UW News

August 6, 2009

Post-stroke depression recovery improved by adding brief psychosocial/behavioral intervention to standard treatment

UW Health Sciences/UW Medicine

Depression is common after a stroke, and can interfere with a stroke patient’s rehabilitation. When a brief psychological/behavioral intervention is added to the standard treatment for their depression, stroke patients tend to have a better, faster remission compared to those on standard treatment only. The findings were published online Aug. 6 in Stroke, a scientific journal of the American Heart Association.

The stroke patients in the study ranged in age from 25 to 90. The patients all had ischemic strokes, which result from inadequate blood flow in the brain.

“The standard treatment for depression after a stroke is antidepressant drug therapy and follow-up to see how the patient is doing,” said Dr. Pamela Mitchell, professor of biobehavioral nursing and health systems at the University of Washington (UW) School of Nursing and lead author of the study. “Antidepressants help with mood and sleep problems, but unless patients learn new ways to think and take action to make their lives better, they may remain low.”

During the intervention, which took place during nine sessions, patients discover what they can do to recognize and elevate their mood, and how to overcome challenges. The interventions were modified for stroke patients from a program that Dr. Linda Teri, UW professor of biobehavioral nursing and health systems, and her colleagues in the UW School of Nursing originally created for people with depression in the early stages of Alzheimer’s disease.

After learning about post-stroke depression and realizing that it is not a moral failing, patients practice ways to manage depression. They begin by thinking of activities that they can enjoy doing. Instead of waiting to feel up to it, they schedule a few of these pleasurable activities.

“Patients start focusing on what’s pleasant in life, not just what’s difficult,” Mitchell said. The patients then figure out if they can still do the activity, or what modifications might make it possible again. Mitchell gave as an example a person who likes taking walks but who now feels unstable on uneven paths. The person might decide to try Mall Walkers or Zoo Walkers to have level surfaces for walking and benches for resting. Another example, she said, might be someone who once loved to garden, but now can’t bend over or kneel. Such a person migh be good at growing container vegetables, bonsai or other small, raised plantings.

After the patients build some enjoyment into their lives, they then learn how to deal with depressive symptoms, to notice what triggers them, to reframe situations, to change negative thinking and behaviors, to get around obstacles, to solve problems, develop plans, and take action. A stroke patient frustrated by getting dressed, Mitchell said, for instance, might obtain clothing and shoes that are easier to put on.

The researchers found that depressed stroke patients who received the nine-session psychosocial and behavioral intervention had a significant lessening of their depression symptoms, almost to the point of remission, and were able to maintain their level of remission when checked one year and two years later. Post-stroke depression patients who received only standard depression treatment improved, too, but more slowly and not to as high a degree.

Patients who completed the intervention also had a better perception of their quality of life and believed they had a better recovery from stroke, compared to the standard treatment group.

“The patients in the intervention group were more likely to get out and do what’s important in their lives and to join in social and family functions,” Mitchell said.

The next step for her research team will be to test whether telephone consultations are as effective as in-person meetings with patients. She is also considering the possibilities of a self-help manual or consultations via video-phone. If these are proven to work, any of them would be a considerable cost-savings compared to home visits, according to Mitchell.

“Our goal is to move the interventions we’ve found to be effective in university research settings into the real-world context of everyday health-care practice in the community,” Mitchell said.

Mitchell’s UW collaborators on the Living Well with Stroke project were Richard C. Veith, professor and chair of psychiatry and behavioral sciences; Kyra J. Becker, professor of neurology; Ann Buzaitis, nurse, UW Medical Center Neurology Clinic; Kevin C. Cain, research scientist, Biostatistics; Michael Fruin, nurse practitioner and clinical faculty member, School of Nursing; David Tirschwell, associate professor of neurology; and Linda Teri, interim chair and professor of psychosocial and community health and director, Northwest Research Group on Aging.

The National Institute of Nursing Research, a component of the National Institutes of Health, funded the research.

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The University of Washington School of Nursing is consistently the nation’s No. 1-ranked nursing school, according to U.S. News & World Report. Ranked No. 2 in research funding from the National Institutes of Health, the UW School of Nursing is a national and international leader in improving the health and well-being of individuals, families and communities, from infant mental health to healthy aging. The school addresses society’s most pressing challenges in health care through innovative teaching, award-winning research and community service. For more information, visit www.son.washington.edu

The National Institute of Nursing Research (NINR) of the National Institutes of Health supports basic and clinical research that develops the knowledge to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and enhance end-of-life and palliative care. For more information about NINR, visit the Web site at www.ninr.nih.gov