Nonpharmacological Treatments Reduce Depression After CABG
From Medscape Medical News
Arch Gen Psychiatry. 2009;66:387-396. Abstract
CBT Superior to Supportive Stress Management and Usual Care
April 14, 2009 ? Two nonpharmacological interventions appear to be more effective in treating depression and preventing relapse than usual care in patients who have undergone recent coronary artery bypass graft (CABG) surgery, new research suggests.
The first randomized, controlled trial for depression after CABG surgery showed that, at 3-month follow-up, 71% of CABG patients on cognitive-behavior therapy (CBT) and 57% of those receiving supportive stress management (SSM) achieved remission compared with 33% of individuals who received usual care.
"This study provides good evidence that if you can refer bypass patients with depression to a qualified cognitive-behavior therapist or, failing that, a supportive stress-management program, this can be very helpful in treating depression and preventing relapse," principal investigator Kenneth Freedland, PhD, from Washington University School of Medicine, in St. Louis, Missouri, told Medscape Psychiatry.
The study is published in the April issue of the Archives of General Psychiatry.
Lack of Research
According to Dr. Freedland, depression in this patient population is common, affecting approximately 20% of individuals recovering from CABG surgery. In addition, he noted, it is well-known that depression has a significant impact on patient outcomes.
"In our lab, we have been studying the role of depression in heart-disease patients for about 25 years, and we know it has all kinds of negative effects in a number of cardiac populations," said Dr. Freedland. "It increases morbidity and mortality as well as functional impairment, decreases quality of life, and interferes with adherence to treatment regimes."
However, Dr. Freedland pointed out that despite depression's significant negative effects, there have been few treatment trials aimed at modifying depression to improve outcomes in patients with post-CABG depression.
To test the efficacy of 2 nonpharmacological treatment approaches for depression in this patient population, the investigators enrolled 123 patients with major or minor depression within 1 year after CABG surgery.
Of these individuals, 40 subjects were randomly assigned to usual care as determined by primary-care or other physicians, and the other patients were assigned to 1 of the 2 treatment groups.
Forty participants in the CBT group received 12 weeks of therapy consisting of weekly 50- to 60-minute sessions with a psychologist or social worker that assisted patients in identifying problems and developing cognitive techniques to overcome them.
The remaining 42 patients received 12 once-weekly supportive stress-management sessions, in which a social worker or psychologist counseled the patient about improving his or her ability to cope with stressful life events.
CBT Effective in Other Patient Populations
The research team selected CBT as 1 of the study interventions because it is well studied and has been shown to be efficacious in reducing depressive symptoms in other patient populations, particularly medically well psychiatric patients.
SSM was selected as a study intervention for 2 reasons. First, said Dr. Freedland, it is not quite as challenging to deliver as CBT but at the same time has a good track record in terms of reducing depression and some of its accompanying symptoms, including anxiety.
Second, he added, stress is a known trigger for depression and also has negative cardiac consequences.
"Many patients who go through cardiac rehabilitation receive some kind of stress-management intervention. It is usually brief and done in a group format, so we thought if we could do a more intensive kind of stress management aimed specifically at relieving depressive and anxiogenic stressors, we may be able to help patients with their depression as well as their heart disease," said Dr. Freedland.
The study's primary outcome was remission of depression defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression (HAM-D). Patients were evaluated at 3, 6, and 12 months.
Secondary outcome measures included potential reductions in anxiety, hopelessness, and perceived stress, as well as physical and mental components of health-related quality of life as measured by the Medical Outcomes Study SF-36.
Usual Care Not Good Enough
Patients in the CBT and SSM groups received these interventions in addition to, and not as a replacement for, any antidepressant medications that they may have been receiving from their physicians.
"It is important to understand that this trial was not designed to assess whether or not these nonpharmacological interventions were superior to antidepressant medication, but rather whether they were effective in reducing depressive symptoms in this patient population relative to usual care, which often involves the use of antidepressants," said Dr. Freedland.
In fact, approximately 50% of patients in all 3 study groups were on some type of antidepressant medication.
Remission of depression at 3 months occurred in a higher proportion of patients in the CBT and SSM groups than in the usual-care group. These differences narrowed at 6 months but widened again at 9 months, with 73%, 57%, and 35% remission rates for CBT, SSM, and usual-care groups, respectively.
Furthermore, said Dr. Freedland, CBT was also superior to usual care on most of the study's secondary outcomes, with the exception of the physical component of health-related quality of life.
"The take-home message from this study is that the usual care for depression that is often provided to patients after bypass surgery just isn't good enough.
"People typically get their depression care from primary-care physicians, and what that often means is they get a prescription for an antidepressant at a relatively low dose and they're off and running. If it works, it works, but too often there's inadequate follow-up, no adjustment of the dosage, and no attempt to try alternative forms of therapy if the initial antidepressant is ineffective. Some of these patients need more intensive treatment than what they are typically offered," said Dr. Freedland.
Call for More Studies
Asked by Medscape Psychiatry to comment on the study, American Psychiatric Association spokesperson Wayne J. Katon, MD, from the University of Washington School of Medicine, in Seattle, said the study's findings may mean more post?CABG-surgery patients with depression will receive treatment.
"Depression is a common problem in post-CABG patients and is associated with decreased quality of life and increased complications and mortality. These data suggest that providing a choice of either meds or therapy may allow treatment of larger numbers of patients. It is easier to provide medication with telephone follow-ups measuring adherence and response and providing further titration of medication," said Dr. Katon.
"Also, recent telephone-based delivery of CBT has been shown to be effective and could also be tried for less ambulatory older patients who would have difficulty traveling regularly to clinics," he added.
Dr. Freedland hopes this research will spark further depression-treatment studies in cardiac patients. "I'm very pleased with the results of the study and think this is very good news for people who struggle with depression after bypass surgery. I hope to see more trials like it in which researchers are testing different interventions and discovering what works best," he said.
Dr. Freedland added that his next research steps include launching a new trial that will examine the efficacy of CBT in the treatment of depression among heart-failure patients.
The study was supported by the National Institute of Mental Health. The authors report no relevant conflicts of interest.
From Medscape Medical News
Arch Gen Psychiatry. 2009;66:387-396. Abstract
CBT Superior to Supportive Stress Management and Usual Care
April 14, 2009 ? Two nonpharmacological interventions appear to be more effective in treating depression and preventing relapse than usual care in patients who have undergone recent coronary artery bypass graft (CABG) surgery, new research suggests.
The first randomized, controlled trial for depression after CABG surgery showed that, at 3-month follow-up, 71% of CABG patients on cognitive-behavior therapy (CBT) and 57% of those receiving supportive stress management (SSM) achieved remission compared with 33% of individuals who received usual care.
"This study provides good evidence that if you can refer bypass patients with depression to a qualified cognitive-behavior therapist or, failing that, a supportive stress-management program, this can be very helpful in treating depression and preventing relapse," principal investigator Kenneth Freedland, PhD, from Washington University School of Medicine, in St. Louis, Missouri, told Medscape Psychiatry.
The study is published in the April issue of the Archives of General Psychiatry.
Lack of Research
According to Dr. Freedland, depression in this patient population is common, affecting approximately 20% of individuals recovering from CABG surgery. In addition, he noted, it is well-known that depression has a significant impact on patient outcomes.
"In our lab, we have been studying the role of depression in heart-disease patients for about 25 years, and we know it has all kinds of negative effects in a number of cardiac populations," said Dr. Freedland. "It increases morbidity and mortality as well as functional impairment, decreases quality of life, and interferes with adherence to treatment regimes."
However, Dr. Freedland pointed out that despite depression's significant negative effects, there have been few treatment trials aimed at modifying depression to improve outcomes in patients with post-CABG depression.
To test the efficacy of 2 nonpharmacological treatment approaches for depression in this patient population, the investigators enrolled 123 patients with major or minor depression within 1 year after CABG surgery.
Of these individuals, 40 subjects were randomly assigned to usual care as determined by primary-care or other physicians, and the other patients were assigned to 1 of the 2 treatment groups.
Forty participants in the CBT group received 12 weeks of therapy consisting of weekly 50- to 60-minute sessions with a psychologist or social worker that assisted patients in identifying problems and developing cognitive techniques to overcome them.
The remaining 42 patients received 12 once-weekly supportive stress-management sessions, in which a social worker or psychologist counseled the patient about improving his or her ability to cope with stressful life events.
CBT Effective in Other Patient Populations
The research team selected CBT as 1 of the study interventions because it is well studied and has been shown to be efficacious in reducing depressive symptoms in other patient populations, particularly medically well psychiatric patients.
SSM was selected as a study intervention for 2 reasons. First, said Dr. Freedland, it is not quite as challenging to deliver as CBT but at the same time has a good track record in terms of reducing depression and some of its accompanying symptoms, including anxiety.
Second, he added, stress is a known trigger for depression and also has negative cardiac consequences.
"Many patients who go through cardiac rehabilitation receive some kind of stress-management intervention. It is usually brief and done in a group format, so we thought if we could do a more intensive kind of stress management aimed specifically at relieving depressive and anxiogenic stressors, we may be able to help patients with their depression as well as their heart disease," said Dr. Freedland.
The study's primary outcome was remission of depression defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression (HAM-D). Patients were evaluated at 3, 6, and 12 months.
Secondary outcome measures included potential reductions in anxiety, hopelessness, and perceived stress, as well as physical and mental components of health-related quality of life as measured by the Medical Outcomes Study SF-36.
Usual Care Not Good Enough
Patients in the CBT and SSM groups received these interventions in addition to, and not as a replacement for, any antidepressant medications that they may have been receiving from their physicians.
"It is important to understand that this trial was not designed to assess whether or not these nonpharmacological interventions were superior to antidepressant medication, but rather whether they were effective in reducing depressive symptoms in this patient population relative to usual care, which often involves the use of antidepressants," said Dr. Freedland.
In fact, approximately 50% of patients in all 3 study groups were on some type of antidepressant medication.
Remission of depression at 3 months occurred in a higher proportion of patients in the CBT and SSM groups than in the usual-care group. These differences narrowed at 6 months but widened again at 9 months, with 73%, 57%, and 35% remission rates for CBT, SSM, and usual-care groups, respectively.
Furthermore, said Dr. Freedland, CBT was also superior to usual care on most of the study's secondary outcomes, with the exception of the physical component of health-related quality of life.
"The take-home message from this study is that the usual care for depression that is often provided to patients after bypass surgery just isn't good enough.
"People typically get their depression care from primary-care physicians, and what that often means is they get a prescription for an antidepressant at a relatively low dose and they're off and running. If it works, it works, but too often there's inadequate follow-up, no adjustment of the dosage, and no attempt to try alternative forms of therapy if the initial antidepressant is ineffective. Some of these patients need more intensive treatment than what they are typically offered," said Dr. Freedland.
Call for More Studies
Asked by Medscape Psychiatry to comment on the study, American Psychiatric Association spokesperson Wayne J. Katon, MD, from the University of Washington School of Medicine, in Seattle, said the study's findings may mean more post?CABG-surgery patients with depression will receive treatment.
"Depression is a common problem in post-CABG patients and is associated with decreased quality of life and increased complications and mortality. These data suggest that providing a choice of either meds or therapy may allow treatment of larger numbers of patients. It is easier to provide medication with telephone follow-ups measuring adherence and response and providing further titration of medication," said Dr. Katon.
"Also, recent telephone-based delivery of CBT has been shown to be effective and could also be tried for less ambulatory older patients who would have difficulty traveling regularly to clinics," he added.
Dr. Freedland hopes this research will spark further depression-treatment studies in cardiac patients. "I'm very pleased with the results of the study and think this is very good news for people who struggle with depression after bypass surgery. I hope to see more trials like it in which researchers are testing different interventions and discovering what works best," he said.
Dr. Freedland added that his next research steps include launching a new trial that will examine the efficacy of CBT in the treatment of depression among heart-failure patients.
The study was supported by the National Institute of Mental Health. The authors report no relevant conflicts of interest.
