November 17, 2009
Telephone-Delivered Care For Treating Depression After CABG Surgery Appears To Improve Outcomes
Patients who received telephone-delivered collaborative care for treatment of depression after coronary artery bypass graft surgery reported greater improvement in measures of quality of life, physical functioning and mood than patients who received usual care, according to a study in the November 18 issue of JAMA. The study is being released early online because of its presentation at an American Heart Association scientific conference.
Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the United States. As many as half of CABG patients report depressive symptoms after surgery, and are also more likely to experience a decreased health-related quality of life (HRQL) and functional status, according to background information in the article. Several trials for treatment of depression have been conducted in cardiac populations, but most achieved less than anticipated benefits with regard to reducing mood symptoms. "Moreover, none used the proven effective collaborative care approach recently recommended by a National Institutes of Health expert consensus panel," the authors write. Collaborative care emphasizes a flexible real-world treatment package that involves active follow-up by a nonphysician care manager who adheres to evidence-based treatment protocols.
Bruce L. Rollman, M.D., M.P.H., of the University of Pittsburgh School of Medicine, and colleagues conducted a randomized trial to test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs. usual physician care. The study included 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression, recruited between March 2004 and September 2007, and observed as outpatients until June 2008. Measures of HRQL, mood symptoms, functioning status and hospital readmissions were gauged via various surveys or tests.
Intervention patients received eight months of telephone-delivered collaborative care, in which a nurse care manager telephoned patients to review their psychiatric history, provide basic psychoeducation about depression and its effect on cardiac disease, and describe treatment options. The nurses worked with patients' primary care physicians and were supervised by a psychiatrist and primary care physician from this study.
The researchers found that intervention patients reported greater improvements in mental HRQL, physical functioning and mood symptoms. Overall, 50 percent of intervention patients reported a 50 percent or greater reduction in mood symptoms from baseline to 8-month follow-up vs. 29.6 percent of patients in usual care. "Men with depression were particularly likely to benefit from the intervention. However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group," the authors write.
"Since a substantial minority of patients did not benefit from our depression intervention, it is vital to identify post-CABG patients most likely to become treatment resistant so as to develop more effective treatments for them. Identifying the intervention components that maximally contribute to our outcomes is also of great interest. However, collaborative care is a complex intervention involving a number of separate mechanisms that have proven difficult to disentangle from the nonspecific effects of increased attention by the care manager."
"Additional research is necessary to develop improved treatments for women and patients with resistant depression, and to examine the economic effect of this intervention," the researchers conclude.
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