At least 11,000 veterans have a stroke each year. Post-stroke depression (PSD) occurs in 25-40% of ischemic stroke survivors and is associated with worse functional outcomes and increased post-stroke mortality. Although effective treatments for PSD exist, studies suggest that PSD is often underdiagnosed and undertreated. The VA has successfully implemented interventions to improve depression detection in primary care, but to date no efforts have been specifically targeted toward improving the detection and treatment of PSD.
The primary aim of the study was to conduct a two-site, quasi-experimental design study to evaluate the effectiveness of a system intervention in improving the proportion of veterans screened and treated for PSD. The system intervention was based on extending the current depression performance measure that mandates yearly CPRS-based depression screening in VA primary care (PC) clinics to target veteran stroke survivors a) following-up in PC within six months of stroke, and b) following-up in VA PC or Neurology clinics. The secondary aim of the study was to evaluate whether a patient-based self-management intervention provides additional benefit beyond the system intervention alone in improving guideline-adherent treatment of depression and improves patient depression symptoms, quality of life, and self-efficacy compared to usual post-stroke care.
The study was approved by all local IRB and R&D committees at the two intervention sites. In Aim 1, clinical improvement teams were formed at each site to focus on adapting the PC annual depression screening reminder for PSD. Each site developed a PSD screening reminder and a treatment reminder for those that screened positive. The reminders had elements common to the Chronic Care Model but also were tailored to each site. The reminders were implemented and ongoing feedback about use was provided to the clinic staff during the study period. PSD screening and treatment rates for the study period and the pre-intervention period were assessed by standardized chart review. Temporal trend data for depression diagnosis and treatment were obtained from national administrative inpatient and outpatient treatment files for all stroke admissions at non-intervention facilities in the two VISNs.
In Aim 2, the self-management program was developed with a menu of topics in a 6-session format delivered over 3 months. Veterans from both sites were enrolled in Aim 2 and randomized to intervention vs. control at or within 3 weeks of stroke discharge. Primary outcome was depression symptoms at 6 months with secondary outcomes including self-efficacy, self-management behaviors, and quality of life.
We compared subject-level depression screening and (for those that screened positive) treatment rates between the study and the pre-intervention periods using odds ratios accompanied by 95% confidence intervals and Chi-square tests. We used multivariate logistic regression to model odds of PSD screening and treatment. Temporal trend data for depression diagnosis and treatment were similarly compared for non-intervention facilities. We evaluated the self-management intervention by comparing changes from baseline to follow-up between intervention and control subjects using two sample t-tests and, where appropriate, linear models adjusting for baseline score.
The Aim 1 cohort included 278 veterans during the intervention period and 374 during the control period. PSD screening increased during the intervention period at both sites: 61% to 87% and 46% to 82%; combined odds of screening of 6.2 (4.2, 9.3), p < 0.001. At least one positive screening was observed in 42% of the cohort during 6 months of follow-up. PSD treatment among those screening positive also increased (combined increase of 73% to 83%, OR 1.8 (0.8, 3.9), p 0.13. Odds of PSD screening were decreased slightly with age, were different by site, and increased with the intervention period (model C-statistic 0.73). Odds of PSD treatment were increased in the intervention period and decreased among black veterans (model C-statistic 0.68). Among 63 subjects enrolled in Aim 2, intervention subjects did not have a significant decrease in depression symptoms compared to control subjects, but intervention subjects had increased self-efficacy for communicating with their physician, reported increased time spent in aerobic activity, and demonstrated increased QOL scores.
Automated depression screening targeting a high-risk group in both PC and specialty care can be accomplished in the outpatient setting and can improve detection of PSD. PSD treatment may also be enhanced by the use of an automated treatment reminder although further evaluation of the impact of the treatment reminder and consideration of other mechanisms to reduce disparities in depression treatment is needed. Participation in a self-management program post-stroke may improve patient self-efficacy for communicating with providers and may promote healthy behavior change and increased QOL post-stroke.
- Damush TM, Ofner S, Yu Z, Plue L, Nicholas G, Williams LS. Implementation of a stroke self-management program: A randomized controlled pilot study of veterans with stroke. Translational behavioral medicine. 2011 Dec 1; 1(4):561-72.
- Damush TM, Jackson GL, Powers BJ, Bosworth HB, Cheng E, Anderson J, Guihan M, LaVela S, Rajan S, Plue L. Implementing evidence-based patient self-management programs in the Veterans Health Administration: perspectives on delivery system design considerations. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:68-71.
- Damush TM, Plue L, Bakas T, Schmid A, Williams LS. Barriers and facilitators to exercise among stroke survivors. Rehabilitation Nursing : The Official Journal of The Association of Rehabilitation Nurses. 2007 Nov 1; 32(6):253-60, 262.
- Damush TM. Implementation of Patient Self-Management Programs among Veterans in VA. Presented at: VA QUERI National Meeting; 2009 Dec 12; Phoenix, AZ.
- Damush T, Plue L, Schmid A, Kent TA, Anderson JA, Murphy C, Kimmel B. Adapting Secondary Stroke Prevention Programs to Local Resource Structures and Front Line Input. Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2009 Feb 17; San Diego, CA.
- Damush TM, Williams LS, Plue LD. Piloting a Depression Screening Reminder to Improve Quality of Care for Post-Stroke Depression. Poster session presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ.
- Damush TM, Williams LS. Development of a Post-Stroke Self-Management Program. Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2008 May 2; Baltimore, MD.
- Damush TM, Williams LS. Development of a Post-stroke Self-management Program. Presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2008 Mar 27; San Diego, CA.
- Damush M, Schmid , Williams S. A Qualitative Analysis of Stroke Survivor's Barriers, Facilitators and Preferences for Physical Activity and Self-Management. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2007 Feb 8; San Francisco, CA.
- Damush TM, Jia H, Ried LD, Qin H, Cameon R, Plue L, Williams LS. Case-Finding Algorithm for Post Stroke Depression in the Veterans Health Administration. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2007 Feb 8; San Francisco, CA.
- Damush TM, Williams LS. Stroke Risk Factors and Readiness to change: Is Stroke a Teachable Moment? Poster session presented at: VA QUERI National Meeting; 2004 Dec 2; Washington, DC.
Aging, Older Veterans' Health and Care, Health Systems
Treatment - Observational
Depression, PTSD, Stroke