Poor uptake of depression care in cardiology

Depression is associated with poorer coronary heart disease (CHD) outcomes; however, routine screening for depression is controversial and difficult to implement in clinical practice, and randomised clinical trial (RCT) evidence is scarce. ¹ The DEPSCREEN-INFO parallel group efficacy RCT reported by Löwe et al ² randomised participants to written patient-targeted feedback versus no written patient feedback after depression screening. The sample comprised in-patients and out-patients with CHD, but also those with arterial hypertension. Löwe et al argued that the role of the patient within the depression screening process had not yet been studied. Previously, we reported two examples of depression screening involving patient, general practitioner and cardiologist feedback in heart failure ³ and cardiac surgery populations. ⁴ Our findings, and those of others, ^5,6 diverge from Löwe et al's in terms of mental health service use.

Lowe et al showed that 13% of participants contacted a psychotherapist, which might reflect generous health insurance benefits in Germany, including up to 2 years of psychotherapy. By comparison, in England an RCT for depression and CHD or diabetes by Coventry et al ⁵ revealed that 33% of individuals randomised to collaborative care did not attend any depression treatment session. Coventry et al ⁵ used the Improving Access to Psychological Therapy (IAPT) services in the English National Health Service (NHS). Other depression screening studies in CHD indicate that uptake of mental health services is <2% in the USA ⁶ and Australia, ⁴ with the latter study providing a rebate for mental health services similar to IAPT. Mounting evidence indicates incongruity between international efforts to improve depression care and the uptake of mental health services by the CHD patients we are targeting with depression screening. Integration of mental health services within cardiology and primary care services may be warranted. Clearly, more concerted efforts are required internationally to improve existing mental health services by adopting innovative methods such as ‘blended’ collaborative care, computerised cognitive–behavioural therapy (CBT) and telehealth. It remains crucial to better align mental health services with CHD patient needs in order to better engage CHD patients.