(4):596–602.
42. Tsoi KK, Chan JY, Hirai HW, Wong SY. Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis [published correction appears in Br J Psychiatry. 2017;211(2):120]. Br J Psychiatry. 2017;210(4):255–260.
43. Watson LC, Zimmerman S, Cohen LW, Dominik R. Practical depression screening in residential care/assisted living: five methods compared with gold standard diagnoses. Am J Geriatr Psychiatry. 2009;17(7):556–564.
44. Wang J, Williams J, Lavorato D, Schmitz N, Dewa C, Patten SB. The incidence of major depression in Canada: the National Population Health Survey. J Affect Disord. 2010;123(1–3):158–163.
45. Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci. 2011;13(1):7–23.
46. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873–1875.
47. Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002;66(6):1001–1008.
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