NCHR’s Public Comments on United States Preventive Services Task Force’s Draft Research Plan on Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents

May 27, 2020

We are writing to express our views on the draft research plan regarding screening for depression, anxiety, and suicide risk among children and adolescents. The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research, policies, and programs on a range of issues related to health and safety. We do not accept funding from companies that make products that are the subject of our work.

We agree that it is very important to examine whether screening programs for depression, anxiety, and increased risk of suicide accurately identify children and adolescents with those conditions, as well as whether screening leads to improved health outcomes among children and adolescents. We agree that it is equally important to assess the potential harms of screening and treatment. There are, however, three points that we suggest should be re-examined in the draft research plan. 

  1. The draft research plan states that studies will be considered if they include major depressive disorder, as defined by DSM criteria. However, it is also stated that studies will be excluded if they include bipolar disorder. Depression is a component of bipolar disorder, and some studies may assess treatments and outcomes for both major depressive disorder and bipolar disorder patients together. It is reasonable to exclude studies that focus exclusively on bipolar disorder. However, informative studies may be missed by excluding studies that include both depression and bipolar disorder.  
  2. The only therapeutic treatments for anxiety that will be systematically reviewed are those using cognitive behavioral therapy (CBT). The effect of other therapies will be summarized but not systematically reviewed or considered in the analytic framework. However, it is unclear what these inclusion and exclusion criteria mean for studies that combine CBT skills with skills taught in other forms of therapy. For example, CBT skills such as cognitive restructuring and behavioral activation are sometimes combined with skills from other forms of therapy, such as dialectical behavior therapy (DBT).[1] These DBT skills have been successfully been used to reduce anxiety in adults.[1, 2] It is unclear whether a study would be included in systematic review if it combined CBT with skills from other therapies, such as DBT, or if studies would only be included if they solely focus on CBT skills. We recommend the separate analyses of studies that combine CBT with skills from DBT, if there are enough studies to review. In addition, we suggest the separate analysis of studies that combine CBT with another type of therapy (other than DBT) if there are enough studies to review. This would provide more thorough information, given the prevalence of integrative therapies that blend tools from different therapies, such as combining CBT and DBT skills.[1]
  3. The investigation into pharmacologic interventions for depression, anxiety, and suicide risk defined in the draft research plan is restricted to first-line pharmacotherapy treatments approved for pediatric use. However, psychiatric pharmacotherapy for children and adolescents frequently utilizes drugs prescribed off-label.[3] If there is research on these off label uses, it would be helpful to review the results to determine the benefits and risks of those pharmacologic interventions for depression, anxiety, and suicide risk. Regardless of one’s views on the appropriateness of off label uses of these drugs, it would provide useful information to investigate the existing evidence regarding the benefits and risks of pharmacologic treatments that healthcare providers may consider prescribing or are likely to prescribe.

 

National Center for Health Research can be reached at info@center4research.org or at (202) 223-4000.

 

References: 

  1.     Webb CA, Beard C, Kertz SJ, Hsu KJ, Björgvinsson T. Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement. Behaviour Research and Therapy. 2016; 81:12-20.
  2.     Gratz KL, Tull MT, Wagner AW. Applying DBT mindfulness skills to the treatment of clients with anxiety disorders. In Acceptance and mindfulness-based approaches to anxiety. 2005 (pp. 147-161). Springer, Boston, MA.
  3.     Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL. Off-label psychopharmacologic prescribing for children: history supports close clinical monitoring. Child and Adolescent Psychiatry and Mental Health. 2008; 2(1):24.