Telephone-delivered collaborative care for post-CABG depression is more effective than usual care for improving quality of life related to mental health
- Correspondence to Robyn Gallagher
University of Technology, PO Box 123 Broadway, Sydney, NSW, Australia;
Rollman and colleagues studied an intervention designed to manage depression following coronary artery bypass graft (CABG) surgery, a common and debilitating condition during recovery. Although other individual interventions have been tested, including antidepressant medication and individual counselling, few have been shown to improve depression. The intervention here, which the authors label ‘Bypassing the Blues’, is unique in that it uses a collaborative care model, managed and delivered by a nurse. Nurses deliver the intervention by telephone, and although there is a protocol, cases may be individualised during weekly reviews with a psychiatrist. Patients are recommended various treatments that foster self-management, including a workbook. Initiation and alteration of antidepressant medications and referral to specialist support are undertaken in consultation with patients' primary care physician. The PHQ-9 is used to monitor participants' depression from week 2, with telephone calls every other week during the acute phase, reducing to every 1–2 months until 8 months of treatment was reached.
The telephone support was tested in a randomised controlled trial (RCT) sampling patients with evidence of depression (n=302). An additional comparison arm of patients without depression was included, and assessments occurred at 2, 4 and 8 months. A total of 252 participants completed the trial, although data from all participants were included. Patients receiving the intervention had greater improvements in mental health (SF-36 MCS) and clinically meaningful improvements in mood (HRS-D) and physical function (DASI) compared with the usual care group at 8 months, with men showing the greatest benefits. Interestingly, men were more likely to use the workbook and women more likely to use pharmacotherapy. Overall, patients in the intervention group were twice as likely to have a 50% or more reduction in depression symptoms by 8 months. Fewer than five patients with depression would need to be treated for one patient to benefit. There were no differences in re-admission rates or the use of psychologist or psychiatrist support.
The study was well designed and conducted; the single-blind RCT was reported clearly, and sampling methods were appropriate. The results cannot be generalised to all CABG patients with depression, as many patients were not eligible or were refused; furthermore, approximately 15% of participants dropped out by 8 months. However, 8 months' follow-up was sufficient to determine long-term benefits of the treatment, and the assessments used were appropriate to the study question. The inclusion of the non-depressed comparison group was not particularly beneficial, except to establish what is well known, namely that depressed people do not do as well.
This study is a useful illustration of a feasible collaborative care model for an at-risk group that has been well investigated but less often treated successfully. It appears that detecting the need for and uptake of pharmacotherapy may have been a key aspect. Although costs were not detailed, implementation of the model of care would require additional resources for the nursing staff, telephone calls and case review; however, these costs are fairly containable. Of course, such an intervention depends in the first place on a collaborative model of care with regular case reviews and communication with primary care physicians, which may take some time to establish. More important, the intervention depends on routine screening of CABG patients for depression, which does not occur in many settings, although the two questions used for initial screening in this study are simple and easy to apply.
The results build on existing evidence for the relative ineffectiveness of single measures for treating depression compared with the use of a combination of methods. More investigation is required into the potential costs of the intervention, and detail needs to be provided on the interaction of professions in the collaborative care model.
Competing interests None.