Screening for depression in adult patients in primary care settings: a systematic evidence review.
BACKGROUND
In primary care settings, prevalence estimates of major depressive disorder range from 5% to 13% in all adults, with lower estimates in those older than 55 years (6% to 9%). In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems to ensure accurate diagnosis, effective treatment, and follow-up.


OBJECTIVE
To conduct a targeted, updated systematic review for the U.S. Preventive Services Task Force about the benefits and harms of screening adult patients for depression in a primary care setting, the benefits of depression treatment in older adults, and the harms of depression treatment with antidepressant medications.


METHODS
MEDLINE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO (1998 to 2007), expert suggestions, and bibliographies of recent systematic reviews.


METHODS
Fair- to good-quality randomized clinical trials or controlled clinical trials; systematic reviews; meta-analyses; and large observational studies of serious adverse events and early discontinuation due to adverse effects. All studies were published in English.


METHODS
Two investigators abstracted, critically appraised, and synthesized 33 articles that met inclusion criteria.


RESULTS
Nine fair- or good-quality trials indicate that primary care depression screening and care management programs with staff assistance, such as case management or mental health specialist involvement, can increase depression response and remission. Benefit was not evident in screening programs without staff assistance in depression care. Seven regulatory reviews or meta-analyses and 3 large cohort studies indicate no increased risk for completed suicide deaths with antidepressant treatment. Risk for suicidal behaviors was increased in young adults (aged 18 to 29 years) who received antidepressants, particularly those who received paroxetine, but was reduced in older adults.


CONCLUSIONS
Examination of harms was limited to serious adverse events, and existing systematic reviews were primarily used. Additional studies published from 2007 to 2008 extend this review.


CONCLUSIONS
Depression screening programs without substantial staff-assisted depression care supports are unlikely to improve depression outcomes. Close monitoring of all adult patients who initiate antidepressant treatment, particularly those younger than 30 years, is important both for safety and to ensure optimal treatment.
O'Connor
Elizabeth A
EA
Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227, USA. Elizabeth.OConnor@kpchr.org
Whitlock
Evelyn P
EP
Beil
Tracy L
TL
Gaynes
Bradley N
BN
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000928:Antidepressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D003863:Depression / Q000175:diagnosis* / Q000628:therapy; D005246:Feedback; D006801:Humans; D008403:Mass Screening / Q000009:adverse effects; D008875:Middle Aged; D010348:Patient Care Team; D011320:Primary Health Care / Q000379:methods*; D011613:Psychotherapy; D018570:Risk Assessment; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D013405:Suicide / Q000523:psychology; D055815:Young Adult
D000928:Antidepressive Agents; D017367:Selective Serotonin Reuptake Inhibitors