麻豆传媒

Most adults should be screened for depression and anxiety, the U.S. Preventive Services Task Force (USPSTF) said in two final recommendation statements.

In one published in JAMA, the Task Force said that all adults -- including those who are pregnant, postpartum, and 65 and older -- should be screened for major depressive disorder (grade B recommendation).

Of note, the Task Force did not recommend screening for suicide risk in these groups due to insufficient evidence in assessing the balance of harms and benefits (grade I).

In a separate , the USPSTF also gave a grade B recommendation to screening adults up to age 64 for anxiety, including those who are pregnant or postpartum. It did not recommend screening adults 65 and older for anxiety, due to insufficient evidence on the balance of its harms and benefits (grade I).

The USPSTF noted that the final recommendations are consistent with its , and its on screening for major depressive disorder.

"Amid the mental health crisis in the United States, the Task Force worked to provide primary care professionals and their patients with recommendations on evidence-based screening," said Michael Silverstein, MD, MPH, vice chair of the USPSTF, in a press release. "Fortunately, screening all adults for depression, including those who are pregnant and postpartum, and screening adults younger than 65 for anxiety disorders is effective in identifying these conditions so adults can receive the care they need."

In an , Gregory E. Simon, MD, MPH, of the Kaiser Permanente Washington Health Research Institute in Seattle, and co-authors noted that "the renewed recommendation for depression screening is expected and should prompt little controversy ... evidence since 2016 only strengthens the arguments for the accuracy of commonly used screening questionnaires and the effectiveness of specific interventions, including antidepressant medications and specific psychotherapies, for people identified by screening."

However, they said that the USPSTF's decision not to recommend screening for suicide risk will likely be met with objections. "Rather than recommending whether clinicians should ask about suicidal ideation, we must recommend how they respond to the answers," they wrote.

The Task Force should also focus on what resources health systems can use to identify people at risk, said Simon and co-authors.

"A just culture for suicide prevention in healthcare would focus on consistent use of optimal care processes rather than determining fault for adverse outcomes," they noted. "Outreach and offers of care must be based in humility, respect for autonomy, and a spirit of collaboration."

In an , Murray B. Stein, MD, MPH, and Linda L. Hill, MD, MPH, of the University of California San Diego, pointed out that "it is important to remember that the USPSTF recommendations are geared toward screening for 'anxiety' -- which is a symptom, sometimes a trait, but not a disorder -- and whereas a positive screen result will often reflect an anxiety disorder, it might alternatively reflect myriad other stress-related anxiety-inducing circumstances (e.g., marital or occupational stress) or anxiety-related conditions (e.g., major depression with anxious distress; alcohol withdrawal)."

"Although not called out in the USPSTF Recommendation Statement, a positive screen result for anxiety should be immediately followed with clinical evaluation for suicidality," they continued. "Though widely understood that depression may be accompanied by suicidal ideation, suicidal intent, or both and that assessment of depression must include an evaluation of suicide risk, the high risk of suicide in the anxious patient -- even in the absence of comorbid depression -- is not widely appreciated, and a positive anxiety screening result may be less likely to trigger suicide screening than a positive depression screen result."

Evidence Behind the Recommendations

The USPSTF's recommendations were based on data from two evidence reports also published in JAMA.

For the recommendations on depression screening, were included in their review, including 32 original studies and 73 systematic reviews.

Data from eight randomized clinical trials showed that screening interventions, many of which included other components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptoms after 6 to 12 months (pooled odds ratio 0.60, 95% CI 0.50-0.73), reported Elizabeth A. O'Connor, PhD, of Kaiser Permanente Center for Health Research in Portland, Oregon, and colleagues.

They noted that several tools were found to have adequate accuracy, including the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, with a pooled sensitivity of 0.85 (95% CI 0.79-0.89) and a specificity of 0.85 (95% CI 0.82-0.88).

For suicide risk screening, data from 27 studies did not demonstrate improvement over usual care. They highlighted one randomized clinical trial of a suicide risk screening intervention, which showed no difference in suicidal ideation after 2 weeks between primary care patients who did and did not receive the screening.

For anxiety, 40 original studies and 19 systematic reviews were included in the . Two screening studies found no benefit and few studies evaluated test accuracy. But O'Connor and colleagues noted that the Generalized Anxiety Disorder (GAD)-2 and GAD-7 screening instruments were found to have adequate accuracy for detecting anxiety disorder based on data from three studies, with the GAD-7 at a cutoff of 10 having a pooled sensitivity of 0.79 (95% CI 0.69-0.94) and a specificity of 0.89 (95% CI 0.83-0.94).

Their evidence also showed that psychological interventions were associated with a small pooled standardized mean difference of -0.41 in anxiety symptom severity in primary care patients with anxiety (95% CI -0.58 to -0.23) in 10 randomized trials.