Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.
To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.
MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.
English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.
Data Extraction and Synthesis
One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.
Main Outcomes and Measures
Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.
For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.
Conclusions and Relevance
Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: May 1, 2023.
Corresponding Author: Elizabeth A. O’Connor, PhD, Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227 (email@example.com).
Author Contributions: Dr O’Connor 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: All authors.
Acquisition, analysis, or interpretation of data: O’Connor, Perdue, Coppola, Henninger, Gaynes.
Drafting of the manuscript: O’Connor, Coppola, Henninger, Gaynes.
Critical revision of the manuscript for important intellectual content: Perdue, Henninger, Thomas, Gaynes.
Statistical analysis: O’Connor, Perdue, Gaynes.
Obtained funding: O’Connor, Gaynes.
Administrative, technical, or material support: Perdue, Coppola, Henninger, Thomas, Gaynes.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was funded under contract HHSA290201500011I, Task Order 75Q80119F32015, and contract 75Q80120D00004, Task Order 75Q80122F32005, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.
Role of 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; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.
Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Iris Mabry-Hernandez, MD, MPH, and Tina Fan, MD, MPH (AHRQ); current and former members of the US Preventive Services Task Force who contributed to topic deliberations; and Melinda Davies, MAIS, and Jill Pope, BA (Kaiser Permanente Center for Health Research) for technical and editorial assistance.
Additional Information: A draft version of this evidence report underwent external peer review in October 2021 from 5 content experts (Ramin Mojtabai, MD, PhD, MPH; Pim Cuijpers, PhD; Tiffany A. Moore Simas, MD, MPH; Raquel Halfond, PhD; Bobbi Jo Yarborough, PsyD) and 3 federal partners (NIH Office of Research on Women’s Health: Rebecca DelCarmen-Wiggins, PhD; Regine Douthard, MD, MPH; Shilpa H. Amin, MD, MJ, CAQ; Damiya E. Whitaker, PsyD, MA; Elena Gorodetsky, MD, PhD; National Institute of Child Health and Human Development: Jackie Wallace, MD, MPH; Centers for Disease Control and Prevention: Erin M. Abramsohn, DrPH, MPH). Comments 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.
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:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
You currently have no searches saved.
You currently have no courses saved.