Ecosystem Focused Therapy for Treating Older Depressed Stroke Survivors

A stroke occurs when blood cannot reach part of the brain, either because of a blocked blood
vessel (ischemic stroke) or because of a burst blood vessel (hemorrhagic stroke). When a
part of the brain is deprived of blood, brain cells in that part often die or are at risk of
dying. In addition to physical difficulties, older adults who survive strokes can also
suffer from depression and cognitive dysfunction. Effective psychotherapy treatments that
provide rehabilitation for problems in emotions and thinking are still needed. Ecosystem
focused therapy (EFT) is a specialized psychotherapy that helps patients learn
problem-solving skills and make adjustments in their environment. This study will determine
the effectiveness of EFT in reducing depression and improving functioning and quality of
life in older adults who experienced an ischemic stroke and are now depressed.

Participation in this study will last 1 year. Participants will be randomly assigned to
receive one of two treatments: EFT or education in stroke and depression (ESD). Both
treatments will be led by therapists and will involve 12 sessions over 25 weeks, with
sessions occurring weekly for the first month, every other week for the second 2 months, and
monthly for the last 3 months. EFT will involve the following: teaching the participant
skills for solving problems related to adjusting to a stroke, altering the participant's
physical environment to accommodate new needs, and helping the family or caregiver to assist
in the participant's adaptation. ESD will involve providing the participant with education
on living with a stroke and depression. Study assessments will include interviews and will
occur at nine time points: at baseline and after 2, 3, 6, 10, 14, 20, 26, and 52 weeks.
These assessments will measure participants' mood, thinking, and functioning. A family
member or caregiver of the older adult participant must also be able to participate in the
study, in order both to complete assessments and effectively implement EFT.

Inclusion Criteria:

- Diagnosis of unipolar major or minor depression, as assessed by the Structured
Clinical Interview for Depression (SCID) for the Diagnostic and Statistical Manual-IV

- Montgomery-Asberg Depression Rating Scale (MADRS) score greater than or equal to 15

- Admitted to Burke Rehabilitation Hospital soon after ischemic stroke

- Mini Mental State Examination (MMSE) score greater than 17

- Command of English sufficient to comprehend study questionnaires and interventions

- Has family member or professional caregiver willing and able to participate in
patient's treatment

Exclusion Criteria:

- Moderately severe to severe dementia, as defined by an MMSE score less than 17

- Moderate to severe aphasia

- Placed in a nursing home after discharge

- Diagnosis of psychotic depression

- High suicide risk (i.e., intent or plan to attempt suicide in near future)

- Presence of illnesses other than stroke (e.g., untreated thyroid or adrenal disease,
pancreatic cancer, and lymphoma)

- Taking drugs known to cause depression (e.g., reserpine, alpha-methyl-dopa, steroids)

- Currently being treated for depression with psychotherapy