Depression after a stroke is extremely common but unfortunately according to the National Institutes of Health post-stroke depression
(PSD) is underdiagnosed.
You mental and emotional health is equally important as your physical health in the healing process after a stroke. PSD is described as having feelings of hopelessness, anger, frustration, sadness, and fear. This can interfere with functioning, the healing process after a stroke, and quality of life. PSD can set in weeks, months, or years after the stroke.
What are the signs caregivers and loved ones should look out for and how does the depression screening protocol help post-stoke patients?
Listen in as Celia McInTosh, DP, NP shares the startling facts on depression in stroke survivors, and the depression screening protocol for post stroke patients.
Selected Podcast
Post-Stroke Depression Protocol
Featured Speaker:
Protocol for Patients with Acute Stroke: A Quality Improvement Project-published in the
the American Association of Neuroscience Nurses.
Celia McInTosh, DP, NP
Celia McInTosh, DP, NP is a nurse practitioner at Rochester Regional Health in the neurology department. She recently has had her evidence-based scholarship project entitled -A Depression ScreeningProtocol for Patients with Acute Stroke: A Quality Improvement Project-published in the
the American Association of Neuroscience Nurses.
Transcription:
Post-Stroke Depression Protocol
Bill Klaproth (Host): There are seven million stroke survivors in the United States according to the National Stroke Association, and approximately 2.3 million develop post-stroke depression or PSD annually. What are the protocols for early detection and treatment of PSD? Here to explain more is Celia McIntosh, a nurse practitioner in the department of neurology at Rochester Regional Health. Celia, thanks for your time. What are the biggest complications associated with post-stroke depression or PSD?
Celia McIntosh (Guest): Well one of the biggest complications is that post-stroke depression can increase mortality; it can lead to poor functional outcomes, decreased the quality of life, decrease social interaction. Ultimately, it can also lead to poor functional recovery for rehab outcomes. Those are some of the major ones -- and also lead to suicide ideation.
Bill: So there’s a lot of things that are associated with PSD, poor functional recovery, suicidal ideation as you said, decreased the quality of life and increased mortality, so it's really good to get at this early -- early detection very important. How do you screen for PSD?
Celia: Well, there’s a lot of different screening tools, and that's basically one of the issues. The PHQ-9 Tool, and looking at – specifically for my organization, we utilize the PHQ-9 Tool. They also have the Hamilton Depression Scale as well, but we felt that the PHQ-9 was very – it’s free, it was reliable. It’s been tested in the stroke population to have good validity and reliability. A lot of the primary care centers are actually using this tool, so that’s actually one of the tools we chose for the screening of post-stroke depression.
Bill: Do you wait for depression symptoms to occur or are all stroke patients automatically screened for PSD?
Celia: Well, this is the thing, in 2012, the Joint Commission in association with the American Heart and the American Association, they said that one of their key recommendations for centers to be comprehensive certified was to screen for depression. We are currently a primary care center, so we are actually ahead of the ball, but the thing of it is there has not really been any consistency in organizations about actually having – like what days to screen – there’s a lot of different barriers. What we have done here is that we have implemented a depression screening protocol typically on the second day of admission once we find out that a patient actually has had a documented stroke on CT scan or MRI. We just screen them to really establish a baseline to see if this is something that they either have or don’t have and then tend to try to rescreen them once they’ve been discharged to follow-up on it.
Bill: So what you’re saying is this is really up to each hospital’s discretion and what you do at Rochester is on the second day of admission you administer the PHQ, which stands for Patient Health Questionnaire. On that second day of admission, you give them that PHQ-9, is that right?
Celia: Yes, especially if they have had a confirmed stroke.
Bill: And then when they leave the hospital, you give the PHQ again to see how they’re progressing?
Celia: Yes, so typically we like the patients to follow-up in seven to ten days, but if they’re not able to follow up within that timeframe, within two to four weeks we try to get them an appointment with our outpatient center so they can get rescreened again so we can keep – like I said, establish if they have had any changes, any worsening of their symptoms, so we can basically trend any changes overall in their depression screen.
Bill: Which is really important. If PSD is identified, how do you treat it?
Celia: Well, the literature suggests that the best thing to do is use antidepressants earlier on because it increases recovery and it increases survival. What we have done within the hospital is if we have someone here that actually has been screened positive, especially if they’re over a score of ten, what we do is we tend to start them on a medication here. And then, like I said, we follow them up every couple of weeks as they’re able to follow up to see if their mood improves or if they are basically – how are they doing overall with their stroke symptoms post-discharge.
Bill: What is the short-term and long-term outcome of early diagnosis and treatment of PSD?
Celia: Well, the literature suggests that -- patients after a stroke can have depression up to five years. The greatest risk of the depression is within the first year, and it’s typically greatest within the first month in the most severe cases. Typically, the earlier it’s being treated, the better the symptom outcome will be. That’s the thing, we really have to continue to monitor it, but the sooner we start the patient on the treatment, especially if we’re seeing that they’re having functional – having lack of interest, lack of motivation, very sad, very tearful, things like that – as long as we see that then we know that it’s going to impact their recovery and the sooner we start them, the better, like I said, the outcome will be. I can’t guarantee that they’re going to be at zero depression, but as long as we’re watching it and trending it, we can make changes based on that.
Bill: So do patients with acute strokes have a higher incidence of PSD?
Celia: When I implemented my study back in 2014, we got a lot of really good data saying that once we started screening, we were able to pick it up. But like I said, there are some barriers. If the patient has some cognitive deficits -- dementia, if they have any agnosia, depending on where the stroke is -- they may have some lack of awareness. There were some of the patients that actually could not be screened but probably would have benefited. From the time that we’ve actually implemented the tool and the screening, we have bene able to pick up on it. I think it’s because we are screening more that we’re now really starting recognizing it and we’re not just treating – saying the patient had a stroke and it’s all a part of the stroke. Well, it’s not just one problem; it’s two different problems. It’s the depression, and it’s the stroke, so we treat them comprehensively, not as one process.
Bill: So the benefits of early detection are very clear. It has the potential to improve short- and long-term patient outcomes, such as helping stroke survivors return to an active life, improve the quality of life and social interaction, decrease mortality, and as you said, improve functional outcomes. And Celia, if you could wrap it up for us, why should someone choose Rochester Regional for their healthcare needs?
Celia: Well, this is the thing, Rochester Regional Health was the first stroke hospital here in Rochester, and we do stroke well. We want to take the most comprehensive approach towards caring for our stroke patients, which means that we not only take care of their physical needs, we take care of their psychological needs, to really help improve their long-term outcomes. That’s why I believe that patients should pick our hospital because we are looking at things comprehensively and not just looking at one individual problem.
Bill: Well Celia, thank you so much for your time, again, today. And thank you for talking to us about the PSD protocols – very important work there. You’re listening to Rock Your Health Radio with Rochester Regional Health. For more information, you can go to RochesterRegional.org, that’s RochesterRegional.org. I’m Bill Klaproth, thanks for listening.
Post-Stroke Depression Protocol
Bill Klaproth (Host): There are seven million stroke survivors in the United States according to the National Stroke Association, and approximately 2.3 million develop post-stroke depression or PSD annually. What are the protocols for early detection and treatment of PSD? Here to explain more is Celia McIntosh, a nurse practitioner in the department of neurology at Rochester Regional Health. Celia, thanks for your time. What are the biggest complications associated with post-stroke depression or PSD?
Celia McIntosh (Guest): Well one of the biggest complications is that post-stroke depression can increase mortality; it can lead to poor functional outcomes, decreased the quality of life, decrease social interaction. Ultimately, it can also lead to poor functional recovery for rehab outcomes. Those are some of the major ones -- and also lead to suicide ideation.
Bill: So there’s a lot of things that are associated with PSD, poor functional recovery, suicidal ideation as you said, decreased the quality of life and increased mortality, so it's really good to get at this early -- early detection very important. How do you screen for PSD?
Celia: Well, there’s a lot of different screening tools, and that's basically one of the issues. The PHQ-9 Tool, and looking at – specifically for my organization, we utilize the PHQ-9 Tool. They also have the Hamilton Depression Scale as well, but we felt that the PHQ-9 was very – it’s free, it was reliable. It’s been tested in the stroke population to have good validity and reliability. A lot of the primary care centers are actually using this tool, so that’s actually one of the tools we chose for the screening of post-stroke depression.
Bill: Do you wait for depression symptoms to occur or are all stroke patients automatically screened for PSD?
Celia: Well, this is the thing, in 2012, the Joint Commission in association with the American Heart and the American Association, they said that one of their key recommendations for centers to be comprehensive certified was to screen for depression. We are currently a primary care center, so we are actually ahead of the ball, but the thing of it is there has not really been any consistency in organizations about actually having – like what days to screen – there’s a lot of different barriers. What we have done here is that we have implemented a depression screening protocol typically on the second day of admission once we find out that a patient actually has had a documented stroke on CT scan or MRI. We just screen them to really establish a baseline to see if this is something that they either have or don’t have and then tend to try to rescreen them once they’ve been discharged to follow-up on it.
Bill: So what you’re saying is this is really up to each hospital’s discretion and what you do at Rochester is on the second day of admission you administer the PHQ, which stands for Patient Health Questionnaire. On that second day of admission, you give them that PHQ-9, is that right?
Celia: Yes, especially if they have had a confirmed stroke.
Bill: And then when they leave the hospital, you give the PHQ again to see how they’re progressing?
Celia: Yes, so typically we like the patients to follow-up in seven to ten days, but if they’re not able to follow up within that timeframe, within two to four weeks we try to get them an appointment with our outpatient center so they can get rescreened again so we can keep – like I said, establish if they have had any changes, any worsening of their symptoms, so we can basically trend any changes overall in their depression screen.
Bill: Which is really important. If PSD is identified, how do you treat it?
Celia: Well, the literature suggests that the best thing to do is use antidepressants earlier on because it increases recovery and it increases survival. What we have done within the hospital is if we have someone here that actually has been screened positive, especially if they’re over a score of ten, what we do is we tend to start them on a medication here. And then, like I said, we follow them up every couple of weeks as they’re able to follow up to see if their mood improves or if they are basically – how are they doing overall with their stroke symptoms post-discharge.
Bill: What is the short-term and long-term outcome of early diagnosis and treatment of PSD?
Celia: Well, the literature suggests that -- patients after a stroke can have depression up to five years. The greatest risk of the depression is within the first year, and it’s typically greatest within the first month in the most severe cases. Typically, the earlier it’s being treated, the better the symptom outcome will be. That’s the thing, we really have to continue to monitor it, but the sooner we start the patient on the treatment, especially if we’re seeing that they’re having functional – having lack of interest, lack of motivation, very sad, very tearful, things like that – as long as we see that then we know that it’s going to impact their recovery and the sooner we start them, the better, like I said, the outcome will be. I can’t guarantee that they’re going to be at zero depression, but as long as we’re watching it and trending it, we can make changes based on that.
Bill: So do patients with acute strokes have a higher incidence of PSD?
Celia: When I implemented my study back in 2014, we got a lot of really good data saying that once we started screening, we were able to pick it up. But like I said, there are some barriers. If the patient has some cognitive deficits -- dementia, if they have any agnosia, depending on where the stroke is -- they may have some lack of awareness. There were some of the patients that actually could not be screened but probably would have benefited. From the time that we’ve actually implemented the tool and the screening, we have bene able to pick up on it. I think it’s because we are screening more that we’re now really starting recognizing it and we’re not just treating – saying the patient had a stroke and it’s all a part of the stroke. Well, it’s not just one problem; it’s two different problems. It’s the depression, and it’s the stroke, so we treat them comprehensively, not as one process.
Bill: So the benefits of early detection are very clear. It has the potential to improve short- and long-term patient outcomes, such as helping stroke survivors return to an active life, improve the quality of life and social interaction, decrease mortality, and as you said, improve functional outcomes. And Celia, if you could wrap it up for us, why should someone choose Rochester Regional for their healthcare needs?
Celia: Well, this is the thing, Rochester Regional Health was the first stroke hospital here in Rochester, and we do stroke well. We want to take the most comprehensive approach towards caring for our stroke patients, which means that we not only take care of their physical needs, we take care of their psychological needs, to really help improve their long-term outcomes. That’s why I believe that patients should pick our hospital because we are looking at things comprehensively and not just looking at one individual problem.
Bill: Well Celia, thank you so much for your time, again, today. And thank you for talking to us about the PSD protocols – very important work there. You’re listening to Rock Your Health Radio with Rochester Regional Health. For more information, you can go to RochesterRegional.org, that’s RochesterRegional.org. I’m Bill Klaproth, thanks for listening.