Depression among Children and Adolescents (Screening)
Evidence Statement
References 
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Updated 12/02/11
Evidence StatementClinical Preventive Service RecommendationsU.S. Preventive Services Task Force RecommendationThe USPSTF recommends screening of adolescents (12 through 18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive, behavioral or interpersonal), and follow-up.1Evidence Rating: B (Recommended/Moderate Certainty) The USPSTF found adequate evidence that screening tests accurately identify MDD among adolescents and that treatment among adolescents with selective serotonin reuptake inhibitors (SSRIs), psychotherapy, and combined therapy (SSRIs and psychotherapy) results in decreases in MDD symptoms.1
The Value of PreventionEconomic Burden of Condition/DiseaseThe economic burden of childhood depression is not available. However, the disorder affects many different service systems, including the child welfare, juvenile justice, mental health, general medical, and education systems; consequently, the total economic burden likely is substantial.Workplace Burden of Condition/DiseaseThe workplace burden of childhood depression includes direct and indirect costs. Children with depression had average annual health care expenditures that were significantly higher ($3,792) than those of children without depression ($754).11 Indirect costs to the employer include absenteeism and reduced productivity of caregiver parents.12 Employees caring for a child with a mental health diagnosis report, on average, 1.4 lost work days and 1.2 early departures from work per month.13Childhood depression also can extend into adulthood and affect the future workforce. Young adults who are diagnosed with adolescent onset depression are at risk of impairment in work, family, and social functions throughout their life.14 Economic Benefit of Preventive InterventionThe economic benefits of depression screening result mainly from averting the lost productivity costs associated with parental productivity and future disease during adulthood.15 Some studies suggest that treatment of depression can lead to decreased general medical costs; however, conclusive evidence for children and adolescents is not available.Estimated Cost of Preventive InterventionIn 2007, the median private sector cost for depression screening using a health risk assessment instrument was $23.16 Approximately 95% of paid claims fell ranged from $12 to $90.16Estimated Cost of TreatmentThe cost of treatment for childhood depression varies depending on the treatment modalities used. In 2008, 53.2% of adolescents who received treatment for depression saw or talked with a medical doctor or other professional about depression, but did not take prescription medication for depression.17 In addition, 40.4% saw or talked with a medical doctor or other professional about depression and used prescription medication for depression.17 The remaining 6.4% only took prescription medication for depression.17The cost of antidepressants varies based on type and dosage; however, only fluoxetine (Prozac®) has been approved by the U.S. Food and Drug Administration (FDA) for use among children.18 The average wholesale prices (AWP) for a 1-month supply of fluoxetine are noted in the following table.9 Table 1: Common Selective Serotonin Re-uptake Inhibitors (SSRIs) approvied by the U.S. Food and Drug Administration-for Use by Children (30-Day Supply).
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive InterventionA cost-effectiveness analysis of screening among adolescents 12 through 18 years of age is not available. Assuming that screening among this age group is comparable with adult screening, the cost-effectiveness would depend on the frequency of screening. An analysis published in 2001 on the cost-effectiveness of annual screening of primary care patients for depression yielded a cost estimate of $192,444 per quality-adjusted life year (QALY), which is not considered cost-effective.21 However, one-time depression screening yielded a cost estimate of $32,053/QALY, which is considered cost-effective.21Condition Specific InformationEpidemiology of Condition/DiseaseMDD is a mental disorder that frequently is diagnosed among children and adolescents.1 An estimated 3% of children and 5.6% of adolescents suffer from major depression.2 However, an estimated 9% to 21% of adolescents are diagnosed with major depression at any one time in a primary care office setting.3Depression manifests itself differently among children than it does among adults. Unlike adult depression, which is characterized by unhappiness or loss of interest in activities, childhood depression symptoms include irritability resulting in tantrums or verbal outbursts, social isolation, decreased school performance, and anger.4 Adolescents are less likely to enjoy pleasurable experiences, and more likely to feel hopeless, increase the amount of time spent sleeping, change weight, use alcohol or drugs, and attempt suicide.5 Morbidity among depressed children and adolescents can cause diminished school performance, early pregnancy, poor social functioning, an increased number of physical illnesses, and substance abuse.1 Depression is present in 35% of adolescent's suicides, making it the most common single disorder predictor of suicide,6 the third leading cause of death among adolescents.7 To be classified as a depressive episode, symptoms must last for at least 2 weeks and can last an average of 7 to 9 months among children and adolescents, with repeated episodes occurring in 40% to 70% of children.8 Condition / Disease Risk FactorsBoth psychosocial and biological factors can contribute to the onset of depression among children and adolescents.9 Major risk factors include having a parent with depression, having co-morbid mental health, or chronic medical conditions and having experienced a major negative life event. Adolescent females have a higher prevalence of major depression (5.9%) as compared to adolescent males (4.6%); this could be due to hormonal changes and different coping styles.10Preventive Intervention InformationPreventive Intervention: Purpose of ScreeningScreening children for depression identifies those with depression, allowing them to access care earlier in the course of their illness.Benefits and Risks of InterventionDepression screening allows individuals suffering from depression to be identified and receive the care indicated. Research suggests that 80% of patients with depression will improve with treatment.22 There also is adequate evidence that selective serotonin reuptake inhibitors (SSRIs), psychotherapy, and combination therapy (SSRIs and psychotherapy) decrease MDD symptoms among adolescents.The major risk of screening and treatment of adolescents (13 years of age or older) lies primarily with the potential harms of SSRIs, which can include suicide ideation, preparatory acts for suicide, or suicide attempts.1 There is little evidence on the harms of combining psychotherapy and SSRIs, but the USPSTF has determined that the harms are likely low. For children younger than 12 years of age, inadequate evidence exists as to the harms or benefits of depression screening, psychotherapy, and combination therapy. Furthermore, SSRIs have been demonstrated as being harmful to this group. Thus, the USPSTF has concluded there is insufficient evidence to make a recommendation on screening and treatment for children.1 Initiation, Cessation, and Interval of ScreeningThere is adequate evidence that screening tests accurately identify MDD among adolescents.1 Depression screening is a covered benefit at each visit for adolescents 12 through 18 years of age.The USPSTF has concluded that, at this time, there is insufficient evidence to recommend screening children 7 through 11 years of age for major depression. Children younger than 12 years of age should be screened only as medically indicated. Intervention ProcessMany depression screening tools (called instruments), currently are available for use with adolescents in the primary care setting. These instruments are composed of standardized questions that assess the number and severity of a patient's depression symptoms. Clinicians can then interpret the results to make a diagnosis of depression or not, and if so, develop a treatment plan. Two common depression screening instruments are the:
Patient Health Questionnaire for Adolescents (PHQ-A) Treatment InformationData demonstrating the effectiveness of pediatric interventions for MDD are limited, especially when compared with the large body of evidence supporting their use among adults. However, studies have been conducted to test SSRIs and other psychotherapies among pediatric populations and provide evidence that effective interventions are available, though long-term effects are not known.25 Intervention goals are decreased negative thoughts, increased involvement in positive activities, and management of interpersonal and psychosocial stressors.Currently, SSRIs are the most prescribed antidepressants for children; however, only fluoxetine (Prozac®) has been FDA-approved for use among this age group. The decision to treat an individual pediatric patient with an antidepressant should be based on the clinical situation and guidelines from mental health specialists.25 Careful consideration must be given to how closely a patient will be able to be monitored either through the clinical setting or at home after initiating a therapy.25 Strength of EvidenceEvidence-Based Research:U.S. Preventive Services Task Force (USPSTF) Strength of Evidence: B (Recommended/Moderate Certainty) The USPSTF has found adequate evidence that screening tests accurately identify MDD among adolescents and that treatment among adolescents using SSRIs, psychotherapy, and combined therapy (SSRIs and psychotherapy) results in decreases in MDD symptoms. Benefit Plan LanguageSummary Plan Descriptive LanguageCovered ScreeningsDepression screening, including the use of standardized depression screening or informal instruments, is a covered benefit.Initiation, Cessation, and IntervalDepression screening is a covered benefit for adolescents 12 through 18 years of age at each visit. Depression screening is covered for children younger than 12 years of age, as medically indicated.CPT Codes
Other Information and ResourcesBusiness Group ResourceNational Institutes of Health ResourceAuthored by:Meinert E, Lawlor G, Perou R. Depression among Children and Adolescents. 2009. Updated 2011.References
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