Background: Depression is relatively common in primary care patients but is not always identified by primary care providers.
Purpose: To systematically review evidence to update the benefits and harms of screening for depression in general and older adults, and to also consider evidence for benefits and harms in pregnant and postpartum women, which was not previously reviewed, to aid the U.S. Preventive Services Task Force in updating its recommendation on this topic.
Methods: We searched MEDLINE, PubMed, PsycINFO, and the Cochrane Collaboration Registry of Controlled Trials through January 20, 2015, to identify relevant literature published after searches of previous reviews of depression screening in general and older adults (new searches beginning January 1, 2009) and pregnant and postpartum women (new searches beginning January 1, 2012). We also examined references of other existing systematic reviews; searched Web sites of government agencies, professional organizations, and other organizations for grey literature; and monitored health news Web sites and journal tables of contents to identify potentially eligible trials. Two investigators independently reviewed identified abstracts and full-text articles against a set of a priori inclusion and quality criteria. One investigator abstracted data into an evidence table and a second investigator checked these data. We conducted random- effects meta-analyses to estimate the benefit of cognitive behavioral therapy (CBT) in pregnant and postpartum women.
Results: We included 71 studies reported in 91 publications. Nine trials addressed screening in general (five trials; n=2,924) and older (four trials; n=890) adults. The remaining targeted pregnant and postpartum women, addressing the benefits of screening (six trials; n=11,869); harms of screening (one trial; n=462); benefits of treatment (18 trials; n=1,638); harms of treatment with second-generation antidepressants (one systematic review, including 15 studies in pregnant women with depression and 109 studies in general pregnant populations, one trial [n=87], and 12 observational studies [n=4,759,735]); and diagnostic accuracy of selected screening instruments (26 studies; n=6,175). Most studies of antidepressant harms were limited to pregnant women, but evidence for other questions primarily focused on postpartum women.
Trials in postpartum women showed 28 to 59 percent reductions in the risk of depression at 3- to 5-month followup after participating in programs involving depression screening, with or without additional treatment components, compared to usual care. For identifying major depressive disorder using a cutoff of 13 on the English-language Edinburgh Postnatal Depression Scale, sensitivity ranged from 0.67 (95% CI, 0.18 to 0.96) to 1.00 (95% CI, 0.67 to 1.00) and specificity ranged from 0.87 (95% CI, 0.79 to 0.93) to 0.99 (95% CI, 0.97 to 1.00). Pooled results for the benefit of CBT in pregnant and postpartum women with screen-detected depression showed a 34 percent increase in the likelihood of remission with CBT (pooled RR, 1.34 [95% CI, 1.19 to 1.50]; k=10; I2=7.9%) compared to waitlist or usual care. Observational evidence showed that second-generation antidepressant use during pregnancy may be associated with small increases in the risk of preeclampsia, postpartum hemorrhage, miscarriage, perinatal death, preterm birth, being small for gestational age, infant seizures, serotonin withdrawal syndrome, respiratory distress, pulmonary hypertension, major malformations, and cardiac malformations.
Screening programs generally increased the likelihood of remission and treatment response in general adult populations (k=5) experiencing depressive symptoms, but typically included additional treatment supports. None of the trials limited to older adults (k=4) showed a benefit of the screening program, and one showed a statistically nonsignificant adverse effect on depression remission.
Conclusions: Although direct evidence of the isolated health benefit of depression screening in primary care is weak, the totality of the evidence supports the benefits of screening in pregnant and postpartum and general adult populations, particularly in the presence of additional treatment supports such as treatment protocols, care management, and availability of specially trained depression care providers. Evidence is least supportive of screening in older adults, where direct evidence is most limited.