Posted on Wednesday 10 February 2016
U.S. Preventive Services Task Force Recommendation Statementby Albert L. Siu, MD, MSPH, on behalf of the U.S. Preventive Services Task ForceAnnals of Internal Medicine. Published online 9 February 2016
Description: Update of the 2009 U.S. Preventive Services Task Force [USPSTF] recommendation on screening for major depressive disorder [MDD] in children and adolescents.Methods: The USPSTF reviewed the evidence on the benefits and harms of screening; the accuracy of primary care–feasible screening tests; and the benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years.Population: This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD.Recommendation: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. [B recommendation] The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.
A Systematic Review for the U.S. Preventive Services Task Forceby 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; and Meera Viswanathan, PhDAnnals of Internal Medicine. Published online 9 February 2016
Background: Major depressive disorder [MDD] is common among children and adolescents and is associated with functional impairment and suicide.Purpose: To update the 2009 U.S. Preventive Services Task Force [USPSTF] systematic review on screening for and treatment of MDD in children and adolescents in primary care settings.Data Sources: Several electronic searches [May 2007 to February 2015] and searches of reference lists of published literature.Study Selection: Trials and recent systematic reviews of treatment, test–retest studies of screening, and trials and large cohort studies for harms.Data Extraction: Data were abstracted by 1 investigator and checked by another; 2 investigators independently assessed study quality.Data Synthesis: Limited evidence from 5 studies showed that such tools as the Beck Depression Inventory and Patient Health Questionnaire for Adolescents had reasonable accuracy for identifying MDD among adolescents in primary care settings. Six trials evaluated treatment. Several individual fair- and good-quality studies of fluoxetine, combined fluoxetine and cognitive behavioral therapy, escitalopram, and collaborative care demonstrated benefits of treatment among adolescents, with no associated harms.Limitation: The review included only English-language studies, narrow inclusion criteria focused only on MDD, high thresholds for quality, potential publication bias, limited data on harms, and sparse evidence on long-term outcomes of screening and treatment among children younger than 12 years.Conclusion: No evidence was found of a direct link between screening children and adolescents for MDD in primary care or similar settings and depression or other health-related outcomes. Evidence showed that some screening tools are accurate and some treatments are beneficial among adolescents [but not younger children], with no evidence of associated harms.
I came to psychiatry drawn by the psychological struggles apparent in so many of the medical patients I’d seen along the way. I just didn’t get it. And learning to view them in the context of the person’s whole biography was, in itself, worth the price of admission for me. When the DSM-III with its expanded focus on distinct disorders came along, I was neither interested nor able to go back, so I went away. I understood and even agreed with many of the criticisms of what had been before, but I couldn’t live with the baby in the bathwater problem. I see non-melancholic depression as a signal that something’s wrong that needs attending rather than just a symptom to be treated. And that’s particularly true in adolescence and young adulthood. I really don’t think there’s a unitary disease, Major Depressive Disorder [MDD], even in adulthood, but I double-dog-really don’t think it exists in children and adolescents – certainly not in the way these articles imply. Five years volunteering in a Child and Adolescent clinic after retirement only reinforced these views.
So as important as I think it is to attend to depression in adolescents, this recommendation and the accompanying review just seem way off the mark. And to present this slide as an updated "Systematic Review" is ludicrous:
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