Professor David Harea, Andrea Driscollb, Andrew Stewartc
a Psychology Department, The University of Melbourne
b Monash University
c Austin Health
beyondblue Victorian Centre of Excellence
Project completion year
Cardiovascular disease is the leading cause of death in Australia and imposes a substantial health and economic burden, which exceeds that for other diseases.
This study aimed to address management of depression by cardiologists in patients with cardiovascular disease, in two parts. The first part aimed to examine predictors of screening, detection and management/treatment of depression in patients with a cardiac condition, by patients’ cardiologists and their usual general practitioners. The second part aimed to identify how cardiologists view depression as a cardiac risk factor.
In study 1, participants were recruited from a general cardiology outpatient clinic, a specialist heart failure clinic and a cardiac rehabilitation program. Participants were assessed for depression (via semi-structured interviews and self-rating questionnaires) and for psychosocial variables and markers of cardiac disease severity. A depression audit survey was developed for GPs. The relationship between the GP diagnosis of depression and actual rate of depression was explored and linked to other psychosocial variables and markers of cardiac disease severity to identify which patients were more likely to have their depression missed or inadequately treated.
Study 2 assessed the views of cardiologists on the diagnosis, screening and management of depression (questionnaire and subgroup focused phone interview). It looked at:
- the rate and methods of depression screening
- whether and how cardiologists managed depression
- views on who should manage depression
- how to best involve cardiologists in detecting and managing depression
- preferences for communication with the other health professionals regarding depressed patients
- whether cardiologists view depression as a risk factor for cardiac disease.
Of the 321 participants in the study, 33 per cent were assessed as having depression including:
- major depression (15 per cent)
- minor depression (10 per cent)
- brief recurrent depression (3.4 per cent)
- dysthymia (4.3 per cent).
In addition, 24.3 per cent reported an episode of major depression in the past year and 42.3 per cent reported experiencing an episode of major depression at some point in their lifetime.
Participants reported that their GP (33.5 per cent) and/or their cardiologist (14.8 per cent) had enquired about their mood. Fifteen per cent reported a GP diagnosis of depression and 4 per cent a cardiologist diagnosis of depression. Regarding treatment, 9.3 per cent of participants reported taking antidepressant medication, 3.3 per cent visited a psychologist at least once and 1 per cent received consultation from a psychiatrist at least once.
Of patients with depression, 47.2 per cent reported telling their GP or another health professional they were experiencing depression. Of these patients, 38.2 per cent reported that their GP had enquired about their mood (versus 23 per cent for cardiologists); and 30.4 per cent reported a GP diagnosis of depression (12 per cent for cardiologists). Of patients with depression, 19.4 per cent were taking antidepressant medication, 7.5 per cent visited a psychologist at least once and 1 per cent visited a psychiatrist at least once. The rate of depression diagnosis by cardiologists was facilitated by the mandatory screening requirement for depression at the specialist heart failure clinic in this study.
GPs were more likely to diagnose depression if patients had:
- increasing severity of depression
- Type 2 diabetes
- lower levels of social support
- absence of hypercholesterolaemia.
Cardiologists were more likely to diagnose depression if patients had:
- chronic heart failure
- Type 2 diabetes
- recent percutaneous coronary intervention.
Patients were more likely to be prescribed antidepressant medication by their GP if they had chronic heart failure or Type 2 diabetes. Patients were more likely to see a psychologist if they had recent acute coronary syndrome or coronary artery bypass graft surgery; this increased referral process could also be related to protocols within the cardiac rehabilitation program within this study.
Five hundred and twenty-six questionnaires (64 per cent response rate) were analysed. Most cardiologists described feeling moderately confident at identifying depression but not treating depression. Most reported screening for depression occasionally and some regularly; only 3 per cent used a formal screening tool. A lack of confidence in identifying depression was the strongest predictor of low screening frequency by cardiologists. Questionnaire responses indicated cardiologists rarely initiated treatment. Of those that did initiate treatment, 42 per cent recommended the use of selective serotonin reuptake inhibitors.
Cardiologists identified GPs as the most preferred profession for identifying and treating depression. However, most were agreeable to using a brief screening questionnaire. Among cardiologists, 43 per cent did not rank cardiologists as being responsible for treating depression; when respondents nominated cardiologists as having some level of responsibility, they ranked themselves third.
Implications for policy, practice and further research
Depression screening is more likely when a patient has chronic heart failure or a recent cardiac event (which may be due to screening protocols at heart failure clinics or rehabilitation programs) or visible levels of anxiety. Patients are more likely to be diagnosed following a recent acute cardiac event or co-morbidly with a chronic condition (heart failure or Type 2 diabetes).
Routine screening should be mandatory for cardiac patients. Consideration of depression should not be limited to those with obvious stressful events or ongoing stressors.
Given that only 3 per cent of cardiologists use tools to screen for depression and their perceived lack of confidence in diagnosing depression, screening should be introduced into routine practice and management guidelines for specific cardiac conditions. Continuing medical education activities to improve confidence in screening for and treating depression could be helpful for cardiologists with an interest in this. Efficient screening and referral mechanisms may be useful for cardiologists who do not think it their role to be involved in managing depression. Above all, collaboration and ongoing communication between cardiologists and other healthcare providers, in particular GPs, is important to ensuring ongoing patient treatment and depression management.