Authors' reply

We thank Dr Tully for his thoughtful comments on the DEPSCREEN-INFO randomised controlled trial. ¹ We share his conclusion about the need to better align mental health services with cardiac patient needs, ^2–4 and we appreciate the studies he cited in his letter. However, these studies did not specifically investigate the efficacy of patient-targeted feedback after depression screening using a randomised controlled study design. In fact, the lack of studies specifically investigating the potential of providing feedback on depression screening results to the patients themselves was the initial point for the DEPSCREEN-INFO trial. Of note, DEPSCREEN-INFO is not a depression screening trial. The screening method was identical across the two conditions, whereas the active component of this trial was the patient-targeted feedback intervention that was applied after depression screening.

Results of the DEPSCREEN-INFO trial indicated that patient-targeted feedback in addition to physician feedback, compared with physician feedback alone, resulted in a small but significant improvement in depression severity 6 months after depression screening. Secondary study results revealed that the patient feedback group was more concerned and more active in their approach to depression than the control group, e.g. by seeking information regarding depression more actively. Although the DEPSCREEN-INFO trial did not investigate the modes of action in more detail, the patient group who received targeted patient feedback appeared to use the opportunity to mobilise coping responses. In response to Dr Tully's assumption that the German healthcare system might offer intensive mental healthcare, our results rather suggest that there is a gap between mental and physical healthcare in cardiology in Germany as well: of the 259 screen-positive patients in both study groups, only two patients (0.8%) were referred to a mental health professional, and in only five patients (2%) was suicidality addressed within the cardiac consultation. However, there were no significant differences between the study groups. ¹

If cardiologists do not refer depressed patients to mental healthcare, then we need interventions that address patients as active partners. In fact, the DEPSCREEN-INFO study results highlight that patient-targeted feedback in addition to depression screening has the potential to engage the patient as an active information seeker and to improve depression severity. However, additional studies are needed to assess the generalisability of our study results to other settings, and to more directly investigate the underlying mechanisms of patient-targeted feedback. To boost the small but significant effect on depression severity, we need to know what single feedback mechanisms are essential to address patients' needs. As empirical data are scarce and feedback interventions are often designed atheoretically, studies are needed to understand the mode of action by which feedback triggers patients to seek help for depression. Recently, a study has shown that treatment for depression after an acute myocardial infarction may decrease the risk of dying 1 year after myocardial infarction. ⁵ We believe that it is worthwhile to further investigate the potential of targeted patient-feedback after depression screening as an easily implementable complement to more intensive interventions in depressed cardiac patients.