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Target Audience: Primary care providers
This grade B recommendation statement from the USPSTF updates its 2009 guideline, which recommended screening for depression in the general adult population when systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (NEJM JW Gen Med Jan 15 2010 and Ann Intern Med 2009; 151:784). The recommendation now includes pregnant and postpartum women, based on research published since 2009. The Affordable Care Act requires that Grade A or B recommendations by USPSTF be supported by health insurance coverage.
The USPSTF found convincing evidence that screening improves accurate identification of adults with depression in primary care settings. Commonly used depression screening instruments include the Patient Health Questionnaire (various forms) in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale in postpartum and pregnant women.
Evidence is lacking on optimal screening intervals, but a reasonable approach might include screening all previously unscreened adults and using clinical judgment to determine if more-frequent screening is warranted in high-risk patients.
Patients with positive screening results should receive additional assessment for severity of depression, comorbid conditions, and alternative diagnoses.
The USPSTF found adequate evidence that programs that combine depression screening with adequate support systems improve clinical outcomes in adults, including pregnant and postpartum women.
Evidence is convincing that antidepressants, psychotherapy, or both are effective in adults (including older adults) with depression identified through screening. Given the potential harms of certain medications to fetuses and newborns, evidence-based counseling interventions should be considered for managing depression in pregnant and postpartum women.
Evidence is adequate that cognitive behavior therapy improves clinical outcomes in pregnant and postpartum women.
The USPSTF found evidence of potential serious fetal harms (e.g., congenital anomalies, neonatal seizures, neonatal death) from use of second-generation antidepressants (e.g., selective serotonin reuptake inhibitors) during pregnancy, but risk for these serious harms is very low.
Siu AL et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016 Jan 26; 315:380. (http://dx.doi.org/10.1001/jama.2015.18392)
O'Connor E et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016 Jan 26; 315:388. (http://dx.doi.org/10.1001/jama.2015.18948)
Comment
This updated recommendation statement reaffirms USPSTF support for depression screening in adults, but the operative phrase is “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” Lack of such systems in many communities and lack of access to care for many patients make these recommendations difficult to implement. Adding pregnant and postpartum women to the list of adults who might benefit from screening is consistent with recommendations from several professional associations, including the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists.