A Systematic Evidence Review
March 2009
Prepared by Selvi B. Williams, MD, MPH, Elizabeth A. O'Connor, PhD, Michelle Eder, PhD, Evelyn P. Whitlock, MD, MPH.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
This report was first published in Pediatrics in March 2009 (Pediatrics 2009;123:e716–e735).
Contents
Abstract
Introduction
Methods
Results
Discussion
Conclusions
References
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Abstract
Context: Depression among youth is a disabling condition that is associated with serious long-term morbidities and suicide.
Objective: To assess the health effects of routine primary care screening for major depressive disorder among children and adolescents aged 7 to 18 years.
Methods: MEDLINE®, the Cochrane Central Registry of Controlled Trials, PsycInfo, the Cochrane Database of Systematic Reviews, recent systematic reviews, experts, and bibliographies from selected studies were the data sources. The studies selected were fair- and good-quality (on the basis of U.S. Preventive Services Task Force criteria) controlled trials of screening and treatment (selective serotonin reuptake inhibitor and/or psychotherapy), diagnostic accuracy studies, and large observational studies that reported adverse events. Two reviewers quality-graded each article. One reviewer abstracted relevant information into standardized evidence tables, and a second reviewer checked key elements.
Results: We found no data describing health outcomes among screened and unscreened populations. Although the literature on diagnostic screening test accuracy is small and methodologically limited, it indicates that several screening instruments have performed fairly well among adolescents. The literature on treatment efficacy of selective serotonin reuptake inhibitors and/or psychotherapy is also small but includes good-quality randomized, controlled trials. Available data indicate that selective serotonin reuptake inhibitors, psychotherapy, and combined treatment are effective in increasing response rates and reducing depressive symptoms. Not all specific selective serotonin reuptake inhibitors, however, seem to be efficacious. Selective serotonin reuptake inhibitor treatment was associated with a small absolute increase in risk of suicidality (ie, suicidal ideation, preparatory acts, or attempts). No suicide deaths occurred in any of the trials.
Conclusions: Limited available data suggest that primary care-feasible screening tools may accurately identify depressed adolescents and treatment can improve depression outcomes. Treating depressed youth with selective serotonin reuptake inhibitors may be associated with a small increased risk of suicidality and should only be considered if judicious clinical monitoring is possible.
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Introduction
Major depressive disorder (MDD) is a debilitating condition that has been increasingly recognized among youth, particularly adolescents. The prevalence of current or recent depression among children is 3 percent and among adolescents is 6 percent.1 The lifetime prevalence of MDD among adolescents may be as high as 20 percent.2-4 Adolescent-onset MDD is associated with an increased risk of death by suicide, suicide attempts, and recurrence of major depression by young adulthood.5-7 MDD is also associated with early pregnancy, decreased school performance, and impaired work, social, and family functioning during young adulthood.6-8 Despite the significant public health burden of MDD, studies have indicated that the majority of depressed youth do not receive any type of treatment.9-11
Mass screening in primary care could help clinicians identify missed cases and increase the proportion of depressed children and adolescents who initiate appropriate treatment. It could also help clinicians to identify cases earlier in the course of disease. Depression-screening tools have been developed that are feasible for use in primary care settings.12 Current, reliable data describing screening practices for pediatric depression, however, are not available. In 1 study from the past decade, providers in community health centers reported screening 64 percent of patients but documented screening for only 3 percent.13 Providers in a health maintenance organization estimated screening an average of 46 percent of their patients.14 These data, however, may overestimate how often primary care clinicians actually screen for depression among pediatric populations. Data based on direct observation or provider and/or patient report after specific clinical encounters would be more reliable.
For mass screening to be effective, it would be necessary for delivered treatments to be effective in improving patients' depression and alleviating suffering more quickly than no treatment. Trials demonstrating the efficacy of drug treatments and time-limited psychotherapies among pediatric populations were first published during the 1990s.15 Presently, fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is the only pharmacologic agent that the U.S. Food and Drug Administration (FDA) has approved for the treatment of pediatric MDD. In 2004, however, the FDA released a black-box warning about suicidality and antidepressant use in pediatric patients. There have been numerous subsequent publications discussing this issue, including the publication of the findings from the FDA meta-analyses evaluating risk of suicidality among 4582 pediatric patients treated with antidepressants.16
Among depressed youth identified in primary care, the majority seem to start treatment.17-19 During 1998, for example, 69.7 percent of youth with visits in primary care for newly identified episodes of depression were either seen by a mental health specialist or received 1 or more dispensings of psychotropic medication in a health maintenance organization during the subsequent 30 to 90 days.17 Similarly, data from the National Ambulatory Medical Care Survey (NAMCS) and the outpatient component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) showed that of adolescent primary care visits in which depression was reported, antidepressants were prescribed 52 percent of the time, and 68 percent of the visits included psychotherapy or counseling.18
In 2002, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to recommend for or against routine screening of children or adolescents for depression (I recommendation).20 At the time of that review, no controlled trials of screening among child or adolescent populations were available.15 Likewise, relatively few studies of diagnostic accuracy, particularly in primary care settings or among children, were available. Furthermore, only 2 trials of SSRIs among pediatric patients with MDD had been published. Our objective was to systematically assess the evidence on screening for MDD among average-risk child and adolescent primary care populations to assist the USPSTF in updating its 2002 recommendation. We have summarized the evidence for the benefits and harms of screening, the accuracy of primary care-feasible screening tests, and the benefits and risks of treating depression by using psychotherapy and/or SSRIs among patients aged 7 to 18 years. The Oregon Evidence-Based Practice Center conducted the review, and the full evidence report is available at http://www.preventiveservices.ahrq.gov. This article summarizes the report's findings.
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Methods
We developed an analytic framework (Figure 1) and 5 key questions (KQs), by using USPSTF methods21, to guide our literature search. For all KQs, we searched for systematic reviews, meta-analyses, and evidence-based guidelines on depression screening, treatment, or associated harms in children and adolescents in the Database of Abstracts of Reviews of Effects (DARE), the Cochrane Database of Systematic Reviews (CDSR), Medline, and PsycINFO from 1998 to May 2006. We also conducted a series of literature searches through May 2007 for each KQ (detailed in Appendix 1) and reviewed the search results for applicability to all KQs. Articles were also obtained from outside experts and through reviewing bibliographies of other relevant articles and systematic reviews. In addition to these searches for published trials, we searched pharmaceutical company and federal agency trial registries for unpublished trials of SSRIs. All searches were limited to articles in English. Inclusion and exclusion criteria specific to each question are detailed in Appendices 2 and 3.
Two investigators independently reviewed all abstracts for KQs 4 and 5. The initial search for KQs 1 through 3 produced a very high yield (3418 abstracts). Therefore, we used a modified approach to reviewing these abstracts as described in Appendix 2. Two investigators evaluated abstracts against a set of inclusion/exclusion criteria, including independent review using design-specific quality criteria based on the USPSTF methods, supplemented by National Institute for Health and Clinical Excellence22 criteria for quality of systematic reviews (Appendix 4). Two investigators critically appraised all studies excluded for quality reasons. Data from included studies were abstracted into evidence tables by 1 investigator and checked by another investigator. Details of our quantitative synthesis approach and rationale are described in detail in Appendix 2. We identified numerous recent systematic evidence reviews relevant to our KQs.16,23-40 Our approach to incorporating these reviews is described in Appendix 2.
We worked with 4 USPSTF liaisons at key points throughout the review process to develop and refine the analytic framework and KQs and to resolve issues around scope and approach. Research was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF. AHRQ staff provided oversight for the project, including reviewing the draft report and assisting in the external review of the draft evidence synthesis.
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Results
KQ1: Does Screening for Depression Among Children and Adolescents in the Primary Care Setting Improve Health Outcomes?
No trials were found that examined health outcomes of depression-screening programs in youth.
KQ1a: Does Screening Increase the Proportion of Patients Identified With and/or Treated for Depression?
No trials were found that examined whether screening led to an increased proportion of children or adolescents identified with and/or treated for depression.
KQ2: Are Depression-Screening Instruments for Children and Adolescents Accurate in Identifying Depression in Primary Care or School-Based Clinics?
The overall body of evidence describing the accuracy of depression-screening instruments for children and adolescents is limited both in quantity and quality. Available evidence applies mostly to adolescents. We identified 9 relevant fair-quality studies4,41-51 that reported the accuracy of 6 different depression-screening instruments (Table 1). Two of the studies were conducted in primary care or school-based health clinics, 1 study was conducted in a community sample, and 6 were conducted in school population samples (not through school health clinics). Most studies restricted study samples to adolescents aged 12 years or older.
The performance characteristics of screening tests were quite varied across the studies. Sensitivity ranged from 18 percent to 100 percent, and specificity ranged from 38 percent to 97 percent. This wide variation may be a result of the large number of instruments that was tested and the great amount of heterogeneity across the populations included. The multiple differences between trials (including lack of replicating results for most of the tools studied) make generalizations difficult. Another important limitation is that all studies had methodologic flaws, including nonrandom selection, excessive delays between screening and diagnostic interviews, high levels of attrition, poor reporting of methods or attrition, small samples, or using a less-than-ideal reference standard. No single study stood out as being of good quality.
Sensitivity in the 2 primary care studies41,42 ranged from 73 percent for the Patient Health Questionnaire for Adolescents (PHQ-A) to 91 percent for the Beck Depression Inventory-Primary Care Version (BDI-PC). Specificity ranged from 91 percent (BDI-PC) to 94 percent (PHQ-A). The prevalence of MDD among the 2 study samples was 9 percent to 11 percent, yielding positive predictive values of 56 percent for both tests and negative predictive values of 97 percent to 99 percent in these 2 primary care samples. Because both studies examined only adolescents, no information was found that is directly applicable to screening younger children presenting to primary care.
Studies that involved younger children tended to have poorer performance.43,49,50 The single study that involved a community sample reported sensitivities ranging from 33 percent to 63 percent for the Strengths and Difficulties Questionnaire (SDQ), examining various combinations of child, parent, and teacher report with 2 different age ranges. The 33 percent sensitivity in the SDQ for child-only report in those aged 11 to 15 years improved to 63 percent when both parent and child reports were used. Sensitivity for those aged 5 to 10 years (parent report only) was 53 percent.
KQ3: What Are the Harms of Screening?
No studies were found that examined harms of depression-screening programs in youth.
KQ4: Does Treatment of Depression (SSRIs and/or Psychotherapy) Among Screen-Detected Children and Adolescents Identified in Primary Care or Comparable Populations Improve Health Outcomes?
We identified 18 fair- or good-quality randomized, controlled trials (RCTs) that reported health outcomes among children or adolescents with MDD treated with SSRIs,52-65 psychotherapy,55-58,66-74 or both an SSRI and psychotherapy55-58 (Table 2). These trials evaluated the short-term efficacy of 5 different SSRIs against placebo-control conditions, 10 different group or individually delivered psychotherapies compared with control conditions, and combined therapy (cognitive behavioral psychotherapy and an SSRI). Two of these trials were conducted in community or school-based clinical settings (both good-quality RCTs),55,72 and the remainder were conducted in academic research centers or in schools. The majority (6 of 9) of SSRI trials included children as young as 8 years old in their study samples. In contrast, the majority of trials that tested psychotherapy interventions included only adolescents aged 12 to 14 years and older. Only 2 psychotherapy trials included 9- or 10-year-olds, and no completed trials included children aged 7 or 8 years.
Nine of the SSRI or psychotherapy trials were rated as good quality according to USPSTF criteria, and 9 were of fair quality. Good-quality trials typically used a multigated screening procedure, including a clinical assessment, to identify depressed participants, measured outcomes through blinded clinical assessments (and often also self-reported depression symptoms), and analyzed intention-to-treat populations, most often by using LOCF (last-observation-carried-forward) data to replace missing values. Depression outcomes were reported after 8 to 12 weeks of SSRI treatment or 4 to 16 weeks of psychotherapy. No controlled data were available for longer-term outcomes. The definition of treatment response differed among trials.
Across the 9 SSRI trials, response rates among treatment and placebo groups varied considerably. Of the patients in treatment groups, 36 percent to 69 percent met response criteria at postintervention follow-up, compared with 24 percent to 59 percent of patients in placebo-control groups. We calculated that the pooled absolute risk difference (RD) in the response rate between treatment and intervention groups was 12 percent (95 percent confidence interval [CI]: 7-16; random-effects analysis) for the 9 SSRI trials, indicating higher response rates among those treated with SSRIs (Figure 2). When considering individual SSRIs, fluoxetine and citalopram both yielded statistically significant higher response rates. Data from meta-analyses of efficacy among children and adolescents analyzed separately in a recent systematic review by Bridge et al26 in 2007 suggested that overall, SSRIs were less effective among children. When restricting the analysis to only fluoxetine trials, however, results were similar for both children (RD: 21 percent [95% CI: 4-37]) and adolescents (RD: 20 percent [95% CI: 7-33]). These results were statistically significant for both groups.
Nine of the 10 psychotherapy trials found that treated patients had higher short-term response rates or a greater reduction in depression symptoms after interventions compared with a variety of control conditions. Two studies included children aged 9 or 10 years, and both reported that mean clinician-rated depression scores improved more among treated patients than control group patients. No trials included children aged 7 or 8 years.
One trial tested the effect of psychotherapy plus an SSRI (fluoxetine) compared with a placebo-control condition.55-58 Among adolescents treated with the combination therapy, 71 percent (95% CI: 62-80) achieved response criteria compared with 34.8 percent (95% CI: 26-44) of placebo-control patients. This trial did not include any patients younger than 12 years.
KQ5: What Are the Adverse Effects of Treatment?
Data describing the adverse effects of SSRIs were available from the 9 RCTs included for KQ4, for which we calculated pooled absolute RDs for suicide-related adverse events (SREs) using data for a subset of trials included in the Bridge et al review.26 SREs include suicidal ideation (ie, passive thoughts about wanting to be dead or active thoughts about killing oneself, not accompanied by preparatory behavior), suicide attempts, or preparatory actions toward imminent suicidal behavior (e.g., a person tries to hang himself or herself but is prevented from doing so by a family member). Data were also available from 4 other meta-analyses that calculated the pooled relative risk (RR) or RD of SREs on the basis of outcomes assessed by using blinded suicidology experts16,26,27 or included other serious adverse events in addition to SREs.40 In addition, data from large retrospective cohort or case-control studies provided observational data describing risk of suicidality, suicide death, and manic conversion.75-78 Previous systematic reviews and meta-analyses did not exclude trials on the basis of quality criteria, and some did not report any quality-rating procedure or results. In contrast, we were able to review published results from all currently completed trials and analyze them in detail by using our typical USPSTF quality-rating criteria. We excluded 2 SSRI trials because of poor methodologic quality.79,80 Authors of previous reviews have also used varying inclusion and exclusion criteria (e.g., MDD trials only, SSRIs only) and have used both fixed-effects and random-effects approaches to meta-analyses, as well as Bayesian methods of meta-analyses. The random-effects and Bayesian approaches assume additional sources of trial-related variation across studies and typically produce RR estimates that are smaller in magnitude and wider in CI. The FDA researchers used fixed-effects methods, validated by results of heterogeneity tests, to calculate the more conservative estimate. Meta-analyses also differed in terms of calculating RR or RD. The FDA analysis focused on RR and, therefore, could not include data from 4 trials (non-SSRI MDD trials) that did not include serious adverse-event outcomes in either group.
Most conservative estimates from the FDA analysis indicate that treating any pediatric population with antidepressants for any indication doubles the RR of a SRE (RR: 1.95 [95% CI: 1.28-2.98]).16 The absolute RD between intervention and control populations in that report was 1 percent (95% CI: 1-2). Published meta-analyses did not report the pooled RD among SSRI trials for treating pediatric MDD, considering data from all currently available completed trials (including a recently published trial of escitalopram65). We calculated the pooled RD of those trials that were of at least fair or good quality and found an absolute RD of 1 percent (95% CI: 0-2; Figure 3). In total, even the most conservative estimates indicate that the risk of suicidality may increase absolutely by 1 percent or 2 percent. No suicide deaths occurred in any of the trials.
Data from observational studies have provided conflicting results regarding the relationship between antidepressant use and suicide attempts and death.75-77 An important limitation of observational studies is the inability to control for confounding by the indication. One additional cohort study found that antidepressant use was associated with an increased risk of conversion from a unipolar depressive disorder to a bipolar disorder.78
The Treatment for Adolescents With Depression Study (TADS) was the only trial that reported adverse effects of combined SSRI and psychotherapy treatment.55,56 The SRE rate among the cognitive behavioral therapy (CBT) plus fluoxetine group was 6 percent compared with 4 percent in the placebo-control group. Results were not statistically different, but the study was not designed to have power to detect a difference of this magnitude.
Results for all KQs are summarized in Table 3.
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Discussion
We found no studies that directly examined the health outcomes of screening children and adolescents for depression. Therefore, we cannot say whether the use of systematic screening improves identification, treatment, and outcomes of depression over standard identification methods. Although some screening instruments seem to have better performance characteristics than others, it is difficult to say the degree to which differences are caused by the quality of the instrument or the characteristics of the population or study. None of the instruments have been studied in large numbers of patients from a variety of settings, including studies by investigators other than those who developed the questionnaires. Of primary importance to this review, 2 primary care studies reported sensitivities of 73 percent and 91 percent and specificities of 91 percent and 94 percent in instruments developed for primary care (the PHQ-A and BDI-PC). Both of these studies examined only adolescents, so no information was found that is directly applicable to younger children. More data were reported in other settings using a variety of instruments, some including younger children (although most were at least 10 years old). In these studies, sensitivities ranged from 18 percent to 100 percent and specificities ranged from 38 percent to 97 percent and differed depending on what instrument, cutoff score, and informant source was used. Data describing the accuracy of using depression-screening instruments in younger children remain very limited. Only 1 study included children younger than 10 and reported generally poor sensitivity and did not report specificity. We found no studies that examined potential harms of systematic, standardized screening for depression in any setting. Theoretical harms are similar to those that have been discussed for suicide-screening programs.81 Until systematic depression screening is tested in a controlled manner, however, actual harms to patients or costs to health care systems, relative to undetected and untreated depression, cannot be measured.
The quantity of efficacy data from RCTs of interventions to treat pediatric MDD is also quite limited, particularly when compared with the large body of evidence supporting efficacy among adults. Despite this limitation in quantity, however, good-quality RCTs have been conducted to test SSRIs and psychotherapies among pediatric populations and provide evidence that efficacious interventions are available, although long-term effects are not known. Meta-analyses have consistently found that fluoxetine is efficacious for treating pediatric populations. Fluoxetine has been studied among both children and adolescents aged 7 to 17 years and is the only drug that is approved by the FDA for treating MDD among youth. Available age-stratified meta-analysis results indicate that fluoxetine is efficacious for both children and adolescents. The absolute RD is ~20 percent for both age groups, which would mean that ~5 children or adolescents with MDD would need to be treated with fluoxetine for 1 to benefit. When combining data from trials of all SSRIs for treating MDD in youth, we found that patients treated with an SSRI were more likely to show a response to treatment than patients treated with placebo pills. These pooled results, however, must be interpreted with caution. Baseline response rates among placebo-treated patients were quite variable across the trials, and some individual SSRIs do not seem to be efficacious. Furthermore, not all SSRIs have been evaluated in pediatric clinical trials. One good-quality trial conducted in community clinics also evaluated combined therapy with fluoxetine plus individual CBT and found that nearly 3 of 4 patients responded to combined therapy, in contrast with only 1 in 3 who responded in the placebo group.55 These results indicate that 2 to 3 adolescents would need to be treated with combined CBT plus fluoxetine therapy for 1 adolescent to benefit from the therapy. Results of psychotherapy trials indicate that a variety of psychotherapy types are efficacious among adolescents, including group CBT and interpersonal psychotherapy (IPT-A).
The most conservative estimates from the final results of the FDA analyses indicate that treating youth with antidepressants leads to a 2 percent absolute increase in risk of experiencing either suicidal ideation or behavior.16 No suicide deaths occurred during these trials. When data are pooled for individual drugs, they have not yielded statistically significant increases in suicide-related outcomes. That lack of statistically significant effects, however, may be a result of lack of power. For fluoxetine, 6 percent (17 of 287) of treated patients and 4 percent (11 of 289) of placebo-control patients experienced either suicidal ideation or behavior during a trial, yielding an absolute RD of 2 percent. This result, however, was not statistically significant.
On the basis of the estimate of increased absolute risk of 2 percent, for 1 patient to develop suicidality attributable to antidepressant therapy, ~50 patients would need to be treated. Authors of several meta-analyses have argued that additional sources of heterogeneity must be incorporated to more accurately assess the true risk of either efficacy or harms. The FDA analyses used fixed-effects models to calculate RDs and risk ratios. In contrast, Bridge et al used a random-effects model that incorporated additional sources of within and between meta-analysis trial heterogeneity. They found that the absolute RD was 1 percent and that the number needed to harm was 112. In either case, available data indicate that a patient is more likely to benefit from treatment than to develop suicidality. Nevertheless, suicidality is an extremely serious condition and could translate, theoretically, into an increased risk of suicide death (current trial data are insufficient to address this issue). As a result, the overall balance of risk and benefit of treatment with antidepressants is not yet clear.
Data are also currently insufficient to determine the role of combined treatment (SSRI plus psychotherapy) on SREs. The TADS was the only RCT included in this review that evaluated combined therapy.55 SREs were less common among patients treated with combined therapy (fluoxetine and CBT; 5.6 percent), compared with fluoxetine alone (8.3 percent) but more common than among patients in the placebo-control group (3.6 percent) These differences, however, were not statistically significant. The trial was not powered sufficiently to detect differences of these magnitudes. Therefore, it is uncertain whether combined therapy would lead to a slight increase in suicidality compared with placebo if more data from larger numbers of patients were available. The additional TADS safety results reported by Emslie et al56 in 2006 indicate that the suicidality results vary depending on how it is measured. Two recent comparative efficacy trials compared combined therapy with SSRI treatment alone, and neither found statistically significant differences between groups for suicidality measures.82,83 The decision to treat an individual pediatric patient with an antidepressant should be based on the clinical situation and guidelines from mental health specialists. Thus, careful consideration must be given to how closely a patient will be able to be monitored, either through the clinical setting or at home, after initiating a therapy. Harms of psychotherapy have not been systematically reported in trials in the past. Recently, Bridge et al84 highlighted the importance of assessing suicidality at baseline and during follow-up assessments in trials of psychotherapy.
This review focuses on MDD and does not address evidence to support screening or treatment for dysthymia, minor depression, or other psychiatric disorders in children and adolescents. Research addressing MDD in children and adolescents is less comprehensive than that for adults. Unlike the adult literature, no research has directly evaluated the benefits of screening for depression in children and adolescents in primary care. There is also a more limited volume of research on screening instruments, on pharmacologic or psychotherapeutic treatments, and on community treatment patterns in children and adolescents, compared with research in depressed adults. Research is particularly limited on screening instruments and treatments appropriate for children aged 10 years and younger.
There are many important areas that have not yet been studied. Future research in this area should include:
- Large-scale RCTs (or well-controlled clinical trials) of primary care or health care system depression-screening programs documenting health outcomes, including harms, and rates of diagnosis and treatment initiation to guide clinicians in depression-screening programs for children and adolescents.
- Descriptive epidemiologic studies describing the prevalence of MDD (diagnosed and undiagnosed, treated and untreated) in children and adolescents in primary health care settings according to age, gender, and race/ethnicity.
- Trials comparing depression treatment adherence and outcomes (including benefits achieved and harms avoided or increased) from depression collaborative care management approaches compared with usual clinical care.
- Analyses of predictors of treatment that may be relevant to the implementation and sustainability of interventions in primary care, such as patient treatment preference or level of provider training needed for delivering effective interventions.
- Comparative effectiveness of pharmacologic and nonpharmacologic treatments for MDD in children and adolescents, particularly those at high risk for suicidality or nonadherence to pharmacotherapy.
- Observational outcomes studies of risks for longer-term outcomes, including mania precipitation, with use of antidepressants, particularly SSRIs.
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Conclusions
Although no trials of screening for pediatric MDD were identified, very limited available data suggest that primary care-feasible screening tools have been reasonably accurate in identifying depressed adolescents. Studies are needed to assess whether these findings can be replicated by other research groups in larger studies that include patients from a variety of primary care settings. Data are also limited regarding treatment of MDD among youth, but evidence from RCTs, including some effectiveness trials, have indicated that available treatments are effective in improving depression outcomes among adolescents. Thus, it is possible that screening among adolescents could lead to increased detection of depression, earlier detection of depression, and greater or earlier improvement in depression symptoms than if patients had never been screened.
Data describing screening among children are inadequate. Effects of treatment among children also need to be understood better, because data indicate that age is a modifier of treatment effects. Treatment of depressed youth with SSRIs is associated with a small increased risk of suicidality and, therefore, should only be considered if judicious clinical monitoring is possible. Specific treatment should be based on individual patients' needs and on mental health treatment guidelines.
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