Taking AIM at post-stroke depression

February 16, 2007

INDIANAPOLIS - Activating patients and developing a monitoring and evaluation system was highly effective in ending or reducing post-stroke depression in patients enrolled in the largest randomized clinical trial to date for this prevalent and disabling consequence of stroke.

Researchers from the Richard L. Roudebush Veterans Administration Medical Center, the Regenstrief Institute and the Indiana University School of Medicine report in the March issue of the journal Stroke, that AIM, a new straight-forward care management program is significantly more effective than usual care, which often focuses solely on antidepressants, in improving depression in stroke survivors.

"Post-stroke depression, which may be the result of a combination of chemical changes in the brain that impair its ability to repair itself as well as functional changes which inhibit social interaction and activity, occurs in about a third of all stroke survivors," said Linda Williams, M.D., associate professor of neurology and a Regenstrief Institute research scientist, who led the study. "Depression after stroke is associated with higher death rates, diminished recovery, increased risk for subsequent stroke and other cardiovascular incidents, and greater health-care utilization." Dr. Williams is chief of neurology at the Roudebush VA Medical Center.

AIM consists of three steps: activating stroke survivors and their families to understand and accept depression diagnosis and treatment; initiating antidepressant medication and monitoring treatment effectiveness.

Thirty-nine percent of AIM patients had complete remission from depression after 12 weeks of treatment as compared with only 23 percent who achieved complete remission with usual care. "That's an impressive difference," says Dr. Williams. "That means that for every 6 or 7 patients you treat with care management, you will have one patient whose depression will completely go away. That's a larger treatment effect compared to other commonly used medical treatments."

A similar magnitude of absolute difference, about 16 percent, was seen in patients whose depression symptoms improved substantially but did not completely end. Forty-four percent of the care management group had reduction of depression symptoms, compared with only 29 percent in the usual care group.

AIM, the new three-part post-stroke depression care management program developed by Dr. Williams and the study co-authors, was administered by nurse care managers under the supervision of physicians. An advantage of the program is that it can be conducted by social workers, nurse practitioners or other providers, and can largely be delivered by telephone.

The randomized study followed 188 ischemic stroke survivors in four Indianapolis hospitals. Ischemic stroke, where blood vessels are blocked, accounts for 85 percent of all strokes. Depression screening occurred within 30 to 60 days post-stroke rather than immediately after the event because emotional changes which occur soon after stroke, called an adjustment reaction, may not develop into depression.

Given the prevalence and often devastating impact of post-stroke depression, the study authors call for physicians to consider active depression screening in this high-risk group.

Dr. Williams and colleagues are currently conducting a follow-up study in two VA facilities which physicians are electronically reminded to administer a depression screening to stroke survivors, and if the results indicate that the patient is depressed, are prompted to initiate and monitor treatment.
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The Stroke study was funded by the National Institute of Neurological Disorders and Stroke.

In addition to Dr. Williams, co-authors of the study are Kurt Kroenke, M.D.; Wanzhu Tu, Ph.D.; and Hugh Hendrie, MB, ChB all of the IU School of Medicine and the Regenstrief Institute; Laurie Plue, M.S., of the Roudebush VA Medical Center; Tamilyn Bakas, D.N.S., of the IU School of Nursing; and Ed Brizendine, M.D. of the IU School of Medicine. The IU schools of medicine and nursing are located at Indiana University-Purdue University Indianapolis, an urban research and academic health sciences campus, with 22 schools and academic units.

Indiana University

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