Published in the February 2007 issue of Today’s Hospitalist.
According to a growing body of evidence, untreated depression among hospitalized patients with acute coronary syndrome (ACS) leads to deteriorating health and higher mortality. But even more disturbing are recent findings that detail just how often depression among these patients goes undiagnosed and untreated, a problem that falls squarely on the shoulders of hospitalists.
Part of the dilemma can be traced to the general problem of under-recognition of depression across all sectors of the health care system, both inpatient and out. But when it comes to heart disease patients in the hospital, recognizing depression is made more difficult by clinicians’ mistaken belief that depressive symptoms are a normal part of cardiac disease, not a co-morbidity that should be treated.
According to a new study of the link between depressive symptoms and ACS, depression is not necessarily a reaction to acute illness. Some symptoms, in fact, may actually persist long after patients’ ACS event. The troubling findings were that three out of four cases of patient depression weren’t identified.
"It’s a global problem," says Alpesh A. Amin, MD, an internist and clinical scholar with the Center for Innovation and Research at the Mid America Heart Institute of Saint Luke’s Hospital in Kansas City, Mo. He and his colleagues looked at the prevalence of unrecognized depression in hospitalized ACS patients. The study appeared in the November 2006 issue of American Heart Journal.
"A lot of providers-and patients too, frankly-consider it to be somewhat natural to have a change in mood or significant depressive symptoms after an event like a heart attack," Dr. Amin says. "Yet study after study has consistently shown that depression is an important co-morbidity, along with cardiac disease, that can adversely affect patients’ cardiac prognosis."
Those adverse effects are even more pronounced, says Dr. Amin, for particularly vulnerable populations, such as minorities.
Widespread prevalence and worse outcomes
Major depression occurs in anywhere from 16% to 23% of patients with ACS, according to Dr. Amin. And depressive symptoms-whether or not the patient is formally diagnosed as having a major depression-are "strong independent predictors," the study authors wrote, "of mortality, worse health status, poorer compliance, recurrent cardiac events and increased health care use."
Depressed ACS patients, Dr. Amin says, are re-hospitalized more, have a significantly longer length of stay, participate in cardiac rehabilitation less, and suffer from lower quality of life than patients who do not exhibit depressive symptoms following a heart attack.
According to the study, Dr. Amin looked at nearly 1,200 patients treated for ACS, both unstable angina and heart attack, at two Kansas City hospitals from March 2001 through October 2002.
Researchers first screened patients using the nine-item patient health questionnaire (PHQ-9) to determine the presence and severity of depressive symptoms. (The PHQ-9 is considered 88% sensitive and specific for the diagnosis of major depressive disorder.) Researchers then compared their findings with the patients’ inpatient record to see if physicians had recognized the problem and done something to treat it.
What they found was not encouraging. Only 24.5% of those ACS patients that the PHQ-9 identified as suffering from moderate to severe depressive symptoms had any documentation of those symptoms in their medical record. Even worse, patients with severe depression were as likely to be missed as moderately depressed ones.
And although study results show that most ACS hospitalized patients with clinically significant depressive symptoms are not recognized before discharge, they also demonstrate that some patients are even less likely than others to have their depression flagged.
While depressive symptoms were recognized in 31% of the white ACS patients, for instance, that was true for only 10% of minorities. Depression was recognized in 35% of patients with some college education, but only in 17% of those who had not attended college.
And researchers found that hospital staff noted moderate to severe depressive symptoms in only 10% of patients with ejection fractions of less than 0.40, compared to 26% of those with an ejection fraction greater than 0.40. That points to a key difficulty in diagnosing the co-morbidity, Dr. Amin explains: confounding symptoms.
"That’s probably a big reason why depression is not picked up," he says. "A low ejection fraction may provide an explanation for patients’ fatigue, insomnia, lack of energy and overall feeling of malaise." And while ACS patients were the only cohort he studied, Dr. Amin wonders about the prevalence of unrecognized depression in patients hospitalized with other conditions.
"You can make the same argument for patients with heart failure or COPD exacerbations, chronic disease populations," he says. "Depression becomes very hard to separate from patients’ other symptoms."
Moving to treatment
The first step to treating depression is diagnosing it, and Dr. Amin says that is where hospitalists come in. Because of their ability to look at the whole patient, not just cardiac symptoms, hospitalists-more so than cardiologists-are attuned to looking for and managing co-morbidities.
And because of their role in improving hospital systems, he adds, hospitalists are in the best position to design and implement system level interventions that will build depression screening into ACS care pathways. Such interventions would ensure that patients with significant depressive symptoms at least receive appropriate follow-up after they leave the hospital.
He compares these interventions to using aspirin and beta-blockers in these patients. At his hospital, nurses now use the PHQ-9, which takes only a few minutes, to screen all ACS patients on their second or third day of hospitalization-"usually at a stable time point."
The hospital then offers patients who have been identified as being depressed a variety of options. Those range from close monitoring and follow-up to a consultation with a psychiatrist, "either arranging that for them prior to their leaving so it’s not left up to the outpatient physician," Dr. Amin says, "or having them seen in the hospital if symptoms, like suicidality, warrant it."
The hospital also makes sure it conveys the information to patients’ primary care physicians. If patients are still depressed one month out, their primary providers can either initiate treatment, titrate existing medications or offer patients other therapies.
Although an argument can be made for waiting a month or so after a heart attack to screen a patient for depression, Dr. Amin says that given the reality of the health care system, patients are more likely to get screened for depression in the hospital than outside during a follow-up appointment.
"There are a lot of potential barriers, but we have great tools to use and care pathways already in place," says Dr. Amin. "It’s important enough to identify high-risk patients that we’re willing to screen in the hospital where our resources are greater."
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.