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.

The Identifying Depression as a Comorbid Condition (IDACC) study³ may provide further insights into these issues. The IDACC study screened hospitalized patients with a range of cardiac conditions (myocardial infarction, congestive cardiac failure, angioplasty, and coronary bypass surgery) for depression using the Center for Epidemiological Studies Depression Scale (CES-D).⁴ The intervention focused on direct patient care by the primary care physician with telephone support to the clinician by specialized hospital staff (either a psychiatry registrar and a cardiac rehabilitation nurse or a psychiatrist). Thus, unlike the Bypassing the Blues trial, IDACC was a collaborative care depression study in patients with a range of cardiac conditions not involving direct telephone contact with the patient.

The IDACC study screened 1541 hospitalized cardiac patients, of whom 669 (43%) were found to have depression. Primary care physicians of patients who scored as either mildly depressed (CES-D 16-26) or moderate to severely depressed (CES-D>26) were randomized into intervention or usual care groups. Intervention, compared with usual care, improved the rates of moderate-to-severe depression at 12-month follow-up (25% vs 35%, respectively; relative risk, 0.72; 95% confidence interval, 0.54-0.96.).⁵

We therefore hypothesize that the benefits observed in the Bypassing the Blues trial may primarily be a result of the increased patient attention by the primary care physician. Focusing on this strategy may not only be simpler, more direct, easier to coordinate, and generalizable to a range of cardiac conditions but also more cost effective.