Background: The benefits of physical exercise in reducing clinically defined depression in the general population have been established, although a review of the evidence for older adults is needed. Objectives: To assess the efficacy of physical exercise for the treatment of depressive symptoms in older adults (>60 years). Data sources: We searched: MEDLINE (1966—May 2008); EMBASE (1980—May 2008); Cumulative Index to Nursing & Allied Health Literature (CINAHL; 1982—May 2008); PsycINFO (1966—May 2008), The Cochrane Library (Issue 2, 2008), and National Research Register (NRR; Issue 2, 2008). Review methods: Randomized controlled trials and quasi-experimental studies of physical exercise interventions for depression were included where 80% or more of participants were >60 years. Abstracts were assessed to determine whether they met specified inclusion criteria. Primary analysis focused on the prevalence of diagnosable depressive disorder following intervention. Secondary outcome was depression or mood scores on standardized scales. Results: Eleven randomized controlled trials with a total of 641 participants were included in the review. Short-term positive outcome for depression or depressive symptoms was found in nine studies, although the mode, intensity and duration of intervention varied across studies. Medium- to long-term effects of intervention were less clear. Conclusion: Physical exercise programmes obtain clinically relevant outcomes in the treatment of depressive symptoms in depressed older people. Exercise, though not appropriate for all in this population, may improve mood in this group. Further research is needed to establish medium- to long-term effects and cost-effectiveness.

Background and Purpose: Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia. Methods: Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori–defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI). Results: Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58–26.16] Western Aphasia Battery–Aphasia Quotient; 5.23 [1.51–8.95] Aachen Aphasia Test–Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3–5+ days/week), and comprehension (4–5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases. Conclusions: Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42018110947.

The aim was to evaluate behavioural therapy as a treatment for low mood in people with aphasia. A randomized controlled trial comparing behavioural therapy plus usual care with a usual care control. Potential participants with aphasia after stroke were screened for the presence of low mood. Those who met the criteria and gave consent were randomly allocated. Participants were recruited from hospital wards, community rehabilitation, speech and language therapy services and stroke groups. Of 511 people with aphasia identified, 105 had low mood and were recruited. Behavioural therapy was offered for up to three months. Outcomes were assessed three and six months after random allocation. Stroke Aphasic Depression Questionnaire, Visual Analog Mood Scales ‘sad’ item, and Visual Analogue Self-Esteem Scale. Participants were aged 29 to 94 years (mean 67.0, SD 13.5) and 66 (63%) were men. Regression analysis showed that at three months, when baseline values and communication impairment were controlled for, group allocation was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), visual analogue ‘sad’ (P = 0.03), and Visual Analogue Self-Esteem Scale (P < 0.01). At six months, group alone was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), and remained significant when baseline values were controlled for (P = 0.02). Mean Stroke Aphasic Depression Questionnaire 10-item hospital version scores decreased from baseline to six months by six points in the intervention group as compared with an increase of 1.9 points in the control group. Behavioural therapy seemed to improve the mood of people with aphasia.

Background and Purpose— The aim of this prospective longitudinal study was to identify factors relating to emotional distress in the first 6 months after stroke in a sample including patients with aphasia. Methods— One hundred patients who were in hospital at 1 month after stroke were recruited and assessed on measures of communication impairment (Sheffield Screening Test), personal activities of daily living (Barthel Index), and emotional distress (Visual Analogue Self-Esteem Scale). Demographic and stroke characteristics were recorded. Patients (n=92) were reassessed on the same measures 6 months after stroke, in addition to assessing extended activities of daily living (Nottingham Extended Activities of Daily Living Scale). Results— Patients were aged 44 to 86 years (51 men), and 21 were classified as having aphasia. Multiple linear regression showed that expressive communication impairment and dependence in personal activities of daily living were significant predictors of emotional distress at 1 month after stroke ( R ² =24%). Expressive communication impairment, emotional distress at 1 month after stroke, and having a more severe stroke were significant predictors of emotional distress at 6 months after stroke ( R ² =55%). Distress levels were similar at 1 month and 6 months after stroke. Demographic characteristics and side of lesion were unrelated to distress. Conclusions— Expressive communication impairment and level of disability in personal activities of daily living were related to distress. Distress was persistent in the first 6 months after stroke. Appropriate treatment strategies need to be developed and evaluated for patients who have communication impairments.

Background: There is currently insufficient evidence for the clinical effectiveness and cost-effectiveness of psychological therapies for post-stroke depression.Objective: To evaluate the feasibility of undertaking a definitive trial to evaluate the clinical effectiveness and cost-effectiveness of behavioural activation (BA) compared with usual stroke care for treating post-stroke depression.Design: Parallel-group, feasibility, multicentre, randomised controlled trial with nested qualitative research and a health economic evaluation.Setting: Acute and community stroke services in three sites in England.Participants: Community-dwelling adults 3 months to 5 years post stroke who are depressed, as determined by the Patient Health Questionnaire-9 (PHQ-9) or the Visual Analogue Mood Scales ‘Sad’ item. Exclusions: patients who are blind and/or deaf, have dementia, are unable to communicate in English, do not have mental capacity to consent, are receiving treatment for depression at the time of stroke onset or are currently receiving psychological intervention.Randomisation and blinding: Participants were randomised (1 : 1 ratio) to BA or usual stroke care. Randomisation was conducted using a computer-generated list with random permuted blocks of varying sizes, stratified by site. Participants and therapists were aware of the allocation, but outcome assessors were blind.Interventions: The intervention arm received up to 15 sessions of BA over 4 months. BA aims to improve mood by increasing people’s level of enjoyable or valued activities. The control arm received usual care only.Main outcome measures: Primary feasibility outcomes concerned feasibility of recruitment to the main trial, acceptability of research procedures and measures, appropriateness of baseline and outcome measures, retention of participants and potential value of conducting the definitive trial. Secondary feasibility outcomes concerned the delivery of the intervention. The primary clinical outcome 6 months post randomisation was the PHQ-9. Secondary clinical outcomes were Stroke Aphasic Depression Questionnaire – Hospital version, Nottingham Leisure Questionnaire, Nottingham Extended Activities of Daily Living, Carer Strain Index, EuroQol-5 Dimensions, five-level version and health-care resource use questionnaire.Results: Forty-eight participants were recruited in 27 centre-months of recruitment, at a recruitment rate of 1.8 participants per centre per month. The 25 participants randomised to receive BA attended a mean of 8.5 therapy sessions [standard deviation (SD) 4.4 therapy sessions]; 23 participants were allocated to usual care. Outcome assessments were completed by 39 (81%) participants (BA,n = 18; usual care,n = 21). Mean PHQ-9 scores at 6-month follow-up were 10.1 points (SD 6.9 points) and 14.4 points (SD 5.1 points) in the BA and control groups, respectively, a difference of –3.8 (95% confidence interval –6.9 to –0.6) after adjusting for baseline PHQ-9 score and centre, representing a reduction in depression in the BA arm. Therapy was delivered as intended. BA was acceptable to participants, carers and therapists. Value-of-information analysis indicates that the benefits of conducting a definitive trial would be likely to outweigh the costs. It is estimated that a sample size of between 580 and 623 participants would be needed for a definitive trial.Limitations: Target recruitment was not achieved, although we identified methods to improve recruitment.Conclusions: The Behavioural Activation Therapy for Depression after Stroke trial was feasible with regard to the majority of outcomes. The outstanding issue is whether or not a sufficient number of participants could be recruited within a reasonable time frame for a definitive trial. Future work is required to identify whether or not there are sufficient sites that are able to deliver the services required for a definitive trial.Trial registration: Current Controlled Trials ISRCTN12715175.Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 23, No. 47. See the NIHR Journals Library website for further project information.