A Johns Hopkins cardiologist well-known for his
studies on the links between depression and
heart attack says there is not nearly enough evidence yet
to support a recent call by the American
Heart Association to begin routine screening of millions of
Americans for depression.
Roy Ziegelstein says the September recommendation is
"premature" and "a massive undertaking"
that would consume a vast amount of clinic staff time and
effort to analyze and follow up on the
questionnaires involved in screening, without a
demonstrated benefit in improving patient care.
An estimated 80 million Americans have some form of
heart disease.
Reporting on a collection of more than 1,500 clinical
studies from around the world, from which
17 were selected for detailed review, Ziegelstein and his
colleagues point to the absence of any
scientific proof that depressed heart patients live longer
or fare better over the long term if they
are screened for depression and treated with drugs and
other therapy.
The team's report, believed to be the largest, most
comprehensive review of all research in the
field, appears in the Nov. 12 edition of the Journal of
the American Medical Association. Its
publication coincided with the AHA's annual Scientific
Sessions in New Orleans.
"Our analysis showed that depression screening tools
worked reasonably well in identifying who
is depressed and who is not, based on such symptoms as
feeling blue or suddenly withdrawing from
routine activities," said Ziegelstein, a professor at the
Johns Hopkins University School of Medicine
and its Heart and Vascular Institute.
Yet he pointed out that that about one in five people
with depression would not be picked up by
screening, and fewer than half of those identified as
depressed by the screening process will actually
be depressed when evaluated more thoroughly.
The team also found that treating depression in people
with heart disease accounted for only a
1 percent to 4 percent change in symptoms compared to those
treated with placebo. Ziegelstein said
that this is "too low to expect meaningful benefits for
many people, particularly since screening
methods are not very precise in identifying people who
would benefit from the treatment."
In addition, he said, before routine screening,
physicians need to consider the potential for
harm to people, as no studies have fully analyzed any
negative impact from treatment side effects, or
misdiagnosis and labeling of heart patients as
depressed.
"Understandably, then, we cannot in good conscience
support screening all heart patients," said
Ziegelstein, vice chairman of medicine at Johns Hopkins
Bayview Medical Center. "This is a difficult
call for us to make, but it is in the best interests of
patients at this time," he said.
The AHA estimates that one in four heart attack
patients experiences feelings of sadness and
develops a gloomy outlook as a result of the injury. Such
depression more than doubles the risk of
death, according to some studies.
But rather than conducting massive, costly screening
at this point, Ziegelstein said, physicians
need to "get to know their patients better, as real
people," and to make clinical assessments of each
patient's mood for signs of depression as they talk about
other things related to their health,
including exercise routines, dietary habits and use of
medications.
"Physicians can start by listening more to their
patients during examinations and by not
interrupting them, which research shows often happens
within the first 20 seconds after patients
initiate conversation," he said.
Making a diagnosis of depression is not difficult for
physicians, he said, "if they use their
examination time well and ask the right questions,"
focusing not only on the physical issues but also on
the patient's overall state of well-being and daily
routine.
"Look and listen for signs of low mood or sadness, or
find out if a patient has recently stopped
or cut back on social contacts or things they used to do
for fun," Ziegelstein said.
As part of the research review, an international team
of researchers sorted more than 1,500
clinical studies of depression to identify studies that
looked at screening heart patients for
depression, and treating and monitoring them. From these,
the team, led by Johns Hopkins-trained
psychologist Brett Thombs, now an assistant professor at
McGill University in Montreal, grouped
together the data from 11 studies that used proven
depression screening tests.
Selected screening studies covered more than 4,000 men
and women, and most involved one of
four commonly used questionnaires to diagnose depression.
Results showed that these tests were on
average 80 percent accurate in detecting people who were
actually depressed.
Another half-dozen clinical trials were evaluated for
the immediate health effects of drug
treatment and counseling among nearly 3,000 men and women
who had been screened and found to be
depressed. Drug treatment mostly involved prescribing
mood-raising selective serotonin re-uptake
inhibitors. Researchers could not find a single study that
screened heart patients for depression and
then demonstrated lasting improvements to health or even a
longer lifespan.
"We don't have any evidence that screening for
depression will benefit people with heart
disease. What we really need is more research on how best
to help them adopt healthy behaviors that
combat depression, such as how to stop smoking, exercise
regularly and maintain a healthy weight,"
Thombs said.
Ziegelstein says the team's collective research will
contribute to a better understanding of how
depression influences heart disease. He also says it will
increase physician support to broaden clinical
care of depressed heart patients to include increased input
from psychologists, psychiatrists and
internists as part of what he calls a more "collaborative
care model" that encompasses care of the
mind and overall body as much as it does the physical
heart.
Funding support for Ziegelstein's research was
provided by the National Center for
Complementary & Alternative Medicine, a member of the
National Institutes of Health, and by the
Miller Family Scholar Program.
In addition to Ziegelstein and Thombs, researchers who
contributed to this study were Cheri
Smith and Karl Soderlund, both of Johns Hopkins. Other
members of the international team of co-
investigators were Peter de Jonge and Marij Zuidersma, of
University Medical Center Groningen, the
Netherlands; James Coyne, University of Pennsylvania School
of Medicine; Mary Whooley, University
of California, San Francisco; Nancy Frasure-Smith, McGill
University; Alex Mitchell, Leicester Royal
Infirmary, United Kingdom; Chete Eze-Nliam, Interfaith
Medical Center, Brooklyn, N.Y.; and Bruno
Lima, Federal University of Ceara School of Medicine,
Fontalezce, Brazil.