Real-world lessons from the implementation of a depression screening protocol in acute myocardial infarction patients: implications for the American Heart Association depression screening advisory

Abstract

Background: The American Heart Association (AHA) statement has recommended routine screening for depression in coronary artery disease with a 2-stage implementation of the Patient Health Questionnaire (PHQ). Because there is little evidence on feasibility, accuracy, and impact of such a program on depression recognition in coronary patients, the AHA recommendation has met substantial debate and criticism.

Methods and results: Before the AHA statement was released, the Mid America Heart and Vascular Institute (MAHVI) had implemented a depression screening protocol for patients with acute myocardial infarction that was virtually identical to the AHA recommendations. To (1) evaluate this MAHVI quality improvement initiative, (2) compare MAHVI depression recognition rates with those of other hospitals, and (3) examine health care providers' implementation feedback, we compared the results of the MAHVI screening program with data from a parallel prospective acute myocardial infarction registry and interviewed MAHVI providers. Depressive symptoms (PHQ-2, PHQ-9) were assessed among 503 MAHVI acute myocardial infarction patients and compared with concurrent depression assessments among 3533 patients at 23 US centers without a screening protocol. A qualitative summary of providers' suggestions for improvement was also generated. A total of 135 (26.8%) eligible MAHVI patients did not get screened. Among screened patients, 90.9% depressed (PHQ-9 ≥10) patients were recognized. The agreement between the screening and registry data using the full PHQ-9 was 61.5% for positive cases (PHQ-9 ≥10) but only 35.6% for the PHQ-2 alone. Although MAHVI had a slightly higher overall depression recognition rate (38.3%) than other centers not using a depression screening protocol (31.5%), the difference was not statistically significant (P=0.31). Staff feedback suggested that a single-stage screening protocol with continuous feedback could improve compliance.

Conclusions: In this early effort to implement a depression screening protocol, a large proportion of patients did not get screened, and only a modest impact on depression recognition rates was realized. Simplifying the protocol by using the PHQ-9 alone and providing more support and feedback may improve the rates of depression detection and treatment.

Figure 1. The Main Objectives and Data Sources of the Study

Abbreviations: MAHVI, Mid America Heart and Vascular Institute, PHQ, patient health questionnaire; TRIUMPH, Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients’ Health Status registry.

Figure 2. Overview of Screening Process and Registry Data

Abbreviations: AMI, acute myocardial infarction; TRIUMPH registry, Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients’ Health Status registry; PHQ, patient health questionnaire.

Figure 3. Variation of Proportion of Patients Being Recognized as Depressed in Hospital Chart Across Sites Within the overall TRIUMPH Registry

Site 1 denotes MAHVI, the site where the formal screening protocol was implemented. The dashed line indicates the averaged depression recognition rate.