The U.S. Preventive Services Task Force has expanded its guidelines for depression screening, saying it is universally helpful to all U.S. adults over the age of 18, including pregnant and postpartum women. The panel says the benefits of treatment, even medication that may affect fetuses, far outweigh any potential risks.
The harm associated with screening adults and treating them with cognitive behavioral therapy is "small to none," the task force said in its final statement, posted this week in JAMA.
The statement also calls for mental health specialists, primary-care providers and health systems to work collaboratively to manage depressive disorders. Experts are lauding the recommendations released Tuesday, but say raising a red flag about depression is just the first step in securing treatment for patients. Next, is ensuring proper diagnosis and treatment.
The new guidelines recommend that primary-care physicians should routinely screen for depression in all adults, whether or not they have risk factors, such as an existing mental health condition or a family history of psychiatric disorders.
In 2009, the task force recommended screenings should only be done by providers who had mental health staff at hand or could easily provide referrals. The task force had also previously believed there was not enough evidence to extend the guidance to pregnant and postpartum women.
The task force's systematic review of the literature on depression screening found there are many gaps in the evidence. For example, they note the lack of large-scale randomized control trials that are applicable to the U.S. population; lack of data on the accuracy of screening and harms of treatment in pregnant women; as well as a dearth of data on the optimal timing for screening and follow-up assessments.
While the new recommendations are a milestone in the journey toward health equity, they are “not good enough,” wrote Dr. Charles Reynolds and Ellen Frank of the University of Pittsburgh, in a commentary posted Tuesday in JAMA Psychiatry. They say the recommendations call for “effective treatment” and “appropriate follow-up,” but understate the effect of recurring chronic conditions.
“Simply stated, it is not enough to get well—staying well is also important,” they said. The need for recommended screening intervals is needed, especially in patients who have experienced major depressive episodes.
Depression is a common diagnosis in family medicine, and many already offer some form of screening said Dr. Wanda Filer, president of the American Academy of Family Physicians. However, the new guidelines will make it more routine and will help patients suffering from chronic health conditions like diabetes and heart disease, which both have a strong tie to chronic depression.
That concern is timely in light of the recent death ofthe president and CEO of Broward Health, who committed suicide less than two weeks after undergoing triple bypass surgery.
“Why this happens is not entirely clear, but there's a very tight alignment,” Filer said, noting that patients with depression tend to have higher rates of heart disease and vice versa. Integrating behavioral health into primacy-care screening can help, she said, because as depressive symptoms get better, so does chronic disease management and outcomes.
The expanded screening however, also raises concerns about the potential for over-prescribing antidepressants, a class of drugs some say is already used too frequently.
A CMS analysis of Medicare Part D drug-spending data released last April found that the antidepressants Cymbalta (duloxetine) and Abilify (aripiprazole) were among the most costly. Spending on Cymbalta topped $1.9 billion and accounted for nearly 7 million claims. Abilify topped $2.1 billion for nearly 3 million claims.
The task force acknowledges that some antidepressants are associated with an increased risk of suicidal behaviors or gastrointestinal bleeding in some patients and potential serious harms to fetuses. “But the likelihood of these serious harms is low,” the task force concluded.
Others have argued, however, that the long-term benefit of psychiatric medications commonly prescribed for serious mental health issues, including major depression, are exaggerated. The benefits “would need to be colossal” to counter the known harms associated with their use, suggested a Danish researcher in a candid debate posted last May in the BMJ, the journal of the British Medical Association.
Dr. Filer counters that depression is a disease for which medication and cognitive therapy in combination are proven to work. “When you put them together it is 2 plus 2 equals 10,” she said. People with major depressive disorder “are much safer and much healthier when they are treated, than when they go untreated and underdiagnosed.”
The new statement recommends universal depression screening with a B grade, which means there is high degree of certainty that the net benefit of the screening is moderate. The highest grade would be an A, which means the benefit is substantial. The lowest D grade indicates that harms outweigh the benefits. There is also an I grade, which means there is insufficient evidence to compare the benefits and harms.
The task force's recommendations, considered the gold standard in the industry, are also known to influence payer coverage. However, as part of the Affordable Care Act, all health plans on the marketplace must cover the depression screening without charging a co-payment or coinsurance. It's part of a list of several preventive-care services offered by the act.
The task force does not offer treatment recommendations, noted Karina Davidson, a task force member and a professor in the departments of medicine, cardiology and psychiatry at the Columbia University Medical Center.
"We encourage that there be proper diagnostic evaluation after a positive screening, and an appropriate consideration by the clinician and the patient as to the correct treatment," she added.