Collaborative Care for Post-CABG Depression

To the Editor: Dr Rollman and colleagues¹ reported the results of the Bypassing the Blues randomized controlled trial. It demonstrated the benefit of stepped collaborative care for postbypass surgery depression. Which components of this stepped-care approach are important and the generalizability of the findings to all cardiac patients with depression are issues that warrant further discussion.

The stepped-care approach involved (1) a nurse care manager in direct telephone contact with the patient; (2) the primary care physician; and (3) the local mental health specialist. Disentangling which components of this complex intervention were beneficial is difficult. In particular, the contribution of the primary care physician may have been underemphasized because the intervention group received more antidepressant medications. Moreover, there are concerns regarding direct patient telephone contact with the nurse care manager, as this strategy has previously been shown to be detrimental.² Regarding the generalizability of the study, the protocol exclusively focused on postbypass depression so that implications for other cardiac conditions are unknown.