USPSTF finalizes recommendations on anxiety, depression, suicide risk screening in youth

The United States Preventive Services Task Force has released final recommendation statements on anxiety, depression and suicide risk screening in children and adolescents.

For the first time, the task force is recommending universal anxiety screening in children and adolescents aged 8 to 18 years, stating that it has a “moderate net benefit.”

The USPSTF also recommended screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years, a mirroring of its 2016 guidelines.

Both are B-grade recommendations.

For children aged 7 years and younger, the USPSTF declared insufficient evidence on the benefits and harms of screening for anxiety (I statement). A lack of evidence was similarly the case in assessing the impact of MDD screening in children aged 11 years and younger, and suicide risk in all children and adolescents (I statement).

According to the CDC, between 2016 to 2019, 9.4% of U.S. youth aged 3 to 17 years (n = 5.8 million) were diagnosed with anxiety, while 4.4% (n = 2.7 million) were diagnosed with depression. Among those groups in 2016, three in four youth (73.8%) with depression also had anxiety.

Recent data have shown an increase in suicide rates among adolescents and young adults, with suicide rates rising among those aged 15 to 24 years from 14.2 per 100,000 in 2020 to 15.3 per 100,000 in 2021, according to the National Vital Statistics System.

In a press release, Lori Pbert, PhD, a task force member and a professor in the department of population and quantitative health sciences at the University of Massachusetts Chan Medical School, called for more research in response to the lack of evidence of screening for both depression and anxiety in younger children, and suicide risk in all youth, “so we can provide health care professionals with evidence-based ways to keep their young patients healthy.”

Anxiety screening

The recommendation on anxiety screening in youth was based on a review of 39 studies (n = 6,065 participants), with 10 studies (n = 3,260 participants) focusing on the accuracy of 12 different anxiety screening instruments and 29 randomized clinical trials (n = 2,805 participants) evaluating treatment interventions.

In the evidence report, Meera Viswanathan, PhD, director of RTI-International University of North Carolina at Chapel Hill Evidence-based Practice Center, and colleagues reported that the prevalence of anxiety disorders in screening accuracy studies ranged from 2.5% to 24%.

The researchers wrote that two of the most widely used screening instruments — the Screen for Anxiety Related Emotional Disorders and the Social Phobia Inventory — were “reasonably accurate, leading to low-to-moderate strength of evidence.”

For anxiety treatment outcomes, Viswanathan and colleagues found cognitive behavioral therapy was associated with:

• increased remission (pooled RR = 2.68; 95% CI, 1.48-4.88);
• loss of any anxiety diagnosis (pooled RR = 3.09; 95% CI, 1.98-4.8); and
• loss of primary anxiety disorder (pooled RR = 3.02; 95% CI, 1.84-4.95).

In a related editorial, John T. Walkup, MD, a professor of psychiatry and behavioral sciences at Northwestern University School of Medicine, Cori M. Green, MD, MSc, an associate professor of clinical pediatrics at Weill Cornell Medicine, and Jeffrey R. Strawn, MD, an associate professor in the department of pediatrics at the University of Cincinnati, wrote that the final recommendation on anxiety screening is ideal because of the high prevalence of psychiatric disorders in children and adolescents.

Despite that frequency, “many children with psychiatric disorders still remain unidentified and untreated, resulting in symptomatic distress, accumulated functional impairment, and other sequelae,” they noted. “Thus, screening in the pediatric primary care setting is important for early identification and offers the potential for earlier and more effective treatment to reduce distress, impairment, and morbidity associated with delayed recognition and treatment.”

The authors said that an anxiety screening strategy focused on identification of family history and family risk factors could offer a more “holistic” approach to identifying psychiatric disorders in adolescents and children.

However, they also warned that a focus on screening instruments as stand-alone methods “neglects the importance of the clinical history, the longitudinal course of symptoms, and the integration of such objective measures with a clinician’s knowledge of disease processes.”

Depression and suicide risk screening

For the depression and suicide risk screening recommendation, Viswanathan and colleagues assessed 30 studies, 21 of which focused on depression (n = 5,433 participants) and 19 on suicide risks (n = 6,290 participants).

In seven studies (n=3,316 participants) that analyzed the accuracy of depression screening instruments, the researchers found that MDD prevalence ranged from 3% to 9% in studies where participants were enrolled from schools or community-based settings, and 11% in the three studies that used participants from nonpsychiatric clinical settings.

A single fair-quality study (n = 580 participants) that had potential high school dropouts aged 14 to 20 years evaluated the Suicide Risk Screen tool and found that suicide risk prevalence ranged from 19% to 22%.

Viswanathan and colleagues noted that suicide risk evidence was deemed insufficient due to inconsistencies in estimates based on the utilized reference standard, along with imprecision and limitations.

“Given that many depression screening instruments include an assessment of suicidal ideation, it is unclear whether a separate, stand-alone instrument to screen for increased suicide risk has value for universal screening in primary care practice,” they wrote.

In a related editorial, Oscar G. Bukstein, MD, MPH, a professor of psychiatry at Harvard Medical School, noted an insufficient suicide risk ruling does not question screening for suicide, “but rather universal screening apart from screening for other risk factors such as depression.”

“Given the salience of depression as a risk factor for suicidal behavior and the value of depression screening as supported by the USPSTF recommendation, screening for suicide under the umbrella of depression screening could accomplish both screening tasks at the same time,” he wrote.

Bukstein concluded that physicians could benefit from using strategies that combine aspects of suicide and mental health screenings, “rather than separate overall risk into several specific problems.”

References:

• Bukstein O. JAMA. 2022;doi:10.1001/jama.2022.15223
• Data and statistics on children’s mental health. https://www.cdc.gov/childrensmentalhealth/data.html. Accessed Oct. 12, 2022.
• Mangione CM, et al. JAMA. 2022;doi:10.1001/jama.2022.16936.
• Mangione CM, et al. JAMA. 2022;doi:10.1001/jama.2022.16946
• Provisional numbers and rates of suicide by month and demographic characteristics: United States, 2021. https://www.cdc.gov/nchs/data/vsrr/vsrr024.pdf. Accessed Oct. 12, 2022.
• U.S. Preventive Services Task Force issues final recommendation statements on screening for anxiety, depression, and suicide risk in children and adolescents. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/screening-anxiety-depression-suicide-risk-final-rec-bulletin.pdf. Published Oct. 11, 2022. Accessed Oct. 12, 2022.
• Viswanathan M, et al. JAMA. 2022;10.1001/jama.2022.16303.
• Viswanathan M, et al. JAMA. 2022;10.1001/jama.2022.16310
• Walkup J, et al. JAMA. 2022;10.1001/jama.2022.15224.