Effect of modernized collaborative care for depression on depressive symptoms and cardiovascular disease risk biomarkers: eIMPACT randomized controlled trial

Published in the journal Brain, Behavior and Immunity. Here is a link to the article.

Regenstrief Institute authors: Christopher M. Callahan, M.D., Sumedha Gupta, PhD, (affiliated scientist), Sujuan Gao, PhD, (affiliated scientist)

Abstract

Although depression is a risk and prognostic factor for cardiovascular disease (CVD), clinical trials treating depression in patients with CVD have not demonstrated cardiovascular benefits. We proposed a novel explanation for the null results for CVD-related outcomes: the late timing of depression treatment in the natural history of CVD. Our objective was to determine whether successful depression treatment before, versus after, clinical CVD onset reduces CVD risk in depression. We conducted a single-center, parallel-group, assessor-blinded randomized controlled trial. Primary care patients with depression and elevated CVD risk from a safety net healthcare system (N = 216, Mage = 59 years, 78% female, 50% Black, 46% with income <$10,000/year) were randomized to 12 months of the eIMPACT intervention (modernized collaborative care involving internet cognitive-behavioral therapy [CBT], telephonic CBT, and/or select antidepressants) or usual primary care for depression (primary care providers supported by embedded behavioral health clinicians and psychiatrists). Outcomes were depressive symptoms and CVD risk biomarkers at 12 months. Intervention participants, versus usual care participants, exhibited moderate-to-large (Hedges’ g = -0.65, p < 0.01) improvements in depressive symptoms. Clinical response data yielded similar results – 43% of intervention participants, versus 17% of usual care participants, had a ≥ 50% reduction in depressive symptoms (OR = 3.73, 95% CI: 1.93-7.21, p < 0.01). However, no treatment group differences were observed for the CVD risk biomarkers – i.e., brachial flow-mediated dilation, high-frequency heart rate variability, interleukin-6, high-sensitivity C-reactive protein, β-thromboglobulin, and platelet factor 4 (Hedges’ gs = -0.23 to 0.02, ps ≥ 0.09). Our modernized collaborative care intervention – which harnessed technology to maximize access and minimize resources – produced clinically meaningful improvements in depressive symptoms. However, successful depression treatment did not lower CVD risk biomarkers. Our findings indicate that depression treatment alone may not be sufficient to reduce the excess CVD risk of people with depression and that alternative approaches are needed. In addition, our effective intervention highlights the utility of eHealth interventions and centralized, remote treatment delivery in safety net clinical settings and could inform contemporary integrated care approaches. Trial Registration:ClinicalTrials.gov Identifier: NCT02458690.

Authors:

Jesse C Stewart¹, Jay S Patel², Brittanny M Polanka³, Sujuan Gao⁴, John I Nurnberger⁵, Krysha L MacDonald⁶, Samir K Gupta⁷, Robert V Considine⁷, Richard J Kovacs⁸, Elizabeth A Vrany⁹, Jessica Berntson¹⁰, Loretta Hsueh¹¹, Aubrey L Shell¹², Bruce L Rollman¹³, Christopher M Callahan¹⁴

Affiliations

¹Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA. Electronic address: jstew@iupui.edu.

²Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.

³Division Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA.

⁴Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA.

⁵Department of Psychiatry and Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA.

⁶Sandra Eskenazi Mental Health Center, Eskenazi Health, Indianapolis, IN, USA.

⁷Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

⁸Division of Cardiovascular Disease, Indiana University School of Medicine, Indianapolis, IN, USA.

⁹Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.

¹⁰Dr. Jessica Berntson Inc., Coquitlam, BC, Canada.

¹¹Department of Psychology, University of Illinois Chicago, Chicago, IL, USA.

¹²Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA.

¹³Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

¹⁴Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, USA.