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Telephone Treatment of Depression Effective After CABG

By Karen Appold

Telephone-based collaborative care intervention following coronary artery bypass surgery improves patients’ quality of life and saves health care dollars.

Screening for depression and then providing a telephone-delivered, nurse-led collaborative care intervention following coronary artery bypass graft (CABG) surgery not only improves health-related quality of life, physical functioning, and mood symptoms, but also lowers medical costs and is highly cost-effective compared with physicians’ standard care,1 according to researchers at the University of Pittsburgh School of Medicine in a paper published in the September-October 2014 issue of General Hospital Psychiatry.

Bruce L. Rollman, MD, MPH, a professor of medicine, psychiatry, biomedical informatics, and clinical and translational science at the University of Pittsburgh School of Medicine, and the principal investigator of the Bypassing the Blues Trial, a National Institutes of Health (NIH)-funded effort, was prompted to study the effects of depression on recovering CABG patients after reading that women who had CABG surgery didn’t do as well as men. “I wondered if it was due to women’s higher risk of depression,” he says. “No one had ever examined this correlation before.”

CABG surgery is a common and costly medical procedure. However, up to one-half of post-CABG patients report elevated levels of depression symptoms after surgery. Studies indicate that these individuals are more likely to experience a poorer health-related quality of life, continued chest pains, and a higher risk of rehospitalization and death.

According to Rollman’s 2009 paper published in the Journal of the American Medical Association, the collaborative care treatment model can significantly speed recovery following CABG surgery.2 “Our analyses of Medicare and other insurance claims data establish the ‘business case’ to policy makers and insurers for widespread adoption,” he says.

However, “One of the holy grails in mental health services research is to demonstrate that treating a common mental health condition such as depression is not only effective and cost-effective, but also cost-saving. This is the first trial to demonstrate all three outcomes,” Rollman says.

Researchers examined Medicare and private medical insurance claims data for 189 participants. After incorporating the $460 average cost to deliver the intervention that included nurse and supervising physician time, patients randomly assigned to the intervention had $2,068 lower median claims costs at one year after bypass surgery compared with those who received their physicians’ usual care ($16,126 vs $18,194). The intervention was also highly cost-effective, producing more quality-adjusted life-years, a measure analysts use to determine the value of different medical actions, while significantly lowering medical claims costs by $9,889 per additional quality-adjusted life-year generated, a first for a collaborative care strategy for treating depression in any patient population.1

“Few procedures done in health care today both increase qualities and reduce costs,” says  Rollman, who notes that the flu vaccine and prenatal care are two such examples. Now treating depression in CABG patients can be added to that list.

An estimated 400,000 CABG surgeries are performed annually in the United States, and studies indicate approximately one in five patients who undergo the procedure experiences clinical depression. Extending this $2,068 savings to all depressed post-CABG patients has the potential to save more than $165 million in medical claims in the first year following surgery, Rollman wrote in his team’s latest report.

Study Method
The collaborative care intervention involved screening patients in the hospital with a clinically efficient two-step method to identify patients with elevated levels of depressive symptoms following CABG surgery. “If patients expressed any depressive symptom on the PHQ-2 in the hospital and continued to report a moderate level of depression as measured by the PHQ-9 two weeks later, then patients were randomized for either our nurse-delivered intervention or their doctor’s usual care for depression,” says Bea Herbeck Belnap, Dr Biol Hum, a senior researcher of mental health interventions at the University of Pittsburgh and one of Rollman’s collaborators. The nurses were trained in guidelines-based care that was supervised by a clinical team that included a psychiatrist, internist, and psychologist.

During the first phone call, “nurses asked about the patient’s mental health history and educated him or her about the interaction between depression and cardiac disease,” Herbeck Belnap says. “They then discussed the symptoms of depression and informed them about their treatment choices.”

During the subsequent calls, nurses supported the patients depending on their treatment choices. If the patient opted for self-management, he or she was mailed a copy of The Depression Helpbook by Wayne Katon, MD; Evette Ludman, PhD; and Gregory Simon, MD, MPH. Nurses discussed the chapters and exercises with the patient. Under the supervision of the clinical team, they discussed pharmacotherapy options with patients, and if a patient indicated interest, conveyed the recommendation to the patent’s physician who would then prescribe the medication. Furthermore, the nurses made suggestions for lifestyle changes, such as getting adequate sleep, going outside for a walk, and stopping tobacco use. “If we couldn’t get patients well, then nurses referred them to community mental health specialists,” Rollman says.

On average, over an eight-month period patients received 10 calls. “When patients did well, we would reduce the frequency of calls,” Rollman says. Some patients received 28 calls while others may have received only one.2

“Patients who engaged in the program found it helpful,” Herbeck Belnap says. “They had someone to talk to who would educate them, make treatment recommendations, and keep an eye on their symptoms.”

Thoughts on the Findings
So why did the interventions work? “Treating depression may reduce patient perception of symptoms, which, in turn, results in potentially inappropriate or excess medical testing,” Rollman explains. “For instance, a patient might interpret mood symptoms as chest pain and go to the hospital to get a stress test and an electrocardiogram.” If this is avoided, cost savings can be realized.

Rollman believes the telephone program met with great success because patients didn’t need to drive to the hospital or to the primary care physician’s office for follow-up. “We met them where they were—over the phone,” he says. “If we couldn’t get people better, we would encourage them to see a mental health specialist and tried to facilitate those referrals.”

Regarding the study’s findings, Rollman says, “I am pleased that the findings turned out as well as they did. Our program has the potential to improve quality of life, keep patients from returning to the hospital, and save money.”

Moving Forward
A 2008 American Heart Association science advisory recommended routine screening and treatment of depression in patients with cardiac disease. Rollman believes that there now is enough evidence to support adoption of the Bypassing the Blues program and similar collaborative care programs.

“Larger integrated care delivery systems and insurance plans are more likely to adopt programs like ours that have the volume of patients with bypass surgery and they can reap the savings and lower claims costs,” he says. “If a private practice physician would implement the program, he or she would save the insurance company money but wouldn’t reap the direct benefit.” Rollman says he would like to identify new resources that will allow his study team to contact study patients again to determine whether treating depression after bypass surgery also reduces mortality.

Although team-based collaborative care for depression has yet to be widely adopted, it is increasingly being provided by integrated health care systems through patient-centered medical homes supported by payment reforms under the Affordable Care Act. Electronic health records could facilitate the care manager communicating with the primary care physician, cardiologist, and patients.

“Our study materials are free and publicly available to anyone interested in implementing our program at www.bypassingtheblues.pitt.edu,” Rollman says. “It’s not difficult to implement a centralized telephone-delivered program like ours.”

Rollman says there are plans to test the program in heart failure patients to determine whether there may be an easier way to implement it using existing staff. Nurses will be trained to treat depression as well as heart failure, which will be compared with treating heart failure alone. The Hopeful Heart Trial will be NIH-funded as well.

— Karen Appold is a medical writer in Pennsylvania.


  1. Donohue JM, Belnap BH, Men A, et al. Twelve-month cost-effectiveness of telephone-delivered collaborative care for treating depression following CABG surgery: a randomized controlled trial. Gen Hosp Psychiatry. 2014;36(5):453-459.
  1. Rollman BL, Belnap BH, LeMenager MS, et al. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. JAMA. 2009:302(19):2095-2103.