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Diagnostic Accuracy of Screening and Treatment of Post–Acute Coronary Syndrome Depression: A Systematic Review

Systematic Review

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Purpose of Review

Evaluate the comparative accuracy of tools for diagnosing depression in patients after an acute coronary syndrome event and the effectiveness of treatments in these patients.

Key Messages

  • The Beck Depression Inventory (BDI)-II screen tool is the most studied and is as accurate in this population as in others.
  • Available depression-screening tools may miss 3 percent of people with depression, but less than 50 percent of those who screen positive have clinically confirmed depression. 
  • Enhanced care interventions that integrate psychiatric treatment into cardiology and primary care settings improve depression symptoms. Current evidence is insufficient to determine if enhanced care improves cardiac outcomes.
  • Combining cognitive behavioral therapy and antidepressant medication may improve depression outcomes but does not clearly improve cardiac outcomes.

Structured Abstract

Objectives. To evaluate (1) the diagnostic accuracy of selected depression screening instruments and strategies versus a validated criterion standard in adult patients within 3 months of an acute coronary syndrome (ACS) event and (2) the comparative safety and effectiveness of a broad range of pharmacologic and nonpharmacologic treatments for depression in adult patients who have received a criterion-based diagnosis of depression or had clinically important depressive symptoms using a validated depression scale and who are within 3 months of an ACS event.

Data sources. We searched PubMed®, Embase®, PsycINFO®, CINAHL®, and the Cochrane Database of Systematic Reviews for English-language studies published from January 1, 2003, to August 15, 2017, that evaluated the accuracy of tools for diagnosing depression in patients after ACS or that evaluated interventions for treating post-ACS patients identified with depression.

Review methods. Two investigators individually screened each abstract and full-text article for inclusion; abstracted data; and rated quality, applicability, and strength of evidence. Where appropriate, random-effects models were used to compute summary estimates of effects.

Results. We identified 21 primary articles describing 10 unique studies that met our inclusion criteria: 6 studies relevant to diagnostic accuracy and 4 studies relevant to treatment effectiveness. For diagnostic accuracy, based on six studies evaluating four instruments involving 1,755 post-ACS patients, evidence suggests that a range of different depression screening instruments produce high (97%) negative predictive values (i.e., percentage of patients who screen negative who do not have the condition) but produce low (<50%) positive predictive values (i.e., percentage of patients who screen positive who actually have the condition). Sensitivity and specificity are greater than 70 percent. A meta-analysis of four studies (1,576 patients) estimated the diagnostic screening performance characteristics of the Beck Depression Inventory (BDI)-II: sensitivity of 90 percent (SOE=high) and specificity of 80 percent (SOE=moderate). For treatment effectiveness, enhanced care interventions that integrate psychiatric treatment into other clinical settings improve depression symptoms more than usual care (mean difference in BDI, -3.5 to -3.8; 2 trials; SOE=moderate); adverse effects did not differ. One trial compared second-generation antidepressants with usual care and found no effect on depression symptoms or quality of life, although, when combined with studies included in the original review, it showed a small positive effect of antidepressants. A large trial found that a combination strategy including cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health–related function, and overall life satisfaction more than usual care (1 trial, 2,481 patients, SOE=high) but had no consistent effect on cardiovascular outcomes (SOE=moderate). Evidence supporting effects of enhanced care interventions on cardiovascular and other outcomes of interest was insufficient.

Conclusions. Among several depression screening tools, the BDI is the most studied. Existing tools miss less than 3 percent of patients with depression, but only 50 percent of patients who screen positive actually have clinically confirmed depression. Enhanced care interventions and a strategy using CBT plus second-generation antidepressants for patients with severe depression or partial response to CBT improved depressive outcomes more than usual care. The effects of depression interventions on cardiovascular outcomes are uncertain.

Citation

Williams JW Jr, Nieuwsma JA, Namdari N, Washam JB, Raitz G, Blumenthal JA, Jiang W, Yapa R, McBroom AJ, Lallinger K, Schmidt R, Kosinski AS, Sanders GD. Diagnostic Accuracy of Screening and Treatment of Post–Acute Coronary Syndrome Depression: A Systematic Review. Comparative Effectiveness Review No. 200. (Prepared by the Duke University Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 18-EHC001-EF. Rockville, MD: Agency for Healthcare Research and Quality; November 2017. DOI: https://doi.org/10.23970/AHRQEPCCER200.

Journal Publication

Nieuwsma JA, Williams JW, Namdari N, et al. Diagnostic accuracy of screening tests and treatment for post–acute coronary syndrome depression: a systematic review. Ann Intern Med. [Epub ahead of print 2017 November 14] doi: http://dx.doi.org/10.7326/M17-1811