Ecosystem Focused Therapy in Post Stroke Depression

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" to accommodate the patient's disability. 5) It "coordinates care with
specialized therapists" with the goal to increase patient participation in rehabilitation and
social activities.

Inclusion Criteria:

1. Age 50 years and older;

2. Diagnosis of unipolar major depression;

3. Montgomery Asberg Depression Rating Scale score ≥ 18;

4. Capacity to provide written consent for both research assessment and treatment;

5. Command of English sufficient to participate in assessments and talking therapy.

Exclusion Criteria:

1. Moderately severe to severe dementia (MMSE score < 20);

2. Greater than mild to moderate aphasia (NIH Stroke Scale: Best Language > 1);

3. Expectation to be discharged to a nursing home;

4. Psychotic depression;

5. Suicidal intent or plan.