Care Management of Poststroke Depression A Randomized, Controlled Trial
ABSTRACT Poststroke depression is a prevalent and disabling disorder, yet evidence regarding the effectiveness of treating poststroke depression is inconclusive. Our objective was to determine the effectiveness of the Activate-Initiate-Monitor care management program for the treatment of poststroke depression.
We conducted a prospective, randomized, outcome-blinded trial in 188 ischemic stroke survivors identified at the time of admission to one of 4 Indianapolis hospitals. Depression screening and enrollment occurred between 1 and 2 months poststroke. The Activate-Initiate-Monitor intervention was a care management program that included Activation of the patient to recognize depression symptoms and accept treatment, Initiation of an antidepressant medication, and Monitoring and adjusting treatment. Usual care subjects received nondepression-related education and were prescribed antidepressants at the discretion of their provider. The primary outcome measure was depression response, defined as a Hamilton Depression Inventory score <8 (remission) or a decrease from baseline of at least 50% at 12 weeks.
Intervention and usual care groups did not differ on any key baseline measures. Both depression response (51% versus 30%, P=0.005) and remission (39% versus 23%, P=0.01) were more likely in the Activate-Initiate-Monitor intervention than in the usual care group. This difference in depression scores was present by 6 weeks and persisted through the 12-week assessment. Serious adverse events did not differ between the 2 groups.
The Activate-Initiate-Monitor care management model is significantly more effective than usual care in improving depression outcomes in patients with poststroke depression.
- SourceAvailable from: Malaz Boustani[Show abstract] [Hide abstract]
ABSTRACT: The purpose of this article is to describe our experience in implementing a primary care-based dementia and depression care program focused on providing collaborative care for dementia and late-life depression. Capitalizing on the substantial interest in the US on the patient-centered medical home concept, the Aging Brain Care Medical Home targets older adults with dementia and/or late-life depression in the primary care setting. We describe a structured set of activities that laid the foundation for a new partnership with the primary care practice and the lessons learned in implementing this new care model. We also provide a description of the core components of this innovative memory care program. Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. We used the reflective adaptive process as a relationship building framework that recognizes primary care practices as complex adaptive systems. This framework allows for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic as well as by information technology resources. We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems.Aging and Mental Health 10/2010; 15(1):5-12. DOI:10.1080/13607861003801052
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ABSTRACT: To serve as a conceptual map of the role of new interventions designed to reduce the burden of late-life depression. We identified three needs to be addressed by intervention research: (1) the need for novel interventions given that the existing treatments leave many older adults depressed and disabled; (2) the need for procedures enabling community-based agencies to offer interventions of known efficacy with fidelity; and (3) the need to increase access of depressed older adults to care. Our model orders novel interventions according to their role in serving depressed older adults and according to their position in the efficacy, effectiveness, implementation, and dissemination testing continuum. We describe three interventions designed by our institute to exemplify intervention research at different level of the model. A common element is that each intervention personalizes care both at the level of the individuals served and the level of community agencies providing care. To this end, each intervention is designed to accommodate the strengths and limitations of both patients and agencies and introduces changes in the patients' environment and community agencies needed in order to assimilate the new intervention. We suggest that this model provides conceptual guidance on how to shorten the testing cycle and bring urgently needed novel treatments and implementation approaches to the community. While replication studies are important, propose that most of the support should be directed to those projects that take rational risks, and after adequate preliminary evidence, make the next step along the testing continuum.International Journal of Geriatric Psychiatry 12/2009; 24(12):1325-34. DOI:10.1002/gps.2287
Article: 18. Post-Stroke Depression[Show abstract] [Hide abstract]
ABSTRACT: Key Points Depression is a common complication post-stroke affecting approximately one-third of patients. The risk factors associated with increased risk for post-stroke depression (PSD) include female sex, past history of depression or psychiatric illness, functional limitations, and cognitive impairment. Despite an abundance of research, the influence of stroke location on the risk for developing post-stroke depression has not been determined. Detection and diagnosis of post-stroke depression is often inconsistent and compliance with guidelines for screening is poor. Identified barriers to routine screening include time pressures and concerns about screening tools. Depression post-stroke has a negative impact on functional recovery. Post-stroke depression impacts negatively upon social activity and vice versa. Post-stroke depression is associated with cognitive impairment. The presence of mental health disorders post stroke is associated with increased risk for mortality. Early initiation of antidepressant therapy in non-depressed individuals is effective in preventing post-stroke depression. Ongoing, individualized contact and support may reduce the risk for deterioration of psychological health following stroke. Heterocyclic antidepressants improve post-stroke depression. SSRI antidepressants are effective in the treatment of post-stroke depression. Further study is required. Bright light therapy may be an effective adjunct to treatment with SSRI antidepressants. The Evidence-Based Review of Stroke Rehabilitation (EBRSR) reviews current practices in stroke rehabilitation.