CABG後の簡単な共同ケアによりうつが減少する

BtB Trial：共同ケアによりバイパス術後うつ病患者のQOLおよび気分が改善する

BtB Trial: Collaborative care improves quality of life and mood of depressed patients after artery bypass graft surgery

冠動脈バイパス術後の回復期にある患者は共同ケアチームの補助により回復が早まると2009年American Heart Association学会レイトブレイキング臨床試験のセッションで発表され、同時にJAMAに掲載された。Bypassing the Blues(BtB)Trialにおいては、電話を基本とした共同ケア治療プログラムは通常のケアと比較し、CABG後8ヵ月の患者の精神および身体健康上の予後においてより有効であり術後再入院をも減少させる可能性もあることが示された。8ヵ月間の観察後、身体機能およびうつ病を評価する検査のスコアは、共同ケアを受けた患者において通常のケアを受けた患者と比較し有意に改善していた。うつ病患者はまた、気分障害の症状が50%以上軽減したと報告する率が高く（50%対29.6%、p<0.001）、特に男性において著明であった（60.5%対33.3%、p<0.001）。治療は男性においてより有効であったが、女性においても有効性は認められた。さらに、共同ケアを受けたうつ病男性は通常の治療を受けた男性と比較し術後8ヵ月間の心血管疾患による再入院率が低かった（13%対23%、p=0.07、うつ病のないCABG後患者における13%と同等）。

Depressed patients recovering from coronary artery bypass graft (CABG) surgery recover faster with a little help from their collaborative care (CC) team, according to findings reported in a late breaking clinical trial at the American Heart Association's Scientific Sessions 2009 and published simultaneously in JAMA.

In the Bypassing the Blues (BtB) Trial, a telephone-based collaborative care treatment regimen proved more effective than usual care at improving mental and physical health outcomes of patients eight months after CABG and may even reduce the rate of rehospitalization following surgery. BtB is the first effectiveness trial of a collaborative care strategy for treating depression following an acute cardiac event.

"We were able to demonstrate that our intervention significantly improved quality of life and reduced adverse mood symptoms as early as two months following surgery and we found a trend toward reduced rehospitalizations at eight months among depressed men randomized to our intervention" said Bruce L. Rollman, M.D., M.P.H., the study's lead author and associate professor of medicine, psychiatry, and clinical and translational science at the University of Pittsburgh School of Medicine. Study nurses screened 2,485 CABG patients for depression at seven Pittsburgh-area hospitals using the two-item Patient Health Questionnaire (PHQ-2), and confirmed the depression finding using the PHQ-9 administered over the telephone two weeks later. Then, 302 patients were randomized to either their doctors' "usual care" (UC) for depression or to eight months of collaborative care delivered via telephone by study nurses working in partnership with other healthcare professionals. The study also included a group of 151 non-depressed post-CABG patients to facilitate comparisons with depressed study patients (total patients: 453).

Study nurses monitored patients' symptoms and relayed treatment recommendations between the patients and their primary care physicians following evidence-based treatment protocols under weekly supervision of a study primary care physician and psychiatrist. Treatment options included antidepressant pharmacotherapy, a self-help workbook, and/or referral to a community mental health specialist. However, patients were required to obtain medication from their PCP and pay for it, as the study did not dispense any medications.

Researchers used the SF-36 questionnaire to assess patients' mental and physical health, the Duke Activity Status Index (DASI) to assess physical functioning, and the Hamilton Rating Scale for depression to assess mood symptoms. As expected, depressed patients had significantly worse scores than non-depressed patients in all of these areas at baseline. At eight months follow-up, compared with those who received usual care, patients who received collaborative care reported significantly improved scores on the SF-36, DASI, and HRS-D. Depressed patients were also more likely to report a 50 percent or greater decline in their adverse (or negative) mood symptoms (50 percent vs. 29.6 percent; p<0.001), which was particularly notable in men (60.5 percent vs. 33.3 percent; p<0.001). While the intervention was more powerful among men, women in the intervention also reported benefits, said Rollman.

Moreover, depressed men tended to have a lower eight-month incidence of rehospitalizations for cardiovascular causes than depressed UC men (13 percent vs. 23 percent; p=0.07) that was similar to non-depressed post-CABG men (also 13 percent).

"Depression is common following CABG surgery and is associated with worse clinical outcomes," Rollman said. "Unfortunately, it's also overlooked by many clinicians caring for these patients despite the availability of several simple screening instruments such as the PHQ-2 and PHQ-9. Although several treatment trials for depression have been conducted in heart patients, most had generally disappointing results. Collaborative care has been proven effective in dozens of trials conducted in primary care settings, but ours is the first to apply this approach to a population with cardiovascular disease and one of the very few studies to examine the impact of treating post-CABG depression."

Rollman characterized BtB as a real-world trial that could be adopted as part of the "medical home" concept now being discussed by Congress. The findings and telephone mode of intervention delivery have major public health implications, particularly for medically frail individuals, those living in rural settings, and others with physical challenges impeding face-to-face depression treatment.

"Now that we have demonstrated the effectiveness of our approach, we're presently looking at Medicare and other insurance claims data to evaluate the cost-effectiveness and possible cost-savings of our intervention which could speed its adoption into routine clinical care," Rollman said.

Study sponsor: National Heart Lung and Blood Institute.

Co-authors are: Bea Herbeck Belnap, Ph.D.; Sati Mazumadar, M.D.; Patricia R. Houck, M.S.; Peter J. Counihan, M.D.; Wishwa N. Kapoor, M.D., M.P.H.; Herbert C. Schulberg, Ph.D.; Charles F. Reynolds III, M.D. (co-principal investigator).

isclosures: None.