Patients who suffer from depression after acute coronary syndrome (ACS) may benefit from stepped treatment, which takes patient preference into account, a recent study suggests. Furthermore this course of action does not appear to result in a significant increase in healthcare costs.
Crucially post-ACS depression has been associated with both an increased risk of ACS recurrence and of all-cause mortality, yet existing treatments have limited effectiveness. Naturally post-ACS depression represents a potential problem for the 1.2 million Americans, and beyond, who survive an ACS event, such as a heart attack or unstable angina, each year.
Participants included in this six-month trial were older than 34 and displayed elevated symptoms of depression two to six months after hospitalisation due to ACS (Beck Depression Inventory I >= 10 on two screenings or >= 15 on one). Exclusion occurred in accordance to criteria described by Whang et al. 2012.
A total of 150 patients were recruited. Following approval, patients were assigned via computer randomisation to either the ‘usual’ or ‘active’ groups. The ‘usual’ group included 77 individuals who continued with standard treatment whilst the 73 participants of the ‘active’ group were given a stepped procedure in which patients chose which treatment mode they would receive.
At the end of the study, 41 participants in the active group were receiving centralised problem-solving treatment (PST), 9 were being prescribed medication (sertraline hydrochloride, citalopram hydrobromide or bupropion hydreochloride), 17 had both and 6 neither.
Whilst it appears that initial treatment allocation was concealed, patients in the active group would have been aware of their allocation after meeting with a research assistant to discuss the benefits and risks of each treatment choice.
Symptoms were initially analysed weekly via the Patient Health Questionnaire 9 (PHQ-9) and later recorded monthly. Providing the minimum improvement criteria (as described in Whang et al. 2012) was not met after six to eight weeks of a particular treatment, a team of PST therapists, psychologists, physicians and nurses suggested an alternative method of treatment in coordination with patient preference.
The results of this trial focus on two areas: depression and healthcare costs. In terms of the treatment of depression, a greater reduction in BDI scores was observed for the active group (-10.1; 95% CI, -12.0 to -8.1) in comparison to the usual group (-6.6; 95% CI, -8.5 to -4.8) producing a change between groups of -3.5 BDI points (95% CI; -6.1 to -0.7; P = 0.01; Hedges g = 0.59). Notably, depression remission (BDI < 10 at 6 months) was found in 24 of the active group and 16 of the usual group (P = 0.04; NNT = 5).
Intriguingly, women in the active group were found to have a greater decrease in depressive symptoms over the course of the study (-6.4; 95% CI, -10.1 to -2.6) when compared to men (-1.6; 95% CI, -6.7 to 3.6), (P = 0.03). A similar theme occurred for patients with diabetes (-6.2; 95% CI, -10.0 to -2.3) when compared to those without (-0.9; 95% CI, -4.6 to 2.7), (P = 0.049). It is important to not that both of these sub-groups were highlighted through post hoc analysis.
In terms of expenses, total healthcare costs were not significantly higher in either group (adjusted change, -$325; 95% CI, -$2639 to $1989; P = 0.78), although active and usual treatment showed increased costs associated with mental health care and hospitalisation respectively.
This study supports the use of treatments which are stepped, centralised and that take patient preference into account. Furthermore the data suggests that post-ACS depression can be reversed without significantly increased healthcare costs. Considering the poor standard of the treatment and screening for this affliction in addition to the increased healthcare costs and associated mortality and morbidity risks, this research presents an important, though preliminary, advancement.
The authors also stress the lack of RCTs that investigate the treatment of post-ACS depression. They suggest that a phase three trial would lead the way to the effective treatment of post-ACS depression. Furthermore they hope that such a trial would potentially shed light on whether the treatment of post-ACS depression lowers associated mortality and recurrence rates. In this theme they state that:
The CODIACS Vanguard provides a basis for future studies to determine whether treating depression reduces mortality and cardiac event recurrence in patients after an ACS event.
Given the preliminary nature of this study, there are several areas which remain to be fully investigated. Most notable is the role that patient preference plays in the alleviation of depressive symptoms, but it is also vital to clarify exactly how these symptoms affect morbidity and mortality.
Several limitations are expressed by the authors and revealed through critical appraisal, these include:
- Inclusion of several patients, with depressive symptoms, who fail to meet the standard major depression threshold
- No comparison between the clinical attention received in each treatment group
- The ‘very preliminary’ nature of the cost estimates
- Lack of proper control or analysis of the level of patient preference in the ‘usual’ group
- Conflicting data suggesting that mortality risk and ACS recurrence associated with post-ACS depression are not significantly different from those associated with other coronary heart disease risk factors (Rozanski et al. 2005)
Davidson KW. Centralized, Stepped, Patient Preference-Based Treatment for Patients With Post-Acute Coronary Syndrome Depression: CODIACS Vanguard Randomized Controlled Trial. JAMA Intern Med. 2013 Jun 10;173(11):997-1004. doi: 10.1001/jamainternmed.2013.915. [PubMed abstract]
Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J AmColl Cardiol. 2005; 45(5):637-651. [PubMed abstract]
Whang W, Burg MM, Carney RM, et al. Design and baseline data from the vanguard of the Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) randomized controlled trial. Contemp Clin Trials. 2012;33 (5):1003-1010. [PubMed abstract]