May 4, 2022, 9:48 a.m. News Staff — On April 12, the U.S. Preventive Services Task Force posted a draft recommendation statement and draft evidence review on screening for depression and suicide risk in children and adolescents, and a separate draft recommendation statement and draft evidence review on screening for anxiety in the same population.
Based on a review of the evidence, the task force recommends screening for major depressive disorder in adolescents ages 12 to 18 years, but also concluded that the evidence is insufficient to assess the balance of benefits and harms of screening for major depressive disorder in children age 11 years or younger, or to assess the balance of benefits and harms of screening for suicide risk in children and adolescents. These are “B”, “I” and “I” recommendations, respectively.
The task force also recommends, based on a review of the evidence, screening for anxiety in children and adolescents ages 8 to 18 years (a “B” recommendation), but has concluded that there is insufficient evidence to assess the balance of benefits and harms of screening in children age 7 years or younger (an “I” recommendation).
The draft recommendations apply to children and adolescents who are not showing signs or symptoms of these conditions. The draft recommendation on depression and suicide risk focuses on screening for major depressive disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and does not address screening for other depressive disorders.
“To address the critical need for supporting the mental health of children and adolescents in primary care, the task force looked at the evidence on screening for anxiety, depression and suicide risk,” said Martha Kubik, Ph.D., R.N., a member of the task force, in a USPSTF bulletin. “Fortunately, we found that screening older children for anxiety and depression is effective in identifying these conditions so children and teens can be connected to the support they need.”
According to the CDC, about 7% of young people ages 3 to 17 years, or roughly 4.4 million children and adolescents, have been diagnosed with anxiety; another 3.2%, or about 1.9 million, have been diagnosed with depression. Additional research published earlier this year indicates that among children and adolescents ages 12 to 17 years, more than one-fifth had ever experienced a major depressive episode, and that in 2019, 18.8% of high school students had seriously considered attempting suicide.
When finalized, the recommendations will replace the 2014 USPSTF recommendation statement on screening for suicide risk in adolescents, adults and older adults, and the 2016 recommendation statement on screening for depression in children and adolescents. The current combined draft recommendation on depression and suicide risk is consistent with the 2014 and 2016 recommendations.
The AAFP supported the previous recommendations.
While the task force has published recommendations on several mental health topics pertaining to children and adolescents, it has not previously made a recommendation on screening for anxiety in this population.
To update the existing recommendations and develop a new recommendation, the task force commissioned a systematic review to evaluate the benefits and harms of screening, screening accuracy, and benefits and harms of treatment of major depressive disorder and suicide risk in asymptomatic children and adolescents that would be applicable in primary care, and to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic children and adolescents.
The evidence review consisted of studies published in PubMed, the Cochrane Library, PsycINFO, CINAHL and trial registries through July 19, 2021, along with bibliographies from retrieved articles and additional studies from outside experts. Additional surveillance of the literature was conducted through Dec. 7, 2021. A total of 78 studies were included.
The task force found no studies that directly evaluated the benefits of screening for depression or suicide risk on health outcomes in screened vs. unscreened participants, and no studies that evaluated the evidence on the harms of screening for depression or suicide risk on health outcomes in children or adolescents.
Thirteen trials addressed the benefits of depression treatment. Psychotherapy was associated with improved symptoms and treatment response. Pharmacotherapy showed statistically significant benefits for improved symptoms, as well as benefits for loss of diagnosis and functional status. One study of collaborative care was shown to be statistically significant for improved symptoms and remission at six months and response to treatment by 12 months, but there were no statistically significant benefits on measures of functioning.
Sixteen trials analyzed the benefits of treatment of suicide risk, but produced limited evidence. A pooled analysis of four trials found that intervention produced a statistically significant difference in suicidal ideation scores compared with control, but findings for health outcomes such as suicide deaths, hospitalization, emergency department visits and number of self-harm events in the remaining 12 trials were mixed or not statistically significantly different.
With regard to anxiety, the task force found no studies that directly evaluated the benefits or harms of screening for anxiety disorders, although they suggested that repeated screening may be most productive in adolescents with risk factors for anxiety. Treatments in the review included psychotherapy, pharmacotherapy, a combination of the two, or collaborative care. Cognitive behavioral therapy was associated with improvement in several anxiety outcomes, such as treatment response, disease remission and loss of diagnosis, compared with usual care or wait-list control, but the evidence on improved functioning with CBT in participants with any type of anxiety was inconsistent.
Similarly, pharmacotherapy was associated with an increased improvement in symptoms and response on the Clinical Global Impressions-Improvement scale compared with placebo, but was inconsistent on measures of functioning. In addition, the frequency of harms was considered greater with pharmacotherapy than with psychotherapy.
Along with the draft recommendation statements and evidence reviews, the USPSTF published a fact sheet to help clinicians and patients better understand the recommendations and the process for submitting public comments.
The task force also provided links to several resources on anxiety, depression and suicide risk from the CDC, the Community Preventive Services Task Force and other organizations, including:
The USPSTF is accepting public comments on the draft recommendation statement and draft evidence review on screening for depression and suicide risk, and the draft recommendation statement and draft evidence review on screening for anxiety, through 11:59 p.m. ET on May 9.
All comments will be considered as the task force prepares its final recommendations. Once the final recommendations are published, the AAFP will review them and determine its stance.