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Screening for Major Depressive Disorder Among Children and Adolescents: a Systematic Review for the U.S. Preventive Services Task Force

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Screening for Major Depressive Disorder Among Children and Adolescents: a Systematic Review for the U.S. Preventive Services Task Force Evidence Synthesis Number 116 Screening for Major Depressive Disorder Among Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. HHSA-290-2012-00015-I, Task Order No. 2 Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, NC Investigators: Valerie Forman-Hoffman, PhD, MPH Emily McClure, MSPH Joni McKeeman, PhD Charles T. Wood, MD Jennifer Cook Middleton, PhD Asheley C. Skinner, PhD Eliana M. Perrin, MD, MPH Meera Viswanathan, PhD AHRQ Publication No. 13-05192-EF-1 February 2016 This report is based on research conducted by the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2012- 00015-I, Task Order No. 2). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients). This report may be used, in whole or in part, as the basis for 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 document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders. None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report. Acknowledgments The authors acknowledge the following individuals for their contributions to this project: Carol Woodell, Loraine Monroe, Janice Handler, current and former members of the U.S. Preventive Services Task Force who contributed to topic deliberations, Robert Cosby, Elizabeth Kato, Karen Lee, Quyen Ngo-Metzger, Tracy Wolff, Evelyn Whitlock, V. Robin Weersing, Megan Jeffreys, Joan Asarnow, Elizabeth McCauley, Kathleen Merikangas, Ellen Shanahan, Stefanie Knauer, Jennifer Alvidrez, Mary Blehar, Rebecca Bitsko, Ericka Boone, Jack Stein, Joel Dubenitz, Layla Esposito, and Sonia Lee. Suggested Citation Forman-Hoffman VL, McClure E, McKeeman J, Wood CT, Middleton JC, Skinner AC, Perrin EM, Viswanathan M. Screening for Major Depressive Disorder Among Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Screening for Depression in Children and Adolescents ii RTI International–UNC EPC Synthesis No. 116. AHRQ Publication No. 13-05192-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2016. Screening for Depression in Children and Adolescents iii RTI International–UNC EPC Structured Abstract Purpose: To evaluate the evidence on screening and treating children and adolescents for major depressive disorder (MDD) for the U.S. Preventive Services Task Force. This update modified the inclusion criteria used in the 2009 review to focus on screening for MDD (i.e., studies reporting that ≥50% of their sample had MDD); thus, we do not address screening or treatment for minor depression or dysthymia. Little is known about the etiological links between subthreshold depression, dysthymia, and MDD or efficacious treatments for less severe forms of depression in children. Focusing on MDD reduces heterogeneity in patient characteristics and targets children and adolescents experiencing more serious symptoms who are most likely to suffer severe functional impairment and suicidality. Data Sources: PubMed/MEDLINE, the Cochrane Library, PsycINFO, ClinicalTrials.gov, HSRProj, the World Health Organization International Clinical Trials Registry Platform, and reference lists of published literature (through February 2015). We re-reviewed studies identified in the 2009 report against the revised inclusion and exclusion criteria. Study Selection: Two investigators independently selected studies reporting on benefits and harms of screening; accuracy of screening tools compared with diagnostic evaluations; and benefits or harms of treatment of MDD compared with placebo, usual care, or waitlist interventions. Data Extraction: One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings using predefined criteria. Data Synthesis: No trials examine the impact of screening for pediatric MDD in primary care on subsequent improvements in depression and other health-related outcomes. No new screening accuracy studies met our criteria. The limited number of screening accuracy studies from the 2009 review that remain in our synthesis suggest that the Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory (BDI) can identify adolescents who are at risk of MDD (PHQ-A sensitivity, 73%; PHQ-A specificity, 94%; BDI sensitivity, 84% to 90%; BDI specificity, 81% to 86%). We found no eligible studies on screening accuracy in children. Additionally, we found one new collaborative care study but no other new psychotherapy or combined therapy intervention studies. One new placebo-controlled study, an acute escitalopram trial in adolescents ages 12 to 17 years, met our criteria for treatment efficacy trials. One fluoxetine trial (ages 12 to 17 years), one escitalopram trial (ages 6 to 17 years), one citalopram trial (ages 7 to 17 years), and one cognitive behavior therapy trial (ages 14 to 18 years) from the 2009 review continued to meet our inclusion and exclusion criteria. Evidence from individual selective serotonin reuptake inhibitor (SSRI) trials demonstrated the efficacy of fluoxetine but not citalopram; one escitalopram trial demonstrated efficacy but the other did not. One collaborative care study demonstrated improvement in symptoms, response, and remission but not functional status. We found no evidence of harms attributable to treatment. Limitations: Our inclusion and exclusion criteria, coupled with our thresholds for quality, resulted in the inclusion of five screening accuracy studies of fewer than 2,900 children and adolescents (none of whom were younger than age 11 years) and six treatment trials that Screening for Depression in Children and Adolescents iv RTI International–UNC EPC randomized fewer than 1,500 children and adolescents with MDD conducted over the past three decades. As a result, we cannot make definitive statements regarding associated benefits or harms, particularly for rare outcomes such as suicidality. Small sample sizes, high attrition, and potentially biased ascertainment of the reference standard in screening studies constrain the evidence base. Evidence gaps sharply limit conclusions for screening in children younger than age 11 years, screening and treatment differences by sex or race/ethnicity subgroups, and MDD treatment other than SSRIs. Conclusion: We found no evidence of a direct link between screening for MDD in children and adolescents in primary care or comparable settings and depression or other health-related outcomes. We found evidence that some screening tools are accurate and some treatments have benefit for MDD among adolescents (but not younger children), with no evidence of associated harms. Although no study found statistically significant harms associated with treatment, lack of precision hampers our ability to rule out effects. Evidence gaps sharply limit conclusions for screening in children younger than age 12 years, screening and treatment differences by sex or race/ethnicity subgroups, and efficacy of MDD treatment other than SSRIs. Screening for Depression in Children and Adolescents v RTI International–UNC EPC Table of Contents Chapter 1. Introduction ............................................................................................................... 1 Overview and Objective ...............................................................................................................1 Previous USPSTF Recommendation ............................................................................................1 Previous USPSTF Conclusions ................................................................................................ 1 Condition Definition .....................................................................................................................2 DSM-5 Definition of MDD .......................................................................................................2 Prevalence
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