Depression Screening and Care in Coronary Heart Disease Patients

The intervention consists of collaborative care, coordinated by a nurse care manager specific to each site (i.e. outpatient cardiology clinic at a tertiary hospital). Clusters who cross-over to the intervention will implement collaborative care for eligible participants, with the initial intervention dependent on each participants baseline depression severity. Level 1) initiation of antidepressant pharmacotherapy or cognitive behavioural therapy for moderate depressive symptoms, Level 2) active antidepressant pharmacotherapy and/or cognitive behavioural therapy for moderately severe depressive symptoms, Level 3) antidepressant pharmacotherapy and cognitive behavioural therapy for severe depressive symptoms. Citalopram will be recommended as first-line therapy based on high tolerance, low drug-drug interactions, and efficacy in prior collaborative care interventions in medical and cardiac patients. The dose recommendations for selective serotonin reuptake inhibitors, starting and maximum dose are: Citalopram 20–40 mg/day, Escitalopram 10–20 mg/day, Sertraline 50–100 mg/day, Paroxetine 20–40 mg/day, Fluoxetine 20–40 mg/day. For, The dose recommendations for serotonin-norepinephrine reuptake inhibitors and atypical antidepressants starting and maximum dose are: Venlafaxine 75–150 mg/day, Duloxetine 40–60 mg/day, Mirtazapine 15–30 mg/qhs. For patients requiring cognitive behavioural therapy, this is made available through the Better Access Initiative and private providers external to the research setting. Cognitive behavioural therapy typically concerns a goal-centred approach to depression over 8-12 weeks, targeting common thoughts and behaviours. Nurse care managers will liaise with each patient’s general physician and cardiologist to help coordinate antidepressant and/or cognitive behavioural therapy. A baseline assessment serves to establish the level of stepped-treatment required (Level 1-3). At an interim review 6 and 12 weeks into active treatment, the intervention will be stepped-up a level of care when a patient’s total depression score (Patient Health Questionnaire-9) does not reduce by 4 points (or alternatively does not reduce below the moderate threshold). If a patient is already receiving the highest level of stepped care, antidepressant therapy will be increased but no higher than maximum doses. The intervention per patient is 18 weeks duration. Fidelity to the intervention will be monitored by auditing Nurse Care Manager's clinical notes and an audit of eligible patients against a set of collaborative care criteria - rated by blinded auditors as either not met, partially met, fully met. Patient adherence will be monitored via a service-use questionnaire.