Screening

Screening for depression

Guidance on screening varies according to country of practice. The author’s view is that children and adolescents with risk factors seen at primary care settings should be screened for major depressive disorder. Risk factors include:

  • Family history of mood disorder

  • History of trauma or recent trauma, including physical or sexual abuse or neglect

  • Significant psychosocial stress (e.g., parental divorce, parental depression, severe parental medical illness, loss of a loved one including pets, conflict in peer or romantic relationships, conflict with parents)

  • Poor performance in school

  • Significant change of functioning

  • Chronic or severe medical illness

  • Certain medication treatment (e.g., corticosteroids, interferon)

  • Recent history of giving birth.

Screening of children and adolescents with risk factors for major depressive disorder is also recommended in the emergency department setting.[63]​ 

Annual universal screening for depression in a primary care setting is recommended for all children ages 12 years and older, even in the absence of specific risk factors, according US-based guidance.[64]​​[65]​​ This approach is endorsed by the US Preventive Services Task Force (USPSTF).[65]​ At present, the USPSTF does not recommend screening for depression in children ages 11 years or younger, based on insufficient evidence of net benefit. However, note that in children in this age group, early identification can facilitate early intervention.[66]​ Children who come into contact with psychiatric services always need to be screened for depression because depression is highly comorbid with other psychiatric disorders.[67]​​​

Screening should be completed by direct clinician interview, in addition to one of the depression rating scales reviewed below.[64]

Reynolds Adolescent/Child Depression Scales (RADS/RCDS)

The RADS/RCDS is a child- and parent-report depression instrument with useful psychometric properties.[72][73]​ It is an effective screening tool but probably not a good instrument for monitoring treatment outcomes.[74]​ It is available in multiple languages and is suitable for both children and adolescents. It is copyrighted, and therefore must be purchased from the publisher.

Mood and Feelings Questionnaire (MFQ)

The MFQ is a self-, parent-, and teacher-reported depression scale for children and adolescents.[75]​ It is a good screening tool and can be used in both clinical and research settings.[76]​ It can be accessed online for clinical or research use. Duke University: Mood and Feelings Questionnaire Opens in new window​ A short version of the MFQ (MFQ-SF) was found to be sensitive in screening for major depressive disorder among youths ages 11-17 in a primary care setting.[77]

Beck Depression Inventory (BDI)

The BDI is a widely used adolescent self-rated depression scale with good psychometric properties.[74][78]​ It is copyrighted, so must be purchased from the publisher.

Child Depression Inventory (CDI)

The CDI is a 27-item, self-rated assessment of depression and/or dysthymic disorder symptoms.[79]​ Items are grouped into 5 factor areas. The CDI is a widely used and accepted assessment for the severity of depressive symptoms with high reliability.

Patient Health Questionnaire (PHQ-9): adolescents

A depression-focussed screening tool such as the PHQ-9 is recommended by the US Preventive Sercives Task Force (USPSTF) for depression screening in adolescents.[65]​ The PHQ-9 is a psychologic assessment for screening, diagnosing, and monitoring the severity of depression or dysthymic symptoms.[80]​ It is a brief self-report scale, and item 9 includes a screening question for suicidal ideation. Diagnostic validity has been established in primary care settings. Note that PHQ-9 contains a question on suicidality; given that a positive response necessitates urgent assessment, this is not an appropriate screening tool for remote screening when a clinician is not immediately available to monitor and act on positive responses (e.g., via patient portal in advance of well visits in primary care).[66]

Depression rating scales may also facilitate measurement of response to treatment over time (''measurement-based treatment'').[66]

Screening for suicidal ideation

Although the USPSTF found insufficient evidence to recommend routine screening for suicide risk in children and adolescents in primary care, the American Academy of Pediatrics (AAP) recommends that pediatricians screen all youth ages 12 years and older for suicide risk at least annually.[65][81]​ The AAP notes that screening at every visit may be indicated for higher risk populations, such as those presenting with psychiatric problems such as depression.[68]

The AAP notes that the emergency department plays a key role in identifying children and youth at immediate risk for suicidality, regardless of whether they are at risk for depression. Use of a brief validated screening tool for suicidality, for example, the Ask Suicide Screening Questions (ASQ) (validated in children ages 10 years and over) or Columbia Suicide Severity Rating Scale for pediatrics (C-SSRC) (validated in children and adults ages 12 years and over) may be helpful in this setting.[82][83][84]

Screening for suicidal ideation in adolescents should typically take place in a confidential manner, without caregivers present, given that young people may be reluctant to report suicidal ideation in the company of caregivers. Use of a brief suicide safety assessment (BSSA) is recommended by the AAP for all patients screening positive for suicide risk, in order to further explore their personal risk and protective factors. Note that the BSSA is different from the initial screening tool, which simply identifies risk.[69]

It is imperative to ask about access to lethal means (firearms, medications, illicit substances, knives, ropes) in the event of a positive screen for suicidal ideation, followed by risk-tailored counseling and mitigation.[68][70] A positive screening result for suicidal ideation should be followed safety planning, an intervention that encompasses helping the patient identify their risk factors for suicidal ideation as well as a series of supports that they can draw on to reduce their risk of self-harm. Children and adolescents who are depressed with severe suicidality without being able to maintain safety, or with significant psychosis, require urgent referral to the emergency department. See: Suicide risk mitigation.

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