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AHRQ announces a new recommendation on screening for depression and other materials from the U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) is an independent panel first convened in 1984 by the U.S. Department of Health and Human Services to develop evidence-based recommendations for clinicians about preventive health care. The Task Force recommends which screening tests, immunizations, preventive medications, and counseling interventions doctors should routinely incorporate into clinical practice. The third USPSTF was convened in late 1998 by the Agency for Healthcare Research and Quality.

The Task Force's newly released recommendation on screening for depression, as well as other new materials, are described here. Previous recommendations and other prevention materials are available at http://www.ahrq.gov/clinic/prevenix.htm.

Pignone, M.P., Gaynes, B.N., Rushton, J.L., and others. (2002, May 21). "Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force." (Contract 290-97-0011). Annals of Internal Medicine 136(10), pp. 765-776.

According to the Task Force, there now is sufficient evidence to encourage primary care clinicians to screen their adult patients for depression. Formal screening can make it easier to identify depression, a common and treatable condition that often is not recognized by patients or their doctors. In releasing this recommendation, the Task Force noted that clinicians should have systems in place to assure accurate diagnosis, effective treatment, and followup if patients are to benefit from screening.

This recommendation updates the Task Force's 1996 recommendation. In 1996, the Task Force identified depression as an important clinical problem and encouraged clinicians to remain alert for signs of depression in their patients, but it concluded that there was insufficient evidence to recommend for or against regular formal screening. Since then, the Task Force has reviewed new evidence from randomized trials that tested various screening tools and interventions for depression. Task Force members found that patients fared best when clinicians recognized the symptoms of depression and made sure that patients received appropriate treatment.

Although there are many tools available to screen for depression, there is little evidence to recommend one over another. Clinicians can choose tools that are appropriate for their patients and practice setting. According to Task Force chairman Alfred Berg, M.D., M.P.H., Chair of the Department of Family Medicine, University of Washington, Seattle, the panel found that asking two simple questions, "Over the past 2 weeks, have you ever felt down, depressed, or hopeless?" and "Have you felt little interest or pleasure in doing things?" may be as effective as using longer screening instruments. An affirmative response to these questions may indicate a need for the use of more in-depth diagnostic tools.

According to the Task Force, 5 percent to 9 percent of adult patients in primary care settings suffer from depression. Depression is often disguised by other problems, and up to 50 percent of these cases go undetected and untreated. Women, people who have a family history of depression, the unemployed, and people with chronic disease are among those at increased risk for depression. Depression increases use of health care services and costs $17 billion in lost workdays each year.

The Task Force concluded that the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression. Although up to 2 percent of children and 4.5 percent of adolescents in primary care settings suffer from depression, there is not enough research about screening or treating this population in the clinical setting. Research in progress at the Agency for Healthcare Research and Quality will add to the currently limited evidence base for children and adolescents.

Miller, J., Chan, B.K., and Nelson, H.D. (2002, May). "Postmenopausal estrogen replacement and risk for venous thromboembolism: A systematic review and meta-analysis for the U.S. Preventive Services Task Force." Annals of Internal Medicine 136(9), pp. 680-690.

Postmenopausal estrogen replacement is widely used in the United States but poses important health risks, including venous thromboembolism. The authors used literature review and meta-analysis to assess this risk. They identified 12 relevant studies (three randomized controlled trials, eight case-control studies, and one cohort study). Their conclusion is that postmenopausal estrogen replacement is associated with an increased risk for venous thromboembolism, and this risk may be highest in the first year of use.

U.S. Preventive Services Task Force. (2002, May). "Aspirin for the primary prevention of cardiovascular events: Recommendations and rationale." American Family Physician 65(10), pp. 2107-2110.

Cardiovascular disease—including ischemic coronary heart disease (CHD), stroke, and peripheral vascular disease—is the leading cause of death in the United States. Each year, over 1 million Americans experience new or recurring heart attack or fatal CHD. The success of aspirin in preventing further clinical disease in some patients with known heart disease has been clearly documented. Based on its review of the literature, the Task Force strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk of CHD. Physicians should discuss both the potential benefits and harms—increased risk of gastrointestinal bleeding and hemorrhagic stroke—of aspirin therapy with patients. The USPSTF found good evidence that aspirin decreases the incidence of CHD in adults who are at increased risk for heart disease. These risk groups include men over 40, postmenopausal women, and younger people with risk factors for CHD (e.g., high blood pressure, diabetes, or smoking). Although the optimal dose of aspirin for chemoprevention has not been established, dosages of approximately 75 mg per day appear as effective as higher doses.

U.S. Preventive Services Task Force. (2002, March). "Screening for bacterial vaginosis in pregnancy: Recommendations and rationale." American Family Physician 65(6), pp. 1147-1150.

Research has consistently shown an association between bacterial vaginosis and adverse pregnancy outcomes, including preterm delivery, premature rupture of the membranes, and preterm labor. Controlled trials have been conducted to determine whether treating bacterial vaginosis with a short course of antibiotic therapy will also improve pregnancy outcomes. Based on its review of the literature, the USPSTF concluded that the evidence is insufficient to recommend for or against routinely screening high-risk pregnant women for bacterial vaginosis. The Task Force recommended against routinely screening average-risk asymptomatic pregnant women for bacterial vaginosis.

U.S. Preventive Services Task Force. (2002, February). "Screening for chlamydial infection: Recommendations and rationale." American Family Physician 65(4), pp. 673-676.

Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen in the United States. There are an estimated 3 million new infections each year, and most people with chlamydial infection are asymptomatic. Chlamydial infection in women can cause urethritis, cervicitis, and pelvic inflammatory disease (PID) and result in ectopic pregnancy, infertility, chronic pelvic pain, and, in pregnant women, adverse pregnancy outcomes. Age is the most important risk marker for chlamydial infection; women and adolescents through age 25 years are at highest risk. Other risk factors include black race, being unmarried, having a prior history of STD, having new or multiple sexual partners, and inconsistent use of barrier contraceptives. The USPSTF recommends that clinicians routinely screen all sexually active women, including pregnant women, 25 years of age and younger for chlamydial infection, as well as other asymptomatic women at increased risk of infection.

U.S. Preventive Services Task Force. (2002, January). "Screening for lipid disorders in adults: Recommendations and rationale." American Family Physician 65(2), pp. 273-276.

The USPSTF found good evidence that lipid measurement can identify asymptomatic middle-aged people at increased risk of coronary heart disease. They also found that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in people with abnormal lipid levels, and it causes few major harms. The Task Force recommends that clinicians routinely screen younger adults (men 20 to 35 years of age and women 20 to 45 years of age) for lipid disorders if they have other risk factors for coronary heart disease. These risk factors include diabetes, a family history of cardiovascular disease (before age 50 in men or age 60 in women), a family history suggesting high lipid levels among family members, and multiple risk factors for coronary heart disease (e.g., tobacco use, high blood pressure).

U.S. Preventive Services Task Force. (2002, April). "Screening for skin cancer: Recommendations and rationale." American Family Physician 65(8), pp. 1623-1626.

Between 1973 and 1995, the incidence of melanoma increased from 5.7 per 100,000 population to 13.3 per 100,000. The elderly, especially elderly men, bear a disproportionate burden of illness and death from melanoma and nonmelanoma skin cancer. Men older than 65 are diagnosed with 22 percent of the new cases of malignant melanoma each year. Women older than 65 are diagnosed with 14 percent of new cases. Basal cell and squamous cell carcinomas, in contrast to melanoma, are very common, especially in the elderly. However, they are infrequently associated with illness and death, even in the absence of formal screening. The USPSTF concluded that the evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination and that the benefits from screening are unproven, even in high-risk patients. Clinicians should be aware that fair-skinned people older than 65, patients with atypical moles, and those with more than 50 moles constitute known groups at substantially increased risk for melanoma. Clinicians should be alert for skin lesions with malignant features—such as asymmetry, border irregularity, diameter greater than 6 mm, or rapidly changing lesions—noted in the context of physical examinations performed for other purposes.

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