Behind the U.S. task force recommendation to screen all children and adults for depression

In a recently published special report, Associate Editor of The BMJ, Jeanne Lenzer, critically calls into question the research methodologies and data underlying the latest U.S. task force recommendation to routinely screen for depression in all children and adults, aged 12 years and older, including pregnant and postpartum women.

“Some task force recommendations rely on questionable research methodologies, including the use of ‘indirect’ evidence; failure to include unpublished data; failure to check reported outcomes versus pre-specified outcomes; and, in at least one case, to have promulgated broad screening recommendations in the absence of a single randomised controlled screening trial (RCT).”

This past year’s recommendation follows a series of similar screening recommendations put forth by the United States Preventive Services Task Force (USPSTF). Lenzer notes this recommendation comes just after Congress significantly cut funds toward the Agency for Healthcare Research and Quality (AHRQ), the task force’s main government agency, in December of 2015.

“It is unclear what effects these threats have had. But in the past few years, the task force has issued several recommendations that are far more liberal in promoting interventions, which some experts say will lead to overtesting and overtreatment.”

The recommendations regarding routine universal depression screenings have sparked significant controversy among specialists in the field (see MIA report) in the past 15 years. Many of these experts, including the academic psychiatrist, Allen Frances, and psychiatry professor, Brett Thombs, express concerns with the risks involved in overdiagnosis, overtreatment, and unnecessary medicalization, especially when considering the potential harm involved in pathologizing sadness in adolescence.

Both the UK National Institute for Health and Care Excellence and the Canadian task force have decided against the recommendation of routine depression screenings, noting that there is not enough existing evidence to justify the potential harm involved in its implementation. Lenzer builds upon this, in this report, by highlighting the lack of evidence, and particularly the fact that there are currently no randomized control trial (RCT) studies to support the aim of this recommendation:

“Because there are no RCTs of depression screening versus no screening that show a health benefit, the task force relied on evidence from studies of the accuracy of screening tests and, separately, of depression treatment approaches.”

Lenzer also highlights the USPSTF’s reliance on published, industry-funded data, despite the U.S. Food and Drug Administration (FDA) guidelines to attend to unpublished data. Similarly, although evidence indicates outsourced researchers are free of financial interests, the evidence-based practice centers (EBCs) where the data are outsourced and conducted, are industry funded.

“Given the history of Congressional punishment of the AHRQ for publishing results believed to interfere with industry interests, conflicts at the institutional level—rather than individual researcher level—are of concern.”

Lenzer’s investigation of USPSTF raises important questions concerning the reliability of task force recommendations and the potential harm that may result from depression screenings. As Thombs describes, the evidence does not support benefits related to screenings of depression, yet there is evidence demonstrating the adverse outcomes linked to treatment through antidepressants, and the prevalence of over-diagnosis and over-treatment of depression in community and primary care settings in the U.S.

Heneghan, a co-author of the Cochrane review, provided The BMJ with this perspective:

“In the face of no evidence, or very low quality evidence, guideline writers should refrain from making recommendations. Indeed many guideline bodies would better serve clinical practice by making fewer recommendations: reflecting more of the uncertainty around treatment decisions. What we need are fewer recommendations and more high quality evidence to base decisions on. Currently we seem to be seeing the exact opposite.”

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Lenzer, J. (2017. Is the United States Preventive Services Task Force still a voice of caution? The BMJ. doi:10.1136/bmj.j743 (Abstract)