Screening for depression and anxiety after stroke: developing protocols for use in the community

Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals

OBJECTIVE

Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals.

DESIGN

Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program.

SETTING

Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia.

PARTICIPANTS

In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals.

MAIN MEASURES

Hospital- and patient-level mood management processes.

RESULTS

Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay.

CONCLUSIONS

Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Impact of Baduanjin exercise combined with rational emotive behavior therapy on sleep and mood in patients with poststroke depression: A randomized controlled trial

BACKGROUND

Poststroke depression (PSD) is one of the most common stroke complications. It not only leads to a decline in patients' quality of life but also increases the mortality of patients. In this study, the method of combining Chinese traditional exercise Baduanjin with psychotherapy was used to intervene in patients with PSD and to explore the improvement of sleep, mood, and serum levels of brain-derived neurotrophic factor (BDNF), 5-hydroxytryptamine (5-HT), and interleukin-6 (IL-6) levels in patients with PSD by combined treatment.

METHODS

A total of 100 patients with PSD who met the inclusion criteria were randomly assigned to Baduanjin group (n = 50) or control group (n = 50). The control group received treatment with escitalopram oxalate and rational emotive behavior therapy, while the experimental group received Baduanjin training in addition to the treatment given to the control group. Changes in sleep efficiency, sleep total time, sleep latency, arousal index, Hamilton Anxiety Rating Scale, Hamilton Depression Scale score, serum BDNF, 5-HT, IL-6 levels, and Modified Barthel Index were measured at baseline, 4 weeks and 8 weeks after intervention, and the results were compared between the 2 groups.

RESULTS

Significantly improvements in the sleep efficiency, sleep total time, serum 5-HT, BDNF levels, and Modified Barthel Index score were detected at week 4 in the Baduanjin group than in the control group (P < .05). Additionally, the sleep latency, arousal index, Hamilton Anxiety Rating Scale, Hamilton Depression Scale scores and IL-6 levels in the Baduanjin group were lower than those in the control group (P < .05). After 8 weeks of treatment, the above indexes in the Baduanjin group were further improved compared with the control group (P < .05), and the above indexes of the 2 groups were significantly improved compared with the baseline (P < .001).

CONCLUSION

Baduanjin exercise combined with rational emotive behavior therapy effectively improves the mood and sleep status of patients with PSD; It increases the serum levels of 5-HT and BDNF while reducing the level of serum proinflammatory factor IL-6; additionally, the intervention alleviates the degree of neurological impairment, upgrades the ability of daily living, and improves the quality of life.

Aphasia, depression, and psychological therapy (ADaPT): A single case design evaluation of a modified cognitive behavioural therapy to treat depressive symptoms in stroke survivors with aphasia

Cognitive behavioural therapy (CBT) can effectively treat depression in the general population, but there is a lack of studies evaluating CBT tailored to specific cognitive and communication needs of individuals with post-stroke aphasia. We aimed to evaluate the feasibility and preliminary efficacy of a modified CBT intervention to ameliorate depressive symptoms. An ABA withdrawal/reversal single case design with concurrent multiple baselines (2.5, 4.5, or 6.5 weeks) was repeated across 10 participants (six male, four female) with post-stroke aphasia and self-reported depression. Participants completed 10 individual intervention sessions with a clinical neuropsychologist and a 4-week follow-up. The primary outcome was self-rated depression, and secondary outcomes included observer-rated symptoms of depression and anxiety. Data were analysed visually and statistically controlling for baseline trend. Feasibility was addressed by analysing recruitment and retention rates, treatment adaptations, and fidelity ratings. Three participants self-reported decreased depression levels during the intervention phase, which was sustained for two participants. Four additional participants improved during the follow-up phase. Close others reported sustained improvements in depressive symptoms (six participants) and anxiety symptoms (seven participants). Modified CBT appears feasible and potentially efficacious in reducing depressive symptoms in post-stroke aphasia. A randomized controlled trial is warranted, and should consider additional treatment sessions.

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.

Tobacco and alcohol consumption and health behaviors among nursing students

Objetive: To evaluate the association between attitudes, health behaviors, and the use of tobacco and alcohol among nursing students. Materials and method: Exploratory, descriptive and cross-sectional study conducted with 182 undergraduate nursing students in the countryside of São Paulo, Brazil. Sociodemographic Information Form, Alcohol Use Disorders Identification Test – C(AUDIT-C), Fagerström Test for Nicotine Dependence (FTND), Attitudes and Health Behaviors Questionnaire (AHBQ), and Patient Health Questionnaire – 2 (PHQ-2) were applied. Results: More than half of the students showed appropriate health behaviors and positive attitudes. Approximately 50% of the participants had consumed alcoholic beverages in the last month. Experimental use of illicit drugs and smoking were also observed. In addition, students who reported excessive alcohol use presented a deficit in self-care. Conclusion: The precariousness in health attitudes and behaviors identified in this study was associated with various patterns of psychoactive substance use. Thus, the results indicate the need for interventions aimed at promoting well-being and a healthy lifestyle in the university environment.

The course of depressive symptoms in the first 12 months post-stroke and its association with unmet needs

AIM

To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs.

METHODS

A prospective cohort study among stroke patients admitted to inpatient rehabilitation. Depressive symptoms were assessed 3, 6, and 12 months post-stroke using the Hospital Anxiety and Depression Scale, and categorized into three trajectories: no (all times <8), non-consistent (one or two times ≥8), or persistent (all times ≥8) depressive symptoms. Unmet needs were assessed using the Longer-Term Unmet Needs questionnaire. Multivariable logistic regression analyses were used to investigate the association between depressive symptoms and unmet needs.

RESULTS

One hundred and fifty-one patients were included, of whom 95 (62.9%), 38 (25.2%), and 18 (11.9%) had no, non-consistent, or persistent depressive symptoms, respectively. Depressive symptoms three months post-stroke persisted in 43.9% and recurred in 19.5% of patients during the first 12 months post-stroke. Depressive symptoms were significantly associated with the occurrence and number of unmet needs (odds ratio 6.49; p = 0.003 and odds ratio 1.28; p = 0.005, respectively).

CONCLUSIONS

Depressive symptoms three months post-stroke were likely to persist or recur during the first 12 months post-stroke. Depressive symptoms are associated with unmet needs. These results suggest that routine monitoring of depressive symptoms and unmet needs should be considered post-stroke.Implications for rehabilitationPatients with depressive symptoms three months post-stroke have a high risk of developing persistent or recurrent depressive symptoms during the first 12 months post-stroke.Unmet needs are associated with both non-consistent and persistent depressive symptoms post-stroke.These results suggest that health professionals should routinely screen for depressive symptoms and health care needs around three months post-stroke.In patients with depressive symptoms at three months post-stroke early treatment of depressive symptoms and addressing unmet needs should be considered and depressive symptoms should be routinely monitored during the first 12 months post-stroke.

Stroke health professionals' management of depression after post-stroke aphasia: a qualitative study

Background: People with post-stroke aphasia commonly experience mental health conditions, with depression having a high prevalence. An understanding of current practice may inform ways to improve psychological care for people with aphasia.Aim: To explore current practice for managing depression after post-stroke aphasia from the perspective of stroke health professionals.Method: Five semi-structured focus groups were conducted with 39 stroke health professionals across the care continuum. Focus groups were transcribed verbatim and analyzed using the method of Interpretive Description.Results: Analysis of verbatim transcripts revealed four core themes: (1) concomitant aphasia and depression after stroke is a challenging area of rehabilitation, (2) mood difficulties and depression are not always a high stroke rehabilitation priority, (3) approaches to identification and management are ad hoc, and (4) stroke health professionals are trying to bridge the gap between clients' psychological care needs and limited services. Sub-themes were also identified.Conclusion: This study demonstrates that health professionals are challenged by and limited in managing depression after post-stroke aphasia. Health professionals have the opportunity to improve services through the translation of evidence-based interventions. The integration of mental health care into stroke rehabilitation may be achieved through policy development, leadership and specialist training.Implications for rehabilitationPeople with aphasia need routine mood screening using aphasia-specific clinical tools and communication support.Stroke health professionals report a need for communication partner training to facilitate mental healthcare for people with aphasia.Family members need to be involved in aphasia rehabilitation to gain psychological care for themselves and the person with aphasia.

Preliminary Screening Recommendations for Patients at Risk of Depression and/or Anxiety more than 1 year Poststroke

GOAL

Depression and anxiety are important complications of stroke but are underdiagnosed in community settings. The current study identified which patients were at increased risk of developing either disorder more than1 year poststroke to assist in targeted screening.

METHODS

Crosssectional survey of 147 adults who had a stroke more than 1 year ago were recruited from stroke advocacy/support groups and an outpatient register. Participants completed the Hospital Anxiety and Depression Scale (HADS) and reported whether they had emotional problems as a stroke inpatient (single item: yes/no). Standardized self-report measures evaluated medical (physical independence, health-related quality of life), cognitive (memory, executive functioning), and psychological (social support) variables. Demographic and stroke-related (stroke type, year) information were also recorded.

FINDINGS

Between 53% and 80% of respondents (n = 117) screened positive for depressed mood and/or anxiety (HADS subscale cut-offs: ≥8 or ≥4). Logistic regression analyses indicated that stroke survivors who reported having emotional problems as inpatients (odds ratio [OR]: 0.23), were female (OR: 3.42), and had poor health-related quality of life (OR: 0.45-0.53) and cognitive problems (OR: 0.68-0.74), were more likely to screen positive for either disorder. Models based on these variables predicted screening outcomes with 91% accuracy.

CONCLUSIONS

Community-based stroke survivors who reported experiencing emotional problems as inpatients, were female, or had poor health-related quality of life (chronic pain, disturbed sleep, communication difficulties) and/or cognitive issues were at greater risk of being depressed/anxious. Targeted screening of these patients may help to identify those who are most in need of more comprehensive clinical assessments and evidence-based interventions.

Efficacy of Cranial Electrical Stimulation and Rational Emotive Behavior Therapy in Improving Psychological Illness among Chronic Stroke Survivors: A Pilot Randomized Controlled Trial

Background

Stroke survivors suffer from significant neuropsychiatric disturbances and these disturbances act as barrier in the motor recovery. Medication is the common treatment but it has adverse effects. Hence, there is a need to find out effective treatments with or without minimal side effects for gross motor recovery of the patient.

Objectives

Cranial electrical stimulation (CES) and rational emotive behavior therapy (REBT) are used as treatment approaches for depression, anxiety, stress, and irrational beliefs in the general population. In the present study, the efficacy of two psycho-therapeutic modalities (CES and REBT) along with conventional physiotherapy management was evaluated on psychological illness, motor recovery, and quality of life among chronic stroke (CS) survivors.

Materials and Methods

A total of 18 patients with CS who scored >10 on Beck Depression Inventory Scale, scored >23 on Mini-Mental state examination scale, and having stroke of duration >6 months-2 years were included in the study. They were divided into two groups, A and B. Group A received CES while Group B received REBT. Both the interventions were given 5 days in a week for 4 weeks. Conventional physiotherapy for 30 min was added to both groups as common intervention. Depression, Anxiety, Stress scale (DASS-42), Pittsburgh Sleep Quality Index (PSQI), and Shortened General Attitude and Belief Scale (SGABS) were used for measuring depression, anxiety, and stress, sleep, attitude and beliefs, respectively, 4 weeks postintervention.

Results

Patients with CS in Group A demonstrated significant improvement, P < 0.05, in Depression, Anxiety, Stress scale-24, PSQI, and MSSI when compared to those of Group B.

Conclusion

CES has the potential to improve psychological illness such as depression, anxiety, stress, attitudes, belief, and thereby quality of life among CS survivors than REBT.

Psychometric properties of the Behavioural Outcomes of Anxiety questionnaire in stroke patients with aphasia

OBJECTIVE

To evaluate the psychometric properties of an observational, carer-completed anxiety screen for aphasic stroke patients.

DESIGN

Phase 1: A cross-sectional questionnaire design to establish psychometric properties. Phase 2: A randomized longitudinal design with treatment and control to evaluate sensitivity to change and repeatability/reliability.

SUBJECTS

Phase 1: 111 patient-carer dyads were recruited through stroke charities: patient mean age 69.7(10. 7), 6.2(5. 2) years since stroke, 76 male; carer mean age 64.7(12. 2), 27 male. Phase 2. A subsample of 50 dyads (29 completed).

MEASURES

All patients completed the Tension Rating Circles and the Frenchay Aphasia Screening Test. Carers completed the Behavioural Outcomes of Anxiety questionnaire, observational versions of the Hospital Anxiety and Depression Scale (HADS-A) and the Generalised Anxiety Disorder-7, and a feedback questionnaire.

INTERVENTION

Phase 2: 25 dyads were offered relaxation training and 25 acted as controls.

RESULTS

The Behavioural Outcomes of Anxiety questionnaire correlated .77 with the HADS-A and Cronbach's Alpha was .82 demonstrating validity and internal consistency. Using HADS-A cut-off > 7 as criterion the area under the curve was 0.90 and at cut-off of > 16 sensitivity (0.85) and specificity (0.85) were both good. Scores declined significantly more in a group given anxiety training ( n = 12) than in a control group ( n = 17), demonstrating sensitivity to change and construct validity. Two-week repeatability/reliability was .92. Feedback suggested the scale was acceptable.

CONCLUSIONS

The Behavioural Outcomes of Anxiety questionnaire shows promise as an anxiety screen for stroke patients with aphasia and is sensitive to change. Further analysis of dimensionality and discriminant validity is needed.

Brief screening for depression and anxiety in vision and other rehabilitation services

The field of physical and sensory rehabilitation is broad, covering a wide variety of health presentations and intervention processes. There is persuasive evidence that unrecognised and untreated mental health disorders, such as depression and anxiety, can have a major impact on physical health status and rehabilitation outcomes across all areas of practice. It is important to have systems in place for the efficient detection and effective treatment of psychological difficulties. This article considers the role of brief mental health screening measures in case identification, with particular focus on brief mental health screening in vision rehabilitation services. As screening is now regarded as part of evidence-based best practice, the authors also consider issues that affect tool selection and implementation.

Predictors of anxiety after stroke: a systematic review of observational studies

BACKGROUND

Anxiety disorders or symptoms are relatively common after stroke. A better understanding of the predictors of anxiety in stroke patients may improve the management of these disorders. The current review was conducted to determine the predictors of anxiety after stroke.

METHODS

Relevant articles concerning population, hospital, or rehabilitation-based studies were identified by searching 10 electronic databases up to May 2014. Methodological quality appraisal, including the validity of prognostic models and data extraction were conducted by 3 reviewers.

RESULTS

A total of 18 studies were identified. Data from 3 population-based studies including 8130 patients, 8 hospital-based studies including 1199 patients, and 7 rehabilitation-based studies including 1103 patients were evaluated. Prestroke depression, stroke severity, early anxiety, and dementia or cognitive impairment after stroke were the main predictors of poststroke anxiety. Older age, physical disability or impairment, and use of antidepressant drugs were not associated with the presence of anxiety. Limitations of studies included wide variation in screening tools and cutoff scores, variability in the time frame of screening for anxiety, use of extensive exclusion criteria, and questionable statistical internal and external validity of the models.

CONCLUSIONS

Lack of methodological and statistical rigor affects the validity of proposed models to predict anxiety after stroke. Future research should focus on testing proposed models on both internal and external samples to ultimately inform future clinical practice.

Meeting the psychological needs of community-living stroke patients and carers: a study of third sector provision

PURPOSE

To elucidate how community stroke staff in a major third sector organisation experienced their role and understood and responded to clients' psychological needs.

METHOD

In stage 1, three focus groups of 28 staff in total were recorded, transcribed and analysed using inductive thematic analysis. Themes were authenticated by new staff groups. In stage 2, these themes informed the construction of a questionnaire delivered through the organisation's intranet by "Survey Monkey".

RESULTS

Five themes emerged from the focus groups: background and context; perceptions of clients' psychological issues; approaches to meeting psychological needs; the experience of working with psychological needs and sources of support; aspirations for future development. Four themes were used in constructing the questionnaire. Responses from 144 staff with diverse qualifications and experience were received; over half encountered 16 (of 35) psychological issues at least once per week. Stroke survivors' needs predominated over carers' needs. Skills used to address psychological problems were identified, also training and support needs and future aspirations. Support needs included information, training and access to specialist consultants.

CONCLUSIONS

Psychological issues were central in the work of third sector community stroke staff; psychological skills were routinely used. Attention to means of supporting and developing these skills is required.

IMPLICATIONS FOR REHABILITATION

Service leaders and commissioners should be aware that third sector community stroke staff frequently deal with a diverse range of psychological issues and perceive psychological care as central. Service leaders should consider providing training in assessment and management of mood and cognition, risk assessment and management and basic counselling. Staff should be provided with access to specialist consultation and better information about psychological aspects of referrals. There is uncertainty about key methods for supporting the delivery of psychological care (supervision, mentoring and peer support) which requires consideration.

Depression and anxiety symptoms post-stroke/TIA: prevalence and associations in cross-sectional data from a regional stroke registry

BACKGROUND

Mood disorders are commonly seen in those with cerebrovascular disease. Literature to-date has tended to focus on depression and on patients with stroke, with relatively little known about post-stroke anxiety or mood disorder in those with transient ischaemic attack (TIA). We aimed to describe prevalence of depression and anxiety symptoms in stroke and TIA cohorts and to explore association with clinical and socio-demographic factors.

METHODS

We used a city wide primary care stroke registry (Glasgow Local Enhanced Service for Stroke - LES). All community dwelling stroke-survivors were included. We described cross-sectional prevalence of depression and anxiety symptoms using the Hospital Anxiety and Depression Scale (HADS). Data on clinical and demographic details was collected and univariable and multivariable analyses performed to describe associations with HADS scores. We examined those with a diagnosis of 'stroke' and 'TIA' as separate cohorts.

RESULTS

From 13,283 potentially eligible stroke patients in the registry, we had full HADS data on 4,079. Of the 3,584 potentially eligible TIA patients, we had full HADS data on 1,247 patients. Across the stroke cohort, 1181 (29%) had HADS anxiety scores suggestive of probable or possible anxiety; 993 (24%) for depression. For TIA patients, 361 (29%) had anxiety and 254 (21%) had depression. Independent predictors of both depression and anxiety symptoms were female sex, younger age and higher socioeconomic deprivation score (all p < 0.001).

CONCLUSION

Using HADS, we found a high prevalence of anxiety and depression symptoms in a community-based cohort of patients with cerebrovascular disease.

The Behavioural Outcomes of Anxiety scale (BOA): a preliminary validation in stroke survivors

OBJECTIVES

To determine the psychometric properties of an observational scale of anxiety.

DESIGN

A cross-sectional and longitudinal survey with stroke survivor-carer dyads.

METHODS

Eighty-nine dyads recruited in community stroke groups completed: a demographic questionnaire; the Behavioural Outcomes of Anxiety scale (BOA), survivor-rated (survivor BOA) and carer-rated (carer BOA) versions; the anxiety scale of the Hospital Anxiety and Depression Scales (HADS-A), also in carer and survivor versions. Twenty-seven survivors and carers repeated the BOA after 1 week.

RESULTS

Correlations between the carer BOA and the survivor HADS-A (r = .55, p < .001) and the survivor BOA (r = .73, p < .001) demonstrated construct validity. Cronbach's alpha for the carer BOA was .81; item statistics did not identify any items for exclusion. The test-retest coefficient at 1 week was 0.83. Receiver operating characteristic analysis against the survivor HADS-A and BOA produced areas under the curve of 0.75 and 0.88, respectively. At a cut-off score of 13/14 sensitivity and specificity against the HADS-A were 0.77 and 0.58, respectively, and 0.86 and 0.68 against the survivor BOA. The impact of stroke on memory was associated with elevated anxiety. Scores for both BOA versions were independent of demographic variables.

CONCLUSIONS

The carer BOA has acceptable psychometric properties and is independent of survivor demographic variables such as age. It identifies self-reported cases with acceptable sensitivity and specificity. It has potential for use with persons unable to self-report anxiety. Further validation is recommended, but its continuing use is supported.

Treating anxiety after stroke using cognitive-behaviour therapy: two cases

Anxiety disorders are common after stroke. However, information on how to treat them with psychotherapy in this population is highly limited. Modified cognitive-behaviour therapy (CBT) has the potential to assist. Two cases of individuals treated with modified CBT for anxiety after stroke are presented. The modification was required in light of deficits in executive and memory function in one individual and in the context of communication difficulties in the other. The anxiety symptoms were treated over seven and nine sessions, respectively. Both participants improved following the intervention, and these improvements were maintained at 3 month follow-ups. Further case-series and randomised controlled designs are required to support and develop modified CBT for those with anxiety after stroke.