Depression screening and management programmes with staff assistance in primary care increase response and remission rates, but programmes without staff assistance do not show benefits
- Correspondence to Steve Wood
Department of Psychological Medicine, Cardiff University, 2nd Floor, Monmouth House, Heath Park, Cardiff CF14 4XN, UK;
Depression is a public health issue of worldwide importance. A World Health Organization study1 estimated that in 2030 the three leading causes of disability-adjusted life years would be HIV/AIDS, depressive disorders and ischemic heart disease. Current social trends, including reductions in the size of family units, increased use of alcohol and drugs, and increased urbanisation and migration suggest that depression will eventually become the leading cause of disability and burden worldwide. Issues relating to its recognition, treatment and management are, justifiably, subjects of much research activity.
This systematic review was carried out on behalf of the US Preventive Services Task Force (USPSTF), an independent panel that develops recommendations for clinical practice. The methods of searching, study selection, data extraction, quality assessment and data analysis followed USPSTF guidelines. The simplicity of the paper's title belies its ambitious scope. In addition to updating the evidence in relation to screening for depression in primary care, the paper sets out to review the evidence on the adverse effects of such screening; the effectiveness of pharmacological and psychological treatments for depression in older adults; and the adverse effects of second-generation antidepressants in depressed adults and older people.
To deal adequately with such disparate issues in a paper of this length is asking a lot, and the authors might perhaps have addressed each of the four main areas under discussion in a series of papers. Reference is made to the full report, available online, and examination of this version reveals that, with tables and appendices, it runs to 167 pages. As presented in the published version, the summary of results relating to screening for depression in primary care is difficult to interpret; for example, no distinction is made as to severity of depression in depressed patients, an important factor in treatment decisions.
The authors' conclusions in relation to screening for depression support those of an earlier Cochrane Review,2 that routine screening has minimal impact on the detection, management or outcome of depression. This is not to say that screening has no part to play. As the authors state, there is good evidence that comprehensive programmes of care do improve the management and outcomes of depression. Some of these incorporate screening, with feedback of results to clinicians; the individual contribution of screening to such improvement, however, is unclear.3
The authors' searches did not identify any studies that addressed whether there are any adverse effects of screening for depression. Consequently, there is no discussion of this in the paper. It is, however, an important consideration. In the UK, the National Screening Committee has produced criteria for appraising the viability, effectiveness and appropriateness of a screening programme.4 One criterion is that the benefit should outweigh the physical and psychological harm. Other authors3 have identified a number of potential harms, including stigma, inappropriate application of clinical diagnoses to transient distress and discrimination by insurance companies.
The effects of pharmacological and psychological treatments for depression in older adults are addressed only in the full online version of the paper. Recent Cochrane reviews5 6 can be consulted in relation to these areas. It is worth noting that in the UK, National Institute for Health and Clinical Excellence (NICE) guidelines for depression are organised in terms of severity and duration of the condition, with additional guidelines for particular age groups as appropriate.
The review concluded that second-generation antidepressants were generally well tolerated, with higher rates of side effects and discontinuation in older age groups. It further concluded that, although the evidence does not suggest an associated increase in completed suicide, there is clear evidence of increased suicidal behaviour, especially in younger adults. These conclusions are largely in accordance with those of the UK National Collaborating Centre for Mental Health in their review that led to the development of the most recent NICE guidelines.7
Competing interests None.