Post-stroke Depression
Conditions
Keywords
Post-stroke depression, Transcranial direct current stimulation, Virtual reality mindfulness-based cognitive therapy
Brief summary
This study investigates whether combining virtual reality mindfulness-based cognitive therapy (VR-MBCT) with transcranial direct current stimulation (tDCS) can effectively treat depression occurring after a stroke (post-stroke depression, PSD). The goal is to determine if this combined approach is more beneficial than either treatment alone or standard care in alleviating depressive symptoms. The study will enroll adults aged 18-65 who have experienced a stroke within the past week, are medically stable, and exhibit moderate to severe depression symptoms. Participants must be right-handed and able to undergo MRI scans and study assessments. Individuals with certain neurological or psychiatric conditions, other major health issues, or specific contraindications for tDCS will not be eligible. Procedures: This is a randomized controlled trial lasting approximately 28 weeks, divided into two phases. In the first phase (8 weeks), participants are randomly assigned to one of four groups: Group 1: Receives sham (placebo) versions of both VR-MBCT and tDCS plus standard medication. Group 2: Receives active tDCS and sham VR-MBCT plus standard medication. Group 3: Receives active VR-MBCT and sham tDCS plus standard medication. Group 4: Receives both active VR-MBCT and active tDCS plus standard medication. Treatments are administered 5-6 times per week for 4 weeks, followed by a 4-week blinded follow-up.The primary outcome is the change in depression scores (HDRS-24、PHQ-9) from baseline to 8 weeks. Secondary outcomes include rates of clinical response, remission, relapse, treatment acceptability, and changes in anxiety, sleep quality, and daily functioning.
Interventions
BEHAVIORALVirtual Reality Mindfulness-Based Cognitive Therapy (Active VR-MBCT)
Participants will receive a structured Virtual Reality Mindfulness-Based Cognitive Therapy program specifically designed for post-stroke depression. The intervention aims to improve emotional regulation and cognitive function through immersive mindfulness exercises. It is administered 5 sessions per week for 4 weeks, with each session lasting approximately 30 minutes. The content includes breathing techniques, and mindfulness practices within a virtual reality environment.
Participants will receive active transcranial Direct Current Stimulation using a programmable stimulator. The anodal electrode will be placed over the left dorsolateral prefrontal cortex (DLPFC) and the cathodal electrode over the right supraorbital area. Stimulation will be administered at 2.0 mA for 30 minutes per session, once daily, for 4 weeks. The device delivers a constant, low-intensity electrical current intended to modulate cortical excitability.
BEHAVIORALSham Virtual Reality Mindfulness Program (Sham VR-MBCT)
Participants in the control groups will experience a sham VR program. It uses the same virtual reality hardware but presents neutral, non-therapeutic content (e.g., nature scenes without guided mindfulness instruction) accompanied by audio containing general psychoeducation about stroke recovery and white noise. The frequency and duration (5 sessions/week, 30 minutes/session for 4 weeks) match the Active VR-MBCT intervention to control for non-specific effects like attention and device use.
The sham tDCS intervention uses the same device and setup as the Active tDCS arm to maintain blinding. The device will deliver a brief initial current ramp (e.g., 30 seconds) to mimic the sensory skin sensation (tingling/itching) of active stimulation, but will then automatically shut off or deliver only a negligible current for the remainder of the 30-minute session. This procedure ensures participants cannot distinguish it from the active stimulation based on initial sensation alone.
Sponsors
Second Affiliated Hospital, School of Medicine, Zhejiang University
Hangzhou Seventh People's Hospital, Affiliated Mental Health Center, Zhejiang University School of Medicine
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
1. Aged 18 to 65 years (inclusive). 2. Stroke onset ≥ 4 weeks, with stable condition and an NIHSS score ≤ 15. 3. Right-handed. 4. Patient must be in a depressive episode, defined by a PHQ-9 score ≥ 5 and confirmed by a HDRS-24 score ≥ 8. 5. Has not used any antidepressants before the enrollment. 6. No contraindications to tDCS (e.g., metal plates in the head, brain implants, aneurysm clips, cochlear implants, cardiac pacemakers, etc.). 7. Has not received systematic psychotherapy (such as MBCT, mindfulness training, or cognitive behavioral therapy) for the current or previous depressive episodes. 8. Has more than 8 years of formal education. 9. Has not received tDCS or other transcranial electrical stimulation treatment for the current or previous depressive episodes. 10. Is able to cooperate with multimodal MRI data collection and follow-up assessments, and can understand and comply with the study requirements.
Exclusion criteria
1. History of treatment-resistant depression, defined as failure to respond to at least two different antidepressant medications of adequate dosage and duration (at least 8 weeks at the maximum recommended therapeutic dose). 2. Other psychiatric diagnoses (e.g., intellectual disability, schizophrenia, affective psychosis, bipolar disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, eating disorders, personality disorders, substance use disorders, post-traumatic stress disorder, panic disorder, or social phobia). Co-morbid anxiety disorder is acceptable. 3. Baseline Mini-Mental State Examination (MMSE) score ≤ 24. 4. Presence of suicidal ideation or plan within 4 weeks prior to baseline. 5. Depressive symptoms are better explained by another clinical condition (e.g., hypothyroidism, anemia, congestive heart failure) or other mental disorders. 6. Presence of severe, unstable cardiovascular, hepatic, renal, hematological, endocrine diseases, or malignancies. 7. Laboratory tests indicating significant impairment: total bilirubin (TBIL) \> 1.5 times the upper limit of normal (ULN); alanine aminotransferase (ALT) or aspartate aminotransferase (AST) \> 3 times ULN; glomerular filtration rate (GFR) ≤ 70 mL/min; or thyroid-stimulating hormone (TSH) outside the normal range. 8. Poorly controlled hypertension (sitting systolic blood pressure (SBP) ≥ 180 mmHg or sitting diastolic blood pressure (DBP) ≥ 110 mmHg at screening or baseline). 9. Epilepsy and/or other neurological diseases (e.g., dementia, traumatic brain injury, Parkinson's disease, Huntington's disease, multiple sclerosis), or any neurological condition leading to increased intracranial pressure, brain damage, or increased risk of seizures. 10. Pregnant, lactating, or planning pregnancy. 11. Significant visual or hearing impairment that prevents participation in interventions or assessments. 12. Received brain stimulation therapy (e.g., ECT, mECT, TMS, rTMS, deep brain stimulation, vagus nerve stimulation) within 3 months prior to baseline. 13. Participation in another clinical trial within 1 month prior to baseline (excluding screening failures). 14. Any other condition deemed by the investigator as unsuitable for participation in the study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Patient Health Questionnaire-9 (PHQ-9) Score | Baseline , Week 1, Week 2, Week 3, Week 4, Week 8, Week 28 | The Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-report scale for assessing depressive symptom severity based on frequency over the past two weeks. Total scores range from 0 to 27, with higher scores indicating greater depression severity. Change in total score from Baseline to Week 28 serves as a primary efficacy measure. |
| Hamilton Depression Rating Scale-24 (HDRS-24) Score | Baseline , Week 1, Week 2, Week 3, Week 4, Week 8, Week 28 | The Hamilton Depression Rating Scale-24 item (HDRS-24) is a clinician-administered scale for assessing depressive symptom severity. Total scores range from 0 to 74, with higher scores indicating greater depression severity. Change in total score from Baseline to Week 28 serves as a primary efficacy measure. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Treatment Retention Rate | Week 4 | The proportion of participants who remain in the study and complete the assigned intervention by the end of Week 4. This will be calculated separately for each group as: (Number of participants randomized - Number of participants who withdrew prior to Week 4) / Number of participants randomized × 100%. |
| Intervention Adherence Rate | Week 4 | The degree to which participants complete the prescribed intervention sessions. It will be calculated as the total minutes of intervention sessions actually attended (or completed in the VR system) divided by the total minutes of intervention sessions prescribed by the protocol up to Week 4, expressed as a percentage. Adherence data will be objectively recorded by the VR system. |
| Change in HAMA Score | Baseline, Week 4, Week 8, Week 28 | The Hamilton Anxiety Rating Scale (HAMA) is a clinician-administered scale used to rate the severity of anxiety symptoms. Total scores range from 0 to 56, with higher scores indicating greater severity of anxiety. The change from baseline to post-intervention will be calculated |
| Change in Snaith-Hamilton Pleasure Scale (SHAPS) Score | Baseline, Week 4, Week 8, Week 28 | The SHAPS is a 14-item scale measuring the ability to experience pleasure. Total scores range from 14 to 56, with higher scores indicating higher levels of anhedonia (reduced pleasure capacity).The change from baseline to post-intervention will be calculated. |
| Change in Five Facet Mindfulness Questionnaire (FFMQ) Score | Baseline, Week 4, Week 8, Week 28 | The FFMQ is a 39-item self-report questionnaire measuring five facets of mindfulness. The total score ranges from 39 to 195, with higher scores indicating higher levels of mindfulness.The change from baseline to post-intervention will be calculated. |
| Change in Pittsburgh Sleep Quality Index (PSQI) Score | Baseline, Week 4, Week 8, Week 28 | The PSQI is a 19-item self-report scale assessing sleep quality and disturbances over a 1-month interval. The global score ranges from 0 to 21, with higher scores indicating worse sleep quality.The change from baseline to post-intervention will be calculated. |
| Change in Patient Health Questionnaire-15 (PHQ-15) Score | Baseline, Week 4, Week 8, Week 28 | The PHQ-15 is a self-report scale for assessing somatic symptom severity. Scores range from 0 to 30, with higher scores indicating greater severity of somatic symptoms.The change from baseline to post-intervention will be calculated. |
| Change in modified Rankin Scale (mRS) Score | Baseline, Week 4, Week 8, Week 28 | The mRS is a clinician-reported measure of global disability after neurological injury, such as stroke. Scores range from 0 (no symptoms) to 6 (death), with higher scores indicating greater disability.The change from baseline to post-intervention will be calculated. |
| Change in 36-Item Short Form Health Survey (SF-36) Score | Baseline, Week 4, Week 8, Week 28 | The SF-36 is a self-reported survey of health status. It yields scores for 8 domains and two summary scores (Physical and Mental Component Summaries). Scores are transformed to a range of 0 to 100, with higher scores indicating better health-related quality of life.The change from baseline to post-intervention will be calculated. |
| Change in Hospital Anxiety and Depression Scale (HADS) Score | Baseline, Week 4, Week 8, Week 28 | The HADS is a 14-item self-report questionnaire specifically designed to screen for anxiety and depressive states in non-psychiatric hospital settings, minimizing the influence of physical illness symptoms. It comprises two subscales (Anxiety and Depression), each with scores ranging from 0 to 21. Higher scores on each subscale indicate greater severity of anxiety or depressive symptoms, respectively.The change from baseline to post-intervention will be calculated. |
| Change in resting-state functional connectivity (fMRI) | Baseline, Week 4, Week 28 | Resting-state functional magnetic resonance imaging (fMRI) is used to assess changes in functional brain network connectivity. Key metrics include alterations in the strength of functional connectivity within and between brain networks relevant to depression and cognition (e.g., Default Mode Network, Central Executive Network). The change in connectivity metrics from baseline to post-intervention will be calculated. |
Contacts
CONTACTLusha Tong, MD
Outcome results
None listed