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
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