Three-step program improves depression in stroke patients

Hospitalists could play an important role in educating patients and families.

Hospitalists and other physicians who care for stroke patients have long known that poststroke depression poses serious risks to long-term health, ranging from reduced functional recovery to increased rates of mortality and morbidity. Recent research suggests that an active care management program can help these patients recover.

Depression occurs in up to one-third of stroke patients and is a major risk factor for poststroke complications
Depression occurs in up to one-third of stroke patients and is a major risk factor for poststroke complications.

In the study, the largest ever randomized, controlled trial of a care management program for poststroke depression, researchers found that an active intervention program for depression achieves better response and remission rates than usual care. The trial, published in the Feb. 15, 2007, online edition of Stroke, used a three-step program called AIM to identify, educate and treat patients showing signs of depression between one and two months poststroke. AIM stands for:

  • Activation of the patient to recognize depression symptoms and accept treatment;
  • Initiation of an antidepressant medication; and
  • Monitoring and adjusting treatment.

Patients in the intervention group had significantly lower rates of depression after 12 weeks of treatment than did those in the control group, which received usual care.

“This is a very helpful study,” said Larry B. Goldstein, MD, director of the Duke Center for Cerebrovascular Disease and the Duke Stroke Center in Durham, N.C. “It underscores the need to have a systematic approach to recognition and treatment of poststroke depression. You have to be proactive, educating patients and their families about the symptoms of depression and getting them involved in their own care.”

Depression increases risk

Depression occurs in up to one-third of stroke patients and is a major risk factor for poststroke complications, experts agree.

“At least five independent studies have demonstrated that for people who have had exactly the same type of stroke—the same impairment, background, age and other factors related to recovery—those who have depression do not have the same levels of recovery of their activities of daily living than those who do not have depression,” said Robert G. Robinson, MD, professor and head of psychiatry at the University of Iowa in Iowa City and a leading expert on poststroke depression. Dr. Robinson's own research, as well as that of other teams, has also demonstrated that short-term cognitive impairment is worse in poststroke patients with depression than in those without.

Perhaps most concerning is the impact of depression on mortality. Patients with depression after a stroke—even mild depression—are more than twice as likely to die in the years following their stroke. “This has now been replicated in four separate, independent studies in Europe and the United States,” Dr. Robinson said.

Despite the high stakes, usual care for poststroke depression is fragmented at best, even though both the American Heart Association and the Department of Defense/Veterans Administration guidelines for stroke care suggest that stroke patients should be screened for depression.

“As far as I know, hospitals are currently not using standard screening tools to assess for depression in poststroke patients,” said Kurt Kroenke, MACP, a professor of medicine at Indiana University School of Medicine in Indianapolis and one of the authors of the Stroke study. “In a busy setting, where most of the care is medical, doctors may or may not spend time asking about depression. But if they do, there's pretty good evidence that even a single question can help. Simply asking the patient if they feel down or depressed has been shown in studies to pick up about 85% to 90% of cases.”

A role for hospitalists?

The AIM intervention study did not take place in the hospital setting; instead, patients were identified and educated, and treatment initiated, well after discharge—between one and two months poststroke. But some experts say that hospitalists can play an important role in early depression interventions.

“A study that we conducted showed that if you treat patients for depression following a stroke right away—within a month—you get significantly better physical recovery than if you wait a few months,” said Dr. Robinson, adding that if hospitalists initiated the AIM program or another hospital-based, organized intervention for stroke-related depression, it would likely improve outcomes. “The evidence we have indicates that the earlier you treat for poststroke depression, the better for recovery. In fact, we're now in the process of publishing a study that shows that giving antidepressants can prevent the development of depression in people who've had strokes.”

“Being attuned to depression even during hospitalization is important,” agreed Dr. Goldstein. “The education component, at least, should probably be done with all patients and families prior to discharge, when you know you'll have access to them.”

Actual clinical depression—as opposed to a more transitory depression after such a major illness, known as an “adjustment reaction”—can be hard to pinpoint in the hospital setting, said stroke specialist David Likosky, ACP Member, a hospitalist and neurohospitalist at Evergreen Hospital Medical Center in Kirkland, Wash. The average length of stay for a stroke patient is 5.2 days, according to the National Hospital Discharge Survey, which may be too short a window for a hospitalist to diagnose and initiate treatment for depression.

“But the activation portion of the study—the patient and family education piece—is particularly applicable to hospitalists,” Dr. Likosky said. “It gives the patient a heads up as to what they need to look for in signs of depression down the road. It's like postpartum depression: When we educate patients and their families in the hospital about what to look for, they're more likely to get help.”

At Evergreen and many other stroke programs, hospitalists are helping to develop education packets to send home with patients to reinforce many important discharge messages, including information about depression. “You have to address a lot of things quickly before the patient leaves the hospital, such as secondary prevention and the need to return to the hospital quickly if symptoms arise, so giving the patient something to take home with them and refer back to helps them to absorb the message,” Dr. Likosky said.

It's also important for hospitalists to identify any early signs of depression in discharge notes for poststroke patients, noted Dr. Likosky. “Transition of care is a major role for the hospitalist,” he said. “We may be able to spend more time with the patient in the hospital than the primary care physician or neurologist can during a follow-up visit, so setting the stage as best we can will go a long way toward improving patient care.”

“It would be ideal, when hospitalists observe depression symptoms and they're not sure if it's an adjustment reaction or genuine depression, if they both include it in their discharge notes and mention to the patient and family that these are symptoms to monitor, just like shortness of breath or chest pain,” said Linda Williams, MD, chief of neurology at the Roudebush VA Medical Center in Indianapolis, research coordinator of the VA Stroke QUERI Center and lead author of the Stroke study.

The next step, experts say, is determining whether successfully treating poststroke depression actually makes a difference in recovery. “That's the big question,” said Dr. Williams. It wasn't part of the original article published in Stroke, but the study authors are now analyzing that data from the clinical trial and expect to have results within the next few months.

“To date, there isn't much data on that,” Dr. Williams noted, “but our study will be able to try to address whether treating depression actually results in better functional outcome.”