Antidepressant, Behavioral Tx May Ease Poststroke Depression

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.