Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression CODIACS Vanguard Randomized Controlled Trial CODIACS Vanguard RCT

Davidson KW, Bigger J, Burg MM, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Controversy remains about whether depression can be successfully managed after acute coronary syndrome (ACS) and the costs and benefits of doing so.

Objective

To determine the effects of providing post-ACS depression care on depressive symptoms and health care costs.

Design

Multicenter randomized controlled trial.

Setting

Patients were recruited from 2 private and 5 academic ambulatory centers across the United States.

Participants

A total of 150 patients with elevated depressive symptoms (Beck Depression Inventory [BDI] score ≥10) 2 to 6 months after an ACS, recruited between March 18, 2010, and January 9, 2012.

Interventions

Patients were randomized to 6 months of centralized depression care (patient preference for problem-solving treatment given via telephone or the Internet, pharmacotherapy, both, or neither), stepped every 6 to 8 weeks (active treatment group; n = 73), or to locally determined depression care after physician notification about the patient's depressive symptoms (usual care group; n = 77).

Main Outcome Measures

Change in depressive symptoms during 6 months and total health care costs.

Results

Depressive symptoms decreased significantly more in the active treatment group than in the usual care group (differential change between groups, −3.5 BDI points; 95% CI, −6.1 to −0.7; P = .01). Although mental health care estimated costs were higher for active treatment than for usual care, overall health care estimated costs were not significantly different (difference adjusting for confounding, −$325; 95% CI, −$2639 to $1989; P = .78).

Conclusions

For patients with post-ACS depression, active treatment had a substantial beneficial effect on depressive symptoms. This kind of depression care is feasible, effective, and may be cost-neutral within 6 months; therefore, it should be tested in a large phase 3 pragmatic trial.

Trial Registration

clinicaltrials.gov Identifier: NCT01032018

Benefits and Costs of Improving Depression Treatment in People With Heart Disease Comment on “Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression” Depression Treatment in People With Heart Disease

Simon GE. — Mon, 10 Jun 2013 00:00:00 GMT

In this issue of JAMA Internal Medicine, Davidson et al describe the benefits of an organized depression care program for outpatients experiencing significant symptoms of depression after acute coronary syndrome (ACS). Patients were screened 2 to 6 months after hospitalization for ACS, and those with significant depressive symptoms were randomly assigned to either a systematic depression treatment program or continued usual care (which might include depression treatment from local medical or mental health providers). The Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) treatment program included the essential elements proven effective in previous collaborative care or depression care management programs: availability of antidepressant pharmacotherapy and structured psychotherapy, systematic assessment of outcomes, a stepped care algorithm for treatment adjustment or intensification, and organized supervision by consulting mental health specialists. Those offered the organized depression treatment program experienced significantly greater improvement (both statistically and clinically) over 6 months. This finding adds to the substantial evidence for the clinical benefit of depression screening and systematic treatment among people with varying stages of heart disease ranging from outpatients with poorly controlled cardiovascular risk factors to patients discharged after revascularization.

AMA Publishing Group: Acute Coronary Syndrome Topic Collection

Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression CODIACS Vanguard Randomized Controlled Trial CODIACS Vanguard RCT

Benefits and Costs of Improving Depression Treatment in People With Heart Disease Comment on “Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression” Depression Treatment in People With Heart Disease