A modest, 12-week collaborative care intervention alleviated depression symptoms – at least in the short term – in depressed patients hospitalized for a wide spectrum of cardiovascular diseases.
The findings, from a randomized, controlled trial in 175 depressed patients hospitalized for acute coronary syndrome, myocardial infarction, arrhythmia, or heart failure, , published March 8 in the journal Circulation: Cardiovascular Quality and Outcomes, suggest that a collaborative care depression management program begun in the hospital could have benefits in these groups even when follow-up is limited to a few phone calls from a care coordinator after discharge.
The current study, published March 8 in the journal Circulation: Cardiovascular Quality and Outcomes, and led by Dr. Jeff C. Huffman and his colleagues at Harvard Medical School and Massachusetts General Hospital, both in Boston, differed from earlier research by initiating the intervention during hospitalization instead of shortly afterward, by enrolling people admitted for a wide range of cardiovascular diseases and by having relatively light postdischarge follow-up, with a maximum of three phone conversations between care coordinators and patients over 12 weeks (Circ. Cardiovasc. Qual. Outcomes 2011;4:198-205).
Also, for baseline and subsequent mental health analyses, Dr. Huffman and his colleagues used clinical depression measures recommended by the American Heart Association (Circulation 2008;188:1768-75): a Patient Health Questionnaire-2 on admission, with patients with positive screens further evaluated using Patient Health Questionnaire-9 (PHQ-9).
Hospital-started interventions have been generally avoided for this type of study, commented Dr. Bruce L. Rollman of the University of Pittsburgh, because some mood symptoms may be related to the hospitalization itself or resolve shortly following hospital discharge. However, for the their study, Dr. Huffman and his colleagues noted, subjects were highly selected, with more than 70% having a prior episode of depression and ongoing symptoms for 1 month before enrollment.
The 85 patients randomized to usual care had a mean age of 62.6 years; 55% were women and 91% were white. In that treatment, a care manager first informed the hospital team of each patient’s depression, then placed follow-up phone calls intermittently until 12 weeks after discharge to assess the patient’s depression status. If the manager determined that depression was ongoing, he or she informed the patient’s primary care physician.
For the 90 subjects in the treatment arm (mean age 62.1, 42% women, 92% white) the care manager provided more elaborate coordination and follow up that included in-hospital tutorials about depression and cardiac disease, help planning postdischarge activities, and postdischarge phone calls to determine whether changes were needed. The coordinator and psychiatrist developed depression treatment recommendations that were then prescribed by the psychiatrist, and the care manager worked to coordinate treatment with all providers.
Patients in both arms were evaluated again 6 weeks, 12 weeks, and 6 months after discharge.
The collaborative care subjects saw significantly greater rates of depression response, as measured by PHQ-9, at 6 weeks, compared with usual care (59.7%, and 33.7%, respectively). At 12 weeks, the difference remained significant but began to narrow, with 51.5% in the intervention, compared with 34.4% in the control arm. No statistically significant difference in depression response was found between the arms at 6 months. Cardiac symptoms were not significantly different at either 6 or 12 weeks between the arms, and hospital readmission outcomes for cardiac symptoms were similar – about 40% – for both groups after 6 months.
Collaborative care programs use nonphysician coordinators to facilitate communication and treatment plans among patients, their primary care doctors, and specialists. Part of the programs’ appeal, said Dr. Rollman in an interview, is that they can be performed on the phone for relatively little cost: “You could potentially do this from a call center in India, or on Skype.”
Several studies have evaluated collaborative care after hospitalization for depressed patients with specific cardiac diseases: Dr. Rollman’s recent 302-patient randomized controlled trial, called Bypassing the Blues, found telephone-administered collaborative care programs associated with significantly better self-reported mental and physical outcomes depressed patients 8 months after coronary artery surgery, compared with standard care (JAMA 2009;302:2095-103).
Dr. Roy Ziegelstein, of Johns Hopkins University’s Center for Mind-Body Research in Baltimore, called the current study important, and pointed to the difference in antidepressant use between the two groups. Of the patients in usual care, 46% were taking an antidepressant on admission, compared with 56% by hospital discharge, he said in an interview. Of patients in the treatment arm, 42% were taking an antidepressant on admission, compared with 83% at discharge, a near-doubling.