LONDON – People with aphasia and low mood after a stroke can benefit from behavioral therapy, the results of a multicenter, randomized controlled trial suggested.

In the Communication and Low Mood (CALM) study, patients who were in the behavioral therapy group reported better mood, as measured by the 21-item hospital version of the Stroke Aphasic Depression Questionnaire (SADQ) at both 3 and 6 months’ follow-up. Mean SADQ scores in the behavioral therapy versus the usual care arm were 16.9 and 19.2 at 3 months (P less than .05) and 17.4 and 21.9 at 6 months (P = .002), with a lower score indicating a better level of mood.

Depression is estimated to affect up to a third of patients after a stroke and can have detrimental effects on patients’ rehabilitation. It can cause psychological distress for patients and caregivers and is linked to higher mortality.

"People with aphasia may be particularly susceptible to depression, but they are often excluded from research," Dr. Shirley Thomas said at the annual European Stroke Conference.

Dr. Thomas of the Institute of Work, Health, and Organisations at the University of Nottingham (England) noted that few studies have looked at the use of psychological interventions for depression after a stroke. The studies that have been conducted have typically excluded people with aphasia because the interventions are often talk based and require good communication skills.

"Behavioral therapy is quite a practical and concrete approach that doesn’t require intact communication skills," Dr. Thomas said. She explained that it "is based on a behavior model of depression, the idea being that people develop depression because they are not getting positive reward and reinforcement from their environment." This "fits" with having aphasia following a stroke, she commented.

The aim of the CALM study, therefore, was to compare usual care alone with usual care plus the addition of a behavioral intervention to address low mood in patients with aphasia.

A total of 511 patients who had aphasia after a stroke were screened for signs of depression, with 105 identified as having "low mood" and consenting to participate in the trial. The mean age of the enrolled patients was 67 years and 63% were men. The trial began a median of 9 months after a stroke.

The behavioral therapy involved one-on-one sessions between a patient and a psychologist in the patient’s home, with up to 20 sessions occurring over a period of 3 months. Each session lasted for 1 hour and included patient education, which involved asking patients how they spent their time, identifying mood-lifting activities, scheduling these activities into each week, helping patients break down large tasks into graded steps, and giving people tasks to complete before the next session. Therapy was tailored to patients’ needs and guided by a manual specifically designed for the trial, which outlined all the various methods that could be used.

Two main instruments were used to assess patients’ mood in the trial: the SADQ and the ‘sad’ item of the Visual Analog Mood Scales (VAMS). Other measures used included the Visual Analog Self-Esteem Scale (VASES) and the Nottingham Leisure Questionnaire (NLQ).

When the VAMS was used, behavioral therapy was associated with significantly better mood at 3 months (P = .033) but not at 6 months. VASES scores were higher at 3 months in the behavioral therapy group than in those who got usual care, indicating better self-esteem, although results did not remain significant at 6 months. The results from the NLQ showed no significant differences between the groups.

A similar percentage of patients in the behavioral therapy and usual care groups took antidepressants (29% and 26%), so the differences that were seen in favor of behavioral therapy are not influenced by the use of these drugs, Dr. Thomas said.

"Overall, we found that the behavioral approaches [used] were appropriate and could be used in patients with aphasia," Dr. Thomas said. "This is important because this is a group of patients that are usually excluded from psychological interventions for mood problems," she added.

"Behavioral therapy appears to be promising, but going forward we need to look in more detail at the duration and content of treatment," Dr. Thomas said. It was unclear when the trial started how many sessions might be needed – no patient actually needed 20 sessions and most received about 10. An intervention period longer than 3 months might be better to integrate behavioral therapy into clinical practice and to ensure the effects are sustained, Dr. Thomas noted, but this needs to be confirmed by additional, larger trials with more statistical power.

The CALM study findings have been published (Clin. Rehabil. 2013;27:398-408). The Stroke Association in London funded the study. Dr. Thomas said she had no relevant financial disclosures.

Aphasic stroke patients' mood lifted by behavioral therapy