ESOC 2026 | COMMITS trial: effectiveness of a motivational interviewing-based intervention in stroke survivors

In terms of a bit of background to COMMITS, we know that after a stroke, psychological problems are really common. About a third of patients at any time point across the pathway will experience depression, and about half will experience depression in the first year. And they also can experience other psychological distress. And these symptoms don’t just affect how people feel. They affect recovery, independence, quality of life. But despite all of this, access to psychological care after a stroke is really limited. And we need to find interventions that can be delivered at scale within routine services. So we did an initial study looking at motivational interviewing, which is a person-centred directive talk-based therapy. And we compared motivational interviewing with usual care. And patients had four weekly sessions up to an hour with the same trained therapist. And this therapy was delivered face-to-face. And we find a significant benefit in terms of mood at three months and 12 months, both in terms of treatment and prevention. And we also had some indication of reduced mortality at three months. But this was much more evident at 12 months, so much so that you only needed to treat 12 patients to prevent one person from dying. But there were some limitations to that study. We didn’t have an attention control. So was it just the additional attention? It was a single site with just four therapists. So we didn’t really get a true understanding of what implementation issues might be if we tried to implement this wider and also because the sample size was relatively small we couldn’t do any meaningful subgroup analysis to try and see who might benefit most. So the COMMITS trial was to try and address some of these issues and we were looking to evaluate motivational interviewing and to see whether it could improve mood post-stroke.

So we recruited 1,246 participants across 16 UK services and patients were randomised to either motivational interviewing plus usual care, attention control plus usual care or usual care alone. And we stratified that randomization by site, age and baseline mood. And those in the motivational interviewing group and the attention control group received four sessions of up to 45 minutes delivered remotely and the attention control group had a social intervention without the motivational interviewing therapy component. At three months we found that motivational interviewing was associated with a small but statistically significant reduction in depressive symptoms compared to usual care and that equated to an adjusted difference of about one point on the PHQ-9. So to try and put that into perspective, it corresponds to a symptom being experienced less frequently over the preceding two weeks. So for example, moving from several days to not at all. The effect for attention control was not significant. And baseline depression was unsurprisingly the strongest predictor of three-month scores, and participants aged 65 and over had lower depressive symptoms overall. But reassuringly, we found no evidence that the outcomes varied by therapists, so it meant that they weren’t driven by individual providers.

In terms of secondary outcomes, we didn’t see any corresponding improvements in terms of function or quality of life. But we believe that the strength of this trial is that it’s the largest trial of a psychological intervention in stroke care. The follow-up rates were really strong for a post-stroke psychological intervention at about 70%, and our outcomes were measured using really well-validated instruments. And importantly, the findings were consistent across multiple analytical approaches, increasing our confidence in the overall pattern. One of the important things to note is that whilst we didn’t set out to recruit those with really mild strokes, the population we actually recruited was mild. We had a median NIHSS of three. And we also had really low baseline psychological morbidity. So we had fewer than one in 10 meeting the criteria for moderate depression or anxiety. And that’s really low, even in a general population, let alone a stroke population.

So I guess the take-home from this study is that motivational interviewing was associated with lower depressive symptoms at three months compared with usual care. Although the effect size was modest, it was consistent across analyses and robust to adjustment. And importantly, this effect was actually observed in a population with mild strokes and low levels of psychological morbidity at baseline. So we think that this highlights the value of motivational interviewing as a preventative approach and highlights its importance in terms of testing it in a more clinically diverse population and over a longer term follow-up.

This transcript is AI-generated. While we strive for accuracy, please verify this copy with the video.