Screening for Depression and Suicide Risk in Children and Adolescents

Abstract

ImportanceDepression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide.ObjectiveTo review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF).Data SourcesPubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.Study SelectionEnglish-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.Data Extraction and SynthesisTwo reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.Main Outcomes and MeasuresTest accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events.ResultsTwenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, −0.58 [95% CI, −0.83 to −0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, −2.25 [95% CI, −4.09 to −0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children’s Depression Rating Scale–Revised mean difference, −3.76 [95% CI, −5.95 to −1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children’s Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, −2.35 [95% CI, −4.06 to −0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different.Conclusion and RelevanceIndirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.

Adolescent Depression from a Developmental Perspective: The Importance of Recognizing Developmental Distress in Depressed Adolescents

“…Adolescent depression is common, and almost 70% of adolescents who have a depressive disorder will have a recurrence within five years, with a four-fold risk of experiencing depression in adulthood [ 4 , 14 , 15 ]. Suicide is the second most common cause of death in this age group, with the rate of depression and suicide worsening in industrialized countries [ 16 , 17 , 18 ]. Any substantial improvements in the treatment of adolescent depression would clearly be welcomed.…”

Screening for Adolescent Depression and Suicide Risk

“…For depression, there were studies that demonstrated benefit, but these studies were rated low strength of evidence and likely contributed to the B recommendation (high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial) for depression screening in the current recommendations, similar to the 2016 USPSTF recommendations . For suicide, the current USPSTF review identified 16 randomized clinical trials that were of good or fair quality. However, pooled results for suicide outcomes and measures of psychosocial functioning found no significant differences in these outcomes except on 1 measure (reported benefits on suicidal ideation) …”

“…In this issue of JAMA , the USPSTF presents an updated Recommendation Statement on screening for depression and suicide risk in children and adolescents, along with an updated Evidence Report and Systematic Review by Viswanathan et al that serves as the basis for current recommendations. In 2014, the USPSTF published recommendations on screening for suicide risk in adolescents and adults and in 2016, on screening for depression in children and adolescents .…”

“…For the current updated recommendations, the USPSTF reviewed 21 studies (N = 5433) for depression and 19 studies (N = 6290) for suicide risk in articles published between June 1, 2012, and July 19, 2021 (most of these studies were published since the 2014 and 2016 reviews). The updated Evidence Report found no direct evidence of benefit for either screening for suicide or depression. Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression.…”

“…For suicide, the current USPSTF review identified 16 randomized clinical trials that were of good or fair quality. However, pooled results for suicide outcomes and measures of psychosocial functioning found no significant differences in these outcomes except on 1 measure (reported benefits on suicidal ideation) …”