Treating Post-ACS Depression Effective, Cost-Neutral

Deborah Brauser

March 07, 2013

Treating depression occurring after acute coronary syndrome (ACS) can be successful and cost-effective, new research suggests.

A randomized controlled trial of 150 ACS patients with depressive symptoms showed that those who for 6 months received stepped treatment, consisting of problem-solving therapy and/or antidepressant medication, had significantly lower symptom scores on the Beck Depression Inventory (BDI) than their counterparts who received locally determined usual care.

In addition, overall estimated healthcare costs did not differ significantly between the groups and were considered cost-neutral within 6 months.

Dr. Karina Davidson

"Although the depression care itself was more expensive for the patients who were in the active treatment arm, we had fewer hospitalizations," lead author Karina W. Davidson, PhD, clinical health psychologist and professor of medicine, cardiology, and psychiatry at Columbia University College of Physicians and Surgeons in New York City, told Medscape Medical News.

"We're very excited that this may be a pathway to having psychiatry and cardiology work more closely together to better improve the overall health of our patients," added Dr. Davidson.

The investigators note that on the basis of these findings, "a large pragmatic trial" should be conducted.

"A large phase 3 trial would inform evidence-based depression treatment guidelines for [these patients], and even has the tantalizing possibility of answering the important question of whether treating depression...lowers mortality and recurrence rates," they write.

The study was published online March 7 in JAMA Internal Medicine to coincide with its presentation at the American College of Cardiology's annual Scientific Sessions.

Skeptics Silenced

According to the researchers, each year, roughly 1.2 million adults in the United States survive an ACS event, such as unstable angina or myocardial infarction. Post-ACS depression is common and may increase the risk for another ACS by 150%, and it may increase the relative risk of all-cause mortality by 100%.

However, routine management of this condition "remains poor because of inefficiencies in depression screening, lack of effective administration of depression treatment, weak depression treatment effects, and limited treatment options if initial efforts fail," the authors write.

Dr. Davidson reported that the Comparison of Depression Interventions after ACS (CODIACS) Vanguard trial was created as a follow-up to an earlier study conducted by her team.

"We had a number of skeptics for our original publication that we would not be able to replicate such a large depressive symptom reduction and cost efficiency if we were to try and run this nationwide," she said.

"Happily, many of those skeptics joined us in running this second trial."

For the CODIACS Vanguard study, 150 patients with scores of 10 or higher on the BDI 2 to 6 months after being hospitalized for an ACS were enrolled at 1 of 5 centers between March 2010 and January 2012.

Participants were randomly assigned to receive for 6 months either centralized depression care/active care, stepped every 6 to 8 weeks on the basis of scores on the Patient Health Questionnaire 9 (n = 73), or usual care (n = 77). The mean age for each group was 59.2 years and 60 years, respectively.

Active care consisted of patient preference for problem-solving treatment given via telephone or the Internet (n = 41), antidepressant medication (n = 9), both (n = 17), or neither (n = 6).

Usual care consisted of letting patients obtain depression treatment from their primary care physician, cardiologist, or other healthcare provider.

The primary outcomes measures were changes in depressive scores, as measured on the BDI, and total healthcare costs.

Feasible, Effective

Results showed that the active care group had significantly greater decreases in depressive symptom scores at the end of treatment than did the usual care group (BDI scores, -10.1 and -6.6, respectively; difference, P = .01).

In additional subgroup analyses, BDI scores in the active treatment group decreased more for the women than for the men (-6.4 vs -1.6, respectively).

Initial estimated mental health costs were higher for the full active treatment group vs the usual care group (difference, $687; P < .001), but hospital costs were lower (by $1010).

As a result, adjusted overall estimated costs were not significantly different between the groups.

"This kind of depression care is feasible, effective, and may be cost-neutral within 6 months," the authors write.

"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."

Dr. Davidson noted that the results of this trial replicated the large reduction in symptoms shown in her previous study, as well as the cost efficiency. "And we're very excited about both those findings," she added.

"We have a very strong signal that offering depression care can happen for more patients in more systems in an efficient way that cardiologists like and that makes sense cost-wise."

Cost Estimate Accurate?

Gregory E. Simon, MD, MPH, from the Group Health Research Institute in Seattle, Washington, writes in an accompanying editorial that the study's finding of symptom improvement "adds to the substantial evidence for the clinical benefit of depression screening and systematic treatment among people with varying stages of heart disease."

However, he notes that observed clinical benefits from the organized depression treatment program "are on the high end" and that clinicians should be careful not to overinterpret this effect — especially because improvement rates in the usual care group "were disappointingly low."

Nevertheless, Dr. Simon writes that the results suggest that "the benefits of greater standardization and quality control may outweigh any benefits of local knowledge and face-to-face contact."

If supported by further research, he notes that this finding could have important implications, especially in rural settings, where local mental health resources are limited.

"Delivering standardized services from a central location may be a viable (or even preferable) alternative."

However, he questions the results of the cost-analyses conducted.

"While the CODIACS investigators conclude that the depression care program was 'cost neutral,' I would be more cautious in interpreting the finding of no significant difference in cost," Dr. Simon writes.

"Instead of concluding that this...program is cost-neutral, I would conclude that this sample is far too small to accurately estimate the effect of the program on use or cost of general medical services — especially the highly variable category of inpatient medical costs," he adds.

Still, he writes, "the finding of generally similar total health services costs is consistent with broader experience to date."

The study was funded by grants from the National Institutes of Health and the National Center for Advancing Translational Sciences. Dr. Davidson and 23 of the other 24 study authors have reported no relevant financial relationships. The remaining study author reports that he or a member of his family owns stock in Pfizer Inc. and Forest Laboratories. Dr. Simon has reported no relevant financial relationships

JAMA Intern Med. Published online March 7, 2013. Abstract, Editorial