From the Editor
“Panel Calls for Depression Screenings During and After Pregnancy”
A government health-care panel making a revision to a past recommendation seems pretty ‘inside baseball’ – and hardly the stuff of international headlines. Last week, though, the decision of the U.S. Preventive Services Task Force to now recommend the screening of pregnant and post-partum women for depression was reported from New York to New Delhi.
For the record, The New York Times story (whose headline appears above) ran on the front page.
Why the change and what are the implications?
This week’s Reading looks at the big decision and we consider: is it a big bust?
“Screening for Depression in Adults US Preventive Services Task Force Recommendation Statement”
Albert L. Siu and the US Preventive Services Task Force (USPSTF)
JAMA, 26 January 2016
The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
So begins the Recommendation Statement just published in JAMA.
The USPSTF reviews varies aspects of screening, concluding:
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation)
This has clear implications in the United States – a B level recommendation means that insurance coverage must include such services. Remember, in the United States, many are covered by private insurance that is regulated. For millions of American women, this short paper will have a big influence.
The reasoning behind statement is interesting. Remember: there is more to screening than deciding whether or not an illness is problematic. Population screening is complicated and ties into different considerations: Are screening tools useful at identifying the problem? Are treatments safe? Are they effective? To pick up on this point, in a 2012 CMAJ analysis, Brett D. Thombs et al. argued against screening for depression in the general population. (!) That paper notes that screening of the general population isn’t recommended in the United Kingdom because of various concerns, including “the high rate of false-positives” (or people who are identified by screening as having depression, but don’t). Let’s be clear: this is an apples-to-oranges comparison, since Thombs et al. looked at the whole population and the new USPSTF recommendation is focused on pregnant and post-partum women – the point, though, is that population health efforts aren’t black and white.
The Siu et al. paper goes into the rationale of their decision, breaking it along several lines: Importance, Detection, Benefits of Early Detection and Intervention and Treatment, Harms of Early Detection and, finally, Treatment. On the last criterion, Siu et al. note some issues with second generation antidepressants, but conclude: “The USPSTF found adequate evidence that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none.”
This paper is a bit of a dry read, but it’s informed by the Evidence Report of Elizabeth O’Connor et al. For those of us who spend much time reading over review papers, this Evidence Report is refreshing in its concise and thoughtful writing.
The paper can be found here:
O’Connor and her co-authors ask a series of questions considering the risk and benefit of screening pregnant and post-partum women.
Does treatment (psychotherapy, antidepressants, or collaborative care) result in improved health outcomes (decreased depressive symptomatology; decreased suicide deaths, attempts, or ideation; improved functioning; improved quality of life; or improved health status) in pregnant and postpartum women who screen positive for depression in primary care?
Their literature review is well summarized by the following figure:
They finally conclude in favour of screening (with a vote for CBT):
The direct evidence suggested that screening pregnant and postpartum women for depression may reduce depressive symptoms in women with depression and reduce the prevalence of depression in a given population, particularly in the presence of additional treatment supports (eg, treatment protocols, care management, and availability of specially trained depression care clinicians). The indirect evidence showed that screening instruments can identify pregnant and postpartum women who need further evaluation and may need treatment. The only identified harm of treatment was the use of antidepressants during pregnancy, although the absolute risk of harm appeared to be small and CBT appeared to be an effective alternative treatment approach. [Emphasis added.]
And tying back to the Thombs et al. analysis, O’Connor and her co-authors didn’t find false positives to be problematic for this population with simple screening tools.
“US Preventive Services Task Force Recommendation Statement on Screening for Depression in Adults: Not Good Enough
Charles F. Reynolds III and Ellen Frank
JAMA Psychiatry, 26 January 2016
The US Preventive Services Task Force (USPSTF) has recommended screening for depression in the general adult population, including pregnant and postpartum women, with the use of brief, self-report instruments like the Patient Health Questionnaire 9 that typically take less than 5 minutes to complete. It further underscores the need for screening to be linked with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The recommendation is silent, however, with respect to the ideal screening interval and the settings with highest potential yield. These are major shortcomings in our opinion.
So begins Reynolds and Frank’s response.
This is an interesting editorial – Reynolds and Frank don’t debate the utility of screening, but they feel that the Recommendation Statement is a bust. “In our view, this recommendation, while more limited in scope than is warranted by the available data, is nonetheless of first-rank importance, given the immense public health burden of depression across the life cycle and its downstream sequelae.”
They like that the Recommendation Statement recognizes the fundamental importance of depression screening, particularly in primary care (where most people with mental illness are actually seen). But they have too sharp criticism: the Recommendation Statement is too vague and too unambitious.
Too vague. Screening suggested but the USPSTF doesn’t spell out how. Too unambitious. Reynolds and Frank flirt with the idea of far more screening in primary care (say every 6 months to 12 months for some patients, aimed at catching depression and subsyndromal depression).
Reynolds and Frank are blunt in their assessment of depression: “we must finally recognize that depression is toxic to the brain. It erodes healthy brain aging and cognitive fitness across the adult life span.”
A few thoughts:
1. This Recommendation Statement is a comment on our times. It says much about our day and age that the USPSTF would give this psychiatric topic so much attention – and that the resulting communication would be published in JAMA (with front page New York Times coverage).
2. This Recommendation Statement is a comment on our field. It’s good that mental illness gets attention; the screening recommendation, though, isn’t symbolic. It’s a call for action, partly built on the belief that screening matters. In other words, if we screen for depression, the USPSFT feels, it’s because we can do something about depression – that is, we have tools in the toolkit. That is a great comment on our field, indeed.
3. This Recommendation Statement was greeted enthusiastically on both sides of the 49th parallel – but is it an overreach? And, by extension, is the Reynolds-Frank call for more screening even more problematic? For one thing, screening recommendations need to be matched by action. There is one state in the U.S. that already does require screening in postpartum women for depression: New Jersey. But the USPSTF-like recommendation has proven something of a bust, at least with patients covered by Medicaid (public insurance for poorer Americans). The reason: there is a lack of resources to handle the people identified in the screening. The New Jersey experience, alas, is what the CMAJ analysis authors had warned about: screening’s good intention isn’t good enough.
4. And there is reason to be more hesitant on depression screening in general. I asked Dr. Scott Patten about the Recommendation Statement. He’s the editor of The Canadian Journal of Psychiatry and a co-author of the CMAJ analysis. He responded:
I personally don’t agree with the recommendation… Screening is usually effective for diseases with a detectable pre-clinical phase where earlier intervention is more effective than later intervention. I think the trouble with screening for depression is that: (1) These tools produce about a 20% false positive rate – so the implication is that one in five adults contacting medical services should be unnecessarily referred for assessment – to me this sounds like a misuse of our precious mental health resources when we can’t seem to deliver basic care to people with actual depressive disorders who are actually seeking help. (2) The epidemiology of MDE tells us that the majority of episodes are brief and self-limited. In prevalence studies the mean duration is about 12-16 weeks which is an average of a large number of very brief episodes and a small proportion of protracted ones. This is not the scenario of a progressive disease course for which screening works (in the classical way) through earlier intervention in the disease course. Instead, because of this kind of epidemiology screening diverts limited resources towards those with the fewest (if any) needs. In my experience (with a couple of screening projects) despite the fact that the prevalence of depression is high, the number of people who are depressed AND can benefit from treatment AND don’t know that they are depressed AND want treatment but haven’t sought it BECAUSE they didn’t know they were depressed (the group that screening could theoretically benefit) is fairly small. Universal screening is not in my opinion an efficient way to deal with that problem and that problem is not the main failing of our health systems for people with depression.
The Thombs et al. analysis from CMAJ can be found here:
The Kozhimannil et al. study on New Jersey and postpartum depression care can be found here:
Reading of the Week. Every week I pick a reading — often articles or papers — from the world of Psychiatry.