Maintaining close contact with patients after they have had a stroke may be
as important as prescribing medications to treat the depression that may
follow, according to researchers at Indiana University School of Medicine and
the Indianapolis Veterans Affairs Medical Center.
About one-third of stroke survivors are diagnosed with depression, and they
tend to recover more slowly and do more poorly in daily activities, even after
accounting for stroke severity. Research into poststroke depression (PSD),
however, has been insufficient to clarify the benefits of treatment for
Depression may follow stroke for several reasons, explained Robert
Robinson, M.D., chair and Paul W. Penningroth Professor of Psychiatry at the
University of Iowa, in an interview. There is some evidence that PSD is
related to the area of the brain injured by the stroke, suggesting that the
stroke itself is involved in the origin of the depression, said Robinson, who
was not involved with the Indiana study. Incidence of depression may also
reflect a family history of the disorder or a reaction to the disability
engendered by the stroke, he said.
The Indiana study found that an intensive combination of education,
treatment, and follow-up improved response to treatment and remission rates,
compared with patients getting usual care.
"PSD is as responsive to treatment as is depression associated with
other serious medical conditions," wrote Linda S. Williams, M.D., an
associate professor of neurology at Indiana University, and colleagues in the
The researchers studied 188 depressed patients who had survived an ischemic
stroke. All had been screened with the PHQ-9 depression scale and tested with
the Hamilton Depression Inventor y (HAM-D). About 72 percent of the
intervention patients and 75 percent of the control group had major
depression; the rest had minor depression. Half the patients were randomized
to receive usual care and half the intervention. There were no significant
differences in stroke, HAM-D, or PHQ-9 scores between the two groups.
Usual-care patients received baseline and telephone sessions alerting them
to recognize and monitor stroke symptoms.
The intervention group first received a 20-minute psychoeducat ional
session informing the stroke survivors and their families about depression,
said Williams in an interview. Patients then began antidepressant treatment,
typically with the SSRIs paroxetine or sertraline, although the physician
could use another antidepressant. If patients were unresponsive or experienced
significant side effects, the algorithm prompted a change to venlafaxine or
another antidepressant if preferred. Some patients in the intervention
discontinued their medication during the first 12 weeks.
For the third element of the intervention, nurse care managers telephoned
each patient twice a month using a standard script to evaluate depression
symptoms, side effects, and adherence. Each case was discussed in a weekly
care-management meeting with study physicians, and medication was adjusted as
The intervention lasted for 12 weeks. Six- and 12-week assessments of
depression were performed by a researcher not involved in care management and
blinded to treatment allocation.
After 12 weeks, 51 percent of the intervention subjects responded
significantly to treatment, meaning they were more likely to record either a
HAM-D score of 8 or less (the standard for remission), or a 50 percent
reduction from baseline, compared with 30 percent of the usual-care
Also, 39 percent of intervention patients achieved depression remission
versus 23 percent of usual-care subjects.
The results should be considered conservative estimates of the treatment
effect for two reasons, said the authors. For one thing, physicians prescribed
antidepressants to 56 percent of patients in the usual-care group. Also, both
groups received an equal number of telephone calls, which eliminated any
differences caused by the effects of attention to patients on the part of
Adherence to treatment is a major issue, especially among an older,
stroke-prone population, said Robinson.
"The recent CATIE and STAR*D trials found that patients
often stopped taking their medications after a few months," he said. So
someone needs to encourage patients to take their pills, and the involvement
of the treating team in this study probably made the difference.
"When they get calls from the project nurses, I think patients feel
that someone is interested in them and cares about what happens to
them," said Robinson.
While the results of the Indiana trial are encouraging, Robinson remains
concerned about the 44 percent of patients in the usual-care group not taking
"Hopefully, no patient would be denied treatment with
antidepressants, since treatment improves physical and cognitive recovery from
stroke," he said.
There were reasons why not all usual-care patients were on antidepressants,
explained study co-author Kurt Kroenke, M.D., professor of medicine in the
School of Medicine and senior scientist at the Regenstrief Institute for
Health Care at Indiana University, Indianapolis, in an interview. As noted
above, about 1 in 4 of all patients endorsed depressive symptoms but did not
have major depression. Some in the control group refused antidepressant
"The usual-care patients were treated at the discretion of their
provider," added Williams. "We didn't mandate that they be
treated, as that wouldn't be usual care. So providers may have decided not to
treat, or they may have suggested treatment but the patient declined to take
We don't know the details of these interactions."
"Our results also suggest that although some stroke survivors may
respond to antidepressants alone, the addition of patient activation and
telephone-based treatment monitoring that includes dose adjustment and
medication changes may further enhance the successful treatment of PSD,"
concluded the researchers. "These data demonstrate that PSD can be
effectively treated with standard antidepressant algorithms based on current
evidence-based guidelines for depression treatment."
"Care Management of Poststroke Depression" is posted at<http://stroke.ahajournals.org/cgi/content/full/38/3/998>;"Depressive
Symptoms and Risk of Stroke" is posted at<http://stroke.ahajournals.org/cgi/content/full/38/1/16>.▪