The Bypassing the Blues trial: Collaborative care for post-CABG depression and implications for future research
ABSTRACTDepressive symptoms are reported by up to one-half of patients following coronary artery bypass graft (CABG) surgery, and are associated with numerous adverse outcomes, including poorer health-related quality of life, worse functional status, and delayed recovery. 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. Yet, many tested interventions have had little or no effect on mood symptoms in cardiac patients. “Collaborative care” is a safe and proven-effective strategy for treating depression in concert with patients’ primary care physicians; however, it had not been tested previously in patients with cardiac disease. This article presents the design and main outcome findings from the National Institutes of Health–funded Bypassing the Blues study, the first trial to examine the impact of a collaborative care strategy for treating depression among patients with cardiac disease, and our efforts to improve upon and expand the model for testing in other cardiac conditions.
FUTURE DIRECTIONS
Despite positive outcomes on HRQoL and mood symptoms generated by BtB and other recent trials,15,56 it remains unclear whether effective depression treatment can reduce cardiovascular morbidity and mortality. Given the trend toward a reduced incidence of rehospitalization for cardiovascular causes among depressed male patients in BtB and findings from COPES56 and other trials,7 we believe a comparative effectiveness trial of reasonable size (N < 2,000 study subjects) and cost will require an intervention capable of producing an ES reduction in mood symptoms of at least 0.50. Furthermore, because of declines in morbidity and mortality over the past decade following CABG surgery and myocardial infarction,1 we also believe heart failure remains the only prevalent cardiovascular disorder for which to conduct this future comparative effectiveness trial.
Because an improvement of at least 0.50 ES in mood symptoms is higher than the ES improvements presently generated by collaborative care treatment approaches, it is critical to develop new interventions that blend the scalability and patient acceptability of telephone-delivered collaborative care with the greater efficacy of more intensive face-to-face counseling strategies. To address this need, we are investigating how best to incorporate Internet-delivered computerized cognitive behavioral therapy (CCBT) and other online strategies for treating depression into the BtB model. CCBT is a new and evolving technology that can improve patients’ access to personalized, convenient, and effective treatment for depression.59 Used primarily in the United Kingdom, Australia, and the Netherlands, CCBT has attracted growing interest by US investigators.60 Importantly, some CCBT programs are able to produce the ES improvements in mood symptoms needed to potentially demonstrate a reduction of cardiovascular morbidity61 and do so reliably, at scale, and at low cost compared with more labor-intensive methods of care.62–64 Still, pilot testing of this innovative treatment approach is necessary to evaluate: (1) whether CCBT will be as effective among depressed patients with cardiovascular disease as among those recruited from primary care settings; (2) how best to integrate CCBT within a collaborative care program linked to cardiovascular patients’ usual sources of cardiac and primary care; and (3) whether incorporating Internet-delivered CCBT into a “traditional” collaborative care program that provides active follow-up, pharmacotherapy monitoring, and mental health specialty referral as options provides either no additional benefit (ES ∼0.30), benefit approaching that of CCBT alone (ES: ∼0.60),61 or an additive or synergistic benefit approaching face-to-face CBT (ES: ≥ 0.80).15,65 Findings from these studies could also have profound implications for changing the way both cardiovascular and mental health conditions are treated66 and direct further attention to the emerging field of e-mental health by other US investigators.60
