AAFP Guideline for the Detection and Management of Post–Myocardial Infarction Depression

Post–Myocardial Infarction Depression Clinical Practice Guideline Panel

doi:10.1370/afm.918

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commentary on guidelines
Jeff C. Huffman

Published on: 06 February 2009
Re: Cardiac Rehab in Post-MI Depression
Lee A. Green

Published on: 25 January 2009
Why Family Physicians Are Important
Thomas L. Schwenk

Published on: 15 January 2009
Cardiac Rehab in Post-MI Depression
John P Erwin

Published on: 15 January 2009

Published on: (6 February 2009)
Page navigation anchor for commentary on guidelines
commentary on guidelines
Jeff C. Huffman, Boston, MA
The AAFP Panel has created an impressive document that outlines the current evidence base—and substantial limitations of the literature—regarding depression following myocardial infarction (MI). Like other panels, they recommend that patients be screened at regular intervals post-MI and, for those patients who are found to be depressed, they recommend that systems be in place to allow monitoring and adjustment of treat...
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The AAFP Panel has created an impressive document that outlines the current evidence base—and substantial limitations of the literature—regarding depression following myocardial infarction (MI). Like other panels, they recommend that patients be screened at regular intervals post-MI and, for those patients who are found to be depressed, they recommend that systems be in place to allow monitoring and adjustment of treatment.
These recommendations are quite reasonable; at the same time, they are exceedingly difficult to accomplish in the real world. Without some concrete process to systematically screen post-MI patients as part of usual clinical care, patients will not have their depression recognized or treated [1]. Even when patients do receive depression screening, more is needed. Screening for depression, when not linked to a clear and comprehensive system of depression management, is cost-ineffective and does not lead to better patient outcomes [2].
However, there are potential solutions. As noted, cardiac rehabilitation is an ideal place for patients to receive depression screening and treatment. Patients can be screened and monitored at regular intervals, and there is often access to specialists for complex cases. Further, cardiac rehab simultaneously addresses other key elements of post-MI recovery, such as education/motivation regarding diet, stress reduction, and exercise. Unfortunately, post-MI patients with depression may be less likely to attend cardiac rehab [3], and some initial improvement of depression might be required before patients can commit to rehab.
Another potential solution is the use of care management systems, in which a nurse care manager coordinates depression screening and, for positive-screen patients, performs further depression evaluation. For patients found to have depression, the care manager provides depression education, monitors symptoms, and assists in treatment coordination between patient, family physician/PCP, and (as needed) specialist. Such programs have been used in primary care settings, with substantial improvements of depressive symptoms and health-related quality of life, and also have been adapted successfully to clinical (non-research) settings [4]. These programs appear to be cost-effective, and, in some cases, are actually cost-reducing [5].
While it may not seem feasible to implement an entire ‘collaborative care’ system within a practice, it may be possible to identify a point person within a practice who coordinates depression screening, education, patient-provider communication, and symptom monitoring. Certainly, given the limited rates of recognition and treatment of post-MI depression, and its strong association with negative medical outcomes, it does seem worth trying a new process to improve the care of these patients.
References
1. Ziegelstein RC, Kim SY, Kao D, et al. Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening? Psychosom Med 2005;67:393-7.
2. Kroenke K. Depression screening is not enough. Ann Intern Med 2001;134:418-20.
3. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Predictors of attendance at cardiac rehabilitation after myocardial infarction. J Psychosom Res 2001;51:497-501.
4. Grypma L, Haverkamp R, Little S, Unutzer J. Taking an evidence-based model of depression care from research to practice: making lemonade out ofdepression. Gen Hosp Psychiatry 2006;28:101-7.
5. Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14:95-100.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 January 2009)
Page navigation anchor for Re: Cardiac Rehab in Post-MI Depression
Re: Cardiac Rehab in Post-MI Depression
Lee A. Green, Ann Arbor, MI
Dr. Irwin raises an important point. The effect of cardiac rehab programs on depression was not part of the AHRQ Evidence Report, though clearly that question should be added to the next iteration of the report. Absent direct comparison trials it is not possible to make an evidence- based claim that cardiac rehab should take precedence over SSRI therapy. However, exercise is known to be beneficial for depression, and sho...
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Dr. Irwin raises an important point. The effect of cardiac rehab programs on depression was not part of the AHRQ Evidence Report, though clearly that question should be added to the next iteration of the report. Absent direct comparison trials it is not possible to make an evidence- based claim that cardiac rehab should take precedence over SSRI therapy. However, exercise is known to be beneficial for depression, and should be part of post-MI care for both physical and psychological health.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (15 January 2009)
Page navigation anchor for Why Family Physicians Are Important
Why Family Physicians Are Important
Thomas L. Schwenk, Ann Arbor, USA
This Guideline is a rigorous and detailed review of an important aspect of quality care in post-MI patients. More importantly, however, it is an example of why family physicians are critical to a high quality health care system. This Guideline describes the integrated delivery of a complex form of biopsychosocial care in a patient with serious chronic disease, and it is not likely to be successful in a fragmented, compa...
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This Guideline is a rigorous and detailed review of an important aspect of quality care in post-MI patients. More importantly, however, it is an example of why family physicians are critical to a high quality health care system. This Guideline describes the integrated delivery of a complex form of biopsychosocial care in a patient with serious chronic disease, and it is not likely to be successful in a fragmented, compartmentalized system of care provided by cardiologists and psychiatrists. These specialists can certainly deliver the care for which they are responsible in a quality way. However, unless they are in the same room at the same time with the patient, the necessary coordination will not occur, an excessively narrow focus will exclude important data and objectives, and the whole will end up less than the sum of the parts. These recommendations are most efficiently and most effectively implemented by a single physician who can prescribe beta-blockers and SSRIs comfortably and at the same time.
Competing interests: I served as a reviewer for this Guideline before publication.
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Competing Interests: None declared.
Published on: (15 January 2009)
Page navigation anchor for Cardiac Rehab in Post-MI Depression
Cardiac Rehab in Post-MI Depression
John P Erwin, Temple, TX
Kudos to Drs. Green, et al on the publication regarding the important issue of post myocardial infarction depression. I was disappointed, however, that there was no mention of the use of a dedicated Phase II and Phase III cardiac rehabilitation. There have been multiple, well done studies indicating marked reduction in the incidence and severity of depression in post-MI patients undergoing cardiac rehabilitation. It should...
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Kudos to Drs. Green, et al on the publication regarding the important issue of post myocardial infarction depression. I was disappointed, however, that there was no mention of the use of a dedicated Phase II and Phase III cardiac rehabilitation. There have been multiple, well done studies indicating marked reduction in the incidence and severity of depression in post-MI patients undergoing cardiac rehabilitation. It should be the first step- before SSRI use based upon published evidence.
Competing interests: None declared
Show Less

Competing Interests: None declared.