Diagnostic Accuracy of Screening and Treatment of Post–Acute Coronary Syndrome Depression

133 Pages·2017·1.26 MB·English

Comparative Effectiveness Review
Number 200
Diagnostic Accuracy
of Screening and
Treatment of Post-
Acute Coronary
Syndrome Depression:
A Systematic Review
e
Comparative Effectiveness Review
Number 200
Diagnostic Accuracy of Screening and Treatment of
Post–Acute Coronary Syndrome Depression: A
Systematic Review
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No. 290-2015-00004-I
Prepared by:
Duke Evidence-based Practice Center
Durham, NC
Investigators:
John W. Williams, Jr., M.D., M.H.Sc.
Jason A. Nieuwsma, Ph.D.
Natasha Namdari, M.D.
Jeffrey B. Washam, Pharm.D.
Giselle Raitz, M.D.
James A. Blumenthal, Ph.D.
Wei Jiang, M.D.
Roshini Yapa, M.B.B.S.
Amanda J. McBroom, Ph.D.
Kathryn Lallinger, M.S.L.S.
Robyn Schmidt, B.A.
Andrzej S. Kosinski, Ph.D.
Gillian D. Sanders, Ph.D.
AHRQ Publication No. 18-EHC001-EF
November 2017
Key Messages
Purpose of Review
Evaluate the comparative accuracy of tools for diagnosing depression in patients after an acute
coronary syndrome event and the effectiveness of treatments in these patients.
Key Messages
• The Beck Depression Inventory (BDI)-II screen tool is the most studied and is as accurate
in this population as in others.
• Available depression-screening tools may miss 3 percent of people with depression, but
less than 50 percent of those who screen positive have clinically confirmed depression.
• Enhanced care interventions that integrate psychiatric treatment into cardiology and
primary care settings improve depression symptoms. Current evidence is insufficient to
determine if enhanced care improves cardiac outcomes.
• Combining cognitive behavioral therapy and antidepressant medication may improve
depression outcomes but does not clearly improve cardiac outcomes.
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This report is based on research conducted by the Duke Evidence-based Practice Center (EPC)
under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD
(Contract No. 290-2015-00004-I). The findings and conclusions in this document are those of the
authors, who are responsible for its contents; the findings and conclusions do not necessarily
represent the views of AHRQ. Therefore, no statement in this report should be construed as an
official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with
the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and
clinicians, health system leaders, and policymakers, among others—make well-informed
decisions and thereby improve the quality of health care services. This report is not intended to
be a substitute for the application of clinical judgment. Anyone who makes decisions concerning
the provision of clinical care should consider this report in the same way as any medical
reference and in conjunction with all other pertinent information, i.e., in the context of available
resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the
author and the Agency for Healthcare Research and Quality. This report may be used and
reprinted without permission except those copyrighted materials that are clearly noted in the
report. Further reproduction of those copyrighted materials is prohibited without the express
permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative
products that may be developed from this report, such as clinical practice guidelines, other
quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is
done, the resulting surveillance report describing the methodology and findings will be found on
the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the
title of the report.
Persons using assistive technology may not be able to fully access information in this report. For
assistance contact [email protected].
Suggested citation: Williams JW Jr, Nieuwsma JA, Namdari N, Washam JB, Raitz G,
Blumenthal JA, Jiang W, Yapa R, McBroom AJ, Lallinger K, Schmidt R, Kosinski AS, Sanders
GD. Diagnostic Accuracy of Screening and Treatment of Post–Acute Coronary Syndrome
Depression: A Systematic Review. Comparative Effectiveness Review No. 200. (Prepared by the
Duke University Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ
Publication No. 18-EHC001-EF. Rockville, MD: Agency for Healthcare Research and Quality;
November 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm. DOI:
https://doi.org/10.23970/AHRQEPCCER200.
iii
Preface
The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based
Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and
private-sector organizations in their efforts to improve the quality of health care in the United
States. These reviews provide comprehensive, science-based information on common, costly
medical conditions, and new health care technologies and strategies.
Systematic reviews are the building blocks underlying evidence-based practice; they focus
attention on the strength and limits of evidence from research studies about the effectiveness and
safety of a clinical intervention. In the context of developing recommendations for practice,
systematic reviews can help clarify whether assertions about the value of the intervention are
based on strong evidence from clinical studies. For more information about AHRQ EPC
systematic reviews, see www.effectivehealthcare.ahrq.gov/reference/purpose.cfm.
AHRQ expects that these systematic reviews will be helpful to health plans, providers,
purchasers, government programs, and the health care system as a whole. Transparency and
stakeholder input are essential to the Effective Health Care Program. Please visit the Web site
(www.effectivehealthcare.ahrq.gov) to see draft research questions and reports or to join an
email list to learn about new program products and opportunities for input.
If you have comments on this systematic review, they may be sent by mail to the Task Order
Officers named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane,
Rockville, MD 20857, or by email to [email protected].
Gopal Khanna, M.B.A. Arlene S. Bierman, M.D., M.S.
Director Director
Agency for Healthcare Research and Quality Center for Evidence and Practice
Improvement
Stephanie Chang, M.D., M.P.H. Agency for Healthcare Research and Quality
Director
Evidence-based Practice Center Program Aysegul Gozu, M.D., M.P.H.
Center for Evidence and Practice Laura Pincock, Pharm.D., M.P.H.
Improvement Task Order Officers
Agency for Healthcare Research and Quality Center for Evidence and Practice
Improvement
Agency for Healthcare Research and Quality
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Acknowledgments
The authors thank Wei Duan-Porter, M.D., Ph.D., W. Schuyler Jones, M.D., and Megan Chobot,
M.S.L.S., for participating in topic refinement; Megan von Isenburg, M.S.L.S., for help with the
literature search and retrieval; and Rebecca N. Gray, D.Phil., and Liz Wing, M.A., for editorial
assistance.
• Key Informants
In designing the study questions, the EPC consulted several Key Informants who represent the
end-users of research. The EPC sought the Key Informant input on the priority areas for research
and synthesis. Key Informants are not involved in the analysis of the evidence or the writing of
the report. Therefore, in the end, study questions, design, methodological approaches, and/or
conclusions do not necessarily represent the views of individual Key Informants.
Key Informants must disclose any financial conflicts of interest greater than $10,000 and any
other relevant business or professional conflicts of interest. Because of their role as end-users,
individuals with potential conflicts may be retained. The TOO and the EPC work to balance,
manage, or mitigate any conflicts of interest.
The list of Key Informants who provided input to this report follows:
Robert Carney, Ph.D. Robert Rich, Jr., M.D., FAAFP
Washington University Community Care of Lower Cape Fear
St. Louis, MO Wilmington, NC
Thomas Denberg, M.D., Ph.D., FACP Matthew Rudorfer, M.D.
Pinnacol Assurance National Institute of Mental Health
Denver, CO National Institutes of Health
Bethesda, MD
Patrick Farrant
The Mended Hearts, Inc. Peter A. Shapiro, M.D.
San Jose, CA Columbia University Medical Center
New York, NY
Glenn Feltz, Psy.D.
Clinical Psychologist Daichi Shimbo, M.D.
Urbana, OH Columbia University Medical Center
New York, NY
Kenneth Freedland, Ph.D.
Washington University School of Medicine Mary Whooley, M.D., FAHA, FACP
St. Louis, MO University of California
San Francisco VA Health Care System
Peter Kaufmann, Ph.D. San Francisco, CA
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, MD
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Technical Expert Panel
In designing the study questions and methodology at the outset of this report, the EPC consulted
several technical and content experts. Broad expertise and perspectives were sought. Divergent
and conflicting opinions are common and perceived as healthy scientific discourse that results in
a thoughtful, relevant systematic review. Therefore, in the end, study questions, design,
methodologic approaches, and/or conclusions do not necessarily represent the views of
individual technical and content experts.
Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any
other relevant business or professional conflicts of interest. Because of their unique clinical or
content expertise, individuals with potential conflicts may be retained. The TOO and the EPC
work to balance, manage, or mitigate any potential conflicts of interest identified.
The list of Technical Experts who provided input to this report follows:
Robert Carney, Ph.D.*
Washington University Robert Rich, Jr., M.D., FAAFP*
St. Louis, MO Community Care of Lower Cape Fear
Wilmington, NC
Thomas Denberg, M.D., Ph.D., FACP
Pinnacol Assurance Bruce Rollman, M.D., M.P.H.*
Denver, CO University of Pittsburgh
Pittsburgh, PA
Glenn Feltz, Psy.D.
Clinical Psychologist Matthew Rudorfer, M.D.
Urbana, OH National Institute of Mental Health
National Institutes of Health
Kenneth Freedland, Ph.D. Bethesda, MD
Washington University School of Medicine
St. Louis, MO Peter A. Shapiro, M.D.*
Columbia University Medical Center
Peter Kaufmann, Ph.D. New York, NY
National Heart, Lung, and Blood Institute
National Institutes of Health Daichi Shimbo, M.D.*
Bethesda, MD Columbia University Medical Center
New York, NY
Kurt Kroenke, M.D., M.A.C.P
Indiana University School of Medicine Mary Whooley, M.D., FAHA, FACP*
VA HSR&D Center for Health Information University of California
and Communication San Francisco VA Health Care System
Indianapolis, IN San Francisco, CA
*Provided input on Draft Report
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Peer Reviewers
Prior to publication of the final evidence report, EPCs sought input from independent Peer
Reviewers without financial conflicts of interest. However, the conclusions and synthesis of the
scientific literature presented in this report do not necessarily represent the views of individual
reviewers.
Peer Reviewers must disclose any financial conflicts of interest greater than $10,000 and any
other relevant business or professional conflicts of interest. Because of their unique clinical or
content expertise, individuals with potential nonfinancial conflicts may be retained. The TOO
and the EPC work to balance, manage, or mitigate any potential nonfinancial conflicts of interest
identified.
The list of Peer Reviewers follows:
Pim Cuijpers, Ph.D. Ian Kronish, M.D., M.P.H.
Vrije Universiteit Amsterdam Columbia University Medical Center
Amsterdam, Netherlands New York, NY
Karina W. Davidson, Ph.D., M.A.Sc. Carl J. Lavie, M.D., FACC, FACP, FCCP
Columbia University Medical Center John Ochsner Heart and Vascular Institute
New York, NY New Orleans, LA
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Diagnostic Accuracy of Screening and Treatment of
Post–Acute Coronary Syndrome Depression: A
Systematic Review
Structured Abstract
Objectives. To evaluate (1) the diagnostic accuracy of selected depression screening instruments
and strategies versus a validated criterion standard in adult patients within 3 months of an acute
coronary syndrome (ACS) event and (2) the comparative safety and effectiveness of a broad
range of pharmacologic and nonpharmacologic treatments for depression in adult patients who
have received a criterion-based diagnosis of depression or had clinically important depressive
symptoms using a validated depression scale and who are within 3 months of an ACS event.
Data sources. We searched PubMed®, Embase®, PsycINFO®, CINAHL®, and the Cochrane
Database of Systematic Reviews for English-language studies published from January 1, 2003, to
August 15, 2017, that evaluated the accuracy of tools for diagnosing depression in patients after
ACS or that evaluated interventions for treating post-ACS patients identified with depression.
Review methods. Two investigators individually screened each abstract and full-text article for
inclusion; abstracted data; and rated quality, applicability, and strength of evidence. Where
appropriate, random-effects models were used to compute summary estimates of effects.
Results. We identified 21 primary articles describing 10 unique studies that met our inclusion
criteria: 6 studies relevant to diagnostic accuracy and 4 studies relevant to treatment
effectiveness. For diagnostic accuracy, based on six studies evaluating four instruments
involving 1,755 post-ACS patients, evidence suggests that a range of different depression
screening instruments produce high (97%) negative predictive values (i.e., percentage of patients
who screen negative who do not have the condition) but produce low (<50%) positive predictive
values (i.e., percentage of patients who screen positive who actually have the condition).
Sensitivity and specificity are greater than 70 percent. A meta-analysis of four studies (1,576
patients) estimated the diagnostic screening performance characteristics of the Beck Depression
Inventory (BDI)-II: sensitivity of 90 percent (SOE=high) and specificity of 80 percent
(SOE=moderate). For treatment effectiveness, enhanced care interventions that integrate
psychiatric treatment into other clinical settings improve depression symptoms more than usual
care (mean difference in BDI, -3.5 to -3.8; 2 trials; SOE=moderate); adverse effects did not
differ. One trial compared second-generation antidepressants with usual care and found no effect
on depression symptoms or quality of life, although, when combined with studies included in the
original review, it showed a small positive effect of antidepressants. A large trial found that a
combination strategy including cognitive behavioral therapy (CBT) and antidepressant
medication improved depression symptoms, mental health–related function, and overall life
satisfaction more than usual care (1 trial, 2,481 patients, SOE=high) but had no consistent effect
on cardiovascular outcomes (SOE=moderate). Evidence supporting effects of enhanced care
interventions on cardiovascular and other outcomes of interest was insufficient.
Conclusions. Among several depression screening tools, the BDI is the most studied. Existing
tools miss less than 3 percent of patients with depression, but only 50 percent of patients who
screen positive actually have clinically confirmed depression. Enhanced care interventions and a
strategy using CBT plus second-generation antidepressants for patients with severe depression or
partial response to CBT improved depressive outcomes more than usual care. The effects of
depression interventions on cardiovascular outcomes are uncertain.
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Contents
Executive Summary ................................................................................................................ ES-1
Introduction ................................................................................................................................... 1
Background ................................................................................................................................. 1
Condition: Post–Acute Coronary Syndrome Depression ....................................................... 1
Screening Strategies ................................................................................................................ 2
Treatment Strategies ............................................................................................................... 2
Scope and Key Questions ........................................................................................................... 3
Scope of Review ..................................................................................................................... 3
Key Questions ......................................................................................................................... 3
Organization of This Report ....................................................................................................... 4
Methods .......................................................................................................................................... 6
Topic Refinement and Review Protocol ..................................................................................... 6
Literature Search Strategy........................................................................................................... 6
Search Strategy ....................................................................................................................... 6
Inclusion and Exclusion Criteria ............................................................................................. 7
Study Selection ..................................................................................................................... 11
Data Extraction ..................................................................................................................... 11
Quality Assessment of Individual Studies ................................................................................ 12
Data Synthesis ........................................................................................................................... 13
Strength of the Body of Evidence ............................................................................................. 14
Applicability ............................................................................................................................. 14
Peer Review and Public Commentary ...................................................................................... 15
Results .......................................................................................................................................... 16
Introduction ............................................................................................................................... 16
Results of Literature Searches .................................................................................................. 16
Description of Included Studies ................................................................................................ 18
Key Question 1: Diagnostic Accuracy of Depression Screening Tests in Post-ACS Patients ............. 18
Description of Included Studies ............................................................................................ 18
Key Points ............................................................................................................................. 20
Detailed Synthesis ................................................................................................................. 21
Strength of Evidence ............................................................................................................. 29
Key Question 2: Comparative Safety and Effectiveness of Depression Treatments in Post-ACS
Patients ...................................................................................................................................... 31
Description of Included Studies ............................................................................................ 31
Key Points ............................................................................................................................. 33
Detailed Synthesis ................................................................................................................. 34
Strength of Evidence ............................................................................................................. 37
Discussion..................................................................................................................................... 40
Findings in Relation to Other Reviews on Depression Screening and Treatment After ACS . 40
Applicability ............................................................................................................................. 44
Implications for Clinical and Policy Decisionmaking ............................................................... 45
Limitations of the Systematic Review Process and Evidence Base ......................................... 46
Research Recommendations ..................................................................................................... 47
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