Depression  in adolescents is a growing health concern. Signs and symptoms (S/S) of depression in adolescents tend to be overlooked by parents and primary care practitioners (PCPs), including nurse practitioners, and are instead considered a normal part of growing up. ¹  However, many adolescents do have clinical depression that is identifiable and treatable.1 Some adolescents are at a greater risk for developing depression than others. Risk factors for depression in this age group are listed in Table 1.²

Common S/S of depression are listed in Table 2.³ Adolescents may be particularly prone to experiencing sadness, hopelessness, poor sleep, decreased appetite or concentration, loss of pleasure in activities, irritability, anger, an social withdrawal.⁴In addition, adolescents with depression are at an increased risk for suicide.¹ Instead of seeking help from a  healthcare practitioner, many adolescents with depression self-medicate by using alcohol or drugs and/or by participating in high-risk sexual behavior.⁵

The estimated prevalence of a major depressive disorder (MDD) in adolescents aged 13-18 is 5.6%,⁶ with MDD being slightly more common in girls than in boys (5.9% vs 4.6%). The rate is higher in members of minorities.⁷Despite increased awareness about depression in teens, this mental disorder continues to go unrecognized and untreated.^7,8 About 75% of adolescents in the United States are seen routinely in a primary care setting, but only 16%-38% of PCPs correctly identify the presence of a mental health condition.⁴

The United States Preventive Services Task Force (USPSTF) recommends routine screening for depression in 12- to 18-year-olds in the primary care setting when appropriate mental health services, including confirmation of diagnosis, psychotherapy, and follow-up, are available.^6,9 The recommendation statement also includes depression screening for any child or teen with one or more of these four risk factors: parental depression, a co-morbid mental health condition, a chronic health problem, or recent experience of a negative life event.

The study

The purpose of this systematic review was to critically evaluate current evidence regarding use of depression screening tools in the adolescent population. The search focused on use of the Center for Epidemiological Studies Depression Scale for Children (CES-DC) ¹⁰and the second revise Beck Depression Inventory (BDI-II).¹¹ Because of the paucity of such studies conducted in the primary care setting, the author included studies done in an emergency department (ED) or a school.

Method—

Formulating a PICO question. This PICO (P, Population; I, Intervention; C, Comparison; and O, Outcome) question was written to guide the search: In adolescents aged 12-18 years (P), is use of a screening tool for depression (I), compared with the usual standard of care (C), more accurate in detecting depression (O)? The author’s goal in posing this PICO question was to determine whether enough evidence exists to support screening adolescents for depression using an appropriate screening tool. This PICO question itself facilitated the search strategy and guided the selection of key words.

Search strategy. The author searched multiple databases, including Medline, Cochrane Library, CINAHL, Eric, PsycINFO, Google Scholar, and the Agency for Healthcare Research and Quality. Key words were mental health, depression, depressive disorder, adolescents, teens, screening, CES-DC, and Beck or BDI-II. The author examined publishe and unpublished works and performed a complete hand search of reference lists of the systematic reviews and other relevant articles from 2005 to 2010. All articles examining use of a screening tool specific for depression in the adolescent population were included, regardless of whether the setting was a primary care practice, an ED, or a school. Thirteen studies met inclusion criteria. A 1999 study was added because it was one of the few conducted in a primary care setting.

Results—

The search revealed two systematic reviews on adolescent depression screening,^6,12but no randomized controlled trials (RCTs). Five descriptive studies using the CES-DC or BDI-II were identified.^13-17 Zuckerbrot et al¹⁸ also published guidelines delineating identification, assessment, and initial management of depression in adolescents. Six studies using the designated screening tools had cross-sectional, predictive, or correlational designs. ^5,19-23Table 3 lists the results and recommendations of these studies.^{5,6,12-17,19-23}

Systematic reviews. The most robust systematic review was conducted by Williams et al⁶ for the USPSTF. The search did not yield any data on health outcomes among screened versus unscreened populations or any studies examining the harms of screening. Although the literature was limited with regard to the use and accuracy of screening tools, several tools, including the Patient Health Questionnaire for Adolescents (PHQ-A),²⁴ the Beck Depression Inventory for Primary Care (BDI-PC),²⁵ and the CES-DC,¹⁰ all performed well.

In their systematic review, Zuckerbrot and Jensen¹² aimed to determine existing evidence for the various methods used to identify adolescent depression in primary care and the identification practices that were in use a the time. The investigators concluded that self-report screening tools were available and that these tools had adequate psychometric properties and feasibility for use in primary care. They discussed two important findings: (1) self-report screening tools were more accurate than physician interviews in identifying depression; and (2) PCPs who relied on patients’ presenting chief complaints to detect depression would miss many teens with depression or depressive symptoms. In addition, they found that, with regard to the usual standard of care, physicians who received additional training improved their ability to detect depression, but not to the same level as that achieved with self-report tools. Although the HEADDSS (home, education, activities, drugs, depression,  safety, and sexuality)  assessment²⁶ is widely used in adolescent health care, Zuckerbrot and Jensen¹² did not find any studies examining its effectiveness in detecting depression. In addition, they found no studies that combined three essential elements: a screening component, an intervention, and an assessment of patient outcomes  at follow-up.

Randomized controlled trials. No RCTs examining the screening  process for MDD in adolescents  were identified in the  search. Hallfors et al⁵ used data from the National Longitudinal Study of Adolescent Health to determine whether gender-specific  patterns of substance use and sexual behavior predicted  depression or vice versa. They used the CES-DC to assess for depression. Overall findings showed that sex and drug behaviors predicted a higher likelihood of depressive S/S, especially among girls, but that depression did not predict high-risk behavior.

Descriptive studies. Scott et al²¹used the BDI-II to ascertain the prevalence of depressive S/S in 351 adolescents presenting to an ED in the Midwest. Significant differences were noted among certain groups of patients: Trauma patients were more likely to refuse screening; patients presenting with a psychiatric diagnosis were more likely to be hospitalized; and patients with a previous history of a mental illness reported significantly more depressive S/S. Rutman et al²² compared the CES-DC with a two-question screening tool in 121 adolescents presenting to an ED, and found that 37% had a positive screen on the CES-DC, with 21% being positive for suicidality, and 40% were positive on the two-question screen. Consistent with other reports, these researchers found higher rates of depressive symptoms in girls.

Lazaratou et al¹³ aimed to clarify the prevalence of depressive S/S in high school students in Athens, Greece, and to evaluate risk factors for these S/S using the CES-DC. A total of 713 students aged 15-18 years were enrolled. Depressive S/S were found to be linked to gender (girls had higher scores than boys), school record (students with better records had lower scores), and the interaction of gender a grade (males had higher scores as they grew older).

Using a school-based sample of more than 20,000 adolescents in grades 7-12, Rhee¹⁴ examined the race-specific prevalence of 10 physical symptoms (head – ache, stomachache, musculoskeletal pain, fatigue, sore throat, dizziness, feeling hot, chest pain, painful urination, cold sweat) in adolescents and the extent to which socioeconomic status and depressive S/S explained racial differences in those symptoms using the CESDC screening tool. Headache was the most common complaint in white students (32%). American Indians had greater complaints of musculoskeletal pain (35%), feeling hot (14%), and chest pain (10%), and blacks reported more urinary symptoms (4%). Differences between whites and blacks were significant for family income and depression. Overall depression scores were higher in blacks than in whites.

Robles-Pina et al ¹⁵ examined students held back one grade during the elementary school years (early school retention) as a predictor of depression in 191 Hispanic urban teens. No significant differences were found between males and females in selfconcept, rate of retention, past feelings of sadness, or gradepoint average (GPA). Females had higher mean scores on the CES-DC than did males, with the gender difference showing a low effect size. Thirty-six percent of Hispanic adolescents had CESDC scores indicating moderate to severe depression. Adolescents retained in school had lower self-concept, greater past feelings of depression, a lower GPA, and higher rates of depression than did non-retained adolescents. All results were significant. The highest predictor of depressionwas lower self-concept.

Chisolm et al¹⁶ used the CESDC and the PHQ-A single-question tool for detecting adolescent depression, and observed the use of mental health services following screening. In this population (N = 996), 24% screened positive for depression and 14% screened positive for suicidal thoughts. Only 16% of adolescents who screened positive for depression accessed mental healthcare services within the next 180 days (P <.01). However, adolescents who acknowledge having suicidal thoughts were 8 times more likely than those who screened negative for suicidal ideation to use behavioral health services. Overall findings showed that adolescents who were screened were more likely to seek physical or mental health services. One plausible explanation of this finding was that the screening process opened lines of communication between patients and practitioners.

Zuckerbrot et al¹⁷ conducted the first and only study examining the feasibility and acceptability of screening for adolescent depression in primary care. Average time for completion of a pencil-and-paper screening tool was 4.6 minutes; the refusal rate for screening was low. Practitioners and parents reported greater satisfaction than dissatisfaction with the screening process. The time burden was not significant.

Winter et al²³  performed one of the few studies assessing screening for adolescent depression in the primary care setting using one of the most reliable screening tools, the BDI-PC. This report focused primarily on the BDI-PC’s psychometric properties. Although the sample size was small (50 females and 50 males), recruitment of subjects was halted because the effect size was so large. Eighty-nine adolescents screened negative and 11 screened positive for MDD. The mean BDI-PC score of the 11 adolescents with positive screens was about 9 times higher than that of the 89 negatively screened teens.

Discussion—

Strengths and limitations of the evidence. Research on adolescent depression has increased over the past 10 years, but few studies have evaluated the screening process in primary care or the use of specific screening tools. The two systematic reviews discussed previously contain the strongest evidence available (Level 1), according to the Rating System for Levels of Evidence.²⁷ However, most of the research is Level VI—evidence from descriptive studies. Each study was also evaluated using the John Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal, with the quality of the scientific evidence ranking as high, good, or low with major flaws.²⁷Studies included in this review were deemed of good quality.

Studies varied in terms of validity, reliability, and applicability. Most were not conducted in a primary care setting. All but one was conducted in the U.S., which increases generalizability of the results. Despite their limitations, all the studies helped answer the PICO question and helped provide evidence for practice guidelines for screening for adolescent depression by PCPs. Guidelines set forth in the USPSTF are supported by the National Institute of Mental Health (NIMH),^1,28 the American Academy of Pediatrics (AAP),²⁹ and the National Association of Pediatric Nurse Practitioners (NAPNAP).³

A critical examination of available research studies regarding screening processes for adolescent depression reveals several gaps. Few RCTs investigated the screening process in primary care settings, and only one study assessed the feasibility of screening. ¹⁷  No studies examined all three critical elements—screening,treatment, and outcomes.

Two screening tools for primary  care use. The BDI-II is a widely accepted instrument for outpatient screening, performs consistently, and is linked to Diagnostic and Statistical Manual, Fourth Edition-Text Revision (DSMIV- TR) criteria.³⁰ However, several disadvantages hamper its use in the primary care setting. Use of the tool incurs a fee, and practitioners must have additional training to use it. The BDI-II has high item difficulty and may require additional assistance in completing it. It appears more appropriate for use in intervention studies examining various treatment options in adolescent depression. The BDI-PC, by contrast, is a self-report instrument designed for primary care use in patients aged 13 years or older.

The CES-DC has not been used consistently in studies reported before 2005. This tool has gained greater popularity and been used more frequently in research  studies in the past few years. The CES-DC has been criticized for not being linked to DSM-IV-TR criteria.^13,29On the plus side, this tool is readily available free of charge and does not require additional training for use. The CESDC’ reliability, validity, mean scores, and case rates of adolescent depression remain consistent across the literature. Therefore, the CES-DC is considered appropriate for use in screening adolescents for depression in the primary care setting.

Recommendations for practice

The USPSTF, in conjunction with the NIMH, has increased awareness of the need for screening for depression in adolescents and  has made practitioners more aware of the prevalence of this  mental illness in this population. ^1,9 The AAP and NAPNAP have launched special tool kits and fellowship programs promoting  screening for mental  health problems in primary care.^3,29Zuckerbrot et al17 found  that screening for depression in a primary care setting is quick, feasible, effective, and well accepted by patients and practitioners. Recommendations for practice include instituting a universal screening program for depression in adolescents aged 12-18 years when mental health services are available to aid in accuracy of the diagnosis, initiation of treatment, and follow-up.⁹

Primary care practices with available mental health support should begin screening adolescents annually for MDD at well-or acute-care visits. The CES-DC is free of charge and easy to use, and has adequate reliability and validity for use in primary care settings. Screening tools can be completed while patients are waiting to see their PCP. Partnering with a mental health practitioner to facilitate transitioning of adolescents from primary care depression screening to engagement in more in-depth psychiatry evaluation and treatment  could enhance the clinical utility of this screening endeavor.

Conclusion

Early identification of depression  in adolescents is a national health priority. PCPs, including primary care NPs, must learn to recognize the subtle S/S of this often-silent epidemic because most patients with undiagnosed depression present to their PCP first.⁸ PCPs must be aware of the common S/S of depression and how these S/S vary in different age groups. Many parents dismiss these S/S as a normal part of growing up. PCPs must be aware of current recommendations for screening, as outlined in the USPSTF 2009 statement.

More research is needed regarding screening for depression in primary care settings. In particular, studies examining the feasibility of screening, identifying efficient procedures for completing the screening and referral processes, and further testing of screening tools would be beneficial. PCPs will then be able to translate these research findings into practice. =

Sharolyn K. Dihigo is a clinical assistant professor and Interim Director of the DNP Program and Lead Teacher in the Primary Care Pediatric Nurse Practitioner  Program at The University of  Texas at Arlington. The author  states that she does not have a financial interest in or other relationship  with any commercial product named in this article.

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