Title: Detection of Depression in Cardiac Inpatients: Feasibility and Results of Systematic Screening
Topic: Prevention/Vascular
Date Posted: 6/7/2010
Author(s): Sowden G, Mastromauro CA, Januzzi JL, Fricchione GL, Huffman JC.
Citation: Am Heart J 2010;159:780-787.
Clinical Trial: No
Study Question: A recent American Heart Association (AHA) Prevention Committee report recommended depression screening of all coronary heart disease patients using two- and nine-item instruments from the Patient Health Questionnaire (PHQ-2 and PHQ-9) to identify patients who may need further assessment and treatment. What is the feasibility and result of such screening on inpatient cardiac units?
Methods: The PHQ-2 was added to the nursing interview data set on three cardiac units in a general hospital; this screen was completed as part of routine clinical care. Screened patients with a PHQ-2 score ≥3 were approached for further depression evaluation (PHQ-9) by a social worker. Rates and results of depression screening, reasons for patients not being screened, and patient acceptance were determined.
Results: For a 12-month period, 4,783 patients were admitted to the cardiac units; 3,504 (73.3%) received PHQ-2 depression screening. The most common reason for not screening was confusion or sedation (21% intensive care unit, 4% in step down). Mean age of all patients was 65.7 years (standard deviation, 14.6 years), and 63.1% of subjects were men. 8.7% had a PHQ-2 score ≥3; 74.1% of the positive-screen patients had a PHQ-9 score of ≥10, suggestive of major depression. Only 53.7% of patients with a PHQ-2 score of 3 had a PHQ-9 score ≥10, compared to 87.1% of those with a PHQ-2 = 6. Nurses (n = 66) reported high satisfaction with the screening process, and mean reported PHQ-2 screening time was 1.4 (±1.1) minutes.
Conclusions: Systematic depression screening of cardiac patients using methods outlined by the AHA Prevention Committee is feasible, well-accepted, and does not appear markedly resource-intensive. Future studies should link these methods to an efficient and effective program of depression management in this vulnerable population.
Perspective: The PHQ-9 is a nine-item depression scale that awards 0-3 points for each question. The nine items are based directly on the nine diagnostic criteria for major depressive disorder. A score of ≥10 is associated with a moderate likelihood of depression and ≥14 a high likelihood. Screening with the PHQ-2 is a validated approach. The two questions address depressed mood and anhedonia in the preceding 2 weeks. Only 9% of subjects in this study had positive PHQ-2 scores, compared to depression rates of at least 15% in other studies of cardiac patients in both the inpatient and outpatient settings. This may be related to the study protocol design to have the PHQ-2 administered during nursing intake. It is also not clear why a social worker was used to help complete the PHQ-9 rather than the patient alone. While patient acceptance was fine, further studies are necessary to help identify the optimal timing for both compliance and accuracy. For example, while 15-20% of patients with an acute coronary syndrome have depression at 4 weeks post-discharge, one-third are new since discharge and a similar number who tested positive in the hospital are no longer depressed. Melvyn Rubenfire, M.D., F.A.C.C.
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