A depression screening tool finds that 54% of acute cardiac patients are at risk of depression; use of the tool improves documentation and referral
- Correspondence to: Brett Thombs
Jewish General Hospital, 4333 Cote Ste, Catherine Road, Montreal, Quebec, Canada H3T 1E4;
Commentary on: Ski CF, Page K, Thompson DR, et al. Clinical outcomes associated with screening and referral for depression in an acute cardiac ward. J Clin Nurs 2012;21:2228–34.
Implications for practice and research
This study found that nurses on cardiovascular care units were able to administer depression screening tools and document referral activities for positive screens.
It is not known whether depression screening improved depression outcomes.
Evidence of benefits in excess of harms, established by well-conducted randomised controlled trials (RCTs) of depression screening interventions, is needed before depression screening is implemented in cardiovascular care settings.
Major depressive disorder (MDD) may be present in up to 20% of heart disease patients and has been associated with poorer cardiac prognosis, reduced quality of life, less favourable self-care behaviours and higher healthcare costs.1 A 2008 American Heart Association (AHA) Science Advisory recommended that all heart patients be routinely screened for depression,2 but the recommendation was not based on a systematic review of the evidence on depression screening in cardiovascular care settings.3
The authors recruited cardiac patients admitted to the cardiac medical or surgical wards of a major Melbourne metropolitan hospital. Patients were administered a five-item version of the Cardiac Depression Scale (CDS) by a study nurse and classified as not at risk of depression, at moderate risk of depression or at high risk of depression. Nurses were provided with a menu of appropriate referral actions for patients with moderate or high risk of depression and recorded any referral procedures implemented.
The authors reported that of 628 admitted patients, 202 were eligible for the study, with the majority of exclusions being due to the inability to communicate in English. They found that, of the 202 eligible patients, 54% (n=109) were at either moderate (19%, n=39) or high (34%, n=70) risk of depression. Among patients with moderate or high risk, the CDS risk score was documented in the patient's medical chart for 91% of patients, discussed with clinicians for 90% and formally communicated to the medical team for 85%. Among high-risk patients, 11 were referred to consultation-liaison psychiatry services, but only 4 agreed to be seen.
To be successful, a depression screening programme must identify a significant number of depressed patients who are not otherwise recognised as depressed, engage those patients in treatment and obtain sufficiently positive treatment results to justify costs and potential harms from screening. Whether or not this is the case must be determined based on evidence from well-conducted RCTs.4 The AHA recommendation for routine depression screening, to the contrary, was made even though no RCTs had tested whether depression screening would benefit heart patients.3 Furthermore, it ignored consistent evidence from primary care settings that screening and referral alone, as done in the present study, may increase the number of patients identified and referred, but not improve depression outcomes.5
Consistent with this, the US Preventive Services Task Force, which makes recommendations for primary care settings, recommends against depression screening outside of the context of complex staff-assisted collaborative care programmes, where integrated supports are in place to ensure appropriate diagnosis, treatment and follow-up.6 Whether or not depression screening would benefit patients even in the context of collaborative care, however, has not been demonstrated in an RCT.4
Ski and colleagues demonstrated that nurses on cardiovascular care units are able to administer depression screening tools and document referral activities for positive screens. This study did not, however, demonstrate that doing this improves outcomes for patients who are screened. Without demonstrated benefit, potential harms from screening must be considered, including the treatment of depression in patients who are incorrectly diagnosed, the initiation of treatment for those with mild symptoms that often resolve without treatment, and, perhaps most importantly, the diversion of scarce resources from other endeavours, such as ensuring better care for heart patients otherwise identified as depressed.4 Before depression screening is recommended for implementation in practice, it is important that the benefits and harms of screening are compared in a rigorous RCT.
Competing interests BT was supported by a New Investigator Award from the Canadian Institutes of Health Research.