Advertisement

Augmented Cognitive Behavioral Therapy for Poststroke Depressive Symptoms: A Randomized Controlled Trial

Published:November 12, 2016DOI:https://doi.org/10.1016/j.apmr.2016.10.013

      Abstract

      Objective

      To evaluate the effectiveness of individually tailored cognitive behavioral therapy (CBT) for reducing depressive symptoms with or without anxiety poststroke.

      Design

      Multicenter, assessor-blinded, randomized controlled trial.

      Setting

      Ambulatory rehabilitation setting.

      Participants

      Patients who had a Hospital Anxiety and Depression Scale-depression subscale (HADS-D) score >7 at least 3 months poststroke (N=61).

      Interventions

      Participants were randomly allocated to either augmented CBT or computerized cognitive training (CCT). The CBT intervention was based on the principles of recognizing, registering, and altering negative thoughts and cognitions. CBT was augmented with goal-directed real-life activity training given by an occupational or movement therapist.

      Main Outcome Measures

      HADS-D was the primary outcome, and measures of participation and quality of life were secondary outcomes. Outcome measurements were performed at baseline, immediately posttreatment, and at 4- and 8-month follow-up. Analysis was performed with linear mixed models using group (CBT vs CCT) as the between-subjects factor and time (4 assessments) as the within-subjects factor.

      Results

      Mixed model analyses showed a significant and persistent time effect for HADS-D (mean difference, −4.6; 95% confidence interval, −5.7 to −3.6; P<.001) and for participation and quality of life in both groups. There was no significant group × time effect for any of the outcome measures.

      Conclusions

      Our augmented CBT intervention was not superior to CCT for the treatment of mood disorders after stroke. Future studies should determine whether both interventions are better than natural history.

      Keywords

      List of abbreviations:

      CBT (Cognitive behavioral therapy), CCT (Computerized cognitive training), CI (Confidence interval), HADS-D (Hospital Anxiety and Depression Scale-depression subscale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hackett M.L.
        • Pickles K.
        Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies.
        Int J Stroke. 2014; 9: 1017-1025
        • Ayerbe L.
        • Ayis S.
        • Crichton S.
        • Wolfe C.D.
        • Rudd A.G.
        The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register.
        J Neurol Neurosurg Psychiatry. 2013; 85: 514-521
        • Mottram P.
        • Wilson K.
        • Strobl J.
        Antidepressants for depressed elderly.
        Cochrane Database Syst Rev. 2006; : CD003491
        • Coupland C.A.
        • Dhiman P.
        • Barton G.
        • et al.
        A study of the safety and harms of antidepressant drugs for older people: a cohort study using a large primary care database.
        Health Technol Assess. 2011; 15 (iii-iv): 1-202
        • Gainotti G.
        • Marra C.
        Determinants and consequences of post-stroke depression.
        Curr Opin Neurol. 2002; 15: 85-89
        • Hackett M.L.
        • Anderson C.S.
        • House A.O.
        Management of depression after stroke: a systematic review of pharmacological therapies.
        Stroke. 2005; 36: 1098-1103
        • Cuijpers P.
        Prevention of depression in chronic medical disorders: a pilot study.
        Psychol Rep. 1988; 82: 735-738
        • Broomfield N.M.
        • Laidlaw K.
        • Hickabottom E.
        • et al.
        Post-stroke depression: the case for augmented, individually tailored cognitive behavioural therapy.
        Clin Psychol Psychother. 2011; 18: 202-217
        • Hackett M.L.
        • Anderson C.S.
        • House A.O.
        • Xia J.
        Interventions for treating depression after stroke.
        Cochrane Database Syst Rev. 2008; : CD003437
        • Lincoln N.B.
        • Flannaghan T.
        Cognitive behavioral psychotherapy for depression following stroke: a randomized controlled trial.
        Stroke. 2003; 34: 111-115
        • De Wit L.
        • Putman K.
        • Baert I.
        • et al.
        Anxiety and depression in the first six months after stroke. A longitudinal multicentre study.
        Disabil Rehabil. 2008; 30: 1858-1866
        • Wilkinson P.R.
        • Wolfe C.D.
        • Warburton F.G.
        • et al.
        A long-term follow-up of stroke patients.
        Stroke. 1997; 28: 507-512
        • Rasquin S.M.
        • Van De S.P.
        • Praamstra A.J.
        • van Heugten C.M.
        Cognitive-behavioural intervention for depression after stroke: five single case studies on effects and feasibility.
        Neuropsychol Rehabil. 2009; 19: 208-222
        • Kootker J.A.
        • Rasquin S.M.
        • Smits P.
        • Geurts A.C.
        • van Heugten C.M.
        • Fasotti L.
        An augmented cognitive behavioural therapy for treating post-stroke depression: description of a treatment protocol.
        Clin Rehabil. 2014; 29: 833-843
        • Kootker J.A.
        • Fasotti L.
        • Rasquin S.M.
        • van Heugten C.M.
        • Geurts A.
        The effectiveness of an augmented cognitive behavioural intervention for post-stroke depression with or without anxiety (PSDA): the Restore4Stroke-PSDA trial.
        BMC Neurol. 2012; 12: 51
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Aben I.
        • Verhey F.
        • Lousberg R.
        • Lodder J.
        • Honig A.
        Validity of the beck depression inventory, hospital anxiety and depression scale, SCL-90, and hamilton depression rating scale as screening instruments for depression in stroke patients.
        Psychosomatics. 2002; 43: 386-393
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Meyer B.C.
        • Lyden P.D.
        The modified National Institutes of Health Stroke Scale: its time has come.
        Int J Stroke. 2009; 4: 267-273
        • Collin C.
        • Wade D.T.
        • Davies S.
        • Horne V.
        The Barthel ADL Index: a reliability study.
        Int Disabil Stud. 1988; 10: 61-63
        • Eriksson G.
        • Chung J.
        • Beng L.
        • et al.
        Occupations of older adults: a cross cultural description.
        OTJR (Thorofare N J). 2011; 31: 182-192
      1. van Erp J. Relaxation exercises (ontspanningsoefeningen; bodyscan, aandacht voor uw lichaam). De hart&vaatgroep; 2010.

        • Judd T.
        Neuropsychotherapy and community integration; brain illness, emotions and behaviour.
        Kluwer Academic/Plenum Publishers, New York1999
        • Spikman J.M.
        • Boelen D.H.
        • Lamberts K.F.
        • Brouwer W.H.
        • Fasotti L.
        Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life.
        J Int Neuropsychol Soc. 2010; 16: 118-129
        • Duncan P.W.
        • Wallace D.
        • Lai S.M.
        • Johnson D.
        • Embretson S.
        • Laster L.J.
        The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change.
        Stroke. 1999; 30: 2131-2140
        • Giaquinto S.
        Comorbidity in post-stroke rehabilitation.
        Eur J Neurol. 2003; 10: 235-238
        • Gainotti G.
        • Azzoni A.
        • Razzano C.
        • Lanzillotta M.
        • Marra C.
        • Gasparini F.
        The Post-Stroke Depression Rating Scale: a test specifically devised to investigate affective disorders of stroke patients.
        J Clin Exp Neuropsychol. 1997; 19: 340-356
        • Bode C.
        • Thoolen B.
        • de Ridder D.
        [Measuring proactive coping. Psychometric characteristics of the Utrecht Proactive Coping Competence scale (UPCC)] [Dutch].
        Psychol Gezond. 2008; 36: 81-91
        • Post M.W.
        • Boosman H.
        • van Zandvoort M.M.
        • Passier P.E.
        • Rinkel G.J.
        • Visser-Meily J.M.
        Development and validation of a short version of the Stroke Specific Quality of Life Scale.
        J Neurol Neurosurg Psychiatry. 2011; 82: 283-286
        • Post M.W.
        • van der Zee C.H.
        • Hennink J.
        • Schafrat C.G.
        • Visser-Meily J.M.
        • van Berlekom S.B.
        Validity of the utrecht scale for evaluation of rehabilitation-participation.
        Disabil Rehabil. 2012; 34: 478-485
        • van Koppenhagen C.F.
        • Post M.W.
        • van der Woude L.H.
        • et al.
        Recovery of life satisfaction in persons with spinal cord injury during inpatient rehabilitation.
        Am J Phys Med Rehabil. 2009; 88: 887-895
        • Hoop de E.
        Efficient designs for cluster randomized trials with small numbers of clusters; stepped wedge and other repeated measurements designs [dissertation].
        Radboud University Medical Centre, Nijmegen2014
        • Lincoln N.B.
        • Flannaghan T.
        • Sutcliffe L.
        • Rother L.
        Evaluation of cognitive behavioural treatment for depression after stroke: a pilot study.
        Clin Rehabil. 1997; 11: 114-122
        • Eriksen S.
        • Gay C.L.
        • Lerdal A.
        Acute phase factors associated with the course of depression during the first 18 months after first-ever stroke.
        Disabil Rehabil. 2015; 38: 30-35
        • van Mierlo M.L.
        • van Heugten C.M.
        • Post M.W.
        • Hajos T.R.
        • Kappelle L.J.
        • Visser-Meily J.M.
        Quality of life during the first two years post stroke: The Restore4Stroke Cohort Study.
        Cerebrovasc Dis. 2016; 41: 19-26
        • Akerlund E.
        • Esbjornsson E.
        • Sunnerhagen K.S.
        • Bjorkdahl A.
        Can computerized working memory training improve impaired working memory, cognition and psychological health?.
        Brain Inj. 2013; 27: 1649-1657
        • Blomer A.M.
        • van Mierlo M.L.
        • Visser-Meily J.M.
        • van Heugten C.M.
        • Post M.W.
        Does the frequency of participation change after stroke and is this change associated with the subjective experience of participation?.
        Arch Phys Med Rehabil. 2015; 96: 456-463
        • Hughes-Morley A.
        • Young B.
        • Waheed W.
        • Small N.
        • Bower P.
        Factors affecting recruitment into depression trials: systematic review, meta-synthesis and conceptual framework.
        J Affect Disord. 2015; 172: 274-290