Impact of a Depression Care Management Program for Hospitalized Cardiac Patients

Study Questions:

What is the impact of a collaborative care depression management program initiated in the hospital for patients with a wide range of cardiac illnesses?

Methods:

A prospective, randomized trial of a low-intensity, 12-week collaborative care program versus usual care was conducted in an urban medical center in 175 depressed patients hospitalized for acute coronary syndrome, arrhythmia, or heart failure. Study outcomes, assessed using mixed regression models to compare groups at 6 weeks, 12 weeks, and 6 months, included mental health (depression, cognitive symptoms of depression, anxiety, and mental health-related quality of life) and medical (physical health-related quality of life, adherence to medical recommendations, and cardiac symptoms) outcomes.

Results:

There was no difference between the intervention and usual care groups for the following: mean age 62 years, gender, marital status, race, coronary risk factors, prior depression or antidepressant use on admission, mental health and quality of life profiles, cardiovascular diagnosis, and cardiovascular medication at discharge. The collaborative care model subjects were more likely to be discharged on antidepressants (83% vs. 56%, p < 0.001). Collaborative care subjects (n = 90) had significantly greater improvements on all mental health outcomes at 6 and 12 weeks, including rates of depression response (collaborative care, 59.7% vs. usual care 33.7%; odds ratio, 2.91; p < 0.003 at 6 weeks; 51.5% vs. 34.4%; odds ratio, 2.02; p < 0.04 at 12 weeks), although these effects decreased after intervention. At 6 months, intervention subjects had significantly greater self-reported adherence and significantly reduced number and intensity of cardiac symptoms.

Conclusions:

Among patients with a broad range of cardiac diagnoses, a collaborative care depression management program initiated during hospitalization led to significant improvements in multiple clinically important mental health outcomes, and had promising effects on relevant medical outcomes after intervention.

Perspective:

This study further validates the evidence that a liaison psychiatry service provided to the in-hospital cardiology service patients can improve mental status and quality of life, which have been shown to be associated with better compliance with evidence-based treatments and lifestyle change. Whether the psychological profiling should be performed in-hospital or within a time point post-discharge will require further study. While approximately 20% of patients on the inpatient cardiology service have depressive symptoms, at 2 weeks post-discharge, the same percentage are depressed, but about one-half have shown spontaneous improvement and are replaced with new-onset post-discharge depression. The message to all care givers of cardiac patients is that depression is common, is associated with a worse outcome, and should be assessed and treated.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Depression, Acute Coronary Syndrome, Psychiatry, Heart Failure, Risk Factors, Cardiology Service, Hospital, Hospitalization, Mental Health


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