Treating Depression After ACS: Seeking an Optimal Treatment Duration

Jeannette Y. Wick, RPh, MBA, FASCP
Published Online: Wednesday, June 4, 2014
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Patients who were treated for persistent depression after an acute coronary syndrome experienced improved outcomes during treatment, but worsened outcomes after treatment ended.

Patients who develop acute coronary syndrome (ACS) are at risk for depression, and depression seriously complicates their clinical outlook. The strength of the evidence is so strong that the American Heart Association recently categorized depression as a risk factor for poor prognosis after ACS. Now, researchers from several leading medical facilities around the world have published a study—the randomized, controlled Coronary Psychosocial Evaluation Studies (COPES) trial—showing a curious reversal in outcomes when ACS patients who were treated for depression discontinue that treatment. Their results were published online on May 14, 2014, in the American Journal of Medicine.
 
The researchers enrolled 157 patients who had experienced persistent depression after hospitalization for ACS. Eighty participants received enhanced depression treatment for 6 months, while the other 77 received usual care. Enhanced depression treatment included stepped, patient-preference-driven care with problem-solving therapy, pharmacotherapy, or both. The researchers observed the patients for an additional 12 months and tracked the composite outcome of death or first hospitalization for myocardial infarction (MI) or unstable angina (UA).
 
In an earlier study, the researchers demonstrated that enhanced depression treatment was beneficial in terms of cardiovascular effects in the first months after ACS was diagnosed. In this earlier study, 4% of patients treated for depression experienced death or hospitalization for MI or UA compared with 14% in the usual care group. The new extension study looked at a longer period.
 
In this 18-month study, the researchers found that the reduced risk of death or hospitalization for MI/UA during the 6-month treatment period did not endure if treatment for depression ended. Actually, the opposite occurred—the researchers documented a “catch-up” in cardiovascular events after the intervention ended. Among the patients treated for depression whose treatment had been discontinued, 14% experienced the composite outcome, compared with 4% in the usual care group.
 
The researchers believe that this is the first study to show a treatment reversal effect when ACS patients’ treatment for depression ends. The study’s finding needs to be tested in larger studies, but if confirmed, the implication is clear: We need to determine the optimal duration of treatment for patients with depression after ACS. Ending treatment prematurely appears to result in adverse outcomes.
 
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.
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