Decrease of depression during stroke and amputation rehabilitation

Depression and Lability: The Effects on Occupation following Stroke

Case study methodology was used to explore the effect of emotional changes following a stroke on engagement in occupation. Two people who had had a stroke, and their partners, were interviewed. The participants' medical case notes from acute, rehabilitation and outpatient treatment were also reviewed. As a result of the stroke, one participant experienced depression and the other lability.

The case studies illustrate the impact that emotional changes can have on the performance of occupations. They also illustrate the reverse, that perceived competence in the performance of occupations can affect emotions, either negatively or positively. The results point to a need for occupational therapists to take an occupational perspective, if wellbeing is to be maximised, as they consider and address the effects of emotional changes with people who have had a stroke.

The relationship between prosthesis use, phantom pain and psychiatric symptoms in male traumatic limb amputees

OBJECTIVES

The purpose of this study was to identify psychiatric symptoms by comparing male patients with traumatic leg amputations (LAs) with healthy controls and to determine the association between these psychiatric symptoms and phantom pain and prosthesis use characteristics.

METHODS

One hundred four volunteers, 51 LA patients (group 1) and 53 healthy controls (group 2) were included. Demographic data including age, height, weight, time since amputation, duration of prosthesis use, and Satisfaction with Prosthesis Questionnaire scores were recorded. Phantom pain was measured a visual analog scale (VAS). Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Rosenberg Self-Esteem Scale, and State-Trait Anxiety Inventory. Correlations were determined between time since amputation, duration of prosthesis use and satisfaction with prosthesis questionnaire scores and psychiatric scale scores.

RESULTS

Amputee patients had higher phobic anxiety, state anxiety, trait anxiety and sleep disturbance scores (p<0.05) than the controls. No difference was determined in terms of psychiatric symptoms between the phantom pain and no phantom pain groups (p>0.05). There were significant negative correlations between time since amputation, duration of prosthesis use, duration of daily prosthesis use, and satisfaction with prosthesis questionnaire scores and psychiatric symptoms.

CONCLUSIONS

Apart from anxiety (state, trait or phobic) and disturbed sleep, other psychiatric symptoms in amputee patients undergoing lengthy prosthetic rehabilitation may not differ from those of healthy controls. The presence and severity of phantom pain appear to be unrelated to general psychiatric symptomatology. Length of time since amputation, length of prosthesis use, daily length of prosthesis use and prosthesis satisfaction are negatively correlated with general psychiatric symptoms. These characteristics must be borne in mind in psychiatric and prosthetic rehabilitation.

Apathy after hip fracture: a potential target for intervention to improve functional outcomes

The authors examined apathy symptoms, their improvement, and their association with functional recovery after a hip fracture. Of 126 participants, 37% had clinically significant apathy symptoms, which predicted functional outcome (i.e., poorer recovery from the fracture among those with higher baseline apathy). Of participants with high baseline apathy, approximately one-third improved; these participants had a better functional outcome than those with persistently high apathy scores. It is concluded that apathy symptoms are common after a hip fracture, but improve in one-third of individuals, with a concomitant functional recovery after hip surgery. Interventions to prevent or improve apathy in elderly persons deserve further attention.

Assessment of anxiety and depression after lower limb amputation in Jordanian patients

OBJECTIVE

This study aimed to assess the prevalence of anxiety and depression among Jordanian lower limb amputees with different clinical characteristics and sociodemographic data (gender, marital status, social support, income, type and level of amputation, and occupation).

METHODS

Participants were 56 patients with unilateral lower limb amputation with mean duration (8.4 +/- 5.75 years). They were recruited from inpatient and outpatient clinics of Jordan University hospital, Royal Farah Rehabilitation Center, and Al-basheer hospital in Amman, Jordan. Participants responded to a questionnaire that included a battery of questions requesting brief information about sociodemographic variables and characteristics of amputation. The level of depression and anxiety in each participating patient was assessed by the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The prevalence of anxiety and depressive symptoms were 37% and 20%, respectively. Factors associated with high prevalence of psychological symptoms included female gender, lack of social support, unemployment, traumatic amputation, shorter time since amputation, and amputation below the knee. These findings were confirmed by a significant reduction of anxiety and depression scores in patients who received social support, patients with amputation due to disease, and patients with amputation above the knee. Presence of pain and use of prosthesis had no effect on the prevalence.

CONCLUSIONS

The findings of the present study highlight the high incidence of psychiatric disability and depression in amputees; it also showed the importance of sociodemographic factors in psychological adjustment to amputation. It is suggested that psychiatric evaluation and adequate rehabilitation should form a part of their overall management.

The rapid resolution of depression and anxiety symptoms after lower limb amputation

OBJECTIVE

To ascertain the course of depressive and anxiety symptoms shortly after amputation and again after a period of inpatient rehabilitation.

DESIGN AND SETTINGS

A cohort study in inpatients admitted to a rehabilitation ward after lower limb amputation.

SUBJECTS

One hundred and five successive admissions over a one-year period.

INTERVENTIONS

Nil.

MAIN MEASURES

Hospital Anxiety and Depression Scale (HADS) on admission and discharge with correlation to demographic and patient features.

RESULTS

At admission, 28 (26.7%) and 26 (24.8%) patients had symptoms of depression and anxiety respectively. This dropped to 4 (3.8%) and 5 (4.8%) by time of discharge, a mean of 54.3 days later. These reductions were statistically significant, as was the association between patients having symptoms of both depression and anxiety (P < 0.001). Patient stay was longer in those with symptoms (depression, P < 0.03; anxiety P < 0.001). There was no association with level of amputation, success of limb-fitting, age or gender. Depressive symptoms were associated with presence of other medical conditions (P < 0.01) and anxiety scores with living in isolation (P < 0.05).

CONCLUSION

Depression and anxiety are commonly reported after lower limb amputation and previously thought to remain high for up to 10 years. We have found that levels of both depression and anxiety resolve rapidly. It is possible that a period of rehabilitation teaching new skills and improving patient independence and mobility may modify the previous bleak outlook of amputees. This positive finding may be useful in the rehabilitation of even the most distressed of amputees.

Effect of Playing Football (Soccer) on Balance, Strength, and Quality of Life in Unilateral Below-Knee Amputees

OBJECTIVE

To investigate the effect of playing football (soccer) on balance, muscle strength, locomotor capabilities, and health-related quality of life in subjects with unilateral below-knee amputation.

DESIGN

Cross-sectional controlled study.

RESULTS

Difference in KAT dynamic balance scores obtained 3 days after was statistically significant in the study group (P < 0.05) but not in the control group (P > 0.05). Differences in static balance test scores was statistically significant between the groups (P < 0.05) in favor of the study group. In isokinetic evaluation, differences in flexion and extension peak torque measures of the lower extremities were not statistically significant between the groups (P > 0.05). Differences in Houghton and Berg balance scales were not found statistically significant between the groups (P > 0.05). Differences in Locomotor Capabilities Index and in the SF-36 in physical functioning, physical role, pain, and emotional role between the groups were statistically significant (P < 0.05) in favor of the study group.

CONCLUSIONS

Our results show that playing football may have positive effects on balance and health-related quality of life in unilateral below-knee amputees.

Does depression, apathy or cognitive impairment reduce the benefit of inpatient rehabilitation facilities for elderly hip fracture patients?

OBJECTIVE

Depression, apathy (amotivation) and cognitive impairment are common comorbidities in hip fracture patients, which may adversely affect functional outcome of rehabilitation. We examined whether postfracture measures of mood, motivation or cognition are associated with rehabilitation outcome (defined as functional improvement) in inpatient rehabilitation facilities (IRFs), as compared to skilled nursing facilities (SNFs).

METHODS

This prospective study examined elderly patients who received surgical fixation for hip fracture and then received post-acute rehabilitation at an IRF or an SNF. Subjects were characterized at baseline for depression using the Hamilton Rating Scale for Depression, apathy/amotivation using the Apathy Evaluation Scale and mild-moderate cognitive impairment using the Mini-Mental Status Examination. Functional recovery was measured over 12-week follow-up using the Functional Independence Measure.

RESULTS

Fifty-eight subjects were discharged from acute care to an IRF and 39 to an SNF. Patients with depression, apathy or cognitive impairment who received rehabilitation at an IRF had significantly better functional outcomes than similarly impaired patients at SNFs, and similar outcomes such as nondepressed, motivated and cognitively intact elderly at IRFs.

CONCLUSION

These findings suggest that depression, amotivation or mild-moderate cognitive impairment after hip fracture do not reduce the benefit of post-acute rehabilitation in an IRF.

Is it safe to use antidepressants after a stroke?

Depression is an important complication of stroke. Although antidepressants are widely used for the treatment of poststroke depression (PSD), prescription is critically influenced by their safety, tolerability and by the impact on co-morbidities. The authors reviewed the literature on the use of antidepressants after stroke. Selective serotonin re-uptake inhibitors are effective and have a good profile of safety and tolerability in PSD. They are, therefore, used as first-line drugs in the treatment of PSD, although potential cardiovascular and cerebrovascular effects, drug-drug interactions and intolerability in a minority of patients have to be considered. Other antidepressants appear to be safe and effective in selected patients. PSD patients should be classified according to their clinical profile for the selection of the drug of choice in particular sub-groups of patients.

Psychosocial adjustment to lower-limb amputation: a review

PURPOSE

To review the existing literature on the social and psychological challenges faced by people with an amputation and to provide a detailed analysis of the literature examining psychological adjustment to these challenges across time.

METHOD

Existing papers on psychological adjustment to amputation were analysed according to their results, methodology, and conclusions.

RESULTS

Although depression and anxiety are relatively high up to 2 years post-amputation, they appear to decline thereafter to general population norms. However, social discomfort and body-image anxiety have also been found among some people with amputations, and these have been associated with increased activity restriction, depression, and anxiety. Factors associated with positive adjustment to limb loss include greater time since amputation, more social support, greater satisfaction with the prosthesis, active coping attempts, an optimistic personality disposition, a lower level of amputation in the case of lower limbs, and lower levels of phantom limb pain and stump pain.

CONCLUSION

The majority of studies on adjustment to amputation are cross-sectional in design and have used noncomparable measures. Furthermore, they have neglected to study many important areas of rehabilitation, including immediate reaction to amputation, adjustment during and shortly after the rehabilitation period, and development of a changed sense of self and identity. In order to address these concerns, more longitudinal and qualitative research is called for. We end by outlining the components of a descriptive phased model of the rehabilitation process.

Psychological aspects of mutilating hand injuries

The immediate and long-term outcome of a mutilating hand injury can be positively influenced by health care professionals adopting a biopsychosocial perspective toward treatment and management. Such an injury produces a psychological and social impact that should be openly and candidly addressed with the injured individual and with the family. The earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome.

Psychological issues in prosthetic and orthotic practice: a 25 year review of psychology in Prosthetics and Orthotics International

In the inaugural edition of Prosthetics and Orthotics International, Fishman identified the psychological sciences as one of six indispensable areas of skill and knowledge in professional prosthetic-orthotic practice. Given the journal's significant role in reporting and developing pertinent research and practice, this review assesses the profile of psychology in prosthetic and orthotic research, as evidenced by the content of Prosthetics and Orthotics International since its inception. A MEDLINE search of the journal's abstracts over a twenty-five year period was conducted using the search terms: 'psychology', 'psychosocial', 'quality of life', 'developmental' and 'coping'. Results of this search are summarised under the following headings: (a) body image; (b) coping and adjustment; (c) developmental issues; (d) psychosocial well-being; (e) quality of life; and (f) psychological factors leading to amputation. On the basis of this review, the authors conclude by highlighting a number of key areas where the psychological aspects of prosthetics and orthotics warrant further investigation and dissemination.

Rehabilitation therapists' recognition of cognitive and mood disorders in geriatric patients

OBJECTIVE

To determine if physical and occupational therapists can recognize 2 known predictors of rehabilitation outcome, cognition and mood, in their geriatric patients.

DESIGN

Survey.

SETTING

Urban academic medical center rehabilitation unit.

PARTICIPANTS

One hundred two consecutive geriatric admissions rated by 20 physical and 8 occupational therapists for the presence of cognitive or affective disorders.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mini-Mental State Examination, Geriatric Depression Scale, and therapists' ratings.

RESULTS

Both disciplines had low rates of accurate detection of both cognitive abnormalities and symptoms of depression. Patients scoring in the intact range of either domain were more likely to be correctly identified by the therapists than were patients whose results were possibly or probably impaired.

CONCLUSION

Rehabilitation therapists had difficulty recognizing patients with cognitive and affective disorders. I recommend including a mental health professional on the treatment team, staff inservicing, and/or the use of standardized measures of mood and mental status to increase recognition of these syndromes in geriatric rehabilitation patients.

Pharmakotherapie emotionaler Störungen bei Patienten mit erworbener Hirnschädigung

Zusammenfassung: Emotionale Störungen sind häufige und klinisch bedeutsame Folgeerscheinungen nach erworbener Hirnschädigung. In den letzten Jahren sind zahlreiche Original- und Übersichtsarbeiten zu epidemiologischen, pathophysiologischen und therapeutischen Aspekten neuro-psychiatrischer Störungen erschienen. Ausgehend von diagnostischen Überlegungen gibt die vorliegende Arbeit eine aktuelle Übersicht zur Pharmakotherapie von Depressionen, emotionaler Instabilität (pathologisches Weinen), organischer Manie (bipolarer Störung), Angststörungen und Antriebsstörungen (Apathie). Patienten mit Schlaganfall und traumatischer Hirnschädigung stehen im Mittelpunkt, so wie in der Forschungs- und Lehrbuch-Literatur. Psychische Störungen bei neurodegenerativen und systemischen Erkrankungen des Gehirns werden nur am Rande erwähnt. Ausführlich werden differentielle Indikationen und Nebenwirkungen neuartiger Antidepressiva diskutiert. Ausblickend werden innovative Therapiestrategien wie CRH-Antagonisten und die präventive Behandlung mit Antidepressiva vorgestellt.

Multidimensional investigation of the structure of coping among people with amputations

In this study, the responses of 61 people with amputations to a measure of coping strategies were submitted to multidimensional scaling and cluster analysis. Interpretations of the three-dimensional solution, aided by the emergence of five coping clusters, suggested that respondents' perceptions of their coping with amputation-related stress were best explained by the following three dimensions: 1) active/confrontive versus passive/avoidance coping; 2) pessimistic/fatalistic versus optimistic/positivistic coping: and 3) social/emotional versus cognitive coping.

Prevention of poststroke depression: 1 year randomised placebo controlled double blind trial of mianserin with 6 month follow up after therapy

OBJECTIVES

(1) To test whether early prophylactic antidepressive treatment by mianserin is able to prevent poststroke depression, and (2) to discover whether mianserin as an antidepressant has any beneficial influence on the outcome of ischaemic stroke.

METHODS

A randomised, double blind, placebo controlled study involved 100 consecutive patients under 71 years old admitted to hospital for an acute ischaemic stroke; they were enrolled to receive 60 mg/day mianserin or placebo for 1 year. They were examined on admission, and at 2, 6, 12, and 18 months with depression, stroke, and functional outcome scales.

RESULTS

According to DSM-III-R, the prevalence of major depression was 6% at the initial stage, 11% at 1 year, and 16% at 18 months. At no time point did prevalences differ between the treatment groups, nor were differences found in depression scales, although at 2 months a greater improvement from initial assessment on the Hamilton depression scale was evident in patients on mianserin (p=0.05). Some beneficial changes on the Hamilton depression scale and Beck depression inventory were found in patients older than 56 (median age) and in men treated with mianserin, but not in other subgroups. Mianserin treatment did not affect stroke outcome as measured by neurological status, nor did it have any influence on functional outcome as measured by Rankin scale or Barthel index.

CONCLUSION

It was not possible to show that early initiation of antidepressant therapy can prevent poststroke depression, because the prevalence of poststroke depression remained low even in patients on placebo. In this stroke population with a low rate of depressive patients, antidepressive medical treatment failed to affect stroke outcome.

The relationship between age, gender and psychological distress in rehabilitation inpatients

Although commonly accepted as the dominant emotional reaction to functional loss, the reported occurrence of depression in rehabilitation patients varies widely. Rather than focusing solely on depressive symptoms, this study furthers our understanding of emotional distress following a functional loss by assessing a range of psychiatric symptoms. A series of rehabilitation patients admitted to an urban hospital inpatient unit is used as the sample (n = 48). Demographic, neuropsychological, and a functional independence measure were included as independent variables. The statistical analysis revealed that-although age was not correlated with years of education, functional status, or neuropsychological impairment-there was a significant inverse relationship between age and reported emotional distress. Utilizing MANCOVA to explore the impact of age and gender on specific groups of psychiatric symptoms revealed that both younger and male patients tended to express psychiatric symptoms more frequently. The importance of considering age and gender in evaluation of emotional distress in rehabilitation is supported in this comprehensive study of psychiatric symptoms.

Poststroke depression: prevalence, course, and associated factors

Despite the considerable amount of research that has been undertaken on poststroke depression, a review of the literature demonstrates that there are many inconclusive findings in the area. In particular, the causes and course of the disorder remain to be firmly established. While studies of prevalence differ with respect to the nature and timing of their assessment procedures, most conclude that poststroke depression has a negative impact on the rehabilitation of the stroke patient. Very little research is available on te relationship between poststroke depression and care-giver burden. However, recent studies have adopted more rigorous methodological procedures, allowing some insights into the complex mixture of factors which determine the occurrence of poststroke depression.

How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of patients who become depressed following a stroke

Fourteen qualified nurses working in a stroke rehabilitation unit were interviewed in order to ascertain their understanding of post-stroke depression, what they do to help a patient who becomes depressed and what they feel unable to do. They were also asked what would improve the situation. The nurses were able to describe the characteristics of depression following a stroke and recognize its effect on the subject's rehabilitation. They were able to identify patients who were becoming depressed and tried to help them to the best of their abilities. They felt constrained, however; mainly by lack of time, limited skills and lack of appropriate training. They themselves wanted to be able to meet the needs of depressed patients and thought that this could be achieved through better staff education and access to other health professionals experienced in providing psychological care. It is recommended that nurses have access to expert personnel both as a source of referral for patients and as a resource for support and guidance to staff. In addition, an education programme combining theoretical and practical aspects of psychological care would be useful.

Depression following a spinal cord injury

OBJECT

Depression is a common problem following a spinal cord injury (SCI) and can greatly interfere with the rehabilitation process because of reduced energy, negative expectations, and social withdrawal. Understanding various factors which influence a vulnerability to depression may improve the diagnosis and treatment of depressive disorders and can improve rehabilitation outcome.

METHOD

A thorough literature search was conducted using Medline, PsychLit, Pyschinfo, and Social Science Citation Index to identify relevant articles published between 1967 and 1995.

RESULTS

A diathesis-stress model is proposed to explain the increased risk of depressive symptoms after a SCI. Biological changes associated with SCI and pre-existing cognitive biases may influence the individual's vulnerability to stressful life events following the injury. The nature and frequency of stressful life events following the injury can tax the individual's coping resources. Furthermore, the perceived quality of social support and the severity of conflict within the family can influence the individual's adaptation.

CONCLUSIONS

Social support and recent stressors should be assessed to identify patients at high risk for depression. Patients are less likely to become depressed if their independence is fostered and they are encouraged to develop new sources of self-esteem. Relatives can be counseled to help maintain supportive relationships within the family.