Depression Intervention Flops for Heart Attack Survivors

A comprehensive depression screening and treatment program didn’t help acute coronary syndrome (ACS) survivors more than usual care or what they could achieve on their own, a 1,500-person trial showed.

Mean quality-adjusted life-years fell by an identical 0.06 over 18 months whether patients were randomized to systematic depression screening plus notification of primary care clinicians and treatment for those with positive results, screening with notification only, or usual care without screening (P=0.98).

“There is compelling evidence that depression is a cardiotoxic risk marker in patients with ACS, strongly and consistently associated with health-related quality of life, independent of traditional factors associated with quality of life,” according to investigators led by Ian Kronish, MD, MPH, of Columbia University Irving Medical Center in New York City.

The lack of any perceptible benefit with depression screening may have to do with the smaller-than-expected 7.1% incidence of positive screening results for depression using the eight-item Patient Health Questionnaire, they suggested in the paper online in JAMA Internal Medicine.

“It is possible that, even among those who initiated depression treatment, those who were identified as depressed by the screening may have been less motivated or interested in treatment and, in turn, less engaged, limiting treatment effectiveness,” they wrote.

In the screen-positive group offered treatment for depression, nearly three-quarters agreed to the patient-preference stepped-care intervention of antidepressants and/or problem-solving therapy.

“Despite the risk associated with depression, our data suggest that a strategy of systematically screening patients with ACS for depression is unlikely to lead to substantial population-level benefits in terms of improved quality of life or depression-free days,” the researchers concluded.

But that doesn’t rule out the value of mental health intervention in the greater coronary heart disease population.

There are randomized data in the literature showing that such patients receiving cognitive behavioral stress management training (CBSM) generally have reduced morbidity and mortality, commented Redford Williams, MD, of Duke University Medical Center in Durham, North Carolina, who was not involved in the study.

“Rather than screening for depression, it might be good for all ACS patients to receive training in CBSM stress management skills, much as all such patients are supposed to receive advice and help in eating a heart-healthy diet and engaging in regular exercise,” Williams told MedPage Today.

Study participants had been enrolled months after an ACS and were required to have no prior history of depression. They came from one of four health systems: HealthPartners in Minneapolis; Duke University Health System; Kaiser Permanente Northwest in Portland; and Kronish’s institution in New York.

Mean age was 65.9 years and 28% of the cohort were women.

In the end, the number of depression-free days was statistically the same among groups (343.1 days vs 351.3 days vs 339.0, P=0.63), with no differences either in rates of death, bleeding, or sleep difficulties at 18 months.

The trial’s findings suggest that existing guidelines advising routine depression screening in patients with ACS may need to be reconsidered, the authors said, though they acknowledged that their findings have questionable applicability to the real world given that approximately half the patients approached had said no to enrolling in the study.

Notably, each study arm had a similar proportion of patients receiving depression treatment by 6 months.

“It is possible that patients assigned to the no screen group became more aware of depressive symptoms through participation in the study, which, in turn, led to increased depression recognition and treatment in this group,” according to Kronish and colleagues.

“There have been public health efforts to increase screening for depression in primary care settings, which may have led to smaller differences in depression screening between the screened and no screen groups,” they continued.

“Future studies could investigate if motivation, interest, adherence, and/or engagement differ between patients with depression detected by screening and patients with depression who are seeking treatment,” the group suggested.