Cognitive Behavioral Psychotherapy for Depression Following Stroke

If you need this it means your doctors and therapists have COMPLETELY FAILED at getting you 100% recovered. 

Cognitive Behavioral Psychotherapy for Depression Following Stroke

A Randomized Controlled Trial

N.B. Lincoln

and

T. Flannaghan

Originally published2 Dec 2002https://doi.org/10.1161/01.STR.0000044167.44670.55Stroke. 2003;34:111–115

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Abstract

Background and Purpose— There is inconclusive evidence of the effectiveness of psychological interventions for depression after stroke. We report the results from a randomized controlled trial of cognitive behavioral therapy (CBT).

Methods— Stroke patients admitted to hospital were invited to complete mood questionnaires 1, 3 and 6 months after stroke. Patients who were depressed were invited to take part in a trial and randomly allocated to receive CBT (n=39), an attention placebo intervention (n= 43), or standard care (n=41). Outcome assessments were undertaken at 3 and 6 months after recruitment, on the Beck Depression Inventory, Wakefield Depression Inventory, Extended Activities of Daily Living scale, London Handicap Scale, and a rating of satisfaction with care.

Results— There were no significant differences between the groups in patients’ mood, independence in instrumental activities of daily living, handicap, or satisfaction with care.

Conclusions— CBT in the treatment of depression following stroke was found to be ineffective in this study. However, because of the small sample size, method of recruitment, and selection criteria, further randomized trials are required.

Depressive disorders following stroke are common. Estimates of the frequency range from 25% to 79%,¹ with most studies indicating the rate being approximately 30%. Variation in prevalence appears to be the result of differing methods of assessment, classification, and screening instruments used. However, the consistent finding is that many people have low mood, which may require treatment. In theory, the principal treatments available for depression in the general population also apply to depressed stroke patients.² Antidepressant medication is often used,³ but concomitant drug therapies⁴ and adverse effects may also limit the extent to which antidepressant drugs are appropriate.

Few studies have considered the use of psychological interventions in the treatment of depression following stroke. Cognitive behavioral therapy (CBT) is an effective treatment of depression in the general population⁵ and in the elderly,⁶ and there is some indication that it may be effective for people with stroke. Lincoln et al⁷ compared a 4-week baseline period with 10 sessions of CBT and found that there was a tendency for improvement in mood. Of the 19 patients who received CBT, 4 patients consistently showed benefit, 6 showed some benefit, and 9 showed no benefit from treatment. The authors concluded that CBT reduced depression in some stroke patients and further evaluation was required. Others^3,8 have also reported single case studies that suggest that CBT may be useful for poststroke depression. Kemp et al⁹ investigated the effects of brief cognitive behavioral group psychotherapy for depression on 41 older adults with and without disabling illness. Older adults with disabling illness (n=18) included some people who had a stroke. Results indicated substantial decreases in depression, but the study did not include a control group.

The aim of the present study was to evaluate CBT as a treatment for depression following stroke. CBT requires a skilled therapist, but the effects observed in previous studies^3,7–9 could have resulted from simply having an interested and supportive therapist available to listen to problems. An attention placebo group was therefore included to enable the effect of additional therapist time and support to be separated from the specific effects of CBT.

Subjects and Methods

Patients admitted to hospital with a stroke were identified from a register. Sociodemographic details and date of onset were recorded from the medical notes. Patients were excluded from the study if they were blind, were deaf, did not speak English, had dementia documented in their medical records, had been treated for depression in the preceding 5 years, or lived outside the locality specified.

Patients living at home were sent a letter 1 month after the stroke asking them to complete and return 2 mood measures, the Beck Depression Inventory (BDI)¹⁰ and the Wakefield Self-Assessment of Depression Inventory (WDI).¹¹ The BDI was chosen as the main measure of mood, which would be sensitive to the effects of CBT. The WDI was also included because it has been used in other stroke rehabilitation studies,^6,7 which would enable comparisons to be made with previous work. Patients were also asked to complete the Barthel Index,¹² and those who scored <10 were excluded because they would be unlikely to be able to participate in the behavioral components of CBT.

For patients who were in hospital or were residing in care establishments, senior members of staff were telephoned and the Barthel was completed. Patients who had a Barthel score >10 were visited by an assistant psychologist, who administered the BDI and WDI verbally.

Patients who scored >10 on the BDI or >18 on the WDI were considered depressed and eligible for inclusion in the study. These patients were sent the London Handicap Scale (LHS),¹³ which has 6 dimensions (mobility, physical independence, occupation, social integration, orientation, and economic self-sufficiency), as a measure of handicap. They were also sent the Extended Activities of Daily Living (EADL) Scale,¹⁴ a measure of independence in activities of daily living. These were collected by an assistant psychologist at a visit. Patients were given a brief outline of the study, and verbal consent was obtained. The assistant psychologist administered the Sheffield Screening Test for Acquired Language Disorders¹⁵ to assess any communication problems. A satisfaction with care rating was obtained to get an overall impression of whether services met their needs. This comprised a visual analogue scale on which patients were requested to indicate by marking across a 10-cm line the percentage of satisfaction with services that they received, from 0% to 100%. Those who had problems understanding the request or in marking the paper were asked to give a verbal percentage, based on the same scale.

Patients were then visited by a research community psychiatric nurse (CPN), who obtained written consent. A semi-structured psychiatric interview was conducted using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN).¹⁶ Responses were entered directly on to a laptop computer program (CATEGO5) that provided a diagnostic classification using International Classification of Diseases, 10th Edition (ICD-10). The SCAN includes the Mini-Mental State Examination (MMSE)¹⁷ as a test of cognitive function. Patients were excluded from the study if they scored ≤23 on the MMSE.

Patients were then randomized to 1 of 3 groups. A computer-generated random number sequence was prepared in advance and sealed in opaque, consecutively numbered envelopes by an independent researcher. The random allocation was not stratified, as there was no prior information on variables likely to affect outcome. The CPN opened the envelopes in sequence, according to the patient number, to determine the intervention.

The three groups were defined as follows:

(1) No intervention (NI): Following randomization, patients in this group had no further contact with the research CPN.

(2) Attention placebo (AP): Patients in this group were offered 10 visits of one-hour duration for 3 months by the research CPN. No formal therapeutic intervention was offered. During the visits, the CPN had a conversation, which focused on day-to-day occurrences and discussion regarding the physical effects of stroke and life changes.

(3) Cognitive behavioral psychotherapy (CBT): Patients were offered 10 one-hour sessions of CBT by the same research CPN over 3 months. Treatment consisted of cognitive and behavioral techniques as used in the treatment of depression¹⁸ and were based on a manual produced from the pilot study.⁷ The techniques included education, graded task assignment, activity scheduling, and identification and modification of unhelpful thoughts and beliefs. Interventions were tailored to meet the individual’s needs.

Patients who did not complete the BDI and WDI at 1 month, were not depressed or were too disabled, scoring <11 on the Barthel Index were reviewed 3 months after stroke, and the same recruitment procedure followed. Those not included were similarly reviewed again 6 months after the stroke using the same procedure.

Outcome assessments were administered by an assistant psychologist, who was blind to the group allocation, 3 and 6 months after randomization. The primary outcome measures were the BDI and WDI, which were sent for patients to complete prior to a visit. The sample size had been calculated on the basis of the pilot study⁷ using these measures. The secondary outcome measures included the EADL scale, the LHS, and a rating of satisfaction with care.

Because the questionnaires used yielded ordinal data, nonparametric statistics were used. A Kruskal-Wallis 1-way ANOVA was performed to compare the 3 groups at each time point. The power calculation indicated that with a significance level of 0.05 and a power of 0.80 it would be possible to detect a difference of 5.3 points on the BDI and 4.7 points on the WDI with 40 patients in each group.

Results

There were 2533 patients admitted with stroke to the Nottingham hospitals between January 1995 and November 1997. Of these, 2361 had 1 stroke during the study period, 77 had 2 strokes, and 6 had 3 strokes. Therefore, the number of people admitted for stroke during the study period and eligible for inclusion was 2444. The recruitment is summarized in Figure 1.

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Figure 1. Recruitment and follow-up of patients. CBT indicates the cognitive behavioral therapy group.

In total, 123 patients were recruited into the study between 1 and 6 months following stroke and randomly allocated. Half the patients (n=61) were recruited at 1 month, 27 at 3 months, and 35 at 6 months after stroke. The distribution of treatment groups (NI, AP, CBT) was equivalent at all 3 time points of recruitment (1, 3, and 6 months) (χ²=2.3, P=0.7). The characteristics of the patients recruited are shown in Table 1.