Depression after heart disease is associated with an increased risk of death or another heart attack. But what is not known is if treating heart attack survivors for depressive symptoms could relieve these symptoms, be cost-effective, and ultimately, reduce medical risk.
A new study from Columbia University Medical Center addressed these questions and discovered a patient-centered approach to manage depression in cardiac survivors can be very beneficial.
Karina W. Davidson, Ph.D., and her research team performed a randomized controlled trial on 150 patients with elevated depressive symptoms two to six months after hospitalization for heart disease.
Patients were recruited from seven centers across the United States; 73 received six months of patient-preference depression care, and 77 received six months of depression care determined by their physician upon notification that the patient had elevated depressive symptoms.
In the study, those in the patient-preference group were given a choice of therapy or antidepressants, or both.
“We tried to help them really think through, what does it take to take a pill every day, what it takes to talk to a person about painful feelings and do homework. We then considered what would fit into their life,” said Davidson.
“Every six to eight weeks, we revisited how their chosen treatment was working for them and helped them make adjustments based upon their feedback.”
Virtual therapy (by phone or web-based) was delivered by two counselors (one at CUMC and one at Yale), to ensure that patients had access to clinicians of a similar skill set. The virtual therapy also helped connect patients with therapists at times that were most convenient for them.
“Maybe 8:00 pm at your home is the right time for you, but not 8:00 pm if you have to go to a clinic or hospital, wait half an hour, and then travel back home afterwards,” said Dr. Davidson.
The therapy used in the trial was problem-solving treatment (PST)—a practical, hands-on approach that asks patients to choose the problems in their life that they want to tackle and teaches them how to problem-solve.
Patients were assigned homework to try the solutions and then returned to talk about what worked and what didn’t, and tackle the next problem.
“What we want to know is whether this kind of patient-preference, centralized, heart disease-specific depression care was feasible and effective, and whether it also has the tantalizing possibility of being cost-neutral within six months,” said Davidson.
Researchers discovered depressive symptoms were reduced more in the patient-preference, centralized depression care group than in the group of patients receiving usual care.
At the start of the trial, patients had an average of 19 points on the Beck Depression Inventory (BDI) depression scale. At the end of the trial, BDI scores in the patient-preference group were significantly reduced, by an average of 3 points more than in the other group.
A score below a 10 on the BDI puts one in the normal range. Almost half of the group who received patient-preference, centralized treatment lowered their scores to the normal range, compared with only one-third of the usual-care group.
Researchers found that providing centralized depression care at seven sites nationwide was effective, suggesting that it is feasible to deliver depression care to those who do not have specialists in their area.
Overall, the total health care costs for the patient-preference depression treatment group was $325 less than for the usual-care group, even when factoring in the cost of therapy. And fewer hospitalizations were seen in the patient-preference group than in the usual-care group.
“We really wanted to know whether we can treat depressive symptoms in a large group of patients nationwide and if doing so ultimately lowers their risk of death or having another heart attack,” said Davidson.
“Routine management of depressive symptoms in heart disease patients has been poor and lacked an evidence base. With these results, which will help us understand what we can do to relieve the suffering of those who experience both disabling problems, we can now propose a large, national trial more effectively and efficiently.”
The study has been published online in JAMA Internal Medicine.