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Major depressive disorder is a ubiquitous and often devastating condition. It accounts for 2.5% of disability adjusted life years worldwide 1 and is the most common mental illness in people who die from suicide. 2 In January 2016, the United States Preventive Services Task Force issued updated recommendations calling for universal screening of adults for depression. This was based on its systematic review of five trials with a total of 2924 participants that examined screening in general adult populations. 3 The task force concluded that "treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity" and that the benefits of screening outweighed its harms. 3 This recommendation goes further than those from countries such as the United Kingdom and Canada, where guidelines suggest that clinicians be alert to possible depression, particularly in people at higher risk. 4 5
Our concern is that the task force implies a straightforward path from screening to intervention (drugs or psychotherapy) and downplays the importance of clinical judgment. While it is useful to highlight the need for improved detection and management of depressive disorders, there is no detailed guidance on the best course of action once depression is identified. Another important omission is any consideration of the cost of screening to the patient, physician, or healthcare system.
A big challenge of treating major depressive disorder is that it can be highly placebo responsive, particularly when symptoms are mild to moderate. 6 7 This...