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Assessment and Treatment of Post-Stroke Depression

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Describe etiology and incidence of post-stroke depression (PSD) ... Signs of Depression Scale (SODS) Six items. Easy to administer. Yes/no response format ... – PowerPoint PPT presentation

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Title: Assessment and Treatment of Post-Stroke Depression


1
Assessment and Treatment of Post-Stroke Depression
  • Dr John McCahill MBChB,MRCPsych,FRCPC,
  • Geriatric Psychiatrist,
  • Alberta Hospital,Edmonton.
  • John.McCahill_at_capitalhealth.ca

2
Goals of presentation
  • Describe etiology and incidence of post-stroke
    depression (PSD).
  • Outline assessment and screening tools for PSD.
  • Outline treatment options and strategies for PSD.

3
Introduction
  • Variety of emotional and behavioural disorders
    can develop following cerebrovascular lesions
  • Major depression
  • Minor depression- depressed mood or loss of
    interest and at least 2 but fewer than 4 symptoms
    of major depression(DSM IV)

4
Prevalence of PSD.
  • Approximately 1/3 of persons will experience
    clinically significant depression at some point
    following a stroke. Hacket, et al., 2005
  • Robinson found a mean prevalence of 19.3 and
    18.5 of stroke survivors had major depression or
    minor depression, respectively, in acute care
    rehabilitation settings. Robinson, RB, 2003
  • No significant difference in incidence between
    hemorrhagic and infarct strokes

5
Prevalence
  • In the subacute phase patients may be in a period
    of adjustment rather than being clinically
    depressed
  • Highest incidence of depression found in the
    first month

6
Course of PSD
  • About 40 of those with PSD will develop symptoms
    within 3 months.
  • 30 of nondepressed patients become depressed
    upon discharge from the hospital.
  • At 6 months, a majority of patients with PSD
    continued to have symptoms.
  • Course of PSD different for major and minor
    depression

7
Major PSD
  • Recovery significantly better in major PSD than
    minor PSD with nearly 75 resolution in symptoms
    after two years.
  • Chemerinski Robinson, 2000.

8
Minor PSD
  • Prognosis worse in patients with minor
    depression.
  • Chemerinski Robinson, 2000

9
PSD associated with
  • Poor functional recovery may delay recovery by
    2 years.
  • Poor social outcomes
  • Reduced quality of life
  • Reduced rehabilitation treatment efficiency
  • Increased cognitive impairment
  • Increased mortality Morris, et al., 1993

10
Risk factors for PSD
  • Biological factors
  • Location of stroke left cortical and
    subcortical lesions risk is controversial
  • Exact neuroanatomical mechanism unknown
  • Presumed disruption in amine pathways

11
Psychosocial factors
  • Pre-stroke history of depression
  • Personality and coping style
  • Inadequate social support, particularly
    significant other.
  • Level of disability functional impairment
  • - cognitive
    impairment

12
Psychosocial risk factors
  • Socioeconomic status found to have no influence
    on PSD risk
  • Conflicting studies on whether higher prevalence
    of PSD in women vs men as in the general
    population
  • Overall,being female does increase the risk
  • Concern there maybe a response bias during
    clinical interview(women more readily report
    symptoms) and using assessment scales(e.g.
    crying questions)

13
Early Predictors of PSDCarota, et al. (2005)
  • Low Barthel Index score http//www.strokecenter.or
    g/trials/scales/barthel.pdf
  • Age lt68 years
  • Crying in first few days
  • Pathological crying (not associated with PSD)
  • Emotionalism (41 developed PSD)
  • Catastrophic reaction (63 developed PSD)

14
Distinguishing types of crying
  • Pathological crying linked to infarct in basis of
    pontis and corticobulbar pathways and occurs in
    response to mood incongruent cues.
  • Emotionalism is crying that is congruent with
    mood (sadness) but patient is unable to control
    crying as they would have before stroke.
  • Catastrophic reaction is crying or withdrawal
    reaction triggered by a task made difficult or
    impossible by a neurologic deficit (e.g. moving a
    hemiplegic arm)

15
Early predictors of PSD
  • Storor and Byrne(2006) found significant
    association between PSD within 14 days of CVA
    and pre-stroke neuroticism and past history of
    any psychiatric illness.

16
Stroke location and Depression
  • Not well understood
  • 2 meta-analyses have studied this
  • Singh et al (1998) looked at 13 studies examining
    lesion location and PSD
  • 6 studies found no difference in depression
    between right and left hemisphere lesions
  • 2 found right sided lesions more likely
  • 4 found left sided lesions more likely
  • All studies noted to be methodically flawed

17
Stroke location and Depression
  • Carson et al (2000) systematic review
  • 48 studies reviewed
  • 38 reports found no significant difference in
    depression risk and lesion site
  • 2 reported an increased risk with left sided
    lesions
  • 7 reported an increased risk with right sided
    lesions
  • 1 reported an increased risk with right parietal
    or left frontal strokes
  • Authors concluded PSD risk not affected by stroke
    location

18
Stroke location and PSD Bhogal et al 2004
19
Stroke location and depression
  • John Hopkins Group (Robinson et al) who initially
    found a potential link with left sided lesions
    and PSD
  • But studies were flawed with selection biases in
    the patient population and findings have not been
    consistently replicated
  • The site and size of the lesion doesnt appear
    strongly correlated with depression although data
    not consistent

20
Stroke location and depression
  • Recent reports suggest that psychosocial risk
    factors
  • age,sex,
  • functional impairment,
  • previous psychiatric disturbance
  • Are greater contributors to PSD risk

21
Diagnosis of PSD
  • Difficult to reliably diagnose
  • Post-stroke depression under-diagnosed by
    non-psychiatric physicians in 50-80 of cases.
    Shuebert, et al. 1992
  • Widespread belief that depression is simply an
    understandable psychological reaction or grief
    response.

22
Overlapping Neurological impairment presents
diagnostic challenges Gaete, et al., 2008
  • Cognitive deficits
  • Fatigue
  • Apathy motivational disorder found in 23-57 of
    patients with stroke.
  • Not correlated with depression
  • Depression correlated with memory and executive
    functioning deficits
  • Anosognosia lack of awareness, denial or
    underestimate of sensory, cognitive of affective
    impairment (60 in R-CVA, 24 L-CVA)

23
DSM-IV Diagnostic criteria for major depression
  • Five or more of the following present during two
    week period
  • and representing a change in function, one
    symptom must be
  • either depressed mood or loss of interest
  • Depressed mood most of the day for most days.
  • Marked reduction in interest or pleasure in most
    activities
  • Significant weight loss or gain, significant
    increase or decrease in appetite
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness inappropriate guilt
  • Reduced ability to think or concentrate
  • Recurrent thoughts of death or suicide

24
Assessment of PSD
  • Clinical interview and history
  • Collateral information from family and caregivers
  • Observational standardized screening measure
  • Self-reports standardized screening measure when
    appropriate

25
Issues in use of self-report screening tools for
PSD Gaete, et al. 2008)
  • Self report measures are quite sensitive to the
    presence of depressive symptoms but lack
    specificity to differentiate from other comorbid
    or confounding factors.
  • Somatic symptoms on self assessment measures may
    play a role in reduced specificity
  • Anosognosia lack of awareness may affect
    sensitivity and specificity of instruments.
  • Physical and cognitive deficits may make use of
    these tools prohibitive.

26
Self-report screening tools for patients without
communication barriers
  • Beck Depression Inventory (BDI-2)
  • Well validated and reliable
  • Easy to administer
  • Well validated and reliable
  • Easy to administer
  • Some difficulty with scale completion reported
  • Sensitivity and specificity best if cut-off score
    is at 10 or greater for PSD.
  • BDI Fast Screen for Medical Patients
  • Potential due to focus on affective rather than
  • somatic symptoms.
  • Not validated yet in stroke populations.
  • Cut of score of 4/5 in Geriatric populations
    recommended.

27
Self-report screening tools for patients without
communication barriers
  • Hospital Anxiety and Depression Scale (HADS)
  • Well tolerated
  • Somatic symptoms excluded
  • 14 items
  • Relatively good date on its use in PSD screening

28
Self-report screening tools for patients without
communication barriers
  • Geriatric Depression Scale (GRS)
  • Designed for screening for depression in older
    individuals
  • Low reliance on affective symptoms
  • Good sensitivity and specificity in stroke
    patients but reports it is not well tolerated in
    hospitalized medical patients in part due to 30
    items.
  • Short form not evaluated in stroke population.

29
Self-report screening tools for stroke patients
with communication barriers
  • Visual Analogue Mood Scale (VAMS)
  • Eight cartoon face and verbal descriptions
  • For stroke patients with communication disorders
  • Not affected by neglect
  • However, not validated yet in stroke population

30
Observational rating scales
  • Post-stroke Depression Rating Scale (PDRS)
  • Ten items
  • Specifically designed to assess depression in
    stroke patients
  • No clear cut-off score
  • Training and experience required to administer
  • Not validated in stroke clinical or research
    settings

31
Observational scales
  • Stroke Aphasia Depression Questionnaire
  • (SADQ-H 21 or SADQ-H 10)
  • Completed by health care professional
  • Observable behavior associated with depression
  • Short version recommended for clinical
    applications though longer version was developed
    for hospital application and is better validated.

32
Observational scale
  • Aphasic Depression Rating Scale (ADRS)
  • Designed to diagnose and monitor depression in
    patients with aphasia
  • Training required to use instrument
  • Cut off score of 9 of 32 items provides good
    sensitivity and specificity for depression in
    patients with Aphasia.

33
Nursing observational scale
  • Signs of Depression Scale (SODS)
  • Six items
  • Easy to administer
  • Yes/no response format
  • Adequate sensitivity and specificity in
    identifying depression in older individuals who
    are medically ill and in stroke patients without
    significant communication problems.

34
Assessment of PSD
  • Detection and Diagnosis often inconsistent
  • Compliance with guidelines for screening is poor
  • Identified barriers to routine screening include
    time pressures and concerns about screening tools
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