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A Systematic Review

Brett D. Thombs, PhD; Peter de Jonge, PhD; James C. Coyne, PhD; Mary A. Whooley, MD; Nancy Frasure-Smith, PhD; Alex J. Mitchell, MSc, MRCPsych; Marij Zuidersma, MSc; Chete Eze-Nliam, MD, MPH; Bruno B. Lima; Cheri G. Smith, MLS; Karl Soderlund, BS; Roy C. Ziegelstein, MD

JAMA. 2008;300(18):2161-2171.

Context  Several practice guidelines recommend that depression be evaluated and treated in patients with cardiovascular disease, but the potential benefits of this are unclear.

Objective  To evaluate the potential benefits of depression screening in patients with cardiovascular disease by assessing (1) the accuracy of depression screening instruments; (2) the effect of depression treatment on depression and cardiac outcomes; and (3) the effect of screening on depression and cardiac outcomes in patients in cardiovascular care settings.

Data Sources  MEDLINE, PsycINFO, CINAHL, EMBASE, ISI, SCOPUS, and Cochrane databases from inception to May 1, 2008; manual journal searches; reference list reviews; and citation tracking of included articles.

Study Selection  We included articles in any language about patients in cardiovascular care settings that (1) compared a screening instrument to a valid major depressive disorder criterion standard; (2) compared depression treatment with placebo or usual care in a randomized controlled trial; or (3) assessed the effect of screening on depression identification and treatment rates, depression, or cardiac outcomes.

Data Extraction  Methodological characteristics and outcomes were extracted by 2 investigators.

Results  We identified 11 studies about screening accuracy, 6 depression treatment trials, but no studies that evaluated the effects of screening on depression or cardiovascular outcomes. In studies that tested depression screening instruments using a priori-defined cutoff scores, sensitivity ranged from 39% to 100% (median, 84%) and specificity ranged from 58% to 94% (median, 79%). Depression treatment with medication or cognitive behavioral therapy resulted in modest reductions in depressive symptoms (effect size, 0.20-0.38; r², 1%-4%). There was no evidence that depression treatment improved cardiac outcomes. Among patients with depression and history of myocardial infarction in the ENRICHD trial, there was no difference in event-free survival between participants treated with cognitive behavioral therapy supplemented by an antidepressant vs usual care (75.5% vs 74.7%, respectively).

Conclusions  Depression treatment with medication or cognitive behavioral therapy in patients with cardiovascular disease is associated with modest improvement in depressive symptoms but no improvement in cardiac outcomes. No clinical trials have assessed whether screening for depression improves depressive symptoms or cardiac outcomes in patients with cardiovascular disease.

Author Affiliations: Departments of Psychiatry (Drs Thombs and Frasure-Smith) and Nursing (Dr Frasure-Smith), McGill University, Montréal, Québec, Canada; Department of Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, Montréal, Québec, Canada (Dr Thombs); Interdisciplinary Center for Psychiatric Epidemiology, Departments of Psychiatry (Dr de Jonge and Ms Zuidersma), and Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (Dr de Jonge); CoRPS-Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology, Tilburg University, Tilburg, the Netherlands (Dr de Jonge); Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia (Dr Coyne); Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco, and Veterans Affairs Medical Center, San Francisco, California (Dr Whooley); Research Centre, Centre Hospitalier de l’Université de Montréal, Research Centre, Montréal Heart Institute, Montréal, Québec, Canada (Dr Frasure-Smith); Department of Cancer and Molecular Medicine, Leicester Royal Infirmary, Leicester, England (Dr Mitchell); Interfaith Medical Center, Brooklyn, New York (Dr Eze-Nliam); Federal University of Ceara School of Medicine, Fortaleza-ce, Brazil (Mr Lima); Harold E. Harrison Medical Library, Johns Hopkins Bayview Medical Center (Ms Smith) and Department of Medicine, Johns Hopkins University School of Medicine (Mr Soderlund and Dr Ziegelstein), Baltimore, Maryland.

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