AAFP Offers Guidance on Depression Care After ACS Events

June 25, 2019 02:22 pm Chris Crawford

The AAFP has released a clinical practice guideline on screening for and treating depression following acute coronary syndrome that was published June 15 in American Family Physician.

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This guideline updates and replaces the Academy's guideline on detection and treatment of depression following myocardial infarction, which was published in 2009 and reaffirmed in 2014.

Updates from the previous guideline include

  • the addition of a consumer/patient representative on the guideline panel;
  • use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology; and
  • an expansion of the target population from patients who have had an MI to those who have had an MI or unstable angina.
Story Highlights
  • The AAFP has released a guideline on screening for and treating depression after acute coronary syndrome that was published June 15 in American Family Physician.
  • Since the previous guideline was released, several new antidepressant medications have hit the market, and insurance coverage of pharmacologic and nonpharmacologic treatments for depression and other behavioral health disorders has improved.
  • Key guideline recommendations include using a standardized depression screening tool, further assessing patients who screen positive to confirm the diagnosis and prescribing certain preferred antidepressant medications -- perhaps along with behavioral therapy -- as treatment.

Guideline co-author Robert "Chuck" Rich, M.D., of Bladenboro, N.C., told AAFP News that since the previous guideline was released, several new antidepressant medications have hit the market, and insurance coverage of pharmacologic and nonpharmacologic treatments for depression and other behavioral health disorders has improved.

"The impact of behavioral health disorders on the management of acute and chronic medical disorders has been increasingly recognized, which has led to increased screening and treatment for behavioral health disorders in medical disorders," he said.

Compared with the previous guideline, Rich said the spectrum of patients affected by acute coronary artery disease, and, therefore, at risk for depression, has been expanded to include not just the patient with MI who has ST segment elevation but also the patient with new-onset unstable angina, as well as the patient with MI and no ST segment elevation.

"These subclasses of the ACS spectrum are at risk of depression and in need of treatment as appropriate," he said.

Key Recommendations

Key recommendations from the new guideline include the following:

  • A standardized depression screening tool (e.g., Beck Depression Inventory-II, Hospital Anxiety and Depression Scale, Geriatric Depression Scale, Patient Health Questionnaire) should be used to screen for depression in patients who have recently experienced an ACS event.
  • In patients who screen positive for depression, further assessment should be conducted to confirm the diagnosis.
  • Antidepressant medication, preferably selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors, and/or cognitive behavioral therapy should be prescribed to improve symptoms of depression in patients who have a history of ACS and have been diagnosed with depression. Tricyclic antidepressants have been associated with multiple adverse effects, including potential cardiotoxicity, and should not be used in patients with heart disease.

Additional Thoughts

Rich said adding a patient representative to the guideline panel gave guideline developers valuable perspective on the real-world impact of the disease process and the positive effects of appropriate and timely diagnosis and treatment of the disorder.

As to the importance of screening for depression in patients who recently had an ACS event, Rich said failing to do so and, thus, not detecting and treating depression in this population appears to be associated with increased cardiovascular mortality, as well as increased overall mortality, based on several observational studies.

"Treatment of depression in this population clearly improves the clinical symptoms of depression, which can subsequently lead to improvements in adherence to prescribed therapy and functional status, as well as possible improvement in return-to-work measures," he said.

On the preferential recommendation for use of SSRIs or SNRIs, Rich said these medication classes had the best safety and effectiveness profiles in this patient population compared with other types of medications.

"Additionally, the combination of (each of) these two categories of medications with CBT had the strongest evidence for benefit, although the use of this pharmacologic and nonpharmacologic combination is subject to problems with availability of CBT services, as well as concerns about patient and provider preference," he said.

Some of the barriers listed in the guideline that are encountered in practice, Rich said, include physician discomfort with the topic, lack of behavioral health support to help manage patients with difficult-to-treat symptoms, time constraints that hinder screening and treating this patient population, possible lack of staff and institutional support to perform this care, and inadequate payment for doing so.

Furthermore, patient factors that can pose barriers to care include worrying about burdening family, friends or physicians with concerns about depression; cultural or spiritual traditions regarding depression; or just a general lack of knowledge on the subject, he added.

All of these factors -- along with disparities involving sex/gender/race/ethnicity and other possible factors -- contribute to underdiagnosis and undertreatment of depression in this patient population, Rich said.

"My take-home message: Remember to screen for depression in the post-ACS population, and if depression is detected or suspected, proceed with treatment, preferably with a combination of medication and CBT where available," he concluded.

Related AAFP News Coverage
Nearly One in 12 U.S. Adults Reports Having Depression
Women Twice as Likely as Men to Be Depressed

(2/19/2018)

Screen All Adults for Depression, Say USPSTF, AAFP
Evidence Shows Screening in Primary Care Setting Is Beneficial

(1/27/2016)

More From AAFP
Familydoctor.org: Heart Attack(familydoctor.org)

Familydoctor.org: Depression(familydoctor.org)