Depression and anxiety screening after stroke: adherence to guidelines and future directions

Sex-Related Differences in Post-Stroke Anxiety, Depression and Quality of Life in a Cohort of Smokers

BACKGROUND

We aimed to study anxiety, depression and quality of life in smokers after stroke by sex.

METHODS

A longitudinal prospective study with a 24-month follow-up of acute stroke patients who were previously active smokers. Anxiety and depression were evaluated with the Hospital Anxiety and Depression scale, and quality of life was evaluated with the EQ-5D questionnaire.

RESULTS

One hundred and eighty patients participated (79.4% men); their mean age was 57.6 years. Anxiety was most prevalent at 3 months (18.9% in men and 40.5% in women) and depression at 12 months (17.9% in men and 27% in women). The worst perceived health occurred at 24 months (EQ-VAS 67.5 in men and 65.1 in women), which was associated with depression (p < 0.001) and Rankin Scale was worse in men (p < 0.001) and depression in women (p < 0.001). Continued tobacco use was associated with worse perceived health at 3 months in men (p = 0.034) and at 12 months in both sexes. Predictor variables of worse perceived health at 24 months remaining at 3 and 12 months were tobacco use in men and neurological damage in women.

CONCLUSION

Differences by sex are observed in the prevalence of anxiety and depression and associated factors and in the predictive factors of perceived health.

Occupational Therapy for Poststroke Anxiety and Depressive Symptoms in Inpatient Rehabilitation

Poststroke anxiety and depressive symptoms (P-SADS) affect one in three people and are associated with decreased participation in activities of daily living. This study sought to characterize occupational therapy (OT) P-SADS care practices and identify factors influencing P-SADS care provision in one U.S. inpatient rehabilitation (IRF) facility. An explanatory sequential mixed-methods study design was used by gathering data from electronic health records (from January 1, 2019 to December 31, 2019) as well as semi-structured interviews with OT practitioners in the IRF. No objective P-SADS screens were documented nor were any P-SADS-focused goals written. Minimal evidence-based P-SADS interventions were identified. Practitioners reported multi-level barriers to OT P-SADS care including limited time, pressure to prioritize physical recovery, and inadequate resources to guide practice. OT practitioner P-SADS care was inconsistent with established evidence-based practice. This research identifies gaps in comprehensive stroke recovery and informs implementation efforts to support evidence-based P-SADS care in IRFs.

Evaluating the feasibility and acceptability of the Mood Assessment Post-Stroke (MAPS) mood screening training

Mood problems are common after stroke, and screening is recommended. Training may support staff knowledge and implementation of screening, but the feasibility of training programmes in the Australian healthcare system has not been formally established. This study aimed to assess the feasibility of a mood screening training for a multidisciplinary team (MDT) of stroke clinicians working in a post-acute inpatient rehabilitation service.Twelve staff from a rehabilitation service at a major hospital in Sydney, Australia participated in a 3-h interactive training session. The feasibility of running the course, assessment of knowledge gained via a consolidation exercise and quiz and acceptability of the training were assessed via focus groups.The in-person modality of the training hindered recruitment and assessment of participants' knowledge, though the actual measures themselves appeared appropriate. Nine participants provided feedback in two focus groups. Thematic analysis identified positive reactions to the training. However, low self-efficacy persisted and organisational/socio-cultural barriers to implementation emerged. Following training, the medical officers of the MDT had successfully implemented routine screening.Overall, the training appeared acceptable and to foster knowledge in staff. However, limitations to recruitment and administering evaluations were identified. The development of flexible online training may improve future evaluations of screening training programmes/pathways.

The influence of a virtual reality entertainment program on depressive symptoms and sedentary behaviour in inpatient stroke survivors: a research protocol for a pilot randomized controlled trial

Background

Sedentary behaviour among stroke inpatients may be due to high rates of depressive symptoms after stroke. Thus, efforts to address depressive symptoms among stroke inpatients are warranted to in turn lessen sedentary behaviour. Despite evidence that virtual reality (VR) is emerging as a method to help with depression, the use of VR to improve depression among inpatient stroke survivors has yet to be studied. In this paper, we report on the protocol investigating the feasibility of a VR entertainment system at improving depressive symptoms among stroke survivors receiving inpatient rehabilitation.

Methods

In this single-blind randomized controlled trial, 30 inpatient stroke survivors from the rehabilitation unit at Kelowna General Hospital will be randomized to either (1) intervention: 3 times per week of VR entertainment for duration of inpatient rehabilitation or (2) control: usual care. Individuals will be included if they have a confirmed diagnosis of stroke, are 19 years of age or older, able to provide informed consent, have physician clearance to participate in the study (medically stable or fit), or are able to understand English. Outcome measures to address depressive symptoms (primary outcome), sedentary behaviour, motivation, anxiety, stress, and happiness (secondary outcome) will be administered at two timepoints: (1) baseline (T1) and (2) post-intervention (T2). Study analyses will consider study feasibility indicators and clinical (statistical) outcomes. Means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables) will be used to summarize the variables. Feasibility indicators will be dichotomized into either ‘success’ if they meet the a priori criteria, or ‘revise’ if they do not meet the criteria. Intervention effects post-intervention (T2) for the primary and secondary clinical outcomes will be estimated using linear regression including baseline (T1) controlling for age and sex.

Discussion

The results of this trial will add to our understanding of depression and sedentary behaviour among individuals receiving inpatient stroke rehabilitation as well as the feasibility of a VR entertainment program to improve depressive symptoms, which will in turn may lessen sedentary behaviour in inpatient stroke survivors.

Trial registration

ClinicalTrials.gov Identifier: NCT04011202 . First posted July 8, 2019 (study postponed from March 2020 to July 2021 due to COVID-19).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01189-8.

Young Adults Rehabilitation Needs and Experiences following Stroke (YARNS): A review of digital accounts to inform the development of age-appropriate support and rehabilitation

AIMS

To explore younger adults' experiences of stroke rehabilitation to inform practice, education and future health policy.

DESIGN

Qualitative analysis of digital and other media sources on public platforms.

METHODS

Between March and June 2020, the experiences of younger adult stroke survivors aged 18 to 45 at the time of the stroke were collected. Data were gathered from publicly available sources, including social media, and from English-speaking users. In total, 117 accounts from 103 participants were identified from films, autobiographical books, blogs, websites, videos, Twitter and Instagram. Data analysis followed narrative and multimodal analysis with a focus on rehabilitation needs.

RESULTS

Younger adult stroke survivors make sense of their experience by reflecting on how stroke has impacted their lives. Accounts reflected an emotional journey between the past self, the present self and evolving self, as well as associated challenges such as the impact on relationships and careers. The majority of accounts presented transitions as problematic, including the receipt of the initial diagnosis, or sometimes misdiagnosis, to returning home and achieving long-term rehabilitation goals. Specialist stroke nurses were considered essential in the rehabilitation process.

CONCLUSION

A complex process of recovery follows stroke for younger adult stroke populations. Challenges to the rehabilitation process need to be better understood and the role of nursing highlighted in future service provision. A series of age-related challenges were highlighted that require attention to improve the care and support offered.

IMPACT

This article informs clinicians, educators, and policymakers of the age-related needs of young adult stroke survivors. Focusing on the individual and the development of age-appropriate person-centred stroke care is important. The study highlights the role of stroke nursing and challenges the current policy focus on older stroke populations as well as arguing for greater awareness of age-appropriate stroke rehabilitation in younger adults following stroke.

Prevalence of Balance Impairment and Factors Associated with Balance among Patients with Stroke. A Cross Sectional Retrospective Case Control Study

Stroke is a major cause of disability worldwide, and balance impairments are common disabling factors in patients with stroke, leading to falls. Thus, the study objectives were as follows: (i) To find the prevalence of balance impairment among patients with stroke. (ii) To find out the factors associated with balance impairment in patients with stroke. This cross-sectional retrospective case control study involved eighty-one post stroke patients with a mean age of 58.36 ± 14.06, recruited from six hospitals, who underwent an assessment of balance, walking speed, depression and isometric strength of the ankle and knee. These patients were later categorized into subjects with good balance (<45) in the Berg balance scale (BBS) and those with poor balance (≥45), as cases and controls, to assess the factors associated with balance impairment using binary logistic regression. The prevalence of balance impairment among patients with stroke was 48.1%. The reduction in power of knee flexors (OR = 0.858), knee extensors (OR = 0.880) and ankle dorsiflexors (OR = 0.820) was found to be significantly associated with balance impairment, along with speed (OR = 1.187 (95% CI = 1.100, 1.280)), depression (OR = 1.331 (95% CI = 1.055-1.679)) and activities of daily living (OR = 0.313 (95% CI = 0.150-0.650)). In summary, around half of the patients with stroke exhibited balance impairments, with females being more prone.

Barriers to integrating routine depression screening into community low vision rehabilitation services: a mixed methods study

BACKGROUND

Undetected depression is common in people with low vision and depression screening has been recommended. However, depression screening is a complex procedure for which low vision practitioners need training. This study examined the integration of routine depression screening, using two questions, and referral pathways into a national low vision service in Wales at 6 months following practitioner training, and identified key barriers to implementation.

METHODS

This pre-post single group study employed a convergent mixed methods design to collect quantitative questionnaire and qualitative interview data on low vision practitioners' clinical practice and perceived barriers to implementing depression screening. Forty practitioners completed questionnaires pre-, immediately post- and 6 months post-training and nine engaged in interviews 6 months post-training. Ordinal questionnaire scores were Rasch-transformed into interval-level data before linear regression analyses were performed to determine the change in scores over time and the association between perceived barriers and clinical practice. Thematic Analysis was applied to the interviews and the narrative results merged with the questionnaire findings.

RESULTS

Before training, only one third of practitioners (n = 15) identified depression in low vision patients, increasing to over 90% (n = 37) at 6 months post-training, with a corresponding increase in those using validated depression screening questions from 10% (n = 4) to 80% (n = 32). Six months post-training, practitioners reported taking significantly more action in response to suspected depression (difference in means = 2.77, 95% CI 1.93 to 3.61, p < 0.001) and perceived less barriers to addressing depression (difference in means = - 0.95, 95% CI - 1.32 to - 0.59, p < 0.001). However, the screening questions were not used consistently. Some barriers to implementation remained, including perceived patient reluctance to discuss depression, time constraints and lack of confidence in addressing depression.

CONCLUSIONS

The introduction of depression screening service guidelines and training successfully increased the number of low vision practitioners identifying and addressing depression. However, standardized screening of all low vision attendees has not yet been achieved and several barriers remain. Healthcare services need to address these barriers when considering mental health screening, and further research could focus on the process from the patients' perspective, to determine the desire for and acceptability of screening.

Screening Adherence for Depression Post Stroke: Evaluation of Outpatients, a London Experience (SAD PEOPLE)

BACKGROUND

Post stroke depression (PSD) is common, and the transition home following discharge may be especially challenging for stroke survivors.

OBJECTIVES

This study aimed to determine how well specific Canadian Best Practice Recommendations for PSD screening were adopted within a stroke rehabilitation outpatient clinic before and after the utilization of a standardized clinical form.

METHODS

Practices were evaluated through retrospective chart review before and after the implementation of the standardized form which cued physicians to administer the Patient Health Questionnaire 9 (PHQ-9) at the first outpatient visit. Participants included those aged ≥18 years with a primary diagnosis of stroke.

RESULTS

One hundred thirty-five subjects' charts were reviewed. Form implementation was associated with increased rates of PSD screening (93.8% versus 0%) and charting regarding mood (55.4% versus 15.7%).

CONCLUSION

This study highlights the frequency of depressive symptoms in an outpatient cohort and demonstrates how screening rates can be improved by using a standardized form. Routine PHQ-9 completion at the first outpatient visit was associated with more physician-patient discussion and documentation regarding mood.

Psychological and emotional needs, assessment, and support post-stroke: a multi-perspective qualitative study

BACKGROUND

International stroke care guidelines recommend the routine assessment and management of psychological and emotional problems post-stroke. Understanding the experiences of those delivering and receiving these services is vital to improving the provision of psychological support post-stroke.

OBJECTIVES

To explore patients', carers', and health professionals' experiences of psychological need, assessment, and support post-stroke while in hospital and immediately post-discharge.

METHODS

Participants were recruited from seven specialist stroke services in the north of England. Qualitative semi-structured interviews and focus groups were conducted with 31 stroke patients, 28 carers, and 66 health professionals. The interviews were recorded and transcribed verbatim and analyzed using thematic analysis.

RESULTS

Two central themes emerged minding the gap: psychological expertise, and protective factors perceived to reduce the need for formal psychological support. The lack of psychological expertise among healthcare professionals working on stroke units was a source of frustration and resulted in other disciplines assuming the role of a psychologist without the required skills and training. Multiple stakeholders discussed the importance of protective factors, including downward social comparison, social support, peer support, communication, and information provision, that were perceived to reduce the need for formal psychological support.

DISCUSSION

Stroke patients need better access to psychological support, including information, advice, and peer or social support. More research is required to establish the effectiveness of alternative options to formal psychological support.

Impact of anxiety on health-related quality of life after stroke: a cross-sectional study

OBJECTIVE

To examine the impact of anxiety on health-related quality of life (HRQOL) of stroke survivors.

DESIGN

Cross-sectional study.

SETTING

Acute stroke unit in a regional hospital.

PARTICIPANTS

Patients (N=374) from an acute stroke unit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence of anxiety was defined as a score of ≥8 on the anxiety subscale of the Hospital Anxiety Depression Scale. HRQOL was measured by the total score and 12 domain scores of the Stroke Specific Quality of Life (SSQOL) scale. Demographic characteristics and history of medical conditions were also recorded. Clinical characteristics were obtained using the following scales: National Institutes of Health Stroke Scale, Barthel Index, Mini-Mental State Examination, and Geriatric Depression Scale (GDS).

RESULTS

Eighty-six (23%) stroke survivors had anxiety. The anxiety group had significantly more women (62.8% vs 35.1%), higher GDS scores (7.5±4.5 vs 3.5±3.6), and lower scores for total SSQOL (3.9±0.6 vs 4.5±0.6) and SSQOL domains of energy (2.0±1.2 vs 3.4±1.4), mood (3.6±1.5 vs 4.6±0.9), personality (3.4±1.7 vs 4.4±1.1), and thinking (2.4±1.2 vs 3.5±1.4), after adjustment for sex and GDS score. In subsequent multivariate regression analysis, the Hospital Anxiety Depression Scale anxiety score was negatively associated with the SSQOL total score (r=-.154) and 5 of the 12 domain scores, namely energy (r=-.29), mood (r=-.102), personality (r=-.195), thinking (r=-.136), and work/productivity (r=-.096).

CONCLUSIONS

Anxiety has a negative effect on HRQOL of stroke survivors, independent from depression. Interventions for anxiety should improve stroke survivors' quality of life.