Purpose: Elevated depressive symptoms are common after acute coronary syndrome (ACS) and associated with adverse cardiovascular outcomes and lower quality of life. We evaluated the cost-effectiveness of enhanced depression care to inform guidelines for depression treatment in post-ACS patients.
Methods: One hundred fifty-seven patients with recent (< 3 months) ACS and persistent depressive symptoms were randomized to (1) enhanced depression treatment, comprising patient preference for problem-solving psychotherapy, antidepressant medication, or both, through the use of a stepped-care algorithm, or (2) evidence-based usual treatment in the Coronary Psychosocial Evaluation Studies (COPES) trial. Standardized measures of quality of life and healthcare utilization were obtained using structured interviews, the Short-Form-12 (SF-12) Health Survey, and medical record review. Total healthcare costs, which comprised antidepressant and anxiolytic medication; ambulatory care visits with mental health specialists, cardiologists, and primary care physicians; and hospitalizations for stable angina, unstable angina, myocardial infarction, and congestive heart failure were estimated using average wholesale drug prices and Medicare reimbursement rates. Outcomes were adjusted for potential confounding by patient demographics, depression severity, type of ACS, and left-ventricular ejection fraction using linear regression models. Non-parametric bootstrap methods were used to determine incremental cost-effectiveness ratios, measured in dollars per quality-adjusted life-year (QALY).
Results: At six-month follow-up, there was a trend toward greater improvements in health utility in the intervention group compared to the control group (0.56 vs. 0.60, p = 0.07). Total healthcare costs were $1,857 for the enhanced depression care group and $2,797 for the usual care group (adjusted difference = -$1,229 per patient, p = 0.09). This difference was largely attributable to lower costs of hospital care for adverse cardiovascular events (difference = -$1,782 per patient, p = 0.01), which offset higher costs for ambulatory care and mental health visits (difference = $536 per patient, p < 0.01). Overall, 5% of patients receiving enhanced depression care compared to 16% of patients receiving usual care were re-hospitalized for ACS or heart failure. In bootstrap analyses, enhanced depression care was 98% likely to be cost-effective at a societal willingness-to-pay threshold of $30,000 per QALY (Figure).
Conclusion: Enhanced depression care for post-ACS patients may reduce healthcare costs and is likely cost-effective. Larger studies with longer follow-up are needed to examine the robustness and durability of these findings. 
See more of: The 34th Annual Meeting of the Society for Medical Decision Making