Behavioral Activation Therapy for Subthreshold Depression in Stroke Patients: An Exploratory Randomized Controlled Trial

Figures & data

Figure 1 Study flow diagram: enrollment to analysis.

Abbreviation: BAT, behavioral activation therapy.

Table 1 Outline of Behavioral Activation Therapy

Time	Objectives	Content
First	1. Introduce and establish a good relationship of trust. 2. Mental health education. 3. Assess baseline. 4. Clarify values in life.	1. Know each other. 2. Introduction of subthreshold depression and behavioral activation therapy. 3. Assessment of psychological state. 4. Record the activity logs.
Second	1. Set short-term and long-term life goals. 2. Schedule activities. 3. Behavioral testing.	1. Set life goals that are achievable in a week or a month (call two old friends, invite two old friends to meet). 2. Based on patients’ values, living environment and physical status, goal-oriented activities with strong sense of pleasure, control, schedule and structure are arranged. 3. Implement activities. Enhance positive experience.
Third and Fourth	1. Behavior monitoring. 2. Hierarchical task allocation. 3. Identify difficult situations and solve problems. 4. Behavioral testing.	1. Identify depression behaviors and health behaviors in activities through activity logs or oral reports, analyze causes and clarify impacts. 2. Set a series of tasks step by step, from easy to difficult, from less to more. 3. Analyze the patient’s internal psychological and external environment, identify and remove possible or actual barriers that interfere with the activation of behavior. 4. Add and implement activities that are valuable and easy to get positive reinforcement from the environment.
Fifth	1. Review. 2. Prevention of recurrence and prognostic strategies.	1. Review of BAT, including theoretical basis, core principles, operation procedures, etc. 2. Identify the high-risk environment for depression recurrence and summarize antidepressant behaviors.
Sixth	Summary	1. Reevaluate. 2. Summarize progress and gains. 3. Evaluate the achievement of short-term and long-term life goals and rebuild new life goals. 4. Talk about the feeling of the activity, say goodbye to each other.

Table 2 Characteristics of Participants by Group (n = 65)

Characteristics		Invention Group (n=33)	Control Group (n=32)	t/χ^2value	P value
Age, mean (SD)		60.60±8.91	63.5±9.13	1.307	0.196
Sex, n (%)	Male	18(54.5)	19(59.4)	0.155	0.694
	Female	15(45.5)	13(40.6)
Marital status, n (%)	Married	24(72.7)	27(84.4)	1.313	0.519
	Divorced	2(6.1)	1(3.1)
	Widowed	7(21.2)	4(12.5)
Education level, n (%)	Illiterate	6(18.2)	5(15.6)	0.777	0.855
	Primary school	18(54.5)	15(46.9)
	Junior school	6(18.2)	8(25.0)
	High school and above	3(9.1)	4(12.5)
Monthly income, n (%)	< 1000	3(9.1)	3(9.4)	1.092	0.779
	1000~2999	12(36.4)	13(40.6)
	3000~4999	14(42.4)	10(31.3)
	≥ 5000	4(12.1)	6(18.8)
Stroke type, n (%)	Ischemic stroke	27(81.8)	28(87.5)	2.003	0.367
	Intracerebral hemorrhage	6(18.2)	3(9.4)
	Mixed	0(0.0)	1(3.1)
Previous stroke, n (%)	Yes	16(48.5)	19(59.4)	0.775	0.379
	No	17(51.5)	13(40.6)
NIHSS, mean (SD)		3.63 ± 3.61	3.84 ± 3.48	0.236	0.815
Lesion locations, n (%)	Basal ganglia	14(42.4)	16(50.0)	2.362	0.797
	The frontal lobe	5(15.2)	6(18.8)
	The thalamus	4(12.1)	2(6.3)
	The temporal lobe	2(6.1)	3(9.4)
	Many parts	5(15.2)	2(6.3)
	Other	3(9.1)	3(9.4)
Degree of disability, n (%)	No disability	9(27.3)	8(25.0)	0.334	0.953
	Mild	16(48.5)	16(50.0)
	Moderate	6(18.2)	5(15.6)
	Severe	2(6.1)	3(19.4)

Table 3 Depression Outcome by Group at 3-Month Follow-Up (n=65)

Time Point	BAT Group, (n=33)	Control Group, (n=32)	Fisher’s Exact test P-value
Categorical outcome			0.041
No depression	20 (60.61)	10 (31.25)
SD	9 (27.27)	12 (37.50)
PSD	4 (12.12)	10 (31.25)

Abbreviations: SD, Subthreshold depression; PSD, Post-stroke depression; BAT, Behavioral activation therapy.

Table 4 Impact of the Intervention on Outcome Measures at Three Time-Points

Outcome Measures	Time Point	BAT Group, Mean (SD) (n=33)	Control Group, Mean (SD) (n=32)	F-Group	P-value	F-Time	P-value	F-Time×Group	P-value
CES-D	T1	23.69 (1.87)	24.46 (1.93)	67.689	0.000	210.234	0.000	6.582	0.002
	T2	19.39 (1.98)	22.13 (1.18)
	T3	16.52 (2.01)	19.16 (1.16)
HAMD-17	T1	13.12 (2.31)	12.38 (2.01)	4.170	0.045	68.471	0.000	6.474	0.003
	T2	10.00 (1.67)	11.15 (1.66)
	T3	7.54 (3.08)	9.34 (2.37)
BAS	T1	31.90 (2.86)	32.28 (2.01)	25.355	0.000	131.078	0.000	17.152	0.002
	T2	37.45 (1.88)	34.19 (1.78)
	T3	38.09 (1.52)	35.97 (1.55)

Abbreviations: CES-D, The Center for Epidemiological Studies Depression Scale; HAMD-17, 17-item Hamilton Depression Scale; BAS, Behavioral Activation System Scales; T1, baseline; T2, six weeks; T3, three months after the group allocation.

Figure 2 CES-D scores for two groups on T1, T2, and T3.

Abbreviations: CES-D, The Center for Epidemiological Studies Depression Scale; T1, baseline; T2, six weeks; T3, three months after the group allocation.

Figure 3 HAMD-17 scores for two groups on T1, T2, and T3.

Abbreviations: HAMD-17, 17-item Hamilton Depression Scale; T1, baseline; T2, six weeks; T3, three months after the group allocation.

Figure 4 BAS scores for two groups on T1, T2, and T3.

Abbreviations: BAS, Behavioral Activation System Scales; T1, baseline; T2, six weeks; T3, three months after the group allocation.