Screen All Adults for Depression, USPSTF Recommends

The US Preventive Services Task Force (USPSTF) today finalized sweeping recommendations to screen all adults for depression, issuing a B recommendation that will require coverage for such checks under the Affordable Care Act (ACA). The update, published in JAMA, calls for expanding screening “regardless of risk factors.” The previous recommendation called for screening when supports were in place or when a clinician’s judgment warranted it.¹

Thus, USPSTF is calling on primary care practices and health plans to have places to send patients who screen positively for depression. While the ACA and federal parity laws have called for equal treatment for those with mental health conditions, that’s sometimes worked better in theory than in practice.

“Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up,” the recommendation reads.

Caught early, depression is highly treatable; most patients can continue with their lives, hold jobs, and maintain relationships. Untreated depression aggravates other medical conditions and accounts for 3.7% of all disability-adjusted life years, and 8.3% of US years lived with disability, according to the National Institute of Mental Health.

Major depression affects an estimated 15.7 million adults over age 18, according to NIMH.

Widespread screening of the general population, with an emphasis on pregnant and postpartum women as called for today, will almost certainly demand more education, focus, and resources for mental health than the United States has previously seen. But the USPSTF’s step is a logical progression from research over the last decade or more, which finds that integrating mental health care into primary care practices leads to better uptake of services and better outcomes for those with depression who also suffer chronic conditions, such as diabetes.

In making its recommendation, USPSTF notes, “Depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well.”

The B recommendation does not come with a specific time frames on how often screening should occur. In an accompanying editorial, Michael E. Thase, MD, of the University of Pennsylvania’s Perelman School of Medicine, said the answer may be different for each patient.²

“For groups at intermediate risk, such as patients receiving regular care for chronic medical conditions such as diabetes or heart disease, it is reasonable to screen at least once a year,” he writes. Patients who are in good health and rarely see their doctor intermittently may need to be screened on each visit.

Both Albert L. Siu, MD, MSPH, writing for the USPSTF, and Thase write that the B recommendation reflects the still-evolving knowledge on major depressive disorder, and the fact that the population in need of mental health care is highly diverse. Matching treatment to patient needs remains a huge challenge, and biomarkers for this purpose do not yet exist. While there are some harms associated with some treatments if there is an incorrect diagnosis after screening, there is little to no harm associated with screening itself.

The shift to universal screening is also attributed to acceptance of the Patient Health Questionnaire or PHQ-9 as a screening tool in primary care practices, which Thase said can identify about 80% of true cases with a predictive value of about 50%.

References

1. Siu AL, Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.

2. Thase ME. Recommendations for screening for depression in adults. JAMA. 2016;315(4):349-350.