Monday, February 8, 2016

New USPSTF and ACP guidelines on depression screening and treatment

- Kenny Lin, MD, MPH

Major depressive disorder is a common condition that responds to psychotherapy and medications, and several screening tools have been validated for use in primary care. However, screening tools will not work if doctors are unable or unwilling to use them; a 2011 analysis by the Robert Graham Center found that family physicians and general internists screened for depression in only 2 to 4 percent of visits. Also, it is not clear if adults with screen-detected depression benefit from treatment to the same extent as those with clinically evident symptoms. This distinction is important since antidepressants may increase suicide risk, and a recent analysis suggested that suicidal ideation is underreported in trials of antidepressants.

In this context, the U.S. Preventive Services Task Force recently reiterated a previous recommendation for primary care clinicians to routinely screen adults for depression, and for the first time found sufficient evidence to screen pregnant and postpartum women. In the Task Force's supporting evidence summary, Dr. Elizabeth O'Connor and colleagues reported:

Among pregnant and postpartum women 18 years and older, 6 trials (n = 11,869) showed 18% to 59% relative reductions with screening programs, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3–5 months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care.

A new clinical practice guideline from the American College of Physicians (ACP) reviewed the comparative effectiveness of treatment for major depressive disorder and recommended that "clinicians select between either cognitive behavioral therapy or second-generation antidepressants ... after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient." The ACP arrived at this relatively non-specific guidance after finding few differences between multiple comparisons: psychotherapy vs. medications; medications vs. exercise; medications vs. St. John's Wort; and switching medications vs. adding cognitive therapy. Benefits and harms of treatments were similar between men and women and in subgroups defined by race and ethnicity.

In an accompanying editorial, Drs. John Williams, Jr. and Gary Maslow urged generalist physicians to "seize the day" to improve diagnosis and treatment of depression through integrated primary and mental health care models, which they defined as consisting of "support for self-management, follow-up that includes careful assessment of treatment adherence and response, coordination with mental health specialists to increase access to psychological treatments, and more intensive treatment of refractory depression."