Comparison of Depression Identification After Acute Coronary Syndrome: Quality of Life and Cost Outcomes

Patients with an acute coronary syndrome (ACS) and comorbid depression have a 2-fold higher
risk for recurrent ACS and mortality, worse quality of life, and higher costs of care than
nondepressed ACS patients. The strength of these observational findings prompted the American
Heart Association (AHA) to advise that routine depression screening for ACS patients and
referral for depression diagnosis and treatment as indicated occur. Unfortunately, there are
no randomized controlled trials (RCT) to inform this potentially expensive screening
recommendation. Additionally, screening guidelines/advisories in the absence of RCT evidence
have recently been extensively criticized (and withdrawn). This poses a serious dilemma for
clinicians, health care systems, and for health care policy leaders. A RCT is urgently needed
to provide evidence for these different constituents about the costs and benefits of the AHA
depression screen and treat algorithm.

Two critical gaps in knowledge must be filled to determine if public health would be improved
by the AHA strategy for depression screening in post-ACS patients: 1) Does this strategy
improve quality-adjusted life years for patients with a recent ACS 2) Is the cost of
providing depression screening and any type of depression treatment within the acceptable and
typical amounts reimbursed for health care services? Our specific aim is to determine the
quality-adjusted life year benefits and health care costs of following the AHA's advisory for
depression screening and then referral for further diagnosis and treatment in post-ACS
patients, if depression is found. To accomplish this aim, we will randomize patients from
four different, geographically diverse health care systems to three different groups: 1) to
the AHA depression screen and treat if depression is found algorithm (screen and treat
intervention group) or: 2) to be screened and a primary care provider notified (screen and
notify intervention group) or: 3) to receive no depression screening (control group).
Health-related quality of life, depressive symptoms, and costs will be obtained from all
patients, so that the benefits and the costs of these three different depression screening
strategies can be compared.

Inclusion Criteria:

- With a documented acute coronary syndrome (ACS) within the past 2-12 months

- Over the age of 21 years

- Has access to a phone

Exclusion Criteria:

Medical Exclusions:

- Terminal illness (life expectancy <1 year as determined by physician/medical record)
defined as, but not limited to:

- NYHA class IV, ACC class D CHF requiring inotropes or mechanical assist devices or
critical aortic stenosis without plan for correction

- End-stage COPD/emphysema

- Advanced cirrhosis with encephalopathy, varices, severe ascites

- Severe rheumatologic diseases requiring frequent hospitalizations, and multiple
cytotoxic agents and/or disease modifying drugs

- Metastatic pancreatic, esophageal, colorectal or stomach cancer

- Metastatic sarcoma, ovarian, melanoma or renal cell cancer

- Metastatic breast cancer with multiple recurrences despite treatment

- Advanced CNS malignancies

- Recurrent hematologic malignancies with multiple recurrences despite treatment

- Persistent AIDS, untreated or treated

Psychiatric Exclusions:

- History of major depression

- Currently receiving depression treatment

- Dementia

- History of bipolar disorder

- History of psychosis

- History of suicide attempt or self-inflicted injuries

- Current alcohol or substance abuse

Other Exclusions:

- Non-English and non-Spanish speaking