Aims
The Coronary Psychosocial Evaluation Studies (COPES) Randomized Controlled Trial was conducted to determine the acceptability and efficacy of interdisciplinary stepped care for depression in patients with ACS.
Methods and Results
This RCT divided patients into two groups of usual care (n=77; observation and evaluation) and stepped care (n=80; patients chose either psychotherapy or pharmacotherapy, then a stepped care approach was adopted). To be included in the study, patients had to be persistently depressed for three months, as there is a potentially high remission rate post-ACS. Patient satisfaction with care was the primary outcome, while secondary outcomes were major adverse coronary events, and changes in depressive symptoms. Results favoured treatment: 54% v 19% were satisfied with care, depression scores were significantly lower, and there were fewer major cardiac events (4% v 13%).
Conclusion
Stepped care for depression in patients with ACS was associated with better treatment satisfaction, a greater reduction in depressive symptoms, and potentially an improvement in cardiovascular prognosis.
Comment:
Previous research has demonstrated that although depression was prevalent post-ACS, standard treatments such as cognitive-behavioural therapy and anti-depressants showed little or no reduction in depressive symptoms in this population. COPES has shown that stepped care for depression can now effectively treat such symptoms, and leads to much higher patient satisfaction and subsequent symptom improvement.
However, half of depressed patients were still not satisfied with treatment, a somewhat lower prevalence of satisfaction than other settings. Furthermore, given the well-established association between depression and cardiovascular prognosis, COPES results tentatively suggest that it may be possible to improve cardiovascular prognosis using stepped care for depression – with the caveats that this is a small sample size with limited power.
A randomized trial would be needed to ascertain this. However, depression still needs to be treated whether or not cardiovascular outcomes can be improved, to enhance quality of life.