Study Questions Screening Heart Attack Patients for Depression
TUESDAY Nov. 11, 2008 -- There's not enough evidence to support a recent American Heart Association (AHA) call to automatically screen heart patients for depression, according to international experts who contend the "premature" recommendation would consume a vast amount of resources without any proof it would improve patient care.
About 80 million Americans have some form of heart disease. The AHA believes there's an important link between depression and cardiac care, and estimates that 25 percent of heart attack patients experience feelings of sadness and develop a gloomy outlook due to their heart troubles. Some studies suggest that depression more than doubles the risk of death.
Screening heart patients for depression would involve use of a questionnaire and other tests to try to identify those who may be depressed, even though they may have no history or clinical indications of depression.
However, researchers from Johns Hopkins University in Baltimore, McGill University in Montreal, and six other institutions from around the world analyzed the findings of 1,500 clinical trials (including 17 selected for detailed review) and concluded there was no scientific proof for the AHA's "massive, expensive and labor-intensive" proposal.
The researchers' conclusions are published in the Nov. 12 special edition of the Journal of the American Medical Association, which coincides with the AHA's annual scientific sessions in New Orleans.
"It's a very appealing idea that non-mental health professionals can administer a quick, easy-to-use depression screening test, and that would somehow benefit patients. Unfortunately, the reality is that it would be an extremely difficult undertaking that wouldn't produce practical benefits for patients," study team leader Brett Thombs, a psychologist and assistant professor in the department of psychiatry at McGill, said in a university news release.
"We discovered that screening alone or screening and referral doesn't help patients. This is true even in primary care, where the doctor is usually better trained than a cardiologist to manage depression," Thombs said. "We see positive effects only in 'enhanced care' or 'collaborative care' environments where they have mental health specialists on call. And even there, we only see tiny effects."
Thombs and his colleagues found that treating depression in heart patients only accounted for a 1 percent to 4 percent change in symptoms, compared to heart patients treated with a placebo.
"Moreover, we found no connection at all between getting treated for depression and cardiovascular outcomes, like having a subsequent heart attack," Thombs said. "That said, in no sense are we saying that depression doesn't matter. Depression leads to a great deal of suffering, cardiovascular effects aside, and it can definitely affect how well people take care of themselves after they've had a heart attack."
What Thombs and his colleagues are saying is that "we don't have the tools in cardiovascular care settings to identify and improve the lives of people who aren't already being treated for depression. What we really need is more research on how best to help heart disease patients adopt healthy behaviors that combat depression, such as how to stop smoking, exercise regularly and maintain a healthy weight."
Based on the findings, "we cannot in good conscience support screening of all heart patients," study co-author and cardiologist Dr. Roy Ziegelstein, vice chairman of medicine at Johns Hopkins Bayview Medical Center , said in a Hopkins news release.
Rather than a massive, costly screening program, Ziegelstein said physicians need to "get to know their patients better, as real people," and look for signs of depression as they discuss other health issues, such as dietary habits, exercise and use of medications.
"Physicians can start by listening more to their patients during examinations and by not interrupting them, which research shows often happens within the first 20 seconds after patients initiate conversation," he said.
The American Academy of Family Physicians has more about depression after a heart attack.
Posted: November 2008
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