There are no randomized controlled trials that support the United States Preventive Services Task Force guideline on screening for depression in primary care: a systematic review

Abstract

BackgroundThe United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.MethodsWe re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.ResultsOf the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.ConclusionsThe USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation.Please see related article: http://www.biomedcentral.com/1741-7015/12/14RegistrationPROSPERO (#CRD42013004276)

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

“…This links to an evolving debate in the literature about the benefits and harms of routine screening for depression in high-risk groups. In both unselected primary care populations and special populations at high-risk of depression, several recent systematic reviews by Meijet et al, 337 Thombs et al 338,339 and others 340 have highlighted the lack of direct evidence from appropriately designed clinical trials on the effects of implementing routine depression screening versus no screening, either alone or in the context of accessible, good-quality mental health care. Measured against this standard of evidence, the recommendation of routine depression screening in general, 339 and in high-risk patients with diabetes, 341 cancer 342 and coronary heart disease, 343 has been criticised as premature.…”

“…In both unselected primary care populations and special populations at high-risk of depression, several recent systematic reviews by Meijet et al, 337 Thombs et al 338,339 and others 340 have highlighted the lack of direct evidence from appropriately designed clinical trials on the effects of implementing routine depression screening versus no screening, either alone or in the context of accessible, good-quality mental health care. Measured against this standard of evidence, the recommendation of routine depression screening in general, 339 and in high-risk patients with diabetes, 341 cancer 342 and coronary heart disease, 343 has been criticised as premature. Furthermore, these and other commentators 344 have expressed concern over the inefficiency of screening, the diversion of scarce resources from other clinical priorities, the potential for wasteful and unnecessary exposure to common side effects of antidepressant medications, particularly in patients with mild, self-limiting depressive symptoms, and possible nocebo effects and stigma from overt labelling.…”

Primary care doctors should not screen their patients for depression

“…RCTs that test the effects of a screening program should at a minimum (1) randomize patients prior to the screening intervention and (2) provide similar treatment resources to patients detected with the condition or health problem in the screening and non-screening trial arms. Otherwise, the effects of screening and the effects of depression treatment, once depression is detected through screening or otherwise, cannot be separated [1,4,5]. The USPSTF has argued that there is evidence that screening and treatment improve depression outcomes [2,3].…”

“…Some of this latter group may then be exposed to the harms of labeling and treatment without any chance of benefit. Thus, recommendations to launch new screening programs should be based on evidence from high-quality RCTs that screening results in sufficiently positive outcomes to justify the costs and potential harms of screening [1,4,5]. RCTs that test the effects of a screening program should at a minimum (1) randomize patients prior to the screening intervention and (2) provide similar treatment resources to patients detected with the condition or health problem in the screening and non-screening trial arms.…”

“…Depression screening, as described by the USPSTF, would involve the routine use of self-report depression symptom questionnaires with prespecified cutoff scores, administered to all patients, regardless of the perceived risk that they may have depression, to identify those who may have depression, but who have not sought treatment and have not otherwise been recognized as depressed by health-care providers or via selfreport [1,4,5]. Thus, screening would occur in presumably asymptomatic patients who are not recognized as having symptoms.…”