Screening

Recommendations

The US Preventive Services Task Force (USPSTF) found convincing evidence to recommend screening for depression in the general adult population, including pregnant and postnatal women and older adults, although public health bodies in some countries (e.g., the UK and Canada) do not recommend routine screening.[132]​​​[152][153]​​ Systems should be in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening. There was insufficient evidence to support universal screening of suicide risk directly.[132]

There are some clinical situations in which routine screening is recommended. For example, because of the high risk for depression after physical trauma, a brief screening instrument like the Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) should be administered to patients admitted to trauma centres, according to US-based guidance.[154]​ Regular routine screening and assessment for depression is recommended for patients with cancer in all phases of the illness, according to European treatment guidelines.[155]

Tools

The PHQ-2 is derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD) tool and quickly and accurately screens for depression with only two questions:[135]

'Over the past 2 weeks, have you felt down, depressed, hopeless?'

'Over the past 2 weeks, have you felt little interest or pleasure in doing things?'

A positive response to either question warrants a thorough review of the Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR) criteria or an equivalent tool.

The PHQ-9 can be used as a diagnostic and disease management tool. The PHQ-9 is a 9-item depression questionnaire that reflects the DSM-5-TR criteria. It classifies current symptoms on a scale of 0 (no symptoms) to 3 (daily symptoms). It has been validated for use in primary care settings. Repeating the PHQ-9 during treatment allows the clinician to objectively monitor response to therapy.

One meta-analysis determined that a screening approach beginning with a PHQ-2, and moving on to a PHQ-9 for PHQ-2 scores of ≥2, was similarly accurate to administering the PHQ-9 to all patients, and reduced the need to administer a full PHQ-9 by over 50%.[156]

Screening in pregnancy

Evidence suggests that screening pregnant and postnatal women reduces the risk of depression.[157][158]​​​ The US guidelines stress the importance of routinely assessing patients for depression during the perinatal period. The American College for Obstetricians and Gynecologists (ACOG) recommends that screening for perinatal depression takes place at multiple timepoints during the perinatal period using the same standardised, validated screening instrument; this includes the initial antenatal visit, later in pregnancy, and at postnatal visits. Examples given include the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire (PHQ-9).[136]​​​

This EPDS is a 10-item questionnaire that is commonly used in the perinatal period. A score of ≥10 suggests depression.[138][139][140]​​​​​ One meta-analysis determined that a cut-off score of 13 or more identified higher-severity cases, while a cut-off score of 11 or above optimised sensitivity and specificity in screening.[159] EDPS includes an assessment of suicidal ideation. Edinburgh Postnatal Depression Scale Opens in new window

ACOG recommends that, when someone answers ‘yes’ to a self-harm or suicide question in the perinatal period, clinicians should immediately assess for likelihood, acuity, and severity of risk of suicide attempt and then arrange for risk-tailored management.[136]​ See Suicide risk mitigation.

Canadian guidance recommends against universal instrument-based screening during the perinatal period, but assumes that, as part of usual care during the perinatal period, care providers will inquire about and be attentive to maternal health and well-being.[160]​ The UK National Institute for Health and Care Excellence (NICE) recommends that healthcare professionals (including midwives, obstetricians, health visitors, and general practitioners) should consider asking two questions to identify possible depression in the perinatal period, at the woman's first contact with primary care, at her first antenatal appointment (usually around week 10 of pregnancy), and postnatally (first year after childbirth):[137]

  • During the past month, have you often been bothered by feeling down, depressed, or hopeless?

  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers 'yes' to either of the initial questions, is at risk of developing a mental health problem, or there is clinical concern, NICE recommends that clinicians consider:

  • Using the EPDS or

  • Using the PHQ-9 as part of a full assessment or

  • Referring the woman to her GP, or, if a severe mental health problem is suspected, to a mental health professional

Women at high risk for depression because of a prior or current history of severe depressive disorder should ideally be under the care of a specialist perinatal psychiatrist; clinicians should ask about depressive symptoms at each contact.[137]

For specific information on screening for depression in the postnatal period, see Postnatal depression.

Screening in older adults

The Geriatric Depression Scale and Cornell Scale for Depression in Dementia have been validated for older adults with and without dementia, respectively.[141][142][143] [ Geriatric Depression Scale Opens in new window ]

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