May 9, 2022
National Center for Health Research’s Comments on U.S. Preventive Services Task Force’s Draft Recommendation on Screening for Depression and Suicide Risk in Children and Adolescents
We are writing to express our views on the U.S. Preventive Services Task Force’s (USPSTF) draft recommendation for screening for depression and suicide risk in children and adolescents.
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 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.
Accurately screening asymptomatic children and adolescents for depression and suicide risk is of crucial importance, as both are on the increase in recent years and can also increase the risk of depression and other mental health conditions later in life. As the USPSTF review highlighted, suicide is the second-leading cause of death among adolescents.
Unfortunately, the currently available evidence on the accuracy of screening tools as well as the potential benefits and harms associated with screening and treatment for major depressive disorder (MDD) and suicide risk are insufficient. For this reason, we agree with the USPSTF “I” grade recommendation for MDD screening in asymptomatic children age 11 years or younger and the “I” grade recommendation for screening for suicide risk in asymptomatic children and adolescents of all ages.
However, we do not agree with USPSTF’s “B” grade recommendation for screening for MDD in asymptomatic adolescents ages 12 to 18 years of age. The “B” grade recommendation is not based on direct evidence of the benefits or harms of screening and treatment of asymptomatic youths. We are particularly concerned that no long-term data on pharmacotherapy interventions are available and that the evidence on health outcomes, such as number of self-harm events, hospitalization, or emergency department visits, is inconclusive. A “B” recommendation based on such poor data is unacceptable, given that the potential harms for screening can lead to labeling and stigma, and also to unnecessary and potentially harmful treatments. For example, Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to be associated with serious adverse events, including the risk for suicidality, and atypical antipsychotics that are widely prescribed for depression are associated with weight gain, irreversible breast development in boys, and other serious complications, including sudden death.
We are also concerned that while seven screening instruments were assessed for this review, each of these seven instruments was only assessed in one or two of the studies, leading to inconsistent and inadequately replicated results. In addition, most of the assessed tools are not widely used in clinical practice. In fact, the tool that is most commonly used with children (the nine-item Patient Health Questionnaire) was not included in any of the reviewed studies. Unfortunately, there is also no evidence on the appropriate screening intervals for depression. Since we agree with the USPSTF recommendation that additional data on the long-term health outcomes of screening for MDD are needed, the B recommendation is premature. More research is also needed on the effects of screening and treatments for different population groups, based for example, on sexual orientation, gender identity, sex, and race.
As USPSTF states in their recommendation, there are several risk factors, including prior episodes of depression, family history of depression, and several psychosocial risk factors that can help identify children and adolescents who are at a higher risk for MDD. We urge the USPSTF to provide health care providers with adequate guidance to identify which groups of patients would benefit the most from screening and treatments, and provide additional information on the appropriate screening tools or interventions.
The National Center for Health Research can be reached at info@center4research.org or at (202) 223-4000.