PRACTICE CHANGER
Use this 2-question tool to screen adolescent patients for major depression during routine visits.1
STRENGTH OF RECOMMENDATION
B: Based on a single cohort study against gold standard; consistent with studies in other populations.
Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics. 2010;125:e1097-e1103.
ILLUSTRATIVE CASE
A mother brings in her 14-year-old daughter for a routine check-up. The girl has no chronic medical problems and an unremarkable physical exam. When you’re alone with your patient, you inquire about substance abuse and sexual activity. She denies both. What questions would you ask to screen for depression?
Estimates of the prevalence of adolescent depression range from 3% to 9%,2-4 and nearly 20% of teens will experience a depressive disorder before the age of 20.2 But less than half of depressed adolescents are diagnosed or treated.2
Depressed teens face multiple risks
Teens with depressive disorders are at elevated risk, not only for poor family and social relationships and difficulties at school, but also for early pregnancy, substance abuse, hospitalization, recurrent episodes of depression, and suicide.2,4 Thirteen percent of adolescents have seriously contemplated suicide, and 6.3% have made a suicide attempt in the previous 12 months.5
The US Preventive Services Task Force (USPSTF) recommends screening all adolescents for depression—provided that effective treatments and counseling are available for those who need it.6 Nearly all primary care clinicians agree that it is important to screen for adolescent depression, yet many feel hindered by both a lack of training and time constraints.2 The study by Richardson et al1 shows that targeted screening can be effective, even when time is tight.
STUDY SUMMARY: 2-question screen is fairly accurate
The Patient Health Questionnaire (PHQ)-9 is a simple and reasonably accurate test for depression in adults.7 A much shorter version, using only the first 2 of the PHQ-9’s questions, is an effective screening tool for adults.8 Richardson et al evaluated this brief screen—the PHQ-2—for adolescent depression.1
The researchers invited 4000 teens (ages 13-17) who had seen a clinician within the previous 12 months to participate in a mailed survey, with parental or guardian approval. The survey included questions about age, gender, height, weight, sedentary and functional behaviors, and overall health, as well as depressive symptoms identified with the PHQ-2. This simple screen asks patients to rate how often in the past 2 weeks they have had:
1) a depressed mood, and/or
2) a lack of pleasure in usual activities.
Each question is scored from 0 to 3, with 0=not at all, and 3=nearly every day.
Next, the authors randomly selected 271 respondents with scores of ≥3 and 228 respondents with scores <3, matched for age and gender. Of those, 89% (n=444) participated in a longer telephone interview, which included the PHQ-9 and the Diagnostic Interview Schedule for Children (DISC-IV). Participants were predominantly female (60%), Caucasian (71%), and from urban areas (83%), with a mean household income of $57,442.
Compared with the DISC-IV—which the researchers considered the gold standard—the PHQ-2 had a sensitivity of 74% and a specificity of 75% at a cut point score ≥3; the sensitivity and specificity were 96% and 82%, respectively, for detecting young people who met the criteria for major depression on the PHQ-9. The area under the receiver operating curve was 0.84 (95% confidence interval, 0.75-0.92), meaning that the PHQ-2 correctly classified 84% of the participants as depressed or not depressed.
PHQ-2 helps identify related symptoms
Most of those with false-positive screens had other mental health problems. These included depressive symptoms that did not meet the criteria for major depression, an episode of major depression within the past year (but not in the last month), significant psychosocial impairment, and clinically significant anxiety symptoms.