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Depressive Disorders

Screening for Depression and Suicide Risk in Children and AdolescentsUpdated Evidence Report and Systematic Review for the US Preventive Services Task Force

To identify the key insights or developments described in this article

1 Credit CME

JAMA

Published Online: October 11, 2022

US Preventive Services Task Force

Article Information and Disclosures

Meera Viswanathan, PhD^1,2;

Ina F. Wallace, PhD^1,2;

Jennifer Cook Middleton, PhD^1,3;

Sara M. Kennedy, MPH^1,2;

Joni McKeeman, PhD⁴;

Kesha Hudson, PhD^1,2;

Caroline Rains, MPH^1,2;

Emily B. Vander Schaaf, MD, MPH⁵;

Leila Kahwati, MD, MPH^1,2

Author Affiliations

¹RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center
²RTI International, Research Triangle Park, North Carolina
³Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
⁴Department of Psychiatry, University of North Carolina at Chapel Hill
⁵Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill

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Abstract

Importance Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide.

Objective To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF).

Data Sources PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events.

Results Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, −0.58 [95% CI, −0.83 to −0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, −2.25 [95% CI, −4.09 to −0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children’s Depression Rating Scale–Revised mean difference, −3.76 [95% CI, −5.95 to −1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children’s Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, −2.35 [95% CI, −4.06 to −0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different.

Conclusion and Relevance Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.

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Article Information

Corresponding Author: Meera Viswanathan, PhD, RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709 (viswanathan@rti.org).

Accepted for Publication: August 25, 2022.

Published Online: October 11, 2022. doi:10.1001/jama.2022.16310

Author Contributions: Dr Viswanathan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Viswanathan, Kahwati.

Acquisition, analysis, or interpretation of data: Viswanathan, Wallace, Cook Middleton, Kennedy, McKeeman, Hudson, Rains, Vander Schaaf.

Drafting of the manuscript: Viswanathan, Kennedy, Rains.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Viswanathan, Wallace, Kahwati.

Obtained funding: Viswanathan, Kahwati.

Administrative, technical, or material support: Viswanathan, Kennedy, Rains.

Supervision: Viswanathan.

Conflict of Interest Disclosures: Dr Vander Schaaf reported that she is a Fellow of the American Academy of Pediatrics and member of American Academy of Pediatrics CATCH Committee. No other disclosures were reported.

Funding/Support: This study was funded under contract HHSA-290-2015-00011-I, Task Order 15, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS), under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not represent the official position of AHRQ or HHS.

Additional Contributions: We acknowledge the following individuals for their contributions to this project: AHRQ staff Iris Mabry-Hernandez, MD, MPH, and Tracy Wolf, MD, MPH; current and former members of the USPSTF who contributed to topic deliberations; RTI International–University of North Carolina Evidence-based Practice Center staff Christiane Voisin, MSLS, Candi Wines, MPH, Nila A. Sathe, MA, MLIS, Carol Woodell, BSPH, Sharon Barrell, MA, Staci Rachman, BA, Michelle Bogus, Sarah Barringer, and Loraine Monroe. USPSTF members, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of the full evidence report underwent external peer review from 4 content experts (Gregory Simon, MD, MPH, University of Washington; Joan Asarnow, PhD, University of California, Los Angeles; Natalie Cort, PhD, William James College; and Raquel Halfond, PhD, American Psychological Association) and a federal partner reviewer (Erin Abramsohn, DrPH, MPH, Centers for Disease Control and Prevention). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF recommendation statement. It did not undergo additional peer review after submission to JAMA.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.