Jason A. Nieuwsma, PhD; John W. Williams Jr., MD, MHSc; Natasha Namdari, MD; Jeffrey B. Washam, PharmD; Giselle Raitz, MD; James A. Blumenthal, PhD; Wei Jiang, MD; Roshini Yapa, MBBS; Amanda J. McBroom, PhD; Kathryn Lallinger, MSLS; Robyn Schmidt, BA; Andrzej S. Kosinski, PhD; Gillian D. Sanders, PhD
Disclaimer: The authors of this manuscript are responsible for its content. Statements in the manuscript should not be construed as endorsement by the AHRQ or U.S. Department of Health and Human Services. The AHRQ retains a license to display, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the agency's contract with the author.
Acknowledgment: The authors thank Wei Duan-Porter, MD, PhD, W. Schuyler Jones, MD, and Megan Chobot, MSLS, for participating in topic refinement; Megan von Isenburg, MSLS, for help with the literature search and retrieval; and Rebecca N. Gray, DPhil, and Liz Wing, MA, for editorial assistance.
Grant Support: This project was funded under contract HHSA290201500004I from AHRQ, U.S. Department of Health and Human Services.
Disclosures: All authors received grant support from AHRQ during the conduct of the study. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1811.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016047032. Statistical code: Available from Dr. Nieuwsma (e-mail, email@example.com). Data set: See Appendix Tables 1, 2, 3, 4, 5, 6, 7, and 8 and AHRQ report (www.effectivehealthcare.ahrq.gov).
Requests for Single Reprints: Jason A. Nieuwsma, PhD, Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 3022 Croasdaile Drive, Suite 301, Durham, NC 27705; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Nieuwsma: Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 3022 Croasdaile Drive, Suite 301, Durham, NC 27705.
Dr. Williams: Durham VA Evidence Synthesis Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701.
Dr. Namdari: Southern California Permanente Medical Group, Department of Psychiatry, 4220 North Roxboro Road, Durham, NC 27704.
Dr. Washam: Duke Heart Center, Box 3943 Medical Center, Durham, NC 27710.
Dr. Raitz: Duke University School of Medicine, Department of Medicine, 2400 Pratt Street, Duke Box 3850, Durham, NC 27710.
Dr. Blumenthal: Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, Box 3119 Medical Center, Durham, NC 27710.
Dr. Jiang: Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, Box 3366 Medical Center, Durham, NC 27710.
Dr. Yapa: University of Colorado, Department of Medicine, 12700 East 19th Avenue, Aurora, CO 80045.
Drs. McBroom and Sanders, Ms. Lallinger, and Ms. Schmidt: Duke University School of Medicine, Duke Clinical Research Institute, 2400 Pratt Street, Room 0311, Durham, NC 27705.
Dr. Kosinski: Duke University School of Medicine, Department of Biostatistics and Bioinformatics, PO Box 17969, Durham, NC 27715.
Author Contributions: Conception and design: J.A. Nieuwsma, J.W. Williams, J.B. Washam, W. Jiang, R. Yapa, A.J. McBroom, G.D. Sanders.
Analysis and interpretation of the data: J.A. Nieuwsma, J.W. Williams, N. Namdari, J.B. Washam, G. Raitz, J.A. Blumenthal, W. Jiang, R. Yapa, A.J. McBroom, A.S. Kosinski, G.D. Sanders.
Drafting of the article: J.A. Nieuwsma, N. Namdari, W. Jiang, R. Yapa, A.J. McBroom, K. Lallinger, G.D. Sanders.
Critical revision for important intellectual content: J.A. Nieuwsma, J.W. Williams, N. Namdari, J.B. Washam, J.A. Blumenthal, W. Jiang, R. Yapa, A.J. McBroom, G.D. Sanders.
Final approval of the article: J.A. Nieuwsma, J.W. Williams, N. Namdari, J.B. Washam, G. Raitz, J.A. Blumenthal, W. Jiang, R. Yapa, A.J. McBroom, K. Lallinger, R. Schmidt, A.S. Kosinski, G.D. Sanders.
Provision of study materials or patients: W. Jiang, K. Lallinger.
Statistical expertise: A.S. Kosinski, G.D. Sanders.
Obtaining of funding: J.A. Nieuwsma, J.W. Williams, A.J. McBroom, G.D. Sanders.
Administrative, technical, or logistic support: W. Jiang, R. Yapa, A.J. McBroom, K. Lallinger, R. Schmidt.
Collection and assembly of data: J.A. Nieuwsma, J.W. Williams, N. Namdari, J.B. Washam, G. Raitz, W. Jiang, R. Yapa, A.J. McBroom, K. Lallinger, G.D. Sanders.
Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression.
To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event.
MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles.
English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments.
2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence.
Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health–related function, and overall life satisfaction more than usual care.
Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest.
Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes.
Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).
Appendix Table 1. Search Strategy for Depression Screening and Treatment in Post-ACS Patients*
Appendix Table 1. Continued
Appendix Table 2. Inclusion and Exclusion Criteria
Appendix Table 2. Continued
Flow of articles through the literature search and screening process.
ACS = acute coronary syndrome; CDSR = Cochrane Database of Systematic Reviews; KQ = key question.
Table 1. Summary of Included Studies
Appendix Table 3. Characteristics of Included Studies on Diagnostic Accuracy of Screening
Appendix Table 4. Characteristics of Included Studies on Depression Treatment
Appendix Table 5. Characteristics of Validated Depression Screening Tools*
Table 2. Accuracy of Tools for Diagnosis of MDD
Meta-analysis of diagnostic accuracy of BDI-II (cutoff ≥14 points) for major depressive disorder.
BDI-II = Beck Depression Inventory II; FN = false-negative; FP = false-positive; TN = true-negative; TP = true-positive.
Appendix Table 6. QUADAS-2 Risk of Bias Assessment for Diagnostic Accuracy Studies
Appendix Table 7. SOE for the BDI-II
Table 3. SOE for Depression Treatments Among Post-ACS Patients
Appendix Table 8. Cochrane Risk of Bias for Treatment Studies
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Nieuwsma JA, Williams Jr. JW, Namdari N, Washam JB, Raitz G, Blumenthal JA, et al. Diagnostic Accuracy of Screening Tests and Treatment for Post–Acute Coronary Syndrome Depression: A Systematic Review. Ann Intern Med. 2017;167:725–735. doi: 10.7326/M17-1811
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Published: Ann Intern Med. 2017;167(10):725-735.
Published at www.annals.org on 14 November 2017
Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Emergency Medicine, Hospital Medicine.
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