NHFA CONSENSUS STATEMENT ON DEPRESSION IN PATIENTS WITH CORONARY HEART DISEASE Associate Professor David Colquhoun 19th October 2013 University of Queensland, Wesley & Greenslopes Hospitals, Brisbane, Australia www.coreresearchgroup.com d.colquhoun@uq.edu.au Slides prepared by David Colquhoun & Jenni Shields
What is Depression? Depression is more than just a low mood it s a serious illness. While we all feel sad, moody or low from time to time, some people experience these feelings intensely, for a long time and often without reason. People with depression find it hard to function every day and may be reluctant to participate in activities they once enjoyed. Depression is one of the most common of all mental health problems. One in five people experience depression at some stage of their lives. Ref: BeyondBlue: the national depression and anxiety initiative.
Thorpe - Depression
Depression and Cardiovascular Mortality Post-MI: 6 and 18 Month Outcome Adjusted RR: at 6 mos = 3.10; at 18 mos: 3.64 Non-depressed Depressed 20% 20 16.5% 15 10 6% 5 3% % of coronary deaths 25 0 6 months 18 months Frasure-Smith N et al. JAMA 1993;270:1819 1825. Frasure-Smith N et al. Circ 1995;91:999-1005.
PREVALENCE RATES OF MAJOR DEPRESSION IN PATIENTS WITH CARDIOVASCULAR ILLNESS 15-20% Unstable Angina-4 14-36% CHF-3 16-20% MI-2 15-23% CAD-1 0% 10% 20% 30% 40% prevalence rate, % 1-Carney. 1995; Hance, 1996; Gonzalez, 1996; Sullivan, 1999; Connerney, 2001; 2-Schleifer, 1989; Ladwig, 1991; Frasure-Smith, 1995; Jiang, 2001; 3-Jiang, 2001; Koenig, 1998; Frasure-Smith, 1993; 4Lesperance, 2000
Lipid Cohort Study This image cannot currently be display ed. Prevalence Of Depression Sub-study 715 of 7883 patients 25 Australian and 7 New Zealand Centres Beck Depression Inventory (BDI-II) >10 Males 27% Females 38% Baseline characteristics similar in depressed and non-depressed No association of depression with Pravastatin treatment in LIPID trial Weyers J, Colquhoun D, Stewart R. Atherosclerosis 2000;151:1-354
Depression and Symptoms major factor in quality of life greater symptoms if angina and atypical chest pains1 2 3 1Channer KR. J R Soc Med 1998;81:62932. 2Channer KS. Stress Med 1987;3:141-46. 3Sirois BS. J Behavioral Med 2003;26(6):535-51.
Risk ratios of classic risk factors and depression Risk ratios of traditional risk factors in the Framingham study compared to risk ratios by meta-analysis by Rugulies. REF: Blumenthal J. Cleveland Clinic Journal of Medicine. 2008 75(2):S48-S53
Lett HS, Blumenthal JA, Babyak MA et al. Depression as a Risk Factor for Coronary Artery Disease: Evidence, Mechanisms and Treatment. Psychosomatic Med 2004;66:305-315
Improvement of Depression leads to subsequent improved drug adherence in CHD patients 2006 Observational Study which noted improvement (BDI) in depression associated with subsequent improved aspirin adherence (electronic bottle)1 2009 SADHART noted after remission of depression improved adherence (BDI)2 2012 Collaborative Care depression treatment program noted improvement in depression (PHQ-9) was associated with subsequent improved drug adherence (P <0.001) Change in anxiety had no relationship to adherence.3 1) Rieckmann N, et al. J Am Coll Cardiol 2006;48:2218-22 2) Glassman AH, et al. Arch Gen Psychiatry 2009;66(9):1022-1029 3) Bauer L, et al. Am J Cardiol 2012;109:1266-1271
Need for a Screening Tool? For Depression in CHD patients It is a prevalent condition in patients with CHD/risk factors for CHD! 1) Misdiagnosis / non-diagnosis in hospital by medical practitioners and nurses. 2) Misdiagnosis in general practice
Recognition of Depression Myocardial Infarction Patients 60 patients clinical impression Vs BDI Johns Hopkins Bayview Medical Centre 30% BDI 10 (depressed) within 5 days of AMI 24 of 32 patient assessments not depressed when BDI 10 (i.e. 75% false negative) 13 of 17 patients assessed not depressed when BDI < 10 (cardiologists) (i.e. 24% false positive) Ziegelstein RC, Bush DE. Psychosomatic Med 2005;67:393-397
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National Heart Foundation of Australia Recommended Screening Tool Patient Health Questionnaire (PHQ-2) YES/NO Version (1) During the past month, have you often been bothered by feeling down, depressed or hopeless? (2) During the past month, have you often been bothered by little interest or pleasure in doing things? * Yes to either question is sufficient for a provisional diagnosis of depression. Elderon L et al. Screening for Depression: Heart And Soul Study. Circ. Cardio Qual Outcomes 2011;4:533-540 McManus D. Screening for Depression: Heart And Soul Study Am J Cardiol 2005;96(8):10761081 Expert Group. NHFA Consensus Statement. MJA On Line 1st May 2013
PHQ2 (Yes/No Version) Prognosis in Heart and Soul Study n=1,024 CHD patients mean 6.27 year follow up. PHQ2 Yes/No Version Yes to either question predicted 55% greater CV events P=0.0005 Elderon L, Smolderen K, Na B, Whooley MA. Circ Cardiovasc Qual Outcomes 2011;4:533-540
Summary Patient Health Questionnaire Yes/No Version Recommended screening tool of the NHFA Ease to remember and use (takes less time than to do a reliable BP!) Ought to be part of usual history taking Widely recommended and used internationally Reasonable sensitivity and specificity compared to psychiatric interview or extensive questionnaires Validated in multiple population and ethnic groups including Indigenous Australians Available at no cost (no royalties)
NHFA consensus recommendations for treatment Exercise Psychosocial - cognitive behavioural therapy - interpersonal psychotherapy Complementary Therapies - up to 50% of depressed patients use these Drugs - mainly serotonin reuptake inhibitors (SSRIs) (Sertraline, Fluoxetine, Citalopram, Mirtazapine) have been tested. - avoid tricyclic antidepressants (TCA) as may increase mortality rates. NHFA Consensus Statement. MJA On Line May 2013
Definition of NHMRC Grades of Recommendations Definition of NHMRC Grades of recommendations Grade of Recommendation Description A Body of evidence can be trusted to guide practice B Body of evidence can be trusted to guide practice in most situations C Body of evidence provides some support for recommendation (s) but care should be taken in its application D Body of evidence is weak and recommendation must be applied with caution
NHMRC Levels of Evidence NHMRC Evidence Hierarchy: Designation of Levels of Evidence Level Intervention I A systematic review of level II studies II A randomised controlled trial II-1 A pseudorandomised controlled trial (i.e. alternate allocation or some other method) III-2 A comparative study with concurrent controls: Non-randomised, experimental trial Cohort Study Case-control study Interrupted time series with a control group III-3 A comparative study without concurrent controls: Historical control study Two or more single arm study Interrupted time series without a parallel control group IV Case series with either post-test or pre-test/post-test outcomes
NHFA recommendations for screening and treatment of depression in patients with CHD Recommendation Grade of Recommendation Level of Evidence 1. For patients with CHD, it is reasonable to screen for depression Grade A Level I 2. Treatment of depression in CHD patients is effective in decreasing depression Grade A Level I 3. Treatment of depression in CHD patients improves CHD outcomes Grade D Level II 4. Treatment of depression in CHD patients changes behavioural risk factors/adherence Grade B Level III-2 5. Exercise is an effective treatment of depression in patients with CHD Grade A Level I 6. Exercise improves CHD outcomes in patients with CHD Grade B Level II NHFA Consensus Expert Group. Med J Aust 2013; on line 1.5.13
Conclusion Depression is common in CHD pts Detection is easy Treatment is effective and safe Recognise and treat NOW - to relieve suffering - probably to improve adherence - possibly to improve CHD prognosis