Depression

Prevention
Screening

Family Practice
Internal Medicine
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

To improve the detection, treatment and outcome of patients with depression

Asymptomatic adults, children, and adolescents

Routine screening for depression in adults, children, and adolescents seen in primary care settings

• Accuracy of screening instruments
• Effectiveness of treatment
• Clinical outcome of depression

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

A systematic review to determine whether routine screening for depression improves detection, treatment and outcome was conducted by the Research Triangle Institute-University of North Carolina Evidence-Based Practice Center from the Agency for Healthcare Research and Quality at the request of the U.S. Preventive Services Task Force (USPSTF) This rigorous, systematic overview provided the basis for a review of evidence by the Canadian Task Force on Preventive Health Care (CTFPHC) in updating the recommendation regarding screening for depression.

Since the USPSTF systematic review included articles up to August 2001, CTFPHC conducted additional searches as an update for research articles on screening for depression, and to obtain Canadian data on burden of suffering in the general population, as well as groups at risk. For research studies, a focused literature search of MEDLINE and the Cochrane database was conducted from January 1, 2001 to September 1, 2002. The search was designed to find key new evidence only, rather than be comprehensive for all related material. For Canadian data on burden of suffering associated with depression, in addition to a MEDLINE search for epidemiologic studies, Statistics Canada was searched for results of key Canadian surveys. Details of these searches are available from the CTFPHC office.

For the burden of suffering update, studies were included if they were relevant to the general Canadian population or large subpopulations in Canada. For the studies addressing screening, only those studies that examined treatment outcomes for adults, children, or adolescents identified by primary care clinicians through screening for depression were included.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Research Design Rating

I: Evidence from randomized controlled trial(s)

II-1: Evidence from controlled trial(s) without randomization

II-2: Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention; dramatic results from uncontrolled studies could be included here

III: Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees

Quality Rating

Good: A study (including meta-analyses or systematic reviews) that meets all design-specific criteria* well

Fair: A study (including meta-analyses or systematic reviews) that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor: A study (including meta-analyses or systematic reviews) that has at least one design-specific* "fatal flaw", or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med 2001;20(suppl 3):21-35.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Critical Appraisal

The Task Force reviewed 1) the initial analytic framework and key questions for the proposed review; 2) the subsequent draft(s) of the complete manuscript providing critical appraisal of the evidence prepared by the lead authors, including identification and double, independent critical appraisal of key studies or recent systematic reviews, and ratings of the quality of this evidence using the task force's established methodological hierarchy; and 3) a summary of the evidence and proposed recommendations.

Consensus Development

Evidence for this topic was presented by the lead author(s) and deliberated upon during task force meetings in May & October 2002, and February 2003. Expert panelists addressed critical issues, clarified ambiguous concepts and analyzed the synthesis of the evidence. At the end of this process, the specific clinical recommendations proposed by the lead author were discussed, as were issues related to clarification of the recommendations for clinical application and any gaps in evidence.

The results of this process are reflected in the description of the decision criteria presented with the specific recommendations. The group and lead author(s) arrived at final decisions on recommendations unanimously.

Procedures to achieve adequate documentation, consistency, comprehensiveness, objectivity, and adherence to the task force methodology were maintained at all stages during review development, the consensus process, and beyond to ensure uniformity and impartiality throughout.

Recommendations Grades for Specific Clinical Preventive Actions

A: The Canadian Task Force (CTF) concludes that there is good evidence to recommend the clinical preventive action.

B: The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C: The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D: The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E: The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I: The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation; however, other factors may influence decision-making.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Peer Review

Subsequent to the Task Force meetings, the lead authors revised the manuscript accordingly. After final revision, the Task Force sent the manuscript to two experts in the field (identified by Task Force members at the meeting). Feedback from these experts was incorporated into a subsequent draft of the manuscript.

Recommendations of Others

Recommendations for the screening for depression from the United States Preventive Services Task Force (USPSTF) were reviewed and discussed.

Recommendation grades [A-E, I] and levels of evidence [I, II-1, II-2, II-3, III, good, fair, poor] are indicated after each recommendation. Definitions for these grades and levels are provided at the end of the "Major Recommendations" field.

The Canadian Task Force on Preventive Health Care (CTFPHC) concludes that there is fair evidence to recommend screening adults in the general population for depression in primary care settings that have integrated programs for feedback to patients and access to case management or mental health care (B recommendation). (Pignone et al., 2002 [I, good]; Katzelnick et al., 2000 [I, good]; Rost et al., 2001 [I, good]; Wells et al., 2000 [I, good])

The CTFPHC concludes that there is insufficient evidence to recommend for or against screening adults in the general population for depression in primary care settings where effective follow-up and treatment* are not available (I recommendation). (Pignone et al., 2002 [I, good])

The CTFPHC concludes that there is insufficient evidence to recommend for or against screening for depression among children or adolescents in primary settings (I recommendation). (Pignone et al., 2002 [I, good])

* "Effective follow-up and treatment" refers to screening programs that are integrated with both feedback to the clinician regarding depression status, as well as a system for managing treatment (antidepressant medications and psychotherapeutic interventions). Trials that included access to case management or mental health care as part of the system of care were particularly effective in reducing depressive symptoms. Since integrated screening and feedback/treatment systems are not the norm in Canadian primary care practice, clinicians are encouraged to advocate for these.

Definitions:

Levels of Evidence

Research Design Rating

I: Evidence from randomized controlled trial(s)

II-1: Evidence from controlled trial(s) without randomization

II-2: Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention; dramatic results from uncontrolled studies could be included here

III: Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees

Quality Rating

Good: A study (including meta-analyses or systematic reviews) that meets all design-specific criteria* well

Fair: A study (including meta-analyses or systematic reviews) that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor: A study (including meta-analyses or systematic reviews) that has at least one design-specific* "fatal flaw", or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med 2001;20(suppl 3):21-35.

Recommendations Grades for Specific Clinical Preventive Actions

A: The Canadian Task Force (CTF) concludes that there is good evidence to recommend the clinical preventive action.

B: The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C: The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D: The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E: The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I: The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation; however, other factors may influence decision-making.

None provided

Maneuver: Screening adults in the general population for depression in settings with integrated feedback and treatment systems

• Level of Evidence: I, good to fair (four randomized controlled trials [RCTs])

Maneuver: Screening adults in the general population for depression in settings without integrated feedback and treatment systems

• Level of Evidence: I, good (systematic review of RCTs)

Maneuver: Screening children and adolescents in the general population for depression

• Level of Evidence: I, good (systematic review of RCTs)

Screening for depression among adults in primary care improves detection of depressed patients, and treatment of depression in these patients improves health outcomes.

Some patients with "false-positive" results on screening may be exposed to further diagnostic investigation that proves unnecessary. This may be associated with increased distress but there is no information available about this theoretical risk. However, some false positive results may be due to chronic dysthymia, and this information may be useful to clinicians.

The Canadian Task Force on Preventive Health Care (CTFPHC) recognizes that in many cases, patient-specific factors need to be considered and discussed, such as the value the patient places on the clinical preventive action; its possible positive and negative outcomes; and the context and/or personal circumstances of the patient (medical and other). In certain circumstances where the evidence is complex, conflicting, or insufficient, a more detailed discussion may be required.

An implementation strategy was not provided.

Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2005 Jan

Canadian Task Force on Preventive Health Care - National Government Agency [Non-U.S.]

The Canadian Task Force on Preventive Health Care (CTFPHC) is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Canadian Task Force on Preventive Health Care (CTFPHC)

Primary Authors: Harriet L. MacMillan, Professor, Departments of Psychiatry and Behavioural Neurosciences and of Pediatrics, Offord Centre for Child Studies, McMaster University; Christopher J.S. Patterson, Professor, Division of Geriatric Medicine, Department of Medicine, R.S. McLaughlin Centre for Research and Education in Aging and Health, McMaster University; C. Nadine Wathen, Research Fellow, Department of Psychiatry and Behavioral Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ont

Chair: Dr. John W. Feightner, Professor, Department of Family Medicine, The University of Western Ontario, London, Ont

Vice-Chair: Dr. Harriet MacMillan, Professor, Departments of Psychiatry and Behavioural Neurosciences and of Pediatrics, Offord Centre for Child Studies, McMaster University, Hamilton, Ont

Members: Drs. Paul Bessette, Professeur titulaire, Département d'obstétrique-gynécologie, Université de Sherbrooke, Sherbrooke, Que.; R. Wayne Elford, Professor Emeritus, Department of Family Medicine, University of Calgary, Calgary, Alta.; Denice S. Feig, Associate Professor, Departments of Medicine, of Obstetrics and Gynecology, and of Health Policy Management and Evaluation, University of Toronto, Toronto, Ont.; Joanne Langley, Associate Professor, Departments of Pediatrics and of Community Health and Epidemiology, Dalhousie University, Halifax, NS; Valerie A. Palda, Assistant Professor, Departments of Medicine and of Health Policy Management and Evaluation, University of Toronto, Toronto, Ont.; Christopher Patterson, Professor, Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ont.; Bruce A. Reeder, Professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Sask

Resource Staff: Ruth Walton, Research Associate, Canadian Task Force on Preventive Health Care, Department of Family Medicine, The University of Western Ontario, London, Ont

Harriet MacMillan was supported by the Wyeth Canada CIHR Clinical Research Chair in Women's Mental Health.

None available

This NGC summary was completed by ECRI on August 10, 2005. The information was verified by the guideline developer on August 25, 2005. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.