Collaborative Care for Depression Can Reduce Risk for Heart Attacks, Strokes

There is powerful evidence that evidence-based collaborative care programs can both improve patients’ depression and anxiety outcomes and at the same time lower overall health care costs. Now, new data suggest that these programs can cut the risk of fatal and nonfatal heart attacks and strokes in older individuals without preexisting heart disease.

The study was headed by Jesse Stewart, Ph.D., of Indiana University-Purdue University Indianapolis. The results were published in the January Psychosomatic Medicine.

Although there is extensive evidence that depression is a risk factor for cardiovascular disease, the few clinical trials that have evaluated whether depression treatment can reduce the rate of heart attacks and strokes have failed to find a significant benefit. The reason why, Stewart and colleagues reasoned, may have been because depression treatment was given too late; all of the trials involved patients with preexisting cardiovascular disease.

Thus Stewart and his group decided to investigate whether depression treatment given before the development of cardiovascular disease might be able to prevent heart attacks or strokes.

Beginning in the late 1990s, Jürgen Unützer, M.D., M.P.H., a professor and vice chair of psychiatry at the University of Washington, and his colleagues conducted a collaborative care trial called the IMPACT trial. In this trial, which Unützer and his coworkers reported in the December 11, 2002, JAMA, they found that collaborative care for depression in individuals aged 60 or older was superior to usual primary care for it.

Stewart and colleagues then followed 235 subjects who had participated in the IMPACT trial for eight years to see whether collaborative care for depression could reduce the subsequent risk of heart attacks and strokes.

First Stewart and his team focused on the 67 subjects who had already had cardiovascular disease at the start of their study. They found that the risk of a subsequent heart attack or stroke was almost as great in those who had received collaborative care for depression as in those who had received usual care for depression—86 percent versus 81 percent.

Then they focused on the 168 individuals who had had no cardiovascular disease at the start of the study. They found that subjects who had received collaborative care depression treatment experienced a significantly lower risk of a heart attack or stroke than did those who had received usual care for depression—28 percent versus 47 percent.

Thus the hypothesis of Stewart and his team appeared to be confirmed: if effective depression treatment is given before the development of cardiovascular disease, it might be able to prevent heart attacks or strokes. But if it is given after the development of cardiovascular disease, then it probably won’t have such an impact.

“We have known for a long time that depression is associated with an increased risk of heart disease,” Unützer said in an interview. “This eight-year follow-up of participants in the IMPACT study suggests that effective collaborative care for depression cut in half the risk of fatal and nonfatal cardiovascular events in those without preexisting heart disease. It further strengthens the argument for evidence-based collaborative care programs like IMPACT that have been shown to improve patient and provider satisfaction and mental and physical health outcomes.”

“Other long-term follow-up of IMPACT participants demonstrates that such improved health outcomes can be achieved while at the same time lowering overall health care costs,” Unützer continued. “Reduced cardiovascular events may be an important part of such long-term savings, and collaborative care programs such as IMPACT can help us achieve the goals of health care reform: better health outcomes at lower costs.”

The study was funded by the National Institute on Aging. ■

An abstract of “Effect of Collaborative Care for Depression on Risk of Cardiovascular Events: Data From the IMPACT Randomized Controlled Trial” is posted at http://www.psychosomaticmedicine.org/content/76/1/29.