October 17, 2022
We are pleased to have the opportunity to express our views for the U.S. Preventive Services Task Force (USPSTF) on the Screening for Depression and Suicide Risk in Adults: Draft Evidence Review.
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with a particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
NCHR has substantial concerns regarding the evidence that the benefits of screening for asymptomatic depression and suicide outweigh the risks. We agree with the USPSTF that the evidence in older adult populations is more limited than for younger adults and did not show a clear benefit. Only four studies examined screening in older adults and only one used a depression measure that was specifically designed for older adults.
It is important to note that the Canadian Task Force on Preventive Health Care (CTFPHC) does not recommend screening asymptomatic adults for depression, based on the lack of direct evidence on the benefits and harms of routinely screening asymptomatic adults. USPSTF points out that the Canadian review only included studies in which the screening intervention was a normal part of care and that had an unscreened comparison group. Thus, only three of the screening studies included in the USPSTF review could have met the Canadian inclusion criteria and were published at the time the review was conducted. The absence of an unscreened comparison group in most studies included in the USPSTF review is especially worrisome, since depression fluctuates over time and thus an intervention can’t be accurately evaluated without a control group. In fact, most studies of antidepressants indicate a substantial improvement over time for the placebo control group, with only a modest benefit attributed to the medication itself. We also agree with the CTFPHC concerns about the potential harms of screening, such as “false positive, unnecessary treatment, labelling and stigma.”
In addition, the USPSTF points out that there is “little synthesized information on the longer-term efficacy of pharmacologic treatment of depression.” Since ineffective antidepressants are often supplemented with a second or third psychotropic drug to treat depression, the potential risks must be carefully evaluated. The draft USPSTF Evidence Review has not adequately considered the well-documented risks of antidepressants and atypical antipsychotic medications that are frequently prescribed for depression. While Cognitive Behavioral Therapy (CBT) is considered the safest, most effective and long-lasting treatment for depression, and is especially recommended for pregnant and breastfeeding women, it is relatively expensive and inconvenient compared to prescription drugs. For that reason, it is unlikely to be available to most adults screened for depression. The USPSTF draft should have focused more attention on the differing risks of specific treatments, and their availability. Online CBT treatment is becoming increasingly available, and the efficacy of specific online programs need to be evaluated. If found to be safe and effective, online CBT could make an important difference in ensuring that the benefits of screening for depression outweigh the risks.
Screening for suicide would be very important if effective, but the task force was unable to find enough evidence to recommend screening for suicide risk in the adult population. Further research is needed to better identify patients at risk of suicide, to determine the appropriate psychotherapy for the management of patients with suicidal thoughts and reducing stigma associated with treatment for suicidal thoughts. Reduction in suicide risk will likely require a comprehensive, multidisciplinary approach that may include an effective screening method among other efforts.
Thank you for considering our views. If you have any questions, we can be reached at info@center4research.org or (202) 223-4000