|A Brief Behavioral Intervention Can Reduce
Depression in Stroke Survivors
A nurse-led behavioral 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 individualized
counseling 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
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 counseling 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
"In designing LWWS, we reasoned that changing the behaviors
commonly associated with depression through an individualized counseling
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
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
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 behavioral
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
"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
NINR 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.
The National Institutes of Health (NIH) — The Nation's
Medical Research Agency — includes 27 Institutes and Centers
and is a component of the U.S. Department of Health and Human Services.
It is the primary federal agency for conducting and supporting basic,
clinical and translational medical research, and it investigates
the causes, treatments, and cures for both common and rare diseases.
For more information about NIH and its programs, visit www.nih.gov.
Reference: Mitchell PH, Veith RC, Becker KJ, Buzaitis
A, Cain KC, Fruin M, Tirschwell DL, and Teri L. Stroke. 2009; TBD.