Objectives and Rationale for Review

Patients who are diagnosed with acute coronary syndrome (ACS) are at increased risk for mental health problems—including major depressive disorder (MDD) and elevated symptoms of depression. For the purpose of this review, ACS refers to clinical symptoms compatible with acute myocardial ischemia and includes unstable angina, non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).

The objectives of the systematic review are:

• To evaluate the diagnostic accuracy of selected depression screening instruments.
• To assess the comparative safety and effectiveness of pharmacologic and nonpharmacologic treatments for depression in adult patients within 3 months of an ACS event.

Key Questions and Scope of Review

The Key Questions (KQs) follow:

KQ 1.

What is the accuracy of depression screening instruments or screening strategies compared to a validated criterion standard in post-ACS patients?

KQ 2.

What are the comparative safety and effectiveness of pharmacologic and nonpharmacologic depression treatments in post-ACS patients?

Figure A shows the scope of the review.

Figure A

Analytic framework. Abbreviations: ACS=acute coronary syndrome; GI=gastrointestinal; KQ=Key Question; NPV=negative predictive value; PPV=positive predictive value; ROC=receiver operating characteristic

Results

KQ 1. Diagnostic Accuracy of Depression Screening Tests in Post-ACS Patients

We identified seven articles representing six studies that examined the accuracy of depression screening instruments or screening strategies in post-ACS patients (Table A).

Table A

Key Question 1 evidence summary.

Key Findings

• Four depression screening instruments have a high negative predictive value (97%) but have low (below 50%) positive predictive values. This means the instruments would miss less than 3 percent of those who have depression, but only 50 percent of patients who screen positive actually have the condition.
• The Beck Depression Inventory (BDI)-II has a sensitivity of 90 percent and a specificity of 80 percent.
• Thresholds for screening in post-ACS patient populations are comparable to thresholds used in general populations (4 studies, 1,576 patients).
• One or two specific items from validated screening scales (BDI-II, Patient Health Questionnaire [PHQ]) may be almost as accurate for diagnostic screening as using the full instrument.

Strength of Evidence

Table B shows the strength of evidence for KQ 1 findings.

Table B

Strength of evidence for the BDI-II depression tool.

KQ 2. Comparative Safety and Effectiveness of Depression Treatments in Post-ACS Patients

We identified 14 articles representing 4 studies that examined the comparative safety and effectiveness of pharmacologic and nonpharmacologic treatments and enhanced care delivery approaches to usual care for the treatment of depression in post-ACS patients (Table C).

Table C

Key Question 2 evidence summary.

No studies were identified that evaluated nutritional supplements, aerobic exercise, cardiac rehabilitation, stress management or atypical antipsychotics, transcranial magnetic stimulation and electroconvulsive therapy.

Key Findings

• Collaborative care interventions, which integrate psychiatric treatment into other clinical settings, improve depression symptoms more than usual care
• Collaborative care, CBT, or antidepressant medications were similar to usual care in reducing major adverse cardiovascular event (MACE) cardiac mortality, all-cause mortality, repeat ACS, revascularization, or hospitalization in individuals following an ACS event
• Evidence did not show increased adverse events among post-ACS individuals treated with collaborative care, CBT, or antidepressant medications compared with usual care

Strength of Evidence

Tables D–F show the strength of evidence for KQ 2 findings.

Table D

Strength of evidence for Key Question 2: Enhanced care versus usual care.

Table F

Strength of evidence for Key Question 2: Antidepressant medication versus usual care.

Table E

Strength of evidence for Key Question 2: CBT and second-generation antidepressant versus usual care.

Discussion

This present review is an update of the original 2005 Agency for Healthcare Research and Quality systematic review.¹ Both reviews found insufficient evidence to support the comparative effectiveness of interventions for improving cardiovascular outcomes, and both reviews recognized the effectiveness of psychosocial interventions and SSRIs on improving depression symptoms in patients after myocardial infarction.

Our systematic review has several implications for clinical and policy decisionmaking. We found that BDI-II was the most often used screening instrument among included studies. BDI-II has a high sensitivity (90%) and specificity (80%) for identifying patients requiring treatment across a range of prevalences. The performance characteristics for the BDI-II in post-ACS patients were similar to the performance in general medical and psychiatric populations. This suggests that other screening instruments that may be more feasible for use in general medical settings (e.g., shorter, easier to administer and score, no licensing fee) may also perform well in post-ACS patients. Some data within our review also suggest that very short questionnaires (1–2 questions) may perform similarly to full instruments although the evidence is currently sparse.

For treatment effectiveness, enhanced care interventions that integrate psychiatric treatment into other clinical settings, second-generation antidepressants, and a combination strategy including cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms more than usual care but had no consistent effect on cardiovascular outcomes. Secondary analyses from the treatment trials showed generally consistent benefit of interventions on depression outcomes by sex and ethnicity. Importantly, these trials use second-generation antidepressants and/or cognitive behavioral therapy. Thus, recommendations should be limited to these interventions and not generalized to all antidepressants (e.g., tricyclic antidepressants), which may have adverse cardiovascular effects. The included studies did not show a clear beneficial effect of depression treatment on cardiovascular outcomes in this post-ACS population.

Conclusions

Among several depression screening tools, the BDI is the most studied. Existing tools miss less than 3 percent of patients with depression (high negative predictive value: 97%), but less than 50 percent of patients who screen positive actually have the condition (low positive predictive value:<50%). Enhanced care interventions and a strategy using CBT plus second-generation antidepressant medication for patients with severe depression or partial response to CBT improve depressive outcomes more than usual care. Given the inconsistency and imprecision of findings, and the small number of studies evaluating cardiovascular outcomes, the effects of depression interventions on such cardiovascular outcomes is uncertain.

Reference

1.

Bush DE, Ziegelstein RC, Patel UV, et al. Post-myocardial infarction depression. Evid Rep Technol Assess (Summ). 2005 May(123):1–8. PMID: 15989376. [PMC free article: PMC4780949] [PubMed: 15989376]