Care Management of Poststroke Depression

Abstract

Background and Purpose— 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. Methods— 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 A ctivation of the patient to recognize depression symptoms and accept treatment, I nitiation of an antidepressant medication, and M onitoring 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. Results— 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. Conclusion— The Activate-Initiate-Monitor care management model is significantly more effective than usual care in improving depression outcomes in patients with poststroke depression.