Draft Research Plan
Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents
April 30, 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.
Abbreviation: KQ=key question.
- Do screening programs for depression, anxiety, and increased risk of suicide in primary care or comparable settings result in improved health outcomes in children and adolescents?
- Do instruments to screen for depression, anxiety, or increased risk of suicide accurately identify children and adolescents with depression, anxiety, and increased risk of suicide in primary care or comparable settings?
- What are the harms associated with screening for depression, anxiety, or increased risk of suicide in primary care or comparable settings in children and adolescents?
- Does treatment (psychotherapy, pharmacotherapy, or collaborative care) of depression, anxiety, or increased risk of suicide result in improved health outcomes in children and adolescents?
- What are the harms of treatment (psychotherapy, pharmacotherapy, or collaborative care) in children and adolescents who are treated for depression, anxiety, or increased risk of suicide?
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
- What is the diagnostic yield from screening for depression, anxiety, or increased suicide risk in typical primary care practice settings?
- What are the minimal clinically important differences for symptoms and functioning on the most common instruments used to measure treatment of depression, anxiety, or increased suicide risk?
- What are the U.S. Food and Drug Administration boxed warnings for pharmacotherapy for the treatment of depression, anxiety, or increased suicide risk?
- What psychotherapies other than cognitive behavioral therapy are used to treat anxiety in children?
- What is the effectiveness of treatment in children and adolescents with persistent depressive disorder and depressive disorders not otherwise specified?
- What proportion of children and adolescents who screen positive for depression, anxiety, or increased suicide risk engage with care?
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.
|Condition definition||Major depressive disorder, as defined by DSM criteria (present in at least 50% of the enrolled study population)
Anxiety disorders include generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism
Definitions for increased risk of suicide may vary by study but may include suicidal ideation (suicidal thoughts or plan for suicide), history of suicide attempts (nonfatal, self-directed, and potentially injurious behavior that is intended to result in death), and deliberate self-harm
Included studies may address these conditions individually or in combination
|Other mental health disorders (e.g., obsessive compulsive disorder, posttraumatic stress disorder, psychotic disorders, bipolar disorder, cyclothymia, adjustment disorder with depressed mood), persistent depressive disorder/dysthymia, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, and depression not otherwise specified; substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified|
|Population||KQs 1–3: Children and adolescents (age ≤18 years). Studies may include:
KQs 4, 5: Children and adolescents (age ≤18 years) with major depressive disorder, anxiety disorders, or increased risk of suicide
A priori subpopulations of interest include by age (children vs. adolescents), race/ethnicity, gender identity, and sexuality
|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 major depressive disorder, anxiety disorders, or an increased risk of suicide; self-report, clinician administered, or electronically delivered (<5 minutes if clinician administered, <15 minutes if self-administered) instruments are eligible
KQs 4, 5 (depression and suicide):
KQs 4, 5 (anxiety):
|KQ 1–3: Studies reporting on a screening instrument that does not have established validity and scoring mechanism for use within clinical practice
KQs 4, 5 (all disorders): Other treatment modalities (e.g., exercise, light therapy, transcranial magnetic nerve stimulation, electroshock treatment, diet and herbal supplements such as St. John’s wort and other complementary and alternative medicine, social marketing, policy, system-level interventions, or adjunctive agents to enhance the effects of antidepressants) except as optional adjunctive components to counseling, care delivery models, or first-line pharmacotherapy agents
Interventions involving components that could not be replicated in most health care settings, including environmental components (media messages, public signage) or interventions on groups in closed (preexisting) social networks (e.g., in daycares, schools)
Pharmacotherapeutic agents that are not FDA approved for pediatric use (e.g., paroxetine)
KQs 4, 5 (anxiety): Psychotherapy other than cognitive behavioral therapy
|Comparators||KQs 1, 3 (screening): Usual care/no screening
KQ 2 (depression and anxiety): Clinical diagnosis based on structured clinical interview by qualified professional using standard diagnostic criteria in place at the time of the study (e.g., DSM-IV or DSM-5)
KQ 2 (suicide): Assessment of increased suicide risk based on clinical interview by qualified professional
KQs 4, 5 (psychotherapy and care delivery model):
KQs 4, 5 (pharmacotherapy): Placebo (including placebo along with psychotherapy, when compared with the active agent plus the same psychotherapy intervention)
|KQs 1, 3: No comparator
KQ 2: Another screening instrument, nonstandardized clinical diagnosis (i.e., diagnosis not made based on existing DSM criteria at the time of the study)
KQs 4, 5: Active intervention (i.e., comparative effectiveness), no comparator
|Outcomes||KQs 1, 4:
KQ 2: Sensitivity, specificity, or data to calculate one or both
KQs 3, 5:
KQ 5 (pharmacotherapy only):
|All KQs: All other outcomes|
|Outcome assessment timing||No minimum followup||Not applicable|
KQs 4, 5:
|Study design||KQs 1, 3: RCTs, CCTs
KQ 2: Studies of diagnostic test accuracy**
KQ 3: Observational studies
KQ 4: RCTs
|All other study designs
KQ 2: Psychometric development and internal (e.g., split sample) validation studies of new instruments; case-control studies (i.e., studies that limit the study sample to only those with and without known mental health symptoms)
KQs 1–4: Systematic reviews of RCTs (reviews will only be used to identify relevant studies)
|Study geography||Primary studies that primarily take place in countries categorized as “Very High” on the 2019 Human Development Index (as defined by the United Nations Development Programme)||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|
|Quality rating||Fair- or good-quality studies||Fair- or good-quality studies|
Abbreviations: CBT=cognitive behavioral therapy; CCT=controlled, clinical trial; DSM=Diagnostic and Statistical Manual of Mental Disorders; FDA=U.S. Food and Drug Administration; KQ=key question; RCT=randomized, controlled trial.