2009：Guideline for 心梗后抑郁症（AAFP ）

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 7, NO. 1 ✦ JANUARY/FEBRUARY 2009 71 AAFP Guideline for the Detection and Management of Post–Myocardial Infarction Depression Ann Fam Med 2009;7:71-79. DOI: 10.1370/afm.918. EVIDENCE-BASED RECOMMENDATIONS The American Academy of Family Physicians (AAFP) Commis-sion on Science convened a panel to review the evidence on the effect of depression on persons after myocardial infarction. The evidence report on this topic was published in May 2005 by the Agency for Healthcare Research and Quality (AHRQ) and is used as the basis for this review.1 The AAFP Post–Myocardial Infarction Depression Clini- cal Practice Guideline Panel (Post-MI Guideline Panel) was charged with examining the evidence and developing an evidence-based clinical practice guideline for the detection and management of persons with postmyocar- dial infarction (post-MI) depression. The following recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they refl ect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. Recommendations Recommendation 1: Patients having a myocardial infarction should be screened for depression using a standardized depression symptom check- list at regular intervals during the postmyocardial infarction (post-MI) period, including during hospitalization (Level A). Insuffi cient data are available to support a recommendation of one particular symp- tom checklist over another. Recommendation 2: Post-MI patients with a diagnosis of depression should be treated to improve their depression symptoms, with systems in place to ensure regular follow-up and monitoring of their treatment response and adherence to treatment (Level A). The recommendation to screen for and treat depression in patients with myocardial infarction is based on randomized controlled trials showing improvement in outcomes for depression. Treatment of depression has not been found to improve cardiac outcomes per se, though the evidence does not yet exclude the possibility of a small benefi t. The literature does not provide guidance regarding the effects of treatment of depression on adherence to tertiary prevention1* measures for coronary disease, such as diet, β-blocker, or aspirin use. The diag- nosis of depression will be informed, not determined, by the screening instrument results from Recommendation 1. Defi nitive diagnosis is ultimately the treating clinician’s responsibility. Post–Myocardial Infarction Depression Clinical Practice Guideline Panel Members of the Post Myocardial Infarction Depression Clinical Practice Guideline Panel are Lee A. Green, MD, MPH, Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; W. Perry Dickinson, MD, University of Colorado Health Sciences Center, Denver, Colorado; Donald E. Nease, Jr, MD, Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Kenneth G. Schellhase, MD, MPH, Department of Family & Community Medicine, Medical College of Wisconsin, Milwaukee, Wiscon- sin; Doug Campos-Outcalt, MD, MPA, American Academy of Family Physicians, Leawood, Kansas; Bellinda K. Schoof, MHA, CPHQ, American Academy of Family Physicians, Leawood, Kansas; Michelle Jeffcott-Pera, MA, American Academy of Family Physicians, Leawood, Kansas Confl icts of interest: none reported CORRESPONDING AUTHOR Lee A. Green, MD, MPH Department of Family Medicine Campus Box 0708 University of Michigan 1018 Fuller Ann Arbor, MI 48190 greenla@umich.edu *In the cardiology literature, tertiary prevention is often referred to as secondary prevention. ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 7, NO. 1 ✦ JANUARY/FEBRUARY 2009 72 POSTMYOC ARDIAL INFARC TION DEPRESSION GUIDELINE Recommendation 3: Selective serotonin reuptake inhibitors (SSRIs) are preferred to tricyclic antidepres- sants for treatment of depression in post-MI patients (Level A). Randomized controlled trials using SSRIs have shown improvement in measures of depression among post-MI patients. The evidence base for treatment with SSRIs is large enough and follow-up has been long enough to show that SSRIs are safe in the post-MI setting and do not share the adverse cardiac effects of tricyclic antidepressants. Insuffi cient evidence is available about other classes of antidepressants to make recommendations for or against their use in post-MI patients. Recommendation 4: Psychotherapy may be benefi cial for treatment of depression in post-MI patients. The existing evidence base does not establish what form of psychotherapy is preferred (Level B). Trials of psychotherapy have used a variety of types of inter- ventions. Taken as a whole, the body of evidence supports benefi t in reducing depression symptoms, but not all studies supported this conclusion. Additionally, the heterogeneous nature of the interven- tions studied precludes direct comparisons. INTRODUCTION Cardiovascular disease remains the leading cause of death and disability among both men and women of all ethnic groups in the United States. Depression is an important predictor of morbidity and mortality in patients with coronary heart disease, particularly after a myocardial infarction, independent of previ- ous cardiac history, coronary artery disease severity, or residual left ventricular function.2 As many as 65% of patients with acute myocardial infarction report experiencing symptoms of depression, and major depression is present in 15% to 22% of these patients.3 In 2003, the AAFP Commission on Clinical Policies and Research (now Commission on Science) decided there was a need for an evidence review on the effect of depression on post-MI patients and successfully nominated the topic to AHRQ. In May 2005, after publication of the AHRQ Evidence Report Number 123,1 the AAFP established the Post-MI Guideline Panel, which was composed of family physicians who were well versed in practice guideline development and the care of post-MI patients with depression. The Post-MI Guideline Panel was charged with examining the evidence and developing an evidence-based clini- cal practice guideline for detection and treatment of depression post-MI. The guideline was peer-reviewed before being reviewed and approved by the AAFP Commission on Science and by the AAFP Board of Directors. The post-MI depression guideline describes the historical context, the methods used to review the literature, the results of the review, the evidence-based recommendations, and recommendations for future research in this area. SCOPE This guideline pertains directly only to patients who have sustained ST-elevation MI (STEMI) or non–ST- elevation MI (NSTEMI). Patients with unstable angina and those with acute coronary syndrome relieved by revascularization (thrombolysis, angioplasty, or bypass surgery) have not been included in studies to date. The studies available do not generally distinguish between STEMI and NSTEMI. Full discussion of the details and comparison of the available screening tools is beyond the scope of this guideline. The user is referred to the US Preventive Services Task Force guideline on depression screening for further information. This guideline is intended to assist the primary care physician who is knowledgeable about depression management to improve practice; it does not replace training in depression management. Management of subsyndromal depression, dysthymia, suicidality, and details of psychopharmacology are beyond the scope of this document. BACKGROUND Depression is a common occurrence after an MI, and many studies (summarized below) have shown it to be associated with an increase in subsequent coronary events and with coronary-related mortality. The correla- tion of depression with adverse cardiac outcomes has led to trials examining the effect of depression treatment on coronary outcomes as well as depression outcomes. METHODS The AAFP strength of recommendation taxonomy (SORT)4 framework was used to grade the recom- mendations for this guideline (see http://www.aafp. org/online/en/home/publications/journals/afp/afpsort. html for details). The recommendations were devel- oped by discussion among the Post-MI Guideline Panel members after review of the AHRQ Evidence Report No. 123,1 completed by the Johns Hopkins University Evidence-based Practice Center (EPC), and subsequent evidence. Decisions were by unanimous agreement; there was no voting, and the data were not amenable to formal methods such as meta-analysis. The evidence reviewed is summarized below. AHRQ Evidence Report The Post-MI Guideline Panel used the AHRQ Evi- dence Report No. 123 as the basis for constructing ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 7, NO. 1 ✦ JANUARY/FEBRUARY 2009 73 POSTMYOC ARDIAL INFARC TION DEPRESSION GUIDELINE this post-MI depression clinical practice guideline. The report provides a full description of the methods used in the AHRQ systematic review.1 Conclusions are based on high-quality randomized controlled tri- als unless otherwise stated. Each key question in this guideline is one of the questions of evidence addressed in that report as nominated by the AAFP. Recom- mendations derive from the fi ndings of the evidence report, as well as additional relevant evidence pub- lished in English language peer-reviewed literature sub- sequent to the date the EPC review was in fi nal form. Updated Evidence Review Because 2 years had elapsed since the original evidence review, the Post-MI Guideline Panel conducted a sys- tematic update of the evidence by reviewing studies published since the AHRQ EPC report. An updated literature search, addressing the same key questions as in the AHRQ EPC report, was performed cover- ing the time period from April 2004 to November 15, 2006. Unlike the original evidence report, the updated report included only information from electronic searches (ie, hand searches were excluded); however, the databases searched were the same as in the origi- nal AHRQ EPC report. Identical search terms were used for the MEDLINE and Cochrane databases.1 The search terms were slightly modifi ed for the remaining 3 databases (ie, EMBASE, CINAHL, and PsycINFO) because of high rates of overlap with the results from MEDLINE (see the Supplemental Appen- dix, available online at http://www.annfammed. org/cgi/content/full/7/1/71/DC1). The literature search resulted in 809 articles. After duplicates were eliminated, 2 reviewers independently scanned the titles and made a determination regarding relevance. The exclusion criteria used in the original evidence report were also used in the updated litera- ture review. Specifi cally, articles were eliminated if (1) they were not in English, (2) they had no human data, (3) they had no original data, or (4) there was no full- text article to review (ie, it was a meeting abstract).1 If both reviewers agreed that an article was irrelevant, it was excluded from further review. Any discrepancies were discussed and resolved by the reviewers. All remaining articles were examined for relevance based upon their abstracts. Each of the 2 reviewers examined the abstracts independently. The reviewers again had to agree to the relevance of the article for inclusion or exclusion in the updated evidence review. All discrepancies were discussed by the reviewers and agreement was reached. If a citation did not have an abstract or the reviewers could not agree on the rel- evance, the full-text article was obtained. Consistent with the AHRQ EPC report, abstracts were marked for relevance to a key question, and those eliminated were given a reason for elimination. This resulted in 71 articles being examined for full-text review. Each full-text article was then examined for rel- evance to the research questions. Consistent with the original evidence report, information was also gath- ered related to the methods and quality of the study. Articles that were unrelated to the study questions were again eliminated resulting in a total of 31 articles for the updated evidence review (Table 1). The AAFP Post-MI Guideline Panel made the determination that this new body of evidence did not contribute any substantive changes to the original evidence report but added more support to it; therefore, both the new evidence as well as the original report were used as the evidence sources for this guideline. RESULTS The Post-MI Guideline Panel used the original key questions as they were written in the AHRQ EPC Table 1. Articles Related to Key Questions Abbreviated Citation Key Question(s) Akhtar et al,5 2004 1 Blumentha et al,6 2004 3 Carney et al,7 2004 3, 4 de Jonge et al,8 2006 1, 3 de Jonge et al,9 2006 3 Dias et al,10 2004 1 Dickens et al, 11 2006 1, 3 Dickens et al,12 2004 1 Drago et al,13 2006 1, 3 Fauerbach et al,14 2005 1, 3 Ginzburg,15 2006 1 Grace et al,16 2005 4 Grunau et al,17 2006 3 Huffman et al,18 2006 1, 5 Huffman et al,19 2006 1 Jaffe et al,20 2006 3 Kaptein et al,21 2006 1, 3 Lacey et al,22 2004 1, 4 Mallik et al,23 2006 1 McGowan et al,24 2004 1 Mohapatra et al,25 2005 1, 4 Parashar et al,26 2006 1, 2, 3 Parker et al,27 2006 1 Schrader et al,28 2004 1 Sorensen et al,29 2006 1, 3 Spijkerman et al,30 2005 1 Spijkerman et al,31 2006 1 Spijkerman et al,32 2005 1 Taylor et al,33 2005 4 Van Melle et al,34 2006 1 Ziegelstein et al,35 2005 1 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 7, NO. 1 ✦ JANUARY/FEBRUARY 2009 74 POSTMYOC ARDIAL INFARC TION DEPRESSION GUIDELINE report1 to guide the evidence panel in collecting the relevant research studies to best inform the report. The questions as they are written below are rephrased to be more relevant to practicing professionals but are not changed in substance. Evidence Summary Evidence Question 1: What Is the Prevalence of Depression During Initial Hospitalization for MI? In the original AHRQ EPC report, prevalences var- ied by type of measure used. For example, use of the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID) yielded prevalences rang- ing from 17% to 27%. Including the ENRICHD trial at 20%36 and validated depression scales, such as the Beck Depression Inventory (BDI), yielded prevalences ranging from 10% to 47%, depending on the cut points used.37-43 The EPC report noted that there was a medium quantity of evidence of reasonable quality to address this question. The updated evidence review continued to show a wide range of prevalences (7.2% to 41.2%) depending on the method used to assess depression. Structured interviews tended to produce lower prevalence esti- mates, and ratings scales, such as the BDI, produced higher prevalence estimates.* In general, across the studies, about 1 of every 5 patients with an MI has depression during an initial hospitalization. Evidence Question 2: What Is the Prevalence of Continued Depression >1 Month Postdischarge and Beyond? It is important to distinguish among the time courses of depression that may be identifi ed, ie, prevalent depression that existed before the MI event and con- tinues afterward, incident depression that begins after an MI, recurrent depression that was in remission but recurs after an MI, and incident depression immedi- ately post-MI that remits spontaneously. Patients iden- tifi ed as depressed at 1 month or longer after discharge include patients with the fi rst 3 of these depression time courses. Incident depression seems most relevant to this guideline, as it is most closely related to the MI event in its time course. In the EPC report 19 stud- ies reported 1-month post-MI depression prevalence data; however, only 3 studies specifi cally addressed patients for whom depression was initially diagnosed immediately post-MI, incident depression, and who were observed for up to 1 month or longer. In these patients, 1-month or greater prevalences ranged from 36.7% to 60%.38,44,45 Studies were rated as having a medium quantity of evidence with reasonable quality. The updated review of the literature found only 1 new study that again reported a 1-month 35.4% prevalence of depression in patients originally given a post-MI diagnosis of depression.26 Evidence Question 3: What Is the Independent Association of Measures of Depression With Post-MI Outcomes? The AHRQ EPC report identifi ed 11 independent studies meeting inclusion criteria that provided data on the association of depression with post-MI mortal- ity.36,46-55 All 11 studies related depression, as assessed 1 time shortly after MI, to survival at times varying from 4 months to 10 years. Studies were judged to be gener- ally of high quality. Eight found a statistically and clin- ically signifi cant association between depression and mortality, whereas 3 did not.56-58 The sex of the patient did not appear to affect the relation between MI and depression, nor did correction for other cardiac risk factors. Subsequent to the AHRQ EPC report, several additional publications meeting criteria addressed the same issue.† All supported the association between post-MI depression and cardiac-related mortality, with a direct relation between severity of depression symp- toms and probability of death.40 The AHRQ EPC report identifi ed 6 independent studies meeting inclusion criteria that reported cardiac event rates among depressed patients.50,59-63 Studies were judged to be of moderate quality. One study50 found that the association between cardiac events and depression disappeared with adjustment for fatigue symptoms, and 2 others found the same when adjust- ing for a measure of anxiety.61,62 Another60 found that the association was signifi cant for older (older than 65 years) but marginal for younger patients. Studies of similar methodological quality published since the EPC report have shown relations between post-MI depres- sion symptoms and hospital readmission21,26,29 and non- fatal cardiac events or symptoms.8,13 Two adequately powered studies26,29 did not support the relation between depression and nonfatal events. The AHRQ EPC report1 identifi ed 11 independent studies meeting inclusion criteria that addressed qual- ity of life among post-MI patients with depression.‡ A variety of effects on physical, psychological, and social health and function have been shown for post- MI patients with depression, some sex-specifi c and some not, with a moderate degree of inconsistency among the studies. These effects were seen across a range of follow-up duration, from 3 months to 5 years. The body of evidence was judged to be of low quality. Most studies of quality-of-life measures since the EPC report8,14,26 have similar fi ndings. One found no relation * References 5,8,10-15,18,19,21-32,34,35. † References 6,7,9,13,17,20,21,26,29. ‡ References 39,41,43,48,56,57,64-68. ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 7, NO. 1 ✦ JANUARY/FEBRUARY 2009 75 POSTMYOC ARDIAL INFARC TION DEPRESSION GUIDELINE between depression at baseline (immediately post-MI) and quality of life, though it did fi nd that a 6-month post-MI measure of depression was associated with reduced quality of life. Three studies reviewed in the EPC report69-71 pro- vided data on surrogate markers for risk of recurrent MI. The studies, judged to be of high quality, found consistent associations between post-MI depression and abnormalities in the frequency spe