We propose to study the efficacy of """"""""Ecosystem Focused Therapy"""""""" (EFT) in post-stroke depression (PSD), a disorder that afflicts a large number of stroke victims and increases mortality, cognitive impairment, and disability for years after stroke. EFT is a new, home-delivered intervention based on our integrative model of PSD, which originated from our clinical biology and treatment studies in late-life depression. It postulates two main paths to PSD. First, stroke and stroke-repair mechanisms contribute to metabolic changes mediating PSD. Second, a """"""""psychosocial storm"""""""" stemming both from the patient's sudden disability and the change in the patient's needs and family life add a biological burden to this cascade of depressogenic events. EFT targets the """"""""psychosocial storm"""""""" of PSD and focuses on the reciprocal interaction between the patient's abilities and the challenges of his/her """"""""ecosystem"""""""" (family, specialized therapists). EFT follows a structured personalization approach based on the """"""""model of adaptive functioning"""""""", in which behavior is a function of the person's competence and the demands of the environment. Thus, EFT continuously """"""""calibrates the environment"""""""" to the PSD patient's competence level and targets the PSD """"""""psychosocial storm"""""""" through five integrated components: 1) It offers an action-oriented, """"""""new perspective"""""""" about the patient's recovery. 2) It provides an """"""""adherence enhancement structure"""""""". 3) It offers a """"""""problem solving structure"""""""" to the patient focusing on problems, valued by the patient, and pertinent to daily function. 4) It helps the family """"""""reengineer its goals, involvement, and plans"""""""" o accommodate the patient's disability. 5) It """"""""coordinates care with specialized therapists"""""""" with the goal to increase patient participation in rehabilitation and social activities. We will recruit 160 PSD patients within 3 months after stroke and randomly assign them to 10 weekly sessions and 4 """"""""booster"""""""" sessions (over 1 year) of EFT or a comparison condition (Education on Stroke and Depression;ESD) both administered by trained social workers (MSW). Our Primary Hypotheses state that: Over a period of 12 weeks, EFT will lead to greater reduction than ESD in: H1) severity of depression;and H2) disability. Our Secondary Hypotheses postulate that: SH1) EFT will lead to higher remission (HAM-Dd10) rates than ESD by 12 weeks;and SH2) EFT participants will have lower scores of depression and disability and higher scores in quality of life than ESD at 26 and 52 weeks. Exploratory Analyses will examine whether disability and depression mediate the effect of each other and whether """"""""self-efficacy"""""""", """"""""behavioral activation"""""""", and adherence to rehabilitation recommendations and/or antidepressants mediate change in depression and disability. We will also explore whether clinical features of PSD and serotonin transporter genotypes moderate the efficacy of ESD.

Public Health Relevance

This study proposes to investigate the efficacy of a novel, home-delivered, psychosocial intervention in reducing depression and disability in depressed stroke survivors. The intervention is designed to enable patients to develop a new perspective and adaptation skills and to change their ecosystem (family, specialized therapists) so as to accommodate the patients'new state. This way, the new intervention can offer an optimal chance at adaptation, by promoting the patients'adherence to rehabilitation and by increasing their sense of competence and their engagement in valued activities.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Interventions Committee for Adult Disorders (ITVA)
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Niederehe, George T
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Weill Medical College of Cornell University
Schools of Medicine
New York
United States
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Avari, Jimmy N; Alexopoulos, George S (2015) Models of care for late-life depression of the medically ill: examples from chronic obstructive pulmonary disease and stroke. Am J Geriatr Psychiatry 23:477-87
Grinspan, Zachary M; Abramson, Erika L; Banerjee, Samprit et al. (2014) People with epilepsy who use multiple hospitals; prevalence and associated factors assessed via a health information exchange. Epilepsia 55:734-45
Morimoto, Sarah Shizuko; Alexopoulos, George S (2013) Cognitive deficits in geriatric depression: clinical correlates and implications for current and future treatment. Psychiatr Clin North Am 36:517-31
Alexopoulos, George S; Wilkins, Victoria M; Marino, Patricia et al. (2012) Ecosystem focused therapy in poststroke depression: a preliminary study. Int J Geriatr Psychiatry 27:1053-60