A brief behavioural intervention can reduce depression in stroke survivors

A nurse-led behavioural intervention can reduce the incidence of depression in stroke survivors, according to the results of a study published in the recent issue of the journal Stroke. The intervention, called Living Well with Stroke (LWWS), provided individualised counselling sessions aimed at increasing pleasant social interactions and physical activity as a way to elevate mood, and was designed to be used alone or in conjunction with antidepressant medications. This study was funded by the National Institute of Nursing Research (NINR), a component of the National Institutes of Health (NIH).

A stroke occurs when the blood supply to a part of the brain becomes blocked or interrupted, leading to brain damage in the affected area. Stroke survivors can experience a range of aftereffects, including impaired mobility or paralysis, pain, speech and language problems, and altered cognition. As many as one-third of stroke survivors also develop post-stroke depression (PSD), which may include intense feelings of loss, anger, sadness, and/or hopelessness.

Compared to stroke survivors without depression, those with PSD tend to have a poorer response to rehabilitation, a longer delay in returning to work, more social withdrawal, and increased use of health care services. They are also at higher risk for subsequent strokes, cardiac events, and death. While antidepressant medications have shown varying degrees of short-term efficacy for PSD patients, few studies have examined non-pharmacologic interventions or long-term outcomes.

In a clinical trial involving over 100 stroke survivors who exhibited symptoms of PSD, Dr Mitchell’s research team compared LWWS against usual post-stroke care. The study participants ranged in age from 25 to 88 years, and 59 percent were male. In addition, over 70 percent had experienced at least one episode of depression prior to their stroke, and 60 percent were taking an antidepressant medication at entry into the study. All participants received standard post-stroke information and continued to see their primary care provider for ongoing medical care.

Those assigned to the LWWS program received nine counselling sessions over two months with a specially trained stroke rehabilitation nurse. In these sessions, the nurse taught the participants problem-solving skills and helped them develop realistic treatment goals. In addition, several sessions were devoted to improving mood by helping the participants identify and increase their participation in pleasant social events and physical activities, such as being with family, listening to music, reading, solving a puzzle, or learning something new.

"In designing LWWS, we reasoned that changing the behaviours commonly associated with depression through an individualised counselling program would lead to a more effective and longer-lasting elevation of mood than is often seen with medications alone," said Dr Pamela Mitchell, the principal investigator of the study.

"Individuals who have suffered a stroke often must make adaptations in their lives and learn to cope with new limitations, both physical and cognitive. Depression during the recovery period can interfere with their ability to fully engage in their treatment regimen or return to family and work," noted Dr Patricia A. Grady, the NINR Director.

Depression scores in the LWWS group were significantly lower after treatment and at a one year follow-up compared to the control group. In addition, more participants in the LWWS group achieved remission – with scores no longer meeting the criteria for depression – compared to the control group both immediately after treatment (47 percent vs. 19 percent), and at a one-year follow-up (48 percent vs. 27 percent). At two years, depression scores continued to decrease and remission rates continued to increase for both groups, although the gap narrowed so that the differences were no longer statistically significant.

For both the intervention and control groups, patients in remission at one year had significantly higher scores in perceived ability, recovery, and social participation than those who were not.

"The success of LWWS shows the importance of including behavioural strategies in the care of stroke survivors. We believe our study is the first to report a clinically significant reduction in depression in these patients over a long term," said Dr Mitchell. "We also showed that achieving remission from depression by any means is an important treatment goal that could promote recovery and sociability."

"This study has the potential to add another tool for health care professionals to use in helping individuals cope following a stroke," added Dr Grady. "Also of note, the LWWS program included instruction to help family members and other informal caregivers identify resources and support services as a way to reduce their caregiving burden, an important aspect of comprehensive post-stroke care."

(Source: National Institute of Nursing Research (NINR): Stroke: August 2009)