VIEWPOINT AND COMMENTARY
To Screen or Not to Screen?Depression in Patients With Cardiovascular Disease
Mary A. Whooley, MD*
Veterans Affairs Medical Center and University of California, San Francisco, California
Manuscript received May 2, 2009;
accepted May 5, 2009.
* Reprint requests and correspondence: Dr. Mary A. Whooley, VA Medical Center and University of California, San Francisco, 4150 Clement Street, San Francisco, California 94121 (Email: mary.whooley{at}ucsf.edu).
 |
Abstract
|
|---|
There is considerable controversy about whether patients with cardiovascular disease should be screened for depression. Depression is known to be associated with increased morbidity and mortality, but screening by itself does not improve either depression or cardiovascular outcomes. Nonetheless, depression deserves treatment regardless of its cardiovascular effects, and screening plus collaborative care is cost effective in primary care settings. Thus, patients with cardiovascular disease should receive routine screening for depression by primary care providers in the context of a collaborative care treatment program.
Key Words: depression • cardiovascular disease • screening
|
Abbreviations and Acronyms
| | AHA = American Heart Association | | CVD = cardiovascular disease |
|
There is considerable controversy about whether screening for depression should be part of standard care for patients with cardiovascular disease (CVD). A 2008 American Heart Association (AHA) Science Advisory recommended routine screening for depression in all patients with coronary heart disease (1), but a subsequent systematic review concluded there is no evidence that screening is of benefit (2). Others have suggested that screening for depression may benefit patients, but only if performed in the context of a collaborative care treatment model, including frequent follow-up by a case manager and streamlined access to a mental health provider (3,4). Now, Ziegelstein et al. (5) say "Never mind," and call for a reassessment of the AHA Science Advisory.
How do we make sense of all of this? Should patients with CVD be screened for depression? Will screening improve cardiovascular outcomes?
The 2008 AHA Science Advisory concluded that "Depression is commonly present in patients with coronary heart disease and is independently associated with increased cardiovascular morbidity and mortality. Therefore, screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment" (1). Given the overwhelming evidence that depression is associated with adverse outcomes in patients with CVD, and the availability of easy-to-administer and reasonably accurate screening instruments (6), it is understandable to think that screening for depression would improve outcomes. Indeed, our primary care colleagues came to this same conclusion 15 years ago when depression had been clearly linked with poor medical outcomes (7), and it was thought that screening and informing health care providers about depression would improve these outcomes.
Unfortunately, subsequent randomized controlled trials addressing this very question found little if any benefit from screening for depression (8–11). Although screening resulted in enhanced recognition and treatment, it did not improve depression because the majority of patients did not receive adequate dosage or duration of antidepressant therapy. Nearly one-half of patients discontinued treatment during the first month, and few received the recommended levels of follow-up care (12). Alas, it was concluded that "there is substantial evidence that routinely administered screening questionnaires for depression have minimal impact on the detection, management or outcome of depression" (13).
The question then became: what else is needed for screening to be of benefit? Numerous randomized trials were conducted to determine whether screening for depression, in combination with a collaborative care intervention, would improve outcomes (14–21). These and other trials eventually concluded that screening can improve depression, but only when combined with a collaborative care intervention (3,4,22). There were also potential harms of screening, including perceived stigma from false-positive results and diversion of health care resources from other needs. However, at least in primary care settings, these potential harms seemed to be outweighed by the benefits of screening plus collaborative care (23).
What is collaborative care? Katon and Unutzer (23) have identified 2 essential elements: 1) a depression care manager (an allied health professional, preferably with a mental health background) to educate patients, provide close follow-up, and monitor treatment adherence; and 2) a psychiatrist to provide case load supervision for depression care managers and clinical advice to primary care providers. Collaborative care interventions typically take 3 to 6 months, and many aspects of treatment can be accomplished over the telephone (4,24–26). Although collaborative care programs can be associated with increased cost in the short term (27), they are cost effective and probably cost saving in the longer term (28–30).
In theory, patients with CVD should be at least as likely as primary care patients to benefit from depression screening in the context of a collaborative care treatment program. However, only a few studies have specifically evaluated this in the cardiovascular care setting. Freedland et al. (31) screened patients for depression after coronary artery bypass surgery and randomly assigned those with depression to cognitive behavioral therapy, supportive stress management, or usual care. Participants who received cognitive behavioral therapy or supportive care were more likely to achieve remission of depression than those who received usual care. In the Bypassing the Blues Trial (32), patients were screened for depression after coronary artery bypass grafting, and those who screened positive were randomly assigned to a collaborative care treatment intervention versus usual care. This study has recently been completed, and preliminary results are promising (33). Another multicenter randomized trial is currently evaluating the effect of a heart failure management program that includes screening plus collaborative care for depression on cardiovascular health status (J. Rumsfeld, M. Sullivan, personal communication, April 2009).
Where does this leave current cardiovascular practice with regard to depression screening? To date, there is no evidence that screening plus collaborative care improves cardiovascular outcomes (2). Importantly, absence of evidence does not equal evidence of absence, and there is also no evidence that screening plus collaborative care has any negative effects on cardiovascular outcomes. However, until we can demonstrate that screening plus collaborative care improves cardiovascular outcomes, the responsibility for screening will continue to remain with the primary care provider.
Does this mean that cardiologists can ignore depression? Absolutely not. Depression is present in at least 1 in 5 patients with CVD and is associated with both poor quality of life and adverse cardiovascular outcomes (34–36). Details about case finding and treatment for depression in patients with CVD have been described elsewhere (6). This simply means that routine screening of patients who are not otherwise suspected to have depression has no proven benefit outside of a collaborative care treatment program. When depression is recognized, the most evidence-based approach is for the cardiologist to make sure that the patient is evaluated by a primary care provider who can offer collaborative care treatment.
Depression meets most criteria for screening (common disease with significant morbidity, low cost and risk of screening, effective therapy available), but whether early detection and treatment improves cardiovascular outcomes is unknown. What we do know is that depression deserves treatment regardless of its cardiovascular effects, reasonable screening tools are available, and screening plus collaborative care is cost effective in primary care settings. Until we are able to demonstrate that screening for depression improves cardiovascular outcomes, patients with CVD should be screened for depression by primary care providers in the context of a collaborative care treatment program. The optimal frequency of depression screening will require further study.
|
References
|
|---|
1. Lichtman JH, Bigger Jr. JT, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association Circulation 2008;118:1768-1775.[Abstract/Free Full Text]2. Thombs BD, de Jonge P, Coyne JC, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review JAMA 2008;300:2161-2171.[Abstract/Free Full Text] 3. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes Arch Intern Med 2006;166:2314-2321.[Abstract/Free Full Text] 4. Williams Jr. JW, Gerrity M, Holsinger T, et al. Systematic review of multifaceted interventions to improve depression care Gen Hosp Psychiatry 2007;29:91-116.[CrossRef][Medline] 5. Ziegelstein RC, Thombs BD, Coyne JC, de Jonge P. Routine screening for depression in patients with coronary heart disease: never mind J Am Coll Cardiol 2009;54:886-890.[Abstract/Free Full Text] 6. Whooley MA. Depression and cardiovascular disease: healing the broken-hearted JAMA 2006;295:2874-2881.[Abstract/Free Full Text] 7. Wells KB, Burnam MA, Rogers W, et al. The course of depression in adult outpatients. Results from the Medical Outcomes Study. Arch Gen Psychiatry 1992;49:788-794.[Abstract/Free Full Text] 8. Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995;311:1274-1276.[Abstract/Free Full Text] 9. Callahan CM, Hendrie HC, Dittus RS, et al. Improving treatment of late life depression in primary care: a randomized clinical trial J Am Geriatr Soc 1994;42:839-846.[Web of Science][Medline] 10. Williams JW, Mulrow CD, Kroenke K, et al. Case-finding for depression in primary care: a randomized trial Am J Med 1999;106:36-43.[CrossRef][Web of Science][Medline] 11. Whooley MA, Stone B, Soghikian K. Randomized trial of case-finding for depression in elderly primary care patients J Gen Intern Med 2000;15:293-300.[CrossRef][Web of Science][Medline] 12. Katon W, von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care Med Care 1992;30:67-76.[CrossRef][Web of Science][Medline] 13. Gilbody S, House AO, Sheldon TA. Screening and case finding instruments for depression Cochrane Database Syst Rev 2005CD002792. 14. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273:1026-1031.[Abstract/Free Full Text] 15. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care Arch Gen Psychiatry 1996;53:924-932.[Abstract/Free Full Text] 16. Wells KB, Sherbourne CD, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial JAMA 2000;283:212-220.[Abstract/Free Full Text] 17. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve depression treatment in primary care BMJ 2000;320:550-554.[Abstract/Free Full Text] 18. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial JAMA 2002;288:2836-2845.[Abstract/Free Full Text] 19. Dietrich AJ, Oxman TE, Williams Jr. JW, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial BMJ 2004;329:602.[Abstract/Free Full Text] 20. Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression Arch Gen Psychiatry 2004;61:1042-1049.[Abstract/Free Full Text] 21. Wells K, Sherbourne C, Schoenbaum M, et al. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial Arch Gen Psychiatry 2004;61:378-386.[Abstract/Free Full Text] 22. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force Ann Intern Med 2002;136:765-776.[Abstract/Free Full Text] 23. Katon W, Unutzer J. Collaborative care models for depression: time to move from evidence to practice Arch Intern Med 2006;166:2304-2306.[Free Full Text] 24. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care BMJ 2000;320:550-554.[Abstract/Free Full Text] 25. Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care Arch Fam Med 2000;9:700-708.[Abstract/Free Full Text] 26. Simon GE, Ludman EJ, Tutty S, Operskalski B, Von Korff M. Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial JAMA 2004;292:935-942.[Abstract/Free Full Text] 27. Gilbody S, Bower P, Whitty P. Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations Br J Psychiatry 2006;189:297-308.[Abstract/Free Full Text] 28. Katon WJ, Schoenbaum M, Fan MY, et al. Cost-effectiveness of improving primary care treatment of late-life depression Arch Gen Psychiatry 2005;62:1313-1320.[Abstract/Free Full Text] 29. Simon GE, Katon WJ, Lin EH, et al. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus Arch Gen Psychiatry 2007;64:65-72.[Abstract/Free Full Text] 30. Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression Am J Manag Care 2008;14:95-100.[Web of Science][Medline] 31. Freedland KE, Skala JA, Carney RM, et al. Treatment of depression after coronary artery bypass surgery: a randomized controlled trial Arch Gen Psychiatry 2009;66:387-396.[Abstract/Free Full Text] 32. Rollman BL, Belnap BH, LeMenager MS, et al. The bypassing the blues treatment protocol: stepped collaborative care for treating post-CABG depression Psychosom Med 2009;71:217-230.[Abstract/Free Full Text] 33. Rollman BL. The Bypassing the Blues Trial: methods and main outcomes. Abstract presented at the Annual Meeting of the American Psychosomatic Society, March 4–7, 2009, Chicago, IL. 34. Rumsfeld JS, Ho PM. Depression and cardiovascular disease: a call for recognition Circulation 2005;111:250-253.[Free Full Text] 35. Ruo B, Rumsfeld JS, Hlatky MA, et al. Depressive symptoms and health-related quality of life: the Heart and Soul Study JAMA 2003;290:215-221.[Abstract/Free Full Text] 36. Whooley MA, de Jonge P, Vittinghoff E, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease JAMA 2008;300:2379-2388.[Abstract/Free Full Text]
Related Article
-
Inside This Issue
J. Am. Coll. Cardiol. 2009 54: A29.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
B. L. ROLLMAN and B. HERBECK BELNAP
The Bypassing the Blues trial: Collaborative care for post-CABG depression and implications for future research
Cleveland Clinic Journal of Medicine,
August 1, 2011;
78(Suppl_1):
S4 - S12.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. F. Ski and D. R. Thompson
Beyond the blues: the need for integrated care pathways
European Journal of Cardiovascular Prevention & Rehabilitation,
April 1, 2011;
18(2):
218 - 221.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C.-A. Chen, S.-C. Liao, J.-K. Wang, C.-I. Chang, I.-S. Chiu, Y.-S. Chen, C.-W. Lu, M.-T. Lin, H.-H. Chiu, S.-N. Chiu, et al.
Quality of life in adults with congenital heart disease: biopsychosocial determinants and sex-related differences
Heart,
January 1, 2011;
97(1):
38 - 43.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. W. DAVIDSON and M. R. KORIN
Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009
Cleveland Clinic Journal of Medicine,
July 1, 2010;
77(Suppl_3):
S20 - S26.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Frasure-Smith and F. Lesperance
Depression and cardiac risk: present status and future directions
Postgrad. Med. J.,
April 1, 2010;
86(1014):
193 - 196.
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Frasure-Smith and F. Lesperance
Depression and cardiac risk: present status and future directions
Heart,
February 1, 2010;
96(3):
173 - 176.
[Full Text]
[PDF]
|
|
|
|
Top
Abstract
References