Author + information
- James A. Blumenthal, PhD* ( and )
- Christopher O'Connor, MD
- ↵*Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3119, Durham, North Carolina 27710
Depression is a serious condition that we now know affects both the body and the mind. As such, we are troubled by the response of Ziegelstein et al. (1) to the American Heart Association Science Advisory's recommendation for screening for depression in cardiac patients (2). To ridicule and dismiss the legitimate recommendation for depression screening with a “Never Mind” was disappointing to those of us involved in the clinical care of patients with coronary disease. It is well established that depression: 1) is especially common in a variety of cardiac patient populations; 2) is associated with a worse prognosis independent of disease severity and other risk factors; 3) is associated with nonadherence and heightened medical expenditures; and 4) is associated with impaired quality of life (3). The claim that “discussing whether they have symptoms of depression” is different from screening for depression is a distinction that is likely to escape most readers and conveys a message that recognizing depression is not important in the care of patients with heart disease.
So why would Ziegelstein et al. (1) object to efforts to identify patients with depressive symptoms? One reason is their claim that there is little evidence that treating depression is effective. Nothing is further from the truth. There are a number of empirically validated therapies for treating depression ranging from cognitive behavior therapy to pharmacotherapy (4), and there is no evidence that these therapies are any less effective in cardiac patients compared with the general population of depressed patients. Not only is there abundant evidence that depression can be successfully treated, it is also noteworthy that physicians routinely assess risk factors that are not modifiable (i.e., age and family history) to evaluate patients' total burden of cardiac risk. Comprehensive risk factor assessment is common in medical practice and may prompt more aggressive treatment of other risk factors that can be favorably altered.
Another objection raised by Ziegelstein et al. (1) is that there are insufficient data to claim that the benefits of screening for depression outweigh the harm. However, they fail to provide any evidence of the harm in assessing depression in the context of a cardiologic examination. They point to the “stigma” of depression, yet their position actually serves to stigmatize the very patients they claim to be concerned about. The last thing that patients need to hear after having a heart attack is that not only are their hearts damaged, but that their mental health also may be impaired. We have long advocated that the traditional “mental health approach” to treating cardiac patients is less likely to be effective and may be counterproductive (5). We believe that the treating physician is in an ideal position to normalize patients' feelings, monitor their depressive symptoms, and prescribe additional treatments when necessary. Although Ziegelstein et al. (1) suggest that depressive screening is expensive and could burden the health care system, they provide no basis for this assertion and the claim that physicians lack the time, expertise, or resources is an inadequate rationalization.
The American Heart Association Science Advisory guidelines were not intended to provide specific instructions for how clinicians should assess depression, but rather were intended to provide clinicians with one possible approach that could be useful in their clinical practices. Instruments such as the Patient Health Questionnaire could provide physicians with a starting point for the “discussion” that Ziegelstein et al. (1) recommend. Although the Patient Health Questionnaire is simple, brief, inexpensive, and easy to administer, there are other instruments and approaches that have been widely used in cardiac patients and are equally cost effective. For example, instruments such as the Beck Depression Inventory show acceptable sensitivity and specificity, although, as with most screening tools, self-report instruments are not meant to replace clinical judgment. The point is that physicians need to be cognizant of depressive symptoms in their patients and take whatever steps are necessary to monitor and treat as needed.
Finally, although we agree with Ziegelstein et al. (1) that there is little evidence currently available that treating depression results in improved clinical outcomes (i.e., reduced mortality and morbidity), there are ongoing studies that are examining this issue. Regardless of the impact on medical outcomes, however, depression is no joke—and the benefits of treating depression on quality of life should be taken seriously.
- American College of Cardiology Foundation
- Ziegelstein R.C.,
- Thombs B.D.,
- Coyne C.J.,
- de Jonge P.
- Lichtman J.H.,
- Bigger J.T. Jr..,
- Blumenthal J.A.,
- et al.
- Rozanski A.,
- Blumenthal J.A.,
- Davidson K.W.,
- Saab P.G.,
- Kubzansky L.
- Blumenthal J.A.