Uptake of a National Anxiety and Depression Screening Program in the Cardiac Rehabilitation Setting

Shot of a compassionate doctor comforting a young woman in a hospital waiting room
To evaluate implementation of the screening protocol or anxiety and depression, data were sourced from the Danish health care system, a nationwide survey was conducted, and health care professionals were interviewed.

A longitudinal study found that a nationwide implementation of screening for anxiety and depression improved with time and required local and national support initiatives. These findings were published in the Journal of Psychosomatic Research.

In Denmark, systematic screening for anxiety and depression during cardiac rehabilitation (CR) was first recommended nationwide in 2013 with a mandatory registration and reporting component. To evaluate implementation of the screening protocol, data were sourced from the Danish health care system between 2013 and 2020, a nationwide survey was conducted in 2013, 2015, 2018, and 2021, and 11 health care professionals were interviewed in 2015 and 2020.

In 2013, the proportion of hospitals that screened regularly for anxiety and depression during CR was 61%. After the new recommendations for systematic screening, the proportion of compliant hospitals increased to 97% in 2015 but decreased to 88% in 2021. For municipalities, the proportion increased from 20% in 2013 to 89% in 2021.

Among hospitals that reported screening, use of the Hospital Anxiety and Depression Scale (HADS) increased from 41% in 2013 to 100% in 2021. For municipalities, the proportion using HADS increased from 42% to 79%, respectively.

The national mean proportion of patients who were screened at hospitals was 60% in 2016 and 63% in 2020 and for municipalities, was 79% in 2017 and 71% in 2019.

Screening practices varied greatly between and within hospitals in 2013 and by 2015, screening practices more closely adhered to guidelines.

During the first semi-structured interviews, clinicians tended to be unsure why screening for anxiety and depression were relevant in CR and were reluctant to change their protocols. The mandatory registration requirement was the impetus to begin screening patients. During the later interviews, clinicians thought they began to learn about the importance of screening patients in the setting of CR.

In general, adherence to screening tended to depend on personal initiative and motivation.

Most sites reported adapting screening procedures to fit with their local practice, using a trial-and-error approach.

This study may have been biased by having little representation from sites that were not compliant with the screening guidelines.

The study authors concluded, “This longitudinal study on implementation of systematic screening for anxiety and depression in CR in Denmark supports the abundant literature showing that guidelines alone are not sufficient to change practice. Our findings emphasize that uptake of screening takes place when guidelines are supplemented with supporting initiatives at both national and local levels and point to the importance of a continuous effort. Despite the relatively extensive initiatives in Denmark, there are still sites not screening, and even among those screening, data indicate that not all eligible patients are screened. Continuous quality improvement work is necessary, and national guidelines for how to deal with noneligibility seem warranted.”


Egholm CL, Helmark C, Rossau HK, et al. Implementation of systematic screening for anxiety and depression in cardiac rehabilitation: Real world lessons from a longitudinal study. J Psychosom Res. 2022;158:110909. doi:10.1016/j.jpsychores.2022.110909