Comparison of Depression Identification After Acute Coronary Syndrome: Quality of Life and Cost Outcomes

Not Applicable

Completed

• Conditions: Acute Coronary Syndrome; Depressive Symptoms
• Interventions: Other: Cognitive Behavioral Therapy (CBT); Other: Standard Care; Other: No intervention; Drug: Antidepressant Medication; Other: Depressive symptom screener

• Registration Number: NCT01993017
• Lead Sponsor: Columbia University

Brief Summary

The purpose of this study is to examine, in a randomized controlled trial, the benefits and costs of the American Heart Association's (AHA) advisory for depression screen and treatment of post-acute coronary syndrome patients.

Detailed Description

Patients with an acute coronary syndrome (ACS) and comorbid depression have a 2-fold higher risk for recurrent ACS and mortality, worse quality of life, and higher costs of care than nondepressed ACS patients. The strength of these observational findings prompted the American Heart Association (AHA) to advise that routine depression screening for ACS patients and referral for depression diagnosis and treatment as indicated occur. Unfortunately, there are no randomized controlled trials (RCT) to inform this potentially expensive screening recommendation. Additionally, screening guidelines/advisories in the absence of RCT evidence have recently been extensively criticized (and withdrawn). This poses a serious dilemma for clinicians, health care systems, and for health care policy leaders. A RCT is urgently needed to provide evidence for these different constituents about the costs and benefits of the AHA depression screen and treat algorithm.

Two critical gaps in knowledge must be filled to determine if public health would be improved by the AHA strategy for depression screening in post-ACS patients: 1) Does this strategy improve quality-adjusted life years for patients with a recent ACS 2) Is the cost of providing depression screening and any type of depression treatment within the acceptable and typical amounts reimbursed for health care services? Our specific aim is to determine the quality-adjusted life year benefits and health care costs of following the AHA's advisory for depression screening and then referral for further diagnosis and treatment in post-ACS patients, if depression is found. To accomplish this aim, we will randomize patients from four different, geographically diverse health care systems to three different groups: 1) to the AHA depression screen and treat if depression is found algorithm (screen and treat intervention group) or: 2) to be screened and a primary care provider notified (screen and notify intervention group) or: 3) to receive no depression screening (control group). Health-related quality of life, depressive symptoms, and costs will be obtained from all patients, so that the benefits and the costs of these three different depression screening strategies can be compared.

Study Timeline

• Study Start: 2013-11
• Study First Submitted: 2013-11-19
• Study First Submitted QC: 2013-11-19
• Study First Posted: 2013-11-25
• Primary Completion: 2018-07-31
• Study Completion: 2019-07-31
• Results First Submitted: 2019-10-24
• Results First Submitted QC: 2019-12-03
• Results First Posted: 2019-12-18
• Status Verified: 2023-04
• Last Update Submitted: 2023-04-12
• Last Update Posted: 2023-04-14

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 1501

Inclusion Criteria

• With a documented acute coronary syndrome (ACS) within the past 2-12 months
• Over the age of 21 years
• Has access to a phone

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Exclusion Criteria

Medical Exclusions:

• Terminal illness (life expectancy <1 year as determined by physician/medical record) defined as, but not limited to:
• NYHA class IV, ACC class D CHF requiring inotropes or mechanical assist devices or critical aortic stenosis without plan for correction
• End-stage COPD/emphysema
• Advanced cirrhosis with encephalopathy, varices, severe ascites
• Severe rheumatologic diseases requiring frequent hospitalizations, and multiple cytotoxic agents and/or disease modifying drugs
• Metastatic pancreatic, esophageal, colorectal or stomach cancer
• Metastatic sarcoma, ovarian, melanoma or renal cell cancer
• Metastatic breast cancer with multiple recurrences despite treatment
• Advanced CNS malignancies
• Recurrent hematologic malignancies with multiple recurrences despite treatment
• Persistent AIDS, untreated or treated

Psychiatric Exclusions:

• History of major depression
• Currently receiving depression treatment
• Dementia
• History of bipolar disorder
• History of psychosis
• History of suicide attempt or self-inflicted injuries
• Current alcohol or substance abuse

Other Exclusions:

• Non-English and non-Spanish speaking

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
AHA Depression Screen & Treat	Cognitive Behavioral Therapy (CBT)	Participants randomized to this arm will complete the Depressive symptom screener (8-item Patient Health Questionnaire, PHQ-8) after randomization. Those with clinically significant score (\>=10) will be offered treatment. Treatment will be delivered according to participant preference, and will be managed according to "stepped care". Stepped care includes, a) participant preference for either brief, cognitive behavioral therapy (CBT), delivered centrally by telephone, or antidepressant medication managed at the local site, or both, or neither, and b) review of progress at approximately 2-month intervals, with "stepping up" of care if sufficient progress is not being realized.
AHA Depression Screen & Treat	Antidepressant Medication	Participants randomized to this arm will complete the Depressive symptom screener (8-item Patient Health Questionnaire, PHQ-8) after randomization. Those with clinically significant score (\>=10) will be offered treatment. Treatment will be delivered according to participant preference, and will be managed according to "stepped care". Stepped care includes, a) participant preference for either brief, cognitive behavioral therapy (CBT), delivered centrally by telephone, or antidepressant medication managed at the local site, or both, or neither, and b) review of progress at approximately 2-month intervals, with "stepping up" of care if sufficient progress is not being realized.
AHA Depression Screen & Treat	Depressive symptom screener	Participants randomized to this arm will complete the Depressive symptom screener (8-item Patient Health Questionnaire, PHQ-8) after randomization. Those with clinically significant score (\>=10) will be offered treatment. Treatment will be delivered according to participant preference, and will be managed according to "stepped care". Stepped care includes, a) participant preference for either brief, cognitive behavioral therapy (CBT), delivered centrally by telephone, or antidepressant medication managed at the local site, or both, or neither, and b) review of progress at approximately 2-month intervals, with "stepping up" of care if sufficient progress is not being realized.
Depression Screen & Notify Arm Type :	Standard Care	Participants randomized to this arm will complete the depressive symptom screener (8-item Patient Health Questionnaire, PHQ-8) after randomization. Those with clinically significant score (\>=10) will have a letter sent to their primary care provider about their positive screen for depressive symptoms, with subsequent actions at the provider's discretion.
Depression Screen & Notify Arm Type :	Depressive symptom screener	Participants randomized to this arm will complete the depressive symptom screener (8-item Patient Health Questionnaire, PHQ-8) after randomization. Those with clinically significant score (\>=10) will have a letter sent to their primary care provider about their positive screen for depressive symptoms, with subsequent actions at the provider's discretion.
No Depression Screen	No intervention	Participants randomized to this arm will not complete a PHQ-8 assessment at randomization, and so will not be screened for depressive symptoms.

Primary Outcome Measures

Name	Time	Method
Quality-Adjusted Life Years (QALYs)	Baseline, 6, 12 and 18 months	Change in QALYs from baseline through 18 months. QALYs are a generic measure of disease burden, including both the quality and the quantity of life lived. One QALY equates to one year in perfect health. To measure change in QALYs, utility scores \[an overall assessment of well-being on a scale from 0 (death) to 1 (perfect health)\], were estimated using the Short Form-6 dimension, with scores derived from responses to the 12-Item Short-Form Health Survey, version 2, at baseline and 6, 12, and 18 months. QALYs for the period from baseline to 18 months were then calculated as the area under the curve by linearly interpolating the utility scores at the 4 assessments. Change in QALYs was then obtained by subtracting the baseline QALY from the observed QALY for an 18-month period, where baseline QALY was calculated under the assumption that the baseline utility score remained constant during the 18-month period.

Secondary Outcome Measures

Name	Time	Method
Cost of Health Care Utilization	Baseline through 18 months	Total cost of health care utilization from baseline through 18 months post-randomization
Depression-free Days	Baseline through 18 months	Depression-free days from baseline through 18 months post-randomization

Trial Locations

Locations (4)

Health Partners institute for Research and Education; 🇺🇸 Bloomington, Minnesota, United States

Columbia University Irving Medical Center; 🇺🇸 New York, New York, United States

Duke University; 🇺🇸 Henderson, North Carolina, United States

Kaiser Foundation Research Institute; 🇺🇸 Portland, Oregon, United States