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Original Investigation
October 21, 2019

Effect of Depression Screening After Acute Coronary Syndromes on Quality of Life: The CODIACS-QoL Randomized Clinical Trial

Author Affiliations
  • 1Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, New York
  • 2Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
  • 3Center for Health Research, Kaiser Permanente, Portland, Oregon
  • 4Department of Medicine, Duke University School of Medicine, Durham, North Carolina
  • 5Center for Personalized Medicine, Northwell Health, New York, New York
  • 6HealthPartners Institute, Minneapolis, Minneapolis
  • 7Department of Medicine, Northwell Health, New York, New York
JAMA Intern Med. 2020;180(1):45-53. doi:10.1001/jamainternmed.2019.4518
Key Points

Question  What is the effect of systematic depression screening with and without provision of enhanced depression care on quality-adjusted life-years and depressive symptoms among survivors of acute coronary syndromes?

Findings  In this randomized clinical trial that included 1500 survivors of acute coronary syndromes, there were no differences in quality-adjusted life-years or depression-free days in those who were and were not screened for depression, even when depression screening was followed by enhanced depression care.

Meaning  Contrary to recommendations from professional societies, systematic depression screening of survivors of acute coronary syndromes may not be warranted.

Abstract

Importance  Patients with acute coronary syndrome (ACS) and elevated depressive symptoms are at increased risk for recurrent cardiovascular events and mortality, worse quality of life, and higher health care costs. These observational findings prompted multiple scientific panels to advise universal depression screening in survivors of ACS prior to evidence from randomized screening trials.

Objective  To determine whether systematically screening for depression in survivors of ACS improves quality of life and depression compared with usual care.

Design, Setting, and Participants  A 3-group multisite randomized trial enrolled 1500 patients with ACS from 4 health care systems between November 1, 2013, and March 31, 2017, with follow-up ending July 31, 2018. Patients were eligible if they had been hospitalized for ACS in the previous 2 to 12 months and had no prior history of depression. All analyses were performed on an intention-to-treat basis.

Interventions  Patients with ACS were randomly assigned 1:1:1 to receive (1) systematic depression screening using the 8-item Patient Health Questionnaire, with notification of primary care clinicians and provision of centralized, patient-preference, stepped depression care for those with positive screening results (8-item Patient Health Questionnaire score ≥10; screen, notify, and treat, n = 499); (2) systematic depression screening, with notification of primary care clinicians for those with positive screening results (screen and notify, n = 501); and (3) usual care (no screening, n = 500).

Main Outcomes and Measures  The primary outcome was change in quality-adjusted life-years. The secondary outcome was depression-free days. Adverse effects and mortality were assessed by patient interview and hospital records.

Results  A total of 1500 patients (424 women and 1076 men; mean [SD] age, 65.9 [11.5] years) were randomized in the 18-month trial. Only 71 of 1000 eligible survivors of ACS (7.1%) had elevated 8-item Patient Health Questionnaire scores indicating depressive symptoms at screening. There were no differences in mean (SD) change in quality-adjusted life-years (screen, notify and treat, –0.06 [0.20]; screen and notify, −0.06 [0.20]; no screen, −0.06 [0.18]; P = .98) or cumulative mean (SD) depression-free days (screen, notify and treat, 343.1 [179.0] days; screen and notify, 351.3 [175.0] days; no screen, 339.0 [176.6] days; P = .63). Harms including death, bleeding, or sleep difficulties did not differ among groups.

Conclusions and Relevance  In patients with ACS without a history of depression, systematic depression screening with or without providing depression treatment did not alter quality-adjusted life-years, depression-free days, or harms.

Trial Registration  ClinicalTrials.gov identifier: NCT01993017

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