Insufficient evidence for screening for major depressive disorder in children

1. From a systematic review, insufficient studies were found examining whether routine screening for pediatric major depressive disorder (MDD) improves depression- or other healthcare-related outcomes.

2. Limited evidence suggests the Patient Health Questionnaire Modified for Adolescents (PHQ-A) and Beck Depression Inventory (BDI) may be the best MDD screening tools for children.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Major depressive disorder (MDD) is prevalent in the pediatric population, with approximately 11% of children aged 8-18 years affected in the last year alone. Moreover, a majority of children suffering from MDD do not receive adequate treatment. A 2009 USPSTF guideline recommended routine screening for MDD in children aged 12 to 18 years in primary care settings, but only if adequate management systems are in place. This review sought to update that guideline by examining available evidence for both screening and treatment of MDD in children. Unfortunately, the review did not find any qualifying trials that directly assessed the benefits and harms of screening children for MDD in primary care settings. Among all MDD screening approaches, the PHQ-A and BDI tools had the highest sensitivity and specificity. In terms of treatment, fluoxetine, fluoxetine with cognitive behavioral therapy (CBT), and collaborative care were associated with the best response rates. This review was limited by strict inclusion criteria (i.e., English language studies related only to MDD screening/treatment in primary care settings), insufficient power to rule out the absence of benefits or harms, and limited generalizability due to heterogeneity in interventions, populations and settings across all included publications. Overall, it is clear that more high-quality studies that examine the utility of pediatric MDD screening in primary care settings are needed.

Click to read the study published today in the Annals of Internal Medicine

Relevant Reading: Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force recommendation statement

In-Depth [systematic review]: This review assessed 5 studies on MDD screening accuracy and 4 trials on treatment efficacy via PubMed, Cochrane Library and PsychInfo searches. There were no meta-analyses or retrospective cohort studies that met inclusion criteria. Across all studies that examined screening accuracy, the PHQ-A and BDI tools had the highest sensitivity (range 73%-90%) and specificity (range 81%-94%). Notably, the positive predictive value was low for these screening tools (range 8%-56%), although the negative predictive value was extremely high (range 97%-99.6%). From the trials that assessed treatment approaches for MDD, it was found that fluoxetine (absolute risk difference 25.7%) and fluoxetine with CBT (absolute risk difference 36.2%; p = 0.001) were associated with a significantly higher response compared to placebo. Additionally, a trial examining collaborative care found that it was associated with significant improvement in response rates at 6 and 12 months compared to the control groups (odds ratios 5.2 and 3.9, respectively).

Image: PD

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