Treatment for Patients with Post-ACS Depression

Depression, becoming the leading cause of years living with disability worldwide, is particularly burdensome when comorbid with a chronic medical disorder. In the United States, 1.2 million patients survive an acute coronary syndrome (ACS) event each year; many of those patients have clinically significant and persistent depression following the event.

Compared with post-ACS patients without depression, those with depression have significantly more ambulatory medical appointment, visits to the emergency department, and higher health costs. In addition, the presence of post-ACS depression is associated with a 150% increased risk of recurrence of ACS and a 100% increase in the relative risk of all-cause mortality. Persistent depression following an ACS event is associated with an even higher risk of morbidity and mortality, according to researchers.

The CODIACS (Comparison of Depression Interventions after Acute Coronary Syndrome) Vanguard trial was conducted to assess the feasibility, efficacy, and costs of a centralized, stepped, patient preference-based depression care system for patients following an ACS event. Results of the trial were reported in JAMA Internal Medicine [2013;173(11):997-1004].

CODIACS was a multicenter, randomized controlled trial that recruited 150 patients from 2 private and 5 academic ambulatory centers across the United States between March 18, 2010, and January 9, 2012. Patients had elevated depressive symptoms, defined as a Beck Depression Inventory (BDI) score ≥10, 2 to 6 months after an ACS. The trial’s primary outcome measures were change in depressive symptoms during 6 months and total healthcare costs.

Patients were randomly assigned to either the active treatment group (n=73), which was defined as centralized depression care (patient preference for problem-solving treatment [PST] given via telephone or the Internet, pharmacotherapy, both, or neither), stepped every 6 to 8 weeks, or to a usual care group (n=77), which was defined as locally determined depression care after physician notification regarding the patient’s depressive symptoms.

Of the 73 patients in the active treatment group, 41 initially chose PST, 9 chose antidepressant medication, 17 chose both, and 6 chose neither. For those who opted for PST, the mean number of sessions was 7.7. Of the patients in the usual care group, 9 received psychotherapy and another 9 received antidepressants new to their treatment regimen.

Patients in the active treatment group experienced a greater reduction in BDI scores compared with the usual care group (-10.1 vs -6.6), resulting in a significant differential change between groups of -3.5 BDI points (95% confidence interval [CI], -6.1 to -0.7; P=.01). Remission of depression symptoms (BDI score <10 at 6 months) occurred in 24 patients (47.1%) in the active treatment group and 16 patients in the usual care group (27.6%) (P=.04).

Mental healthcare costs for patients in the active care group were significantly higher than for those in the usual care group (adjusted change, $687; 95% CI, $466-$909; P<.001). Average hospital costs were lower in the active treatment group compared with the usual care group (adjusted change, -$1010; 95% CI, -$3294 to $1274; P=.39). As a result of the offset, “total healthcare costs in the study intervention group were not higher than in the comparison group,” the researchers noted.