CIENCIASMEDICASNEWS: U.S. Preventive Services Task Force: Final Research Plan ► Primary Care Screening for Depression in Adults

U.S. Preventive Services Task Force: Final Research Plan

The U.S. Preventive Services Task Force posted today a
final research plan on primary care screening for depression
in adults. The draft research plan for this topic was posted for
public comment from March 27 to April 23, 2014. The Task
Force reviewed all of the comments that were submitted and
took them into consideration as it finalized the research plan.
To view the final research plan, please go
to http://www.uspreventiveservicestaskforce.org/uspstf14/depradult/depradultfinalresplan.htm.

U.S. Preventive Services Task Force banner

Primary Care Screening for Depression in Adults

The final Research Plan is used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center. The resulting Evidence Report will form the basis of the USPSTF Recommendation Statement on this topic.

The draft Research Plan was available for comment from March 27 until April 23, 2014 at 5:00 p.m., ET. To view the draft Research Plan, click here.

I. Analytic Framework

General Adult Population, Including Older Adults

Select Text Description below for details.

[D] Select for Text Description.

Pregnant and Postpartum Women

[D] Select for Text Description.

II. Key Questions to Be Systematically Reviewed

General Adult Population, Including Older Adults

Do primary care depression screening programs in the general adult population, including older adults, result in improved health outcomes (decreased depressive symptomatology; decreased suicide deaths, attempts, or ideation; improved functioning; improved quality of life; or improved health status)?
1. Does sending depression screening test results to providers (with or without additional care management supports) result in improved health outcomes?
2. Does the effect of screening vary by population characteristics*?
What are the harms associated with primary care depression screening programs in the general adult population, including older adults?
1. Do the harms vary by population characteristics*?

Pregnant and Postpartum Women

Do primary care depression screening programs in pregnant and postpartum women result in improved health outcomes (decreased depressive symptomatology; decreased suicide deaths, attempts, or ideation; improved functioning; improved quality of life; or improved health status)?
1. Does sending depression screening test results to providers (with or without additional care management supports) result in improved health outcomes?
2. Does the effect of screening vary by population characteristics*?
What is the test performance of the most commonly used depression screening instruments in pregnant and postpartum women in primary care?
1. Do the test performance characteristics of the screening instruments vary by population characteristics*?
What are the harms associated with primary care depression screening programs in pregnant and postpartum women?
1. Do the harms vary by population characteristics*?
Does treatment (psychotherapy, antidepressants, or collaborative care) result in improved health outcomes (decreased depressive symptomatology; decreased suicide deaths, attempts, or ideation; improved functioning; improved quality of life; or improved health status) in pregnant and postpartum women who screen positive for depression in primary care?
1. Do the effects of the interventions vary by population characteristics*?
What are the harms of treatment in pregnant and postpartum who screen positive for depression in primary care?
1. Do the harms vary by population characteristics*?
2. What is the prevalence of other selected serious harms of treatment with antidepressants in the general (i.e., not limited to primary care) population of pregnant and postpartum women?

* Population characteristics include sex, age, race/ethnicity, comorbid conditions, and new-onset depression versus recurrent depression.

III. Contextual Questions

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

How effective are usual care methods in identifying patients with depression (i.e., do they avoid underdiagnosis and overdiagnosis)?
What is the acceptability of primary care depression screening to providers and patients?
How is treatment managed in patients who screen positive for depression (e.g., how likely is it that treatment will be initiated or recommended by the provider and accepted by the patient, and how likely is the patient to receive a full therapeutic dose of treatment)? What is the acceptability of depression treatment to patients and providers?
Is treatment (psychotherapy or pharmacologic) effective for relatively mild depression?
Is treatment (psychotherapy or pharmacologic) effective for adults and older adults whose depression is identified through screening in primary care?
What is the accuracy of the Patient Health Questionnaire and the Geriatric Depression Scale, two of the most commonly used depression screening instruments, in identifying patients with depression?

IV. Research Approach

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Report. Criteria are overarching as well as specific to each of the key questions (KQs).

	Include	Exclude
General Adult Population, Including Older Adults
Condition definition	Focus on major depressive disorder, persistent depressive disorder/dysthymia, and depression not otherwise specified, or “depression” with no further diagnostic specificity	Trials restricted only to persons with bipolar disorder, schizoaffective disorder, seasonal affective disorder, cyclothymia, substance-induced mood disorder, minor depression, or adjustment disorder with depressed mood
Aim	Studies targeting depression screening	Studies restricted to screening or treatment of suicidality, bipolar disorder, or treatment-resistant depression
Population	Adults, including older adults, age 18 years and older	Nonhuman populations Children and adolescents (age <18 years), except when related to harms of antidepressants in pregnant women Persons in institutions (e.g., psychiatric inpatients or prison inmates) Persons in long-term care (e.g., nursing homes) Trials limited to persons with comorbid conditions Trials within closed preexisting social networks (e.g., church, worksite programs)
Intervention	Brief standardized instrument designed to identify persons with depression (no more than 15 minutes if completed prior to visit, no more than 5 minutes if completed during visit); self-report, clinician-administered, or electronically delivered	Trials primarily using treatment modalities other than psychotherapy or FDA-approved antidepressants (e.g., exercise, electroshock treatment, St. John's wort, social marketing, policy, system-level interventions, or adjunctive agents to enhance the effects of antidepressants)
Comparator	Usual care, no screening, and screening with no feedback of results to providers
Outcomes	Benefits of screening (KQ 1): Primary health outcomes Depression symptoms Depression remission Other health outcomes Depression response Suicide deaths, attempts, or ideation All-cause mortality Quality of life Functioning (including days of missed work) Change in health status (e.g., improvement in comorbid conditions or reduction in physical complaints) Emergency department visits or inpatient stays Harms of screening (KQ 3): Treatment avoidance Deterioration in patient-provider relationship Other harms reported by screening trials Labeling or stigma Inappropriate/unnecessary treatment
Timing of outcome assessment	≥6 weeks after baseline
Setting	Primary care settings (e.g., internal medicine, family medicine, obstetrics/gynecology, family planning, military health clinics, university-based health clinics) Virtual (e.g., online screening tools), if patients are identified through screening in primary care or other population-based screening Psychotherapy: Mental health clinic setting acceptable only if patients are identified through screening in primary care or other population-based screening	Community/university research laboratories or other nonmedical centers Mental health clinics (unless recruitment is through primary care screening) Correctional facilities School classrooms Worksites Inpatient/residential facilities Emergency departments
Study design	RCTs, CCTs	All other study designs
Country	Countries categorized as “Very High” on the Human Development Index (as defined by the World Health Organization)	Countries not categorized as “Very High” on the Human Development Index
Language	English	Languages other than English
Study quality	Fair or good	Poor, according to design-specific USPSTF criteria
Pregnant and Postpartum Women
Condition definition	Focus on major depressive disorder, persistent depressive disorder/dysthymia, and depression not otherwise specified, or “depression” with no further diagnostic specificity	Trials restricted only to persons with bipolar disorder, schizoaffective disorder, seasonal affective disorder, cyclothymia, substance-induced mood disorder, minor depression, or adjustment disorder with depressed mood
Aim	Screening (KQs 1, 3) and treatment (KQs 4, 5): Studies targeting depression screening and treatment Diagnostic accuracy of screening (KQ 2): Studies addressing accuracy of depression screening instruments Harms of antidepressants (KQ 5): Studies addressing harms of antidepressants	Studies restricted to screening or treatment of suicidality, bipolar disorder, or treatment-resistant depression
Population	Screening (KQs 1, 3): Pregnant and postpartum women age 18 years and older Treatment (KQs 4, 5): Pregnant and postpartum women who screen positive for depression in a primary care setting or are identified through other population-based screening	Nonhuman populations Children and adolescents (age <18 years), except when related to harms of antidepressants in pregnant women Persons in institutions (e.g., psychiatric inpatients or prison inmates) Persons in long-term care (e.g., nursing homes) Trials limited to persons with comorbid conditions Trials within closed preexisting social networks (e.g., church, worksite programs)
Intervention	Screening (KQs 1, 3): Brief standardized instrument designed to identify persons with depression (no more than 15 minutes if completed prior to visit, no more than 5 minutes if completed during visit); self-report, clinician-administered, or electronically delivered Instrument accuracy (KQ 2):): Limited to the most widely used screening tools in this population—the Patient Health Questionnaire (PHQ), in any form, including the related Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD, depression section), and the Edinburgh Postpartum Depression Scale (EPDS) Treatment (KQs 4, 5): Primary care–relevant interventions, including psychotherapy, FDA-approved 2nd-generation antidepressants, and collaborative care	Treatment modalities other than psychotherapy or FDA-approved antidepressants (e.g., exercise, electroshock treatment, St. John's wort, social marketing, policy, system-level interventions, or adjunctive agents to enhance the effects of antidepressants)
Comparator	Screening (KQs 1, 3): Usual care, no screening, and screening with no feedback of results to providers Treatment (KQs 4, 5): Psychotherapy No intervention Usual care Waitlist Attention control Minimal intervention (e.g., usual care limited to no more than 15 minutes of information) Antidepressants No intervention Placebo Waitlist Collaborative care Usual care	Treatment (KQs 4, 5 ): Active intervention (i.e., comparative effectiveness)
Outcomes	Benefits of screening (KQ 1) and treatment (KQ 4): Primary health outcomes Depression symptoms Depression remission Other health outcomes Depression response Suicide deaths, attempts, or ideation All-cause mortality Quality of life Functioning (including days of missed work) Change in health status (e.g., improvement in comorbid conditions or reduction in physical complaints) Child/infant outcomes (continuation of breastfeeding, achievement of recognized developmental milestones, reduced abuse or neglect) Emergency department visits or inpatient stays Diagnostic accuracy of screening (KQ 2): Sensitivity Specificity Positive predictive value Negative predictive value Equivalent data to make such calculations (i.e., 2 x 2 table) Harms of screening (KQ 3): Treatment avoidance Deterioration in patient-provider relationship Others harms reported by screening trials Labeling or stigma Inappropriate/unnecessary treatment Harms of antidepressant treatment (KQ 5): Suicidality Serotonin syndrome Cardiac effects Seizures (bupropion only) Fetal/infant harms (neonatal death, major malformations, small for gestational age/low birth weight, preeclampsia)
Timing of outcome assessment	Screening (KQs 1, 3): ≥6 weeks after baseline Diagnostic accuracy of screening (KQ 2): Maximum of 2 weeks between screening and reference standard Treatment (KQs 4, 5): ≥6 weeks after baseline for treatment and harms of psychotherapy or collaborative care No minimum followup for harms of antidepressants
Setting	Primary care settings (e.g., internal medicine, family medicine, obstetrics/gynecology, pediatrics [for postpartum screening], family planning, military health clinics, university-based health clinics) Virtual (e.g., online screening tools), if patients are identified through screening in primary care or other population-based screening Psychotherapy: Mental health clinic setting acceptable only if patients are identified through screening in primary care or other population-based screening Harms of antidepressant treatment (KQ 5): Any outpatient clinical setting	Community/university research laboratories or other nonmedical centers Mental health clinics (unless recruitment is through primary care screening) Correctional facilities School classrooms Worksites Inpatient/residential facilities Emergency departments
Study design	Benefits of screening (KQ 1), harms of screening (KQ 3), and benefits of treatment (KQ 4): RCTs, CCTs Diagnostic accuracy (KQ 2): Comparison with gold standard (structured or semistructured diagnostic interview or a nonbrief [>5 minutes] unstructured interview with mental health clinician) within 2 weeks of screening in populations that include a full spectrum of patient severity for the given setting (i.e., studies cannot limit patient pool to only nondepressed and known/highly likely depressed patients) Harms of antidepressant treatment (KQ 5): Systematic reviews; large comparative cohort or case-control observational studies published after identified systematic reviews that include observational studies “Large” is operationalized as: n ≥10,000 with at least 6 months of followup for suicide attempts and deaths n ≥1,000 with at least 3 months of followup for other outcomes	All other study designs
Country	Countries categorized as “Very High” on the Human Development Index (as defined by the World Health Organization)	Countries not categorized as “Very High” on the Human Development Index
Language	English	Languages other than English
Study quality	Fair or good	Poor, according to design-specific USPSTF criteria

Abbreviations: FDA = Food and Drug Administration; RCT = randomized, controlled trial; CCT = controlled clinical trial

V. Response to Public Comment

The draft Research Plan for this topic was posted for public comment from March 27 to April 23, 2014. Several comments requested that the USPSTF examine the effects of a positive screen on subsequent treatment processes, such as treatment initiation, referral for treatment, referral acceptance, and compliance. To address these factors more fully, the USPSTF broadened one contextual question. The USPSTF also expanded the inclusion criteria for studies to include several outcomes (e.g., emergency department visits, inpatient stays, and several child-related outcomes for pregnant and postpartum women) in response to comments.

AHRQ Publication No. 14-05208-EF-5
Current as of July 2014

Internet Citation:

U.S. Preventive Services Task Force. Primary Care Screening for Depression in Adults: Final Research Plan. AHRQ Publication No. 14-05208-EF-5. http://www.uspreventiveservicestaskforce.org/uspstf14/depradult/depradultfinalresplan.htm