Post Stroke Depression

Implementing Evidence in the Detection and Treatment of Post Stroke Depression

Implementing Evidence in the Detection and Treatment of Post Stroke Depression

Principal Investigators: Linda Williams, MD and Teresa Damush, PhD

Project Funding Number IMV 04-096 funded by the VA Medical Care

October 1, 2005-September 30, 2008

Our immediate objective is to test an intervention to improve Post Stroke Depression (PSD) detection and treatment rates, and to refine it in preparation for a multi-site, multi-Veteran Integrated Service Networks (VISN) study.  In this three year proposal, we will develop, implement, and evaluate an implementation intervention based on the Chronic Care Model.  In addition to the decision support, clinical information system, and delivery system aspects of this system intervention and, since many system interventions do not include tools to improve patient self management, our study will also pilot test the additional effect of a self-managment intervention to help patients manage post-stroke symptoms.  As has recently been argued, depression outcomes cannot be improved by solely focusing on providers or simply activating patients.  Our long term objective is to conduct a multi-site study to demonstrate the effectiveness of the intervention in improving PSD care and patient outcomes in veterans, and to ultimately disseminate an effective implementation strategy across the Veterans Administration (VA) that will result in improved evidence-based care for veterans with PSD.

To address our immediate objective, we wil evaluate two specific study aims using a quasi-experimental design.  We will compare change in depression screening and treatment in veteran stroke survivors with two intervention sites to the base rate of PSD screening and treatment in these two sites in the 12 months prior to the study.  All other facilities in the two VISNs represented will serve as control sites.  The primary aim of the study is to evaluate the effectiveness of a system intervention to improve the proportion of veterans screened and treated for PSD.  The system intervention is based on extending the use of the current depression performance measure that mandates yearly depression screening in VA Primary Care (PC) clinics to target veteran stroke survivors a) following-up in PC clinics within 6 months of stroke, and b) following-up in VA Neurology Clinics.  As such, this proposal advances the science of implementation research by evaluating the impact of targeting a high risk population for additonal screening using an existing tool and also by extenting the use of a PC based management intervention to determine whether it provides additional benefit beyond the system intervention alone in improving patient depression symptoms, quality of life, and self-efficacy, and in improving guideline-adherent treatment of depression compared to usual post-stroke care.  Subjects for the secondary aim will be recruited from the two intervention sites and will be randomized, stratified by site, to the patient self-management intervention or usual care.