CODIAC QoL: Screening for Depression after ACS

(thoughtful music) – My name is Ian Kronish, today
I’m going to be presenting you the results of the CODIAC’s QoL trial. A randomized trial of depression
screening in ACS patients. So why do we care about
depression screening in this patient population? Well to begin with, depression
is very common after ACS with about one in five having
elevated depressive symptoms and one in 10 having major depression. Those patients who have
depression are at increased risk for recurrent cardiovascular
events and mortality. Actually double the risk. They also have a higher health care cost and lower quality of life. Based on these findings
multiple professional societies have recommended systematic
depression screening in ACS patients but thus far
no one had ever tested this in a randomized trial. There are reasons to believe
that depression screening may not be effective in
part because patients who are identified to have
depression through screening may not be engaged in
subsequent depression treatment and the treatments may be less effective. There are also the potential for harms including the effect of labeling patients with a psychiatric illness and side effects from
antidepressant medications that may be more likely to be prescribed. So with that in mind we conducted a multi-site randomized control trial of four healthcare systems
around the United States and patients were randomized
to one of three groups. Depression screening with the PHQ-8, a commonly used depression instrument, as well as referring patients
who had a positive screen to depression treatment that
was provided through the study. These patients also had their treatment providers notified
of the positive screen. The second group was just
called screen and notify in which they were
screened with the PHQ-8, their providers were notified, but depression treatment was
not provided by the study. And then the third group did not undergo depression screening. We enrolled 1,500 patients into the study with even distribution
across the three groups. And we found, the key
findings that we found, were first of all the rate of detecting depression was only 7%. This was lower than we had expected. The second major finding was
that we found no difference in depressive symptoms or
in quality of life scores between the three groups. And quality of life was our major primary outcome for the trial. We also did not find any harm in terms of increased reporting of side
effects from antidepressants nor increased mortality. So we think these findings are important for several reasons. To begin with, it may
be that recommendations for systematic depression screening, at least in the manner
that we did this trial, may be premature until there’s
more definitive evidence for a clear benefit. We don’t wish clinicians
to take home the message that depression is not important. Certainly depression does confer increase cardiovascular risk. It also goes along with lower
adherence to medical treatment and if clinicians suspect depression, we certainly wish that they would go on to evaluate it further and get the help of a mental health specialist if needed. But the idea of routinely
screening every patient for depression does consume
healthcare resources and may not be cost effective. (thoughtful music)

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