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The Stroke Outcome Study - a randomised controlled trial of psychological treatment
Depressed mood is a common problem after stroke- it affects quality of life and potentially effects rehabilitation outcomes - but there are few good studies to inform decisions on the best way to intervene or prevent it. The antidepressant trials are small, and the trials of psycho-social interventions do not show any consistent benefits. As a result, Professor Allan House and colleagues were funded through the NHS R&D programme to evaluate the effect of a brief psychological intervention, given to stroke patients (and carers) after discharge. We assessed its effects on psychological distress, major depression, social activities, carer outcomes and satisfaction. We also conducted an economic analysis - to find out what the therapy cost, as well as what it did.
The psychological intervention was evaluated within an RCT, by comparing it with treatment-as-usual and non-specific support from volunteer visitors. The intervention was a form of problem-solving therapy, structured into 6 sessions within a manual. The aim of the therapy was to teach problem-solving skills, to help patients and carers to cope with stroke's consequences. The therapists, both psychiatric nurses, aimed to see patients every fortnight.
The volunteer visitors were given
brief training in the effects of stroke and were asked to
visit patients 6-8 times. About half the volunteers had personal
or family experience of stroke.
During 1995-97 we screened 1400 living patients from Leeds
and Bradford hospitals within 1 month of stroke, to assess
fitness to participate (including sufficient speech &
cognition). At the baseline interview around 20% of the 448
recruited patients were rated as depressed. After interview
patients were randomised to one of the 3 strands.
At 6 months follow-up there was no difference between patients in the three groups in levels of psychological distress or rates of depression, although there were trends for lower rates in the therapy group. Patients in the therapy group were more satisfied with aspects of post-discharge care. There were no differences between carers in the three groups in carer strain or psychological distress. Carers in the problem-solving group were more satisfied with three aspects of care.
At 12 months follow-up patients
in the three groups had similar levels of social activity
and disability. Patients in the problem-solving group had
lower psychological distress scores (p<.05) and fewer cases
of major depression (not statistically significant). The median
distress score (GHQ-28) in therapy patients was 1 point lower
than in the volunteer group and 2 points lower then in the
treatment-as-usual group. Therapy group patients were more
satisfied with several aspects of their care. There were no
differences between carers in the three groups in carer strain
or distress, but carers in the therapy group were more satisfied
with one aspect of care. We followed up over 90% of living
patients, and more patients in the therapy group refused.
The economic analysis involved compiling data on all services
used by the patient after discharge. These included the GP,
community health services, social service input, residential
care costs and re-admission to hospital. It also included
the cost of the interventions (CPN + supervision for therapy,
travel expenses and average wage for the volunteers). Therapy
reduced distress, but was more expensive than the other 2
groups. A cost-effectiveness analysis showed that, compared
with volunteers, problem-solving therapy was £1200 per
person more expensive with a mean improvement of 1.3 GHQ points.
Whether this additional cost is worth paying, is a decision
for the purchaser.
The results are encouraging.
We have shown that a short-term psychological treatment is
acceptable to most stroke patients and can be effective in
reducing psychological distress. No effect was found in carers,
although many were absent from the therapy sessions. We hope
that others will want to evaluate problem-solving therapy
in stroke. A multi-centre trial would answer some of the questions
left by this study. We are equally keen to evaluate the training
and supervision of other staff in using the therapy manual.
Please contact Peter Knapp for further details of the study's
methods and findings.
Peter Knapp, Lecturer, School of Healthcare Studies, University
of Leeds [0113 392 6737; p.r.knapp@leeds.ac.uk ]
