AHA is premature in calling for routine screening of depression in heart patients

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There is not nearly enough evidence yet to support a recent call by the American Heart Association (AHA) to begin routine screening of millions of Americans for depression, according to research published in the Nov. 12 edition of the Journal of the American Medical Association, and timed to coincide with this week’s AHA’s Scientific Sessions in New Orleans.

Roy Ziegelstein, MD, a professor at the Johns Hopkins University School of Medicine and its Heart and Vascular Institute in Baltimore, said that the September AHA recommendation is “premature,” and “a massive undertaking” that would consume a vast amount of clinic staff time and effort to analyze and follow-up on the questionnaires involved in screening, without a demonstrated benefit in improving patient care.

He noted that an estimated 80 million Americans have some form of heart disease.

Reporting on more than 1,500 clinical studies, from which 17 were selected for review, Ziegelstein and his colleagues pointed to the absence of any scientific proof that depressed heart patients live longer or fare better over the long term if they are screened for depression and treated with drugs and other therapy.

Yet, he noted that that about one in five people with depression would not be picked up by screening, and fewer than half of those identified as depressed by the screening process will actually be depressed when evaluated more thoroughly.

The researchers found that treating depression in people with heart disease only accounted for a 1 percent to 4 percent change in symptoms compared to those treated with placebo. Ziegelstein said that this is "too low to expect meaningful benefits for many people, particularly since screening methods are not very precise in identifying people who would benefit from the treatment.”

He said that before routine screening, physicians need to consider the potential for harm to people, as no studies have fully analyzed any negative impact from treatment side effects, or misdiagnosis and labeling of heart patients as depressed.

"Understandably, then, we cannot in good conscience support screening all heart patients," Ziegelstein wrote. “This is a difficult call for us to make, but it is in the best interests of patients at this time.”

Rather than massive, costly screening at this point, Ziegelstein said that physicians need to “get to know their patients better, as real people,” and to make clinical assessments of each patient's mood for signs of depression as they talk to them about other things related to their health, including exercise routines, dietary habits, and use of medications.

Making a diagnosis of depression is not difficult, he added, “if they use their examination time well and ask the right questions,” not focusing only on the physical issues but also on the patient's overall state of well-being and daily routine.

As part of the research review, an international team of researchers sorted more than 1,500 clinical studies of depression to identify studies that looked at screening heart patients for depression, treating and monitoring them. From these, the team, led by Johns Hopkins-trained psychologist Brett Thombs, PhD, from McGill University in Montreal, grouped together the data from 11 studies that used proven depression screening tests.

Selected screening studies covered more than 4,000 men and women, and most involved one of four commonly used questionnaires to diagnose depression, according to Ziegelstein. Results showed that the tests were on average 80 percent accurate in detecting people who were actually depressed.

Another half-dozen clinical trials were evaluated for the immediate health effects of drug treatment and counseling among nearly 3,000 men and women who had been screened and found to be depressed. Drug treatment mostly involved prescribing mood-raising selective serotonin reuptake inhibitors.

According to Ziegelstein, researchers could not find a single study that screened heart patients for depression and then demonstrated lasting improvements to health or even a longer lifespan.

"We don't have any evidence that screening for depression will benefit people with heart disease. What we really need is more research on how best to help them adopt healthy behaviors that combat depression, such as how to stop smoking, exercise regularly and maintain a healthy weight,” Thombs concluded.