University of Groningen Does Evidence Support the American Heart Association's Recommendation to Screen Patients for Depression in Cardiovascular Care? An Updated Systematic Review Thombs,

Objectives: To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes. Background: A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD. Methods: CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT. Results: There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes. Conclusions: There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence. Citation: Thombs BD, Roseman M, Coyne JC, de Jonge P, Delisle VC, et al. (2013) Does Evidence Support the American Heart Association’s Recommendation to Screen Patients for Depression in Cardiovascular Care? An Updated Systematic Review. PLoS ONE 8(1): e52654. doi:10.1371/journal.pone. 0052654 Editor: Jerson Laks, Federal University of Rio de Janeiro, Brazil Received September 12, 2013; Accepted November 20, 2012; Published January 7, 2013 Copyright: 2013 Thombs et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This research was supported by a grant from the Canadian Institutes for Health Research (KRS 111754). Dr. Thombs is supported by a New Investigator Award from the Canadian Institutes of Health Research and an Établissement de Jeunes Chercheurs award from the Fonds de la Recherche en Santé Québec. Ms. Roseman is supported by a Master’s Training Award from the Fonds de la recherche en santé Québec, a McGill University Provost’s Graduate Fellowship and a McGill University Principal’s Graduate Fellowship. Ms. Delisle is supported by a Master’s Training Award from the Fonds de la recherche en santé Québec, and McGill University Graduate Studies Fellowship. Dr. Ziegelstein is supported by the Miller Family Scholar Program of the Johns Hopkins Center for Innovative Medicine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have read the journal’s policy and have the following conflicts: Drs. Thombs and Ziegelstein were authors of a study on the diagnostic accuracy of depression screening tools that was included in this systematic review. Dr. de Jonge was an author of two studies on the treatment of depression. No other authors have any conflicts of interest to declare. No authors have any relationship to industry. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials. * E-mail: brett.thombs@mcgill.ca Introduction Major depressive disorder (MDD) is present in approximately 20% of coronary heart disease (CHD) patients [1] and is associated with poorer cardiac prognosis [2]. A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening of all CHD patients [3]. Screening is reasonably considered for important and prevalent conditions that can be effectively treated, but are not readily detected without PLOS ONE | www.plosone. org 1 January 2013 | Volume 8 | Issue 1 | e52654 screening. For screening to be recommended, benefits in excess of potential harms should be demonstrated in well-conducted randomized controlled trials (RCTs) [4]. The AHA recommendation, however, was not based on a systematic review of evidence of likely benefits and harms of the recommended screening intervention, and a systematic review published one month after the Science Advisory reported that no trials had tested whether depression screening in CHD improved patient outcomes [5]. The AHA invests considerable resources in ensuring that practice guidelines are revised rapidly to reflect new evidence [6]. Providing current evidence-based guidelines also requires that recommendations not based on sufficient evidence are revised, and the AHA has done this on a number of occasions [7]. The objective of the present systematic review was to determine whether evidence has been accrued in the last 4 years that would support the AHA Science Advisory on depression screening or whether the Science Advisory should be revised. Review questions included: Key Question #1: What is the accuracy of depression screening instruments in CHD? Key Question #2: Does treatment of depression in CHD improve depressive symptoms or cardiac outcomes? Key Question #3: Does depression screening in CHD improve depression outcomes? Methods This systematic review updates a previous review from November 2008 [5]. Detailed methods were registered in the PROSPERO prospective register of systematic reviews (CRD42011001670). Search strategy To update the previous review [5], we searched the CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases from January 1, 2008 through December 2, 2011 (File S1). One search sought studies of screening accuracy (Key Question #1), and a second sought RCTs of depression treatment (Key Question #2) and screening (Key Question #3). Additional searching included reference lists and forward citation of included articles, relevant systematic reviews (File S2), selected journals (December 2011–April 2012; File S3), and trial registries. Identification of eligible studies Eligible articles were original studies in any language with data on adult patients in cardiovascular care settings based on diagnosis or procedure, including mixed populations if CHD data were reported separately. Eligible diagnostic accuracy studies (Key Question #1) reported data allowing determination of sensitivity, specificity, positive predictive value, and negative predictive value compared to a Diagnostic and Statistical Manual of Mental Disorders diagnosis of MDD or an International Classification of Diseases depressive episode, established with a validated diagnostic interview administered within 2 weeks of the screening tool. Eligible articles for Key Question #2 were RCTs comparing depression treatment with placebo or usual care among CHD patients with MDD or an International Classification of Diseases depressive episode based on a validated diagnostic interview. For trials of patients with MDD and other conditions (e.g., minor depression), we sought original study data for patients with MDD for trials with 80% power to detect a 0.50 standardized mean difference effect size (n = 64 per group). Eligible articles for Key Question #3 were RCTs that compared depression outcomes between CHD patients who underwent depression screening and those who did not. Two investigators independently reviewed titles/abstracts for eligibility with full-text review of articles identified as potentially eligible by one or both. Disagreements after full-text review were resolved by consensus. Chance-corrected agreement was assessed with Cohen’s k. Evaluation of eligible studies Two investigators independently extracted study data (File S4) and assessed risk of bias with discrepancies resolved by consensus. Risk of bias was assessed with the revised Quality Assessment for Diagnostic Accuracy Studies tool for Key Question #1 (File S5) and the Cochrane Risk of Bias tool for Key Question #2 (File S6). Data presentation and synthesis For Key Question #1 (diagnostic accuracy), data were extracted based on optimal cutoffs identified by study authors. For Key Question #2 (treatment) when multiple outcomes were reported, designated primary outcomes were prioritized, followed by observer-rated scales, then self-report measures. Post-intervention effect sizes were reported using the Hedges’s g statistic (standardized difference between 2 means). The most comprehensive cardiovascular outcome available was extracted. For Key Question #1, studies were heterogeneous in terms of patient samples, screening tools and cutoffs, and whether they used standard scoring thresholds versus sample-specific thresholds based on exploratory data analysis. For Key Question #2, studies had heterogeneous patient samples, therapeutic interventions, and treatment durations. No eligible studies were identified for Key Question #3. Thus, results were not pooled quantitatively. Results Key Question #1: Diagnostic Accuracy Of 1,442 citations, 1,405 were excluded after title/abstract review and 29 after full-text review, leaving 8 eligible articles (Figure 1; k= 1) [8–15], although one [9] was included in the previous review. Two additional articles were identified through other methods [16,17]. Adding these to 9 from the previous review [9,18–25] resulted in 18 articles [8–25] on 15 unique cohorts (Table 1). Two studies [26,27] from the previous review were exclu