Screening for poststroke mood disturbance within inpatient stroke units

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Screening for post-stroke mood disturbance within
inpatient strokeunits

• Dr Marion Murray
• Clinical Neuropsychologist
• Lothian Stroke MCN
• marion.murray_at_lpct.scot.nhs.uk
• 22 September 2006

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Outline

• Background to audit
• Results of audit
• Protocol
• Discussion

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Background to audit

• Discussion with ward staff in stroke units
• SIGN 64 Guidelines
• MCN philosophy

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Discussion with ward staff

• Difficulty with diagnosing mood disorders
  post-stroke
• Particular difficulty in assessing mood
  disturbance in those with communication problems
• Apparent wide variation in clinical practice
  across the different stroke units in Lothian
• Ambiguity over use of screening questionnaires
  for assessing mood disturbance

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SIGN Guidelines

• SIGN 64 (2002) guidelines 4.14 recommend that
  all stroke patients should be screened for mood
  disturbance. Some form of screening should occur
  initially and at 3 months intervals or key stages
  of the rehabilitation process and after
  rehabilitation support has been lost. If mood
  disorder is suspected then it is recommended that
  the individual should be referred on to an
  appropriately trained professional for a full
  assessment.

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SIGN guidelines for treatment

• In terms of psychological treatment SIGN
  guidelines indicate that patients with complex
  psychological problems should be treated by staff
  with therapeutic expertise. In terms of
  pharmacological treatment SIGN guidelines
  indicate that antidepressants should not be used
  to prevent depression. However, it is recommended
  that patients with diagnosed depression should be
  offered a course of pharmacological treatment

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Aims of audit

• To survey practice for screening mood
  disturbance, specifically highlighting diagnosis
  and treatment of depression within the inpatient
  stroke units across Lothian.
• Use this information to help unify practice in
  keeping with current guidelines across the remit
  of the Stroke MCN

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Audit design

• Retrospective case-note audit
• Conducted July November 2004
• Inpatient case notes discharged between January
  to May 2004.
• n 124

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Results 1.

• Is mood disturbance routinely screened for?
• Some comment within 1st month in 65 of all cases
• Disturbed mood queried in 34 of all patients (n
  42)
• What screening methods are used?
• On 7 occasions screening questionnaires were used
  (HADS 6 vs GDS 1)
• Who uses screening questionnaires?
• Docs 4 vs Nurses 1 vs OTs 1 vs ?? - 1

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Results 2.

• Further full assessment?
• Never clearly documented in notes
• Prevalence of mood disorder?
• 16 - depressed (20 cases)
• 10 - anxiety (12 cases)
• 2 - co-morbid anxiety depression (3 cases)
• 3 - emotionally labile (4 cases)
• Total n 39

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Results 3.

• Treatment?
• Medication
• Depression n 18
• Anxiety n 5
• Co-morbid anxiety depression n 2
• Lability n 2
• Total n 27
• Psychological/Other therapy
• n 0

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Results 4.

• Treatment monitoring?
• Often observational or clinical impression of
  effectiveness noted (NB 89 this was done in 0
  2 weeks after commencing medication)
• Only 2 x screening questionnaires
• On 4 occasions there was a change of medication
• Only in one case was there a clear plan for
  monitoring mood at point of discharge.

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Action

• Devised protocol for screening for mood disorder
  post-stroke
• Staff training on screening for mood disturbance
  and basic strategies to try to enhance mood
• Suggested medical staff meet to discuss optimal
  pharmacological management
• Intend to complete audit cycle at some point

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Protocol

• 3 weeks after admission screen all patients for
  mood disorder using the SADQ-H 10 and at
  3-monthly intervals thereafter and/or point of
  discharge.
• At any time (except 1st 2 weeks post-stroke) if
  you are concerned that an individual might be
  suffering from a mood disorder then complete the
  SADQ-H 10 and follow the suspected mood disorder
  protocol.
• If mood disorder is suspected from the SADQ-H 10
  then further screening using either the GDS-15 or
  the anxiety items from the HADS should be
  completed.
• There should be some form of clinical interview
  before any treatment is started.
• Check symptoms are consistent with mood
  disturbance and not other physical or cognitive
  changes following stroke.

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SAD-Q H 10

• 1 Does he/she have weeping spells?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 2 Does he/she have restless disturbed nights?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 3 Does he/she avoid eye contact when you talk to
  him/her?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 4 Does he/she burst into tears?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 5 Does he/she indicate suffering from aches and
  pains?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 6 Does he/she get angry?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 7 Does he/she refuse to participate in social
  activities?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 8 Is he/she restless and fidgety?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 9 Does he/she sit without doing anything?
• Every day this week (3)On 4-6 days this week
  (2)On 1- 4 days this week (1)Not at all this
  week (0)
• 10 Does he/she keep him/herself occupied during
  the day?

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SAD-Q H 10 cut-offs

• We recommend 10 for protocol
• But
• Leeds et al (2004) suggest 14
• Bennett et al. (2006) suggest 5 or 6 for
  depression and 4 or 5 for anxiety

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Protocol cont.

• Check for other medical issues that could be
  underlying low mood or anxiety
• Check for other environmental factors that could
  be contributing to low mood or anxiety.
• In addition to considering anti-depressant
  medication other non-pharmacological changes
  should be considered.
• These may include encouraging patient to be more
  active in goal setting, encouraging interaction
  with other patients, volunteers, reducing noise
  on ward etc.
• All treatment should be documented and monitored
  throughout admission
• Mention of mood state should be included in a
  patients discharge summary.

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Other action points

• Staff Training
• Ongoing different units are more amenable than
  others.
• Nurses most enthusiastic
• Medical Staff meeting
• No action
• Repeat Audit
• In pipeline but waiting for new ICP paperwork

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Discussion Points

• Views on who should complete mood screening and
  further assessment
• Views on treatment options
• Cut-offs for screening tools specificity vs
  sensitivity
• ..