Depression in Heart Patients

Two of every five patients who experience acute coronary syndrome (ACS) will have depression—a very important psychosocial predictor of poor cardiovascular prognosis.

“A growing body of evidence suggests that mental health problems complicate physical health conditions and that this relationship worsens clinical outcomes, increases hospitalization, and adversely affects quality of life,” Joseph A. Ladapo, MD, PhD, of New York University in New York City.

He and colleagues predicted that treatment of depression after ACS would be cost effective and improve patient outcomes.  They conducted a randomized, controlled study comparing enhanced depression care with usual care in patients with ACS and persistent depression 3 months after discharge.  Ladapo and colleagues defined enhanced depression care as problem-solving psychotherapy, antidepressant use or both.

Their conclusion at the close of the 6-month, prospective trial involving 157 patients was that treatment for depression reduced total per-patient healthcare costs by more than 40% and was cost effective for almost all patients.

An assessment of quality of life showed improved health utility in the intervention group.  Interviews 6 months after discharge showed that in the intervention group 51% were using antidepressants or anxiolytics and 75% had visited a mental health specialist at least once for a total cost of $1,083.  In the control group 30% were using antidepressants or anxiolytics and 35% had seen a mental health professional, for an average of $554.

The extra costs for the intervention group were more than offset by the significant reduction in hospitalization for ACS and heart failure (5% vs. 16%), with a mean cost savings of $1,782 for the intervention group and unmeasured improvement in quality of life.

Total healthcare costs averaged $1,857 in the intervention group and $2,797 for the usual-care arm, resulting in an adjusted difference of $1,229, which did not achieve statistical significance (P=0.09). Because the intervention was cost saving, the investigators could not calculate a cost-effectiveness ratio.

The research was reported in Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4448, and was supported by the National Heart, Lung, and Blood Institute; the Health Resources and Services Administration; and the American Heart Association.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Therapy by Telephone

Can therapy for depression work when done by telephone?  The short answer is yes.  This type of therapy may be slightly less effective than face-to-face meetings, but patients are less likely to drop out of phone therapy. 

These were the findings of David Mohr and colleagues at the Northwestern University Feinberg School of Medicine published in the Journal of the American Medical Association in June of this year.  Mohr said, “One of the things we’ve found over the years is that it’s very difficult for people with depression to access psychotherapy.”  The authors speculated that reducing time commitments, transportation problems and cost may play a role in the lower drop-out rate for phone therapy.

Around 25% of all primary care visits are with patients who have clinically significant depression, according to the authors.  Cognitive behavioral therapy is an effective treatment for depression, but the drop-out rate is high.

Researchers in the randomized study had 325 people diagnosed with depression undergo 18 weeks of therapy, half by phone and half in person.  The quality of the telephone therapy was calculated to be equivalent to in-person treatment. By the end of the period 53 participants had dropped out of face-to-face therapy compared with 34 in the phone therapy group.

Patients in both groups felt decreased levels of their depression, however six months later patients who met with their therapists in person tended to feel less depressed than those who had phone sessions, but the difference was very small.

“At this point these findings do suggest that psychotherapy for depression can be administered both safely and effectively over the phone. Providers can be comfortable doing that and insurers and payers should feel comfortable” reimbursing for it, Mohr said.  Cognitive behavioral therapy by phone, “can overcome barriers to adhering to face-to-face treatment.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Antidepressants in Dementia

As many as 20% of patients with dementia may also have depression.  The usual treatment is a selective serotonin reuptake inhibitor or a noradrenergic and specific serotonergic antidepressant.  But some research has questioned the effectiveness of these treatments.

In a study published in The Lancet, (volume 378, Issue 9789, pages 403 - 411, 30 July 2011), Sube Banerjee MD, a London-based expert in old age psychiatry, and his colleagues concluded that because there was an absence of benefit compared with placebo and increased risk of adverse events, the practice of using these antidepressants should be reevaluated.

“Depression is one of the most important co-morbidities in dementia.  It is a source of great distress yet the treatments we use are not proven,” said Dr. Banerjee.

In their parallel-group, double-blind, placebo-controlled study of more than 326 patients with Alzheimer’s dementia, decreases in depression scores at 13 and 39 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (Zoloft) or 108 who received mirtazapine (Remeron).

“I am surprised by just how unequivocal our findings are,” said lead author Banerjee, professor of mental health and aging at King’s College London, Institute of Psychiatry, United Kingdom.  “The present practice of use of these antidepressants with usual care for first-line treatment of depression in Alzheimer’s disease should be reconsidered,” write the authors.

“The message is to think before using antidepressants for depression in dementia.  It may well be that these symptoms will resolve with the problem-solving and information-giving that is implicit in good-quality dementia care,” added Dr. Banerjee. The investigators suggest that antidepressants be reserved for “individuals whose depression has not resolved within 3 months of referral, apart from those in whom drug treatment is indicated by risk or extreme severity.”

Funding for this study was provided by the UK National Institute of Health Research HTA Programme.

Combating Fatigue in Cancer

Pilot Study

A team of researchers from Australia and New Zealand conducted a small pilot study to help determine an appropriate dose of methylphenidate hydrochloride, a central nervous system stimulant, to treat fatigue in patients with advanced cancer.

They reported in Journal of Palliative Medicine that 5 mg twice daily would be an appropriate dose to test in a definitive study. Ten patients provided consent.

After a three-day assessment, patients received titrated methylphenidate hydrochloride at doses ranging from 5 mg a day to 15mg twice a day. Nine patients completed eight days and five received the maximum dose at day 15. Three patients were satisfied with the results at a lower dose and were not willing to increase it.

The team noted a pattern of rapidly improving fatigue and depression at 5 mg twice daily.

Journal of Palliative Medicine, Volume 13, Number 10, Oct. 2010

Spiritual Pain in Advanced Cancer: Symptom for Hospice Chaplains to Address

Quality of Life Can Improve

A vast majority of advanced cancer patients receiving palliative care consider themselves spiritual and religious.  But spiritual pain is still common and is linked to lower quality of life.  This is another place in which the holistic hospice approach to mind and body may improve life’s final stage.

A study done by the Division of Geriatrics and Palliative Medicine, The University of Texas Medical School at Houston, Texas, examined the frequency and intensity of spirituality, religiosity, and spiritual pain, and how spiritual pain was associated with symptom expression, coping, and spiritual quality of life.

Researchers interviewed 100 patients with advanced cancer and had them complete questionnaires assessing their symptoms and ability to cope. 

Spiritual pain was reported in 44%, and was associated with lower spiritual quality of life. Patients with spiritual pain reported that it contributed adversely to their physical/emotional symptoms. There was a trend toward increased depression, anxiety, anorexia, and drowsiness among patients with spiritual pain, although this may not have been significant after corrections.

Every Pathways Hospice patient can have visits from extremely well qualified spiritual care counselors to give unbiased spiritual or religious support to patient or family members, to identify and resolve spiritual concerns, to explore the meaning of life, to administer sacraments, or to be a warm listening presence when needed.

This study can be found at J Pain Symptom Manage.  2011; 41(6):986-94 (ISSN: 1873-6513).

Coffee May Help Depression

You may have read about the benefits of one or two cups of coffee a day: reduced risk of type 2 diabetes, Parkinson’s disease and dementia.  Now it looks as though a little java may also decrease the risk for depression.

“There is certainly much more good news than bad news, in terms of coffee and health,” says Frank Hu, MD, MPH, PhD, nutrition and epidemiology professor at the Harvard School of Public Health.

New research published after a 10-year study of more than 50,000 older women suggest that the risk for depression may decrease as coffee consumption increases.  Those who drank 2-3 cups a day had a 15% decreased risk of depression compared to women who drank one cup a day or less.

“People have often worried that drinking caffeinated coffee might have a bad effect on their health, but there is more and more literature, including this study, showing that caffeine may not have the detrimental effect previously thought,” according to lead author Michel Lucas, PhD, RD, epidemiologist/nutritionist at Harvard School of Public Health in Boston.

The study is published in the September 26 issue of the Archives of Internal Medicine.

Care at Home vs. Hospitalization

Home Fares Better for Heart Failure Patients

Hospitalization, the standard venue for short-term medical care, may be hazardous for the elderly according to a study reported in the Archives of Internal Medicine in September, 2009.*  The study evaluated the feasibility and effectiveness of physician-managed home care for selected patients with acute decompensation of chronic heart failure.  The prospective, single-blind, randomized trial followed patients 75 years or older who had been hospitalized.  They were randomly assigned to a Geriatric Home Hospitalization Service or a general medical ward.

Overall Improved Status

Findings demonstrated no significant difference in the number of deaths or subsequent hospitalizations, but the mean time until the first additional admission was longer for the patients cared for in their own homes.  Only the home patients experienced improvements in depression, nutritional status and quality-of-life scores.

The research concluded that home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF.
  
*Arch Intern Med. 2009 Sep 28;169(17):1569-75.

For more information about Pathways Home Health services for patients with chronic heart failure, please visit www.pathwayshealth.org/home-health.