Every child over the age of 12 should be screened for depression, according to a new statement from the American Academy of Pediatrics. AAP joined the United States Preventative Task Force in endorsing the new marching orders, which call on physicians to administer brief depression surveys to their adolescent charges each year, using a self-reported questionnaire, which teens can complete on their own. Still, some physicians remain skeptical and worry that indiscriminate screening could do more harm than good, especially in underserved communities.
“Teenagers are often more honest when they’re not looking somebody in the face who’s asking questions,” Rachel Zuckerbrot, a psychiatrist at Columbia University and co-author on the report that describes the reasoning behind the new universal screening guidelines, told NPR. “It’s an opportunity for the adolescent to answer questions about themselves privately.”
Barely half of the adolescents with depression are diagnosed before they reach adulthood and a lot of those missed opportunities fall on primary care physicians. Studies suggest family doctors and pediatricians fail to identify nearly 70 percent of the depressed youth in their care. And even when depression is flagged early, only about half of teens are treated within the standard of care. “It’s a huge problem,” Zuckerbrot says.
Zuckerbrot helped engineer a solution to that problem in 2007, by developing the first set of guidelines that primary care doctors could use to reliably screen adolescents for depression. She has since updated her study and her 2017 report, now adopted by AAP, recommends doctors administer a brief questionnaire to every adolescent once per year. One version asks: “Over the past two weeks, how often have you been bothered by any of the following problems: feeling down, depressed or hopeless? Or, little interest or pleasure in doing things?”. Doctors are not currently obligated to adopt Zuckerbrot’s guidelines, but it’s reasonable to suspect that your local pediatrician might sneak in a few questions about depression during your 12-year-old’s next visit.
It’s worth noting that Zuckerbrot and colleagues did not recommend universal screening in their 2007 report, citing the controversial nature of the prescription. And even though the AAP, the USPSTF, and Zuckerbrot’s updated 2017 study advise universal depression screenings for teens, some of its opponents consider it a poor decision.
Chief among their concerns is that many adolescents do not have access to psychiatric services. When a physician identifies a teen as “depressed” there is unavoidable stigma that goes with the diagnosis. That stigma is only mitigated or justified by the fact that the teen can get the help that he or she needs. Absent that promise of help, it is questionable whether it’s a good idea for doctors to use universal screening tools—which simply creates a larger pool of teens who must live with the knowledge that they have a problem that cannot be fixed. Similar ethical arguments surround universal screenings for conditions like Alzheimer’s disease, which have no cure.
When the USPSTF endorsed universal screenings for depression in 2014, pediatrician and author Lawrence Diller expressed his dismay in The LA Times. “No one would say preventing suicide is a bad thing,” he wrote. “But researchers haven’t been able to link screening to a decrease in suicides…There’s a little bit of data to indicate that screening methods work to identify depressed teens, but these are from well-funded academic screening programs. In the real world of public mental health, I seriously question whether this will be implemented the way these academic studies are performed.”
Diller also worried that universal screenings would tempt doctors to over-prescribe psychiatric drugs, such a selective serotonin reuptake inhibitors (SSRIs), rather than addressing the circumstances that often lead to teen depression, such as problems at home. “The evidence for treatment of teenage depression is weak for both behavioral therapy and drug treatment,” he wrote. “An alternative to screening would be better mental health awareness programs, such as a video teaching teens about depression and suicide, and for counselors also to work with the teenager’s family and acknowledge the community situation.”
But Zuckerbrot maintains that, without universal screening, thousands must muddle through adolescence without therapy. “Given the high prevalence of adolescent depression, the evidence that adolescent depression can be persistent, the fact that adolescence is a time of significant brain maturation, and longitudinal studies that reveal that adolescents with depression have significant problems as adults, it is important to try to identify and treat adolescents with depression early in the course of the disorder,” she writes. “Screening with a systematic tool will identify more adolescents with depressive disorders than not screening at all.”