Kids as young as 8 should be screened for anxiety, even if they're not showing signs or symptoms, the U.S. Preventive Services Task Force (USPSTF) advised in a final recommendation statement, suggesting a "moderate net benefit."
The task force also recommended that adolescents ages 12 to 18 be universally screened in primary care for major depressive disorder (grade B), but not other depressive disorders like minor depression or dysthymia.
The USPSTF fell short of recommending suicide risk screening for this older age group, deeming the current evidence insufficient to do so, despite acknowledging that suicide is the second-leading cause of death among youth ages 10 to 19.
Both final recommendation statements were simultaneously published in JAMA.
Professional Pushback
The final statements affirm the draft guidelines proposed back in April, which were subsequently met with backlash from several national organizations for failing to recommend suicide risk screening. The American Foundation for Suicide Prevention, Blueprint for Youth Suicide Prevention, and the American Academy of Pediatrics (AAP) released a joint statement urging the USPSTF to reconsider the guidance, emphasizing that their organizations all support universal screening for suicide risk in youth ages 12 and older.
"Youth may keep suicidal thoughts to themselves and will not bring up the topic unless directly asked," said May Lau, MD, MPH, a member of the AAP Section on Adolescent Health Executive Committee, in a statement after the draft guidelines were released. "By screening all youth for suicide, we can identify those that are at risk and connect them with the services they need."
The American Psychological Association also voiced concerns, "strongly urging" the USPSTF to modify the report to include suicide risk screening.
However, during the open public comment period, the task force said it "reviewed the evidence on the accuracy of these screening tools and clarified that determining the accuracy of these screening tools using established USPSTF methodology was too uncertain for the USPSTF to recommend."
In an accompanying editorial, Oscar G. Bukstein, MD, MPH, of Boston Children's Hospital, explained that the task force's "absence of a recommendation for suicide screening among adolescents in primary care settings does not call suicide screening into question but rather universal screening apart from screening for other risk factors such as depression."
He went on to point out that because depression is a risk factor for suicidal behavior, "screening for suicide under the umbrella of depression screening could accomplish both screening tasks at the same time."
Beyond screening and identifying all at-risk youth, proper follow-up and implementing evidence-based interventions are the real tricky parts, Bukstein warned, especially given the lack of access to mental health professionals.
How to Screen and Treat
When screening for anxiety among youth, the USPSTF acknowledged that available tests tend to greatly vary: some are broad, some are very specific, and some are too lengthy to use regularly in clinical practice. The task force referenced the two tests most commonly used in practice -- SCARED and Social Phobia Inventory -- but advised that a positive screening test should be followed up with a confirmatory diagnostic assessment.
In another accompanying editorial, John T. Walkup, MD, of the Ann and Robert H. Lurie Children's Hospital in Chicago, and colleagues warned against relying on these screening tests alone when identifying kids with anxiety.
"Rating scales, at their best, reflect the pattern of symptoms but lose their relevance if the clinician does not integrate the rating scale data with the child's clinical history," they wrote.
"Pediatric clinicians are ideally positioned to address this challenge," they continued. "Their early and longitudinal patient and family engagement, combined with their knowledge of the risk factors, characteristic ages of onset, symptom patterns, course, and known patterns of comorbidity, will help ensure that rating scale data are appropriately contextualized."
According to a systematic review and evidence report on 39 studies evaluating anxiety in children, cognitive behavioral therapy was associated with symptom improvement, response, remission, and loss of diagnosis. Pharmacotherapy was also associated with symptom improvement and response. While there were some reported harms with these strategies, they were generally rare.
As for depression, the USPSTF recommended using the 9-item Patient Health Questionnaire (PHQ-9), noting that it's the most common screening instrument in clinical practice, as well as the full PHQ modified for adolescents (PHQ-A) and the Center for Epidemiologic Studies Depression Scale.
While the recommendation statements focus on screening asymptomatic youth for anxiety and depression, the task force advised to look out for certain factors in patients that could put them at higher risk. For depression, this can include a combination of factors like family history, prior depressive episodes, other mental health conditions, or environmental factors.
The task force also noted that Black children have had a higher prevalence of both depression and suicide attempts in more recent years.
According to the 21 studies included in the evidence report on depression in adolescents, psychotherapy was associated with improved symptoms, significant clinical response, and loss of diagnosis, and pharmacotherapy was linked to improved symptoms, remission, and functioning.
None of the 19 studies on suicide risk looked specifically at the benefits of screening. However, nonpharmacological suicide risk interventions -- like psychotherapy, counseling, and support -- were tied with lower suicidal ideation scores measured on the Beck Hopelessness Scale. Other suicide outcomes like suicide attempt and deliberate self-harm weren't significantly different with these interventions.
The USPSTF also proposed nearly identical screening recommendations for adults with anxiety and depression in new draft guidance released a few weeks ago. Those draft recommendations are open for public comment through October 17.
Disclosures
The USPSTF is an independent, voluntary body financially supported by the Agency for Healthcare Research and Quality.
Primary Source
JAMA
Secondary Source
JAMA
Additional Source
JAMA
Additional Source
JAMA
Additional Source
JAMA
Source Reference: Walkup JT, et al “Screening for pediatric anxiety disorders” JAMA 2022; DOI: 10.1001/jama.2022.15224.
