A new recommendation from the U.S. Preventive Services Task Force endorses the need for routine screening of all adolescents for clinical depression.
The task force recommended that physicians screen adolescent patients aged 12–18 years for major depressive disorder provided that systems are in place to ensure further evaluation, psychotherapy, and follow-up. But the task force concluded that there was insufficient evidence to make a recommendation about screening younger children aged 7–11 years (Pediatrics 2009;123:1223–8).
In 2002, the task force examined depression screening in adolescents and found there was not enough evidence at that time to recommend for or against routine screening. However, new evidence on the effectiveness of medications and psychotherapy to treat depressed adolescents and the reliability of screening instruments to detect depression in this group prompted the task force members to recommend screening.
In its recommendation, the task force concluded that adolescents aged 12–18 years could be effectively treated for major depressive disorder with selective serotonin reuptake inhibitors or with a combination of SSRIs and either cognitive-behavioral therapy or interpersonal psychotherapy. But because of the suicide risks associated with the use of SSRIs, the task force recommended that they be prescribed only when the patient can be closely monitored.
The best approach is likely to be a combination of careful medication management and a referral for psychotherapy, Dr. Tom DeWitt, a member of the task force and director of general and community pediatrics at Cincinnati Children's Hospital Medical Center, said in an interview.
Widespread screening is critical because of the high prevalence of depression among adolescents and the serious consequences of leaving the condition untreated, he said. It is estimated that about 6% of adolescents have major depressive disorder, with the lifetime prevalence among adolescents possibly as high as 20%, according to the report.
Although the recommendation is meant to apply to all teens, physicians should pay special attention to adolescents who have a parental history of depression, have comorbid mental health or chronic medical conditions, experience a major negative life event, or have other risk factors for depression.
Other professional organizations have already come out in favor of somewhat more limited screening of adolescents for depression. For example, the American Medical Association recommends screening adolescents for depression if they have risk factors such as a family history or substance abuse.
Despite support for screening adolescents for depression, most physicians don't have systems in place to ensure formal, routine screening. Instead, physicians might ask some general questions about the adolescent's mood or changes in behavior, Dr. DeWitt said.
Part of the reason for the failure to do routine preventive screening may be financial, said Dr. Ted Epperly, president of the American Academy of Family Physicians. The current reimbursement system doesn't pay physicians for providing depression screening and when a service isn't paid for, it often doesn't get done, he said in an interview.
The payment system needs to be realigned to offer incentives for preventive screening, including depression screening, said Dr. Epperly of Boise, Idaho. That type of investment in prevention would have enormous clinical and systemwide financial benefits.
Most depression screening tools are questionnaires that can be filled out in the waiting room and quickly scored by the physician. Although this requires practices to invest time and energy in ensuring that screening occurs, the bigger challenge may be what to do when the screen raises a red flag. Currently, there are not enough adolescent psychiatrists to meet the demand. One option is to reach out to local psychologists to provide the psychotherapy component of treatment, Dr. Epperly said.
For primary care physicians who have the time and the interest, resources are available to help them provide more mental health treatment within their own practices, said Dr. Cathryn Galanter of the division of child and adolescent psychiatry at Columbia University in New York.
One resource is the REACH Institute's Mini-Fellowship in Primary Pediatric Psychopharmacology. As part of this program, Dr. Galanter trains primary care clinicians to screen, evaluate, diagnose, and treat adolescents with mental health problems in their practices. Another resource is the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) toolkit.