No link between primary care mental health screening, depression in children, adolescents

Researchers from the University of North Carolina and RTI International found no evidence of a direct link between screening children and adolescents for major depressive disorder in primary care settings and depression, according to data published in the Annals of Internal Medicine.

However, the researchers added that evidence revealed some screening tools are accurate, and some treatments are beneficial for adolescents, but not young children, with no evidence they will cause harm.

“Primary care providers can play a critical role in identifying depression among children and adolescents, particularly because youth with mental health issues frequently use primary care services,” Valeria Forman-Hoffman, PhD, MPH, a research epidemiologist at RTI International, in Research Triangle Park, North Carolina, and colleagues wrote. “Because primary care providers are often the first point of professional contact for children and their families during times of distress, they can facilitate early identification of mental health issues, begin initial treatment and refer children, as necessary, for further mental health assessment and treatment.”

The study's release coincided with the U.S. Preventive Services Task Force issuing an update to its recommendations for the screening of depression in children and adolescents. The B grade recommendation includes changes that reflect evidence of little harm of pharmacotherapy as long as patients are closely monitored, according to the authors.

Seeking to update the 2009 U.S. Preventive Services Task Force (USPSTF) review on primary care screenings for major depressive disorder (MDD) in children and adolescents, the researchers examined published and online literature from May 2007 to February 2015. They included trials and systematic reviews of treatment, screening studies and large cohort studies for harms.

Researchers collected literature from PubMed, the Cochrane Library and PsychInfo. Unpublished literature was found through searches of ClinicalTrials.gov, Health Services Research Projects in Progress, and the WHO. Only English-language studies were included, and none included children younger than 11 years. In all, the study included five screening studies including nearly 2,900 children and adolescents, six treatment trials with findings published in eight papers that included less than 1,500 children and adolescents with MDD. Just two new treatment efficacy studies met their criteria.

According to the researchers, no trials directly assessed the benefits or harms of MDD screening among children or adolescents in primary care. They similarly did not find any research addressing whether screenings increase the prevalence of MDD in children and adolescents. However, they found evidence from five studies indicating tools such as the Beck Depression Inventory and Patient Health Questionnaire Modified for Adolescents revealed “reasonable accuracy” for identifying MDD in adolescents. In the six treatment trials, the researchers found individual fair- and good-quality studies of fluoxetine, fluoxetine combined with cognitive behavioral therapy, escitalopram, and collaborative care, demonstrated treatment benefits, with no associated harms.

“Primary care providers need to be aware of potential risk factors for MDD and attempt early intervention, particularly among patients who have already had an episode of major depression,” Forman-Hoffman and colleagues wrote. “The burden of universal screening requires clear evidence of net benefit for making screening recommendations. Given the paucity of evidence on the etiologic links among subthreshold depression, dysthymia and depression, we chose to focus on screening for existing MDD rather than prevention.” – by Jason Laday

Disclosure: Forman-Hoffman reports other work for the Agency for Healthcare Research and Quality and Substance Abuse and Mental Health Services Administration. See the full study for all other authors’ relevant financial disclosures.