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Screening heart patients for depression not effective

University of Leicester/Leicester Partnership Trust involved in research

Issued on 14 November 2008

In a study to be published in the Journal of the American Medical Association (JAMA), researchers at McGill University, Johns Hopkins University and six other institutions from around the world, including the University of Leicester/Leicester Partnership Trust, question the American Heart Association's recent suggestion that millions of North American cardiac patients be automatically screened for depression. Such screening would involve administering a questionnaire and other tests to try to identify individuals who might have had no history or clinical indications of depression but who may, nonetheless, be depressed.

The AHA maintains that the link between depression and cardiac care is important.

But Dr. Brett Thombs of McGill and the affiliated Jewish General Hospital, and Dr. Roy Ziegelstein, of Johns Hopkins, say there is not nearly enough medical evidence to support such a "massive, expensive and labour-intensive undertaking," and in fact provide evidence that testing for depression would not benefit patients in a cardiac care environment.

"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," said Thombs, a psychologist and assistant professor in the Department of Psychiatry at McGill's Faculty of Medicine and at the JGH. "Unfortunately, the reality is that it would be an extremely difficult undertaking that wouldn't produce practical benefits for patients."

The study drew upon a collection of more than 1,500 clinical studies from around the world, of which 17 were selected for detailed review.

"We discovered that screening alone or screening and referral doesn't help most patients. This is true even in primary care where the doctor is usually better trained than a cardiologist to manage depression," said Thombs. "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."

The researchers found that treating depression in people with heart disease only accounted for a 1 per cent to 4 per cent change in symptoms compared with those treated with placebo. This result, Ziegelstein said, is "too low to expect meaningful benefits for most people, particularly since screening methods are not very precise in identifying people who would benefit from the treatment."

"Moreover, we found no connection at all between getting treated for depression and cardiovascular outcomes, like having a subsequent heart attack," Thombs added. "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.

"We're just saying 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 behaviours that combat depression, such as how to stop smoking, exercise regularly and maintain a healthy weight."

Dr Alex Mitchell, honorary senior lecturer in psycho-oncology in the Department of Cancer and Molecular Medicine at the University of Leicester and consultant in the Leicester Partnership Trust, was part of the group investigating the merits of screening tests for depression.

Dr Mitchelll, who is based at the Leicester Royal Infirmary, said: “The findings highlight a lack of evidence relating to actual patient benefits following screening and only modest improvements in depression following treatment.”

Previously, Dr Mitchell has questioned the recommendations from NICE that two simple questions may be sufficient to detect depression in primary care (Br J Gen Pract 2007;57:144–51) perinatal settings (Journal of the American Board of Family Medicine 2008; 21 (4): 317-325) and cancer (British Journal of Cancer (2008) 98, 1934–1943).

He added: “The message for clinicians is that although rapid screening for depression is practical it should not replace a thorough clinical assessment.”

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Other researchers who contributed to this study include Peter de Jonge, Ph.D., of the University Medical Center Groningen, Netherlands; James Coyne, Ph.D., of the University of Pennsylvania School of Medicine, in Philadelphia; Mary Whooley, M.D., of the University of California, San Francisco; Nancy Frasure-Smith, Ph.D., of McGill; Alex Mitchell, M.Sc., M.R.C. Psych, of the University of Leicester/Leicester Royal Infirmary, UK; Marij Zuidersma, M.Sc., of Groningen; Cheri Smith, M.L.S., and Karl Soderlund, B.S., of Johns Hopkins, Chete Eze-Nliam, M.D., M.P.H., of Interfaith Medical Center in Brooklyn, N.Y.; and Bruno Lima, of the Federal University of Ceara School of Medicine, in Fontalez-ce, Brazil.