The Bypassing the Blues trial: Collaborative care for post-CABG depression and implications for future research

Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the United States.¹ However, up to one-half of post-CABG patients report significant increases in mood symptoms following surgery,² and these individuals are more likely to report poorer health-related quality of life (HRQoL) and worse functional status,³ and to experience higher risk of rehospitalizations⁴ and death⁵ despite a satisfactory surgical result.

Strategies to detect and then manage depression in CABG patients and in cardiac populations are of great interest given the potential for depression treatment to reduce cardiovascular morbidity.

In recognition of the prevalence and excess burdens associated with this condition, a recent American Heart Association (AHA) Science Advisory has advocated regular screening and treatment of cardiac patients for depression.⁶ Yet, the Advisory has been controversial,^7,8 as most depression treatment trials conducted in patients with cardiac disease have had less-than- anticipated impact on mood symptoms,^7,9–14 cardiovascular morbidity,^7,9,10,14 or mortality.^{7,9–11,13–15} Possible explanations include: (1) dependence solely on single antidepressant agents^9,14 that, in general, are often ineffective,¹⁶ untolerated, or otherwise discontinued by patients¹⁷; (2) reliance on psychologic counseling in elderly, medically ill populations who may be either unwilling or unable to adhere to successive face-to-face encounters with a therapist^10,13; (3) inadequate consideration of patients’ preferences for type and location of treatment^18,19; (4) insufficient treatment adherence^20,21; (5) perceived stigma of depression²²; (6) brief duration of treatment and followup^9,13,14; and (7) higher-than-expected spontaneous remission rates for depression.^10,14

Reprinted, with permission, from Effective Clinical Practice (Wagner EH. Eff Clin Pract 1998; 1:2-4). Copyright 1998 American College of Physicians. All rights reserved.

Over the past 15 years, numerous trials have supported use of the flexible real-world collaborative care approach to improve outcomes for depression^27,28 as well as a variety of other chronic medical conditions^29–32 and at a lower total cost of care.^33,34 This strategy is supported even outside the framework of a trial.^35,36 Moreover, collaborative care was the clinical framework³⁷ for a Robert Wood Johnson Foundation program to realign clinical and financial incentives for providing sustainable high-quality depression treatment in primary care.^38–41 It is also embraced by depression improvement initiatives supported by the MacArthur (https://www.depression-primarycare.org/)⁴² and Hartford (https://impact-uw.org/)⁴³ Foundations. In recognition, a National Heart Lung and Blood Institute–sponsored working group on the assessment and treatment of depression in patients with cardiovascular disease endorsed testing of collaborative care strategies for treating depression in combination with “usual cardiologic care” as a method to improve clinical outcomes.²³ Collaborative care has also emerged as an integral part of the “patient-centered medical home” model presently advocated by leading professional organizations to organize and reimburse PCPs for providing high-quality chronic illness care.⁴⁴

Despite this interest in collaborative care, to date, only the “Bypassing the Blues” (BtB) trial has reported the impact of this depression treatment strategy on the clinical outcomes of a population with cardiac disease.⁴⁵ In an effort to help disseminate collaborative care more broadly into routine practice as envisioned by the AHA Science Advisory, we pre sent the key design elements and main outcome findings from BtB, along with our efforts to improve upon and expand the model for testing in other cardiac conditions.

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