Coronary Heart Disease (CHD) and depression are currently two of the most important causes of disability in high-income countries  and it is projected that the same will apply to low and middle income countries by 2030 . These conditions often co-exist with approximately 15% of Myocardial Infarction (MI) patients experiencing major depressive disorder (MDD) and another 15-20% exhibiting mild to moderate depression . Patients with post-MI depression are more likely to report impaired health related quality of life (HRQOL) , poorer medication adherence  and utilisation of health services , increased morbidity and suicide risk , and poorer CHD risk factor profiles, work outcomes  and survival . In particular, depression results in poor uptake and completion of CHD secondary prevention or cardiac rehabilitation programs , which have been shown to play a pivotal role in improving CHD risk factor profiles and other clinical outcomes. Indeed, compared with non-depressed patients, depressed patients are three times less likely to be compliant with medical treatment recommendations . The clinical benefits of CHD secondary prevention programs are well documented and include decreased risk of fatal and non-fatal recurrent MI and CVD , improved HRQOL, and lower rates of rehospitalisation [13, 14]. However, despite the high prevalence of depression following a diagnosis of CHD and the poor outcomes associated with the group , it remains poorly recognised and managed in CHD patients.
Traditionally, CHD secondary prevention programs are delivered face-to-face in clinic- or hospital-based settings; however, they suffer from low participation rates due to a range of barriers including poor accessibility and access . Symptoms of depression following Acute Coronary Syndrome (ACS) - including hopelessness, helplessness, and apathy - can further impede participation in secondary prevention programs. Contemporary approaches to CHD secondary prevention may help to overcome this treatment gap. A recent meta-analysis demonstrated that innovative, tele-based CHD secondary prevention programs may transcend some of the barriers to participation in traditional rehabilitation programs, and they are effective in improving behavioural and clinical outcomes for cardiac patients . Further, telephone-delivered therapy has proven effective for patients with depression  and more recently, for those with co-morbid depression following a cardiac event. For example, a tele-health, nurse-delivered, collaborative care intervention for coronary artery bypass graft surgery patients suffering from depression significantly improved depression outcomes, mental health components of HRQOL and disease specific physical functioning .
Psychological based therapies [19, 20], pharmacologic approaches (namely Selective Serotonin Reuptake Inhibitors), and composite approaches to treatment [22, 23] have all demonstrated improvements in depression for CHD patients, especially for those with recurrent depression . While pharmacologic and psychological approaches have yielded comparable effect sizes in reducing depression , Cognitive Behaviour Therapy (CBT) has been shown to be particularly favourable for improving depression outcomes for cardiac patients, with an American Heart Association report endorsing its use . Evidence from a number of well designed trials also demonstrate its effectiveness in reducing depression in cardiac patients when compared with other approaches . For example, compared to usual care (UC), Freedland and colleagues (2007) demonstrated that CBT displayed greater and more durable effects than the other approaches . However, relatively little is known about its effectiveness under 'real world' delivery conditions, particularly using a tele-based approach.
The feasibility of combining a tele-health, depression management program using CBT with a CHD secondary prevention program for ACS patients is yet to be established in the 'real world' setting. The effects of such a program could go beyond treating depression to improve all aspects of HRQOL and CHD risk factors, and demonstrate significant economic advantages over more traditional modes of delivery. This paper presents the study protocol for a randomised, multi-centre, feasibility trial of a tele-health intervention for ACS patients with depression ('MoodCare'). We hypothesise that the trial will demonstrate the feasibility of the MoodCare intervention through improving key depression and HRQOL outcomes at 6 months, with increased participant satisfaction, and will be cost-effective compared with UC.