All primary care doctors, including pediatricians and family physicians, should screen adolescents routinely for depression, new recommendations of the U.S. Preventive Services Task Force said, and those doctors should have a system in place to connect young people to treatment for depression if they need it.
The group decided that there was good evidence to support screening for all young people between the ages of 12 and 18. For children younger than 12, there is not enough evidence around which tests work and which treatments are effective to recommend that doctors screen all individuals in this age group.
The new recommendations for screening adolescents “very much parallel the recommendations for adults (18 and older),” said Dr. Alex H. Krist, associate professor of family medicine at Virginia Commonwealth University and member of the Task Force that wrote the recommendations, which came out on Monday in the Annals of Internal Medicine.
The last iteration of the recommendations for both adolescents and adults, in 2009, stated that doctors should only screen for depression if systems were in place to help at-risk individuals get appropriate treatment and followup care. That is no longer enough. Doctors should put those systems in place, if they haven’t already, and screen everyone.
“We believe that health care has advanced a lot and it’s more the norm to have systems in place,” Krist said.
The Task Force did not outline the types of systems that primary care doctors could create, but there is a range of possibilities, such as having mental health providers in the primary care practice or referring at-risk patients to therapists at other clinics or in the community, Krist said. Some experts think the best situation for patients is to have mental health providers in the clinic so they can go directly to them for a diagnosis and to discuss treatment options.
“The front line of adolescent mental health is in the pediatric and family care practice,” said Dr. Gary Maslow, an assistant professor of pediatrics and psychiatry and behavioral sciences at Duke University, who co-authored an editorial about the new recommendations. The guidelines reiterate how important it is for primary care doctors to screen adolescents, he said.
Screening adolescents is not difficult, Maslow said. “I don’t think it’s that much more complex than the things [doctors] are already doing.”
But the payoff is big. “The biggest challenge is identifying adolescents.” They might look fine but “without screening they fall thru the cracks and don’t come to attention until the symptoms get worse,” Maslow said. “I think we have medications and therapies that are effective.”
Antidepressants are OK for adolescents
The recommendations specified two types of questionnaires for doctors to use to screen adolescents. One of them, the PHQ-A, is a version of the nine-question test for adults called the Patient Health Questionnaire, modified for adolescents. The other is based on a 21-question survey that asks about symptoms of depression.
The Task Force did not provide guidance on how often doctors should screen adolescents because “there are not as much data about what the best interval is,” Krist said. “In my practice, we aim to check adolescents and adults every year, commonly during a wellness exam.”
Another change in the current recommendations is to support the use of antidepressant medication for treating adolescents who have depression. “In 2009 the evidence of benefits was around therapy … so we were advocating therapy. Now we are saying it can be medication, therapy or a combination,” Krist said. A common therapy for this age group is cognitive behavioral therapy, which focuses on modifying thoughts and behaviors.
Recent research has found that escitalopram, known as Lexapro, was associated with better recovery from depressive symptoms among adolescents 12 to 17 years of age than a placebo control, and was not associated with greater adverse effects. The two antidepressants approved for use in adolescents are fluoxetine, known as Prozac, and Lexapro, for individuals starting at age 8 and 12, respectively.
In recommending certain medications and therapies, the Task Force considered studies that held these treatments up to a number of different standards, such as whether they improved adolescents’ quality of life, physical and social health and also whether they reduced the rates of young people taking their own lives.
“Suicide attempts and completed suicides are a concern with depression in adolescents and they were considered in the recommendations,” Krist said. According to recent data, 17% of high school students in the United States have seriously considered taking their own life in the last year and 8% have attempted suicide.
Depression in young children
Although the current guidelines did not recommend screening children younger than 12, they also did not recommend against it, Krist said. “Our recommendations are really a call for more evidence,” for every aspect of depression in this age group, from screening and diagnosis to treatment and followup, he said.
“Childhood depression is important. If families are concerned their child is depressed we want them to talk with their clinician, or if a clinician is concerned we want them to do further evaluation and treatment as needed,” Krist said.
One of the questions that remain is how common depression is among children under 12 years of age. About 8% of adolescents have suffered depression in the last year, according to U.S. surveys, which is similar to the rate among adults in the United States.
Last month, the U.S. Preventive Services Task Force published new recommendations for depression screening in adults; it highlighted the importance of screening women who are pregnant or who have recently given birth.