Draft Research Plan
Screening for Depression, Anxiety, and Suicide Risk in Adults, Including Pregnant and Postpartum Persons
May 07, 2020
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
This new topic incorporates and updates the evidence related to screening for and treatment of depression and suicide risk while adding evidence related to screening for and treatment of anxiety disorders and combination approaches that address more than one of these conditions.
- Do depression, anxiety, and suicide risk screening programs in primary care or comparable settings result in improved health outcomes in adults, including pregnant and postpartum persons?
- Does sending depression, anxiety, and suicide risk screening test results to providers (with or without additional care management supports) result in improved health outcomes?
- Do instruments to screen for depression, anxiety, and/or high suicide risk accurately identify adults, including pregnant and postpartum persons, with depression, anxiety, and high suicide risk in primary care or comparable settings?
- What are the harms associated with screening for depression, anxiety, and suicide risk in primary care or comparable settings in adults, including pregnant and postpartum persons?
- Does treatment of depression, anxiety, or high suicide risk (psychotherapy or pharmacotherapy) result in improved health outcomes in adults, including pregnant and postpartum persons?
- What are the harms of treatment of depression, anxiety, or high suicide risk (psychotherapy or pharmacotherapy) in adults, including pregnant and postpartum persons?
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
- What is the differential effect of screening for depression, anxiety, or suicide risk separately compared with screening for one or more of these conditions at the same time?
- What health care system supports (e.g., collaborative care) can help ensure appropriate diagnosis and followup, treatment engagement and retention, and improved outcomes?
- How well do suicide risk screening instruments predict future suicide attempts?
- What is known about the validity of the most commonly used or recommended instruments to screen for depression, anxiety, and suicide risk in U.S. racial/ethnic minority patients?
The Proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions.
||Other mental health disorders (e.g., obsessive-compulsive disorder, posttraumatic stress disorder, psychotic disorders, bipolar disorder, cyclothymia, adjustment disorder with depressed mood, and other depressive disorders [persistent depressive disorder/dysthymia, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition], and other anxiety disorders [agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition]).|
|Population||KQs 1–3: Adults (age ≥19 years), including pregnant and postpartum persons. Trials may include:
KQs 4, 5:
All KQs: A priori subpopulations of interest include pregnant and postpartum persons, older adults, and individuals identified through population-based screening in primary care or community settings.
|Interventions||KQs 1, 3: Screening interventions with or without additional provider or patient-facing elements such as referral support, treatment guidelines, symptoms monitoring, and standardized treatment. Screening tools must be brief standardized instruments designed to identify persons with depression, anxiety, and/or high risk of suicide; self-report, clinician-administered, or electronically delivered (<5 minutes for clinician-administered instruments, <15 minutes for self-administered instruments).
KQ 2: Limited to the most widely recommended or used screening tools:
KQs 4, 5: Intervention to address depression, anxiety, and/or risk of suicide, including
|KQ 2: Other screening instruments.
KQs 4, 5:
|Comparators||KQs 1, 3 (Screening):
KQ 2 (Diagnostic accuracy):
KQs 4, 5 (Counseling):
KQs 4, 5 (Pharmacotherapy):
|Active intervention (i.e., comparative effectiveness).|
|Outcomes||KQs 1, 4:
KQ 2: Sensitivity, specificity, or data to calculate one or both.
KQs 3, 5:
KQ 5 (Pharmacotherapy only):
|KQs 1, 4: Rate of identification of persons with depression, anxiety, or high risk of suicide (e.g., trials of clinician training to identify persons at high risk of suicide that report no patient outcomes).|
|Outcome assessment timing||KQs 1, 3–5: ≥6 weeks after baseline, except for suicide death or self-harm (no minimum followup).
KQ 5 (Harms of pharmacotherapy): No minimum followup.KQ 2: Maximum of 2 weeks between screening and reference standard.
|Setting||KQs 1–3: Primary care settings (e.g., internal medicine, family medicine, obstetrics/gynecology, pediatrics [for postpartum screening], family planning, military health clinics, university-based health clinics) or comparable (e.g., identification through health plan administrative databases).
KQs 4, 5:
KQs 4, 5:
|Study design||KQs 1, 3: Randomized, controlled trials; controlled clinical trials
KQ 2: Systematic reviews and studies of diagnostic accuracy reporting sensitivity and specificity (or comparable statistics) compared with an independently assessed gold standard (structured or semistructured diagnostic interview or a nonbrief [>5 minutes] unstructured interview with mental health clinician) within 2 weeks of screening in populations that include a full spectrum of patient severity for the given setting (i.e., studies cannot limit the patient pool to only nondepressed and known/highly likely depressed patients).
|All KQs: All other study designs.
KQ 2: If unable to limit to existing systematic reviews, case-control studies will be used (i.e., studies that limit the study sample to only participants with and without known mental health symptoms).
|Study geography||Reviews and primary studies that primarily take place in countries categorized as “Very High” on the 2018 Human Development Index (as defined by the United Nations Development Programme) (published 2019).||Reviews in which >50% of included studies take place in countries not categorized as “Very High” on the Human Development Index.|
|Publication language||English||Any language other than English|
|Publication year||1980 or later||Prior to 1980|
|Quality rating||Fair or good-quality studies||Poor-quality studies|