Depression Screening/Treatment after ACS Yields No Benefit

In a large group of patients with acute coronary syndrome (ACS) and without a history of depression, systematic depression screening, with or without follow-up treatment, failed to improve outcomes vs usual care.

Depression is a well-recognized outcome of ACS: approximately 10% of ACS patients meet criteria for major depressive disorder and ACS patients with depression face twice the risk of mortality or recurrent cardiovascular (CV) events. Study authors, led by Ian M. Kronish, MD, MPH, associate director, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center in New York City, write in JAMA Internal Medicine, that these data and wide availability of effective treatments for depression have led multiple professional societies to recommend depression screening in post-ACS patients followed by treatment where appropriate.

The results of most studies showing depression treatment effective in this patient population, however, are limited by their enrollment of only patients seeking treatment.

This is the first study to examine depression screening and subsequent treatment in patients with ACS.

Study participants had experienced documented ACS within 2 to 12 months of enrollment and had no history of depression and were drawn from 4 major US health systems:  HealthPartners in Minneapolis; Duke University Health System; Kaiser Permanente Northwest in Portland; and New York–Presbyterian/Columbia University Irving Medical Center, New York.

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

The 1500 patients were randomized to 3 groups:

1. No depression screening
2. Screening and notifying the PCP
3. Screening, notifying the PCP, and providing enhanced depression treatment that had been found effective in patients with ACS (although not patients who had been screened for depression)

The primary outcome was change in quality-adjusted life years (QALYs) and the secondary outcome depression-free days at 18 months after randomization.

There were no significant differences in the change in mean QALYs among groups (−0.06 [0.20]; −0.06 [0.20]; and −0.06 [0.18]; P=.98) or in the number of depression-free days (343.1 days vs 351.3 days vs 339.0, P=0.63).

There also were no differences in change in CEDS-10 or PHQ-8 depressive symptoms from baseline to 18 months.

Authors' proposed explanations for lack of benefit of depression screening include: 

• A smaller than expected proportion of participants had positive depression screening results

• Nearly 25% of those who had positive screening results declined enhanced depression care, which may have limited the potential for screening to have an impact on QOL.

• Even among those who did initiate treatment, those identified by screening may have been less motivated, thus less engaged, further limiting beneficial effect.

The authors point to corroborating evidence from studies of depression screening in other contexts, specifically:  use of an electronic prompt for PCPs to screen for depression/anxiety as well as pain vs pain only in osteoarthritis patients in England did not result in decreased depressive symptoms; also, the very low yield of an incentivized program of depression screening for primary care patients with coronary artery disease or diabetes led to abaondonment of support for the use of screening as a quality indicator in the United Kingdom.

In their discussion, the authors underscore the  “…compelling evidence that depression is a cardiotoxic risk marker in patients with ACS, strongly and consistently associated with quality of life,” but conclude that despite the magnitude of the risk, their results suggest little population-level benefit to systematic screening for depression among ACS patients.

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