March 18, 2013
All patients with stroke should be considered to be at high risk for post-stroke depression (PSD), which can occur at any stage of recovery.
Common risk factors associated with PSD include increasing stroke severity, functional dependence, presence of cognitive impairment, and history of previous depression. Increased functional dependence (e.g. requiring help with activities of daily living) and having a history of pre-stroke depression may be the two most salient risk factors for the development of PSD.
7.1.1 Screening for Post stroke Depression:
- All patients with stroke should be screened for depressive symptoms using a validated tool [Evidence Level A]. Refer to reference table 7.1 A for some suggested tools. (Table 7.1A)
- Screening should also include evaluation of risk factors for depression, particularly a history of depression [Evidence Level C].
- Screening should take place at various stages throughout the continuum of stroke care [Evidence Level C]. Stages of care may include:
- during acute care stay, particularly if evidence of depression or mood changes are noted;
- following hospital discharge from the emergency department or inpatient setting to an outpatient or community-based healthcare setting;
- throughout rehabilitation within inpatient, outpatient, and home-based settings, according to client progress;
- periodically, following discharge to the community, during follow-up appointments and/or during periodic health assessments with primary care practitioners and consulting specialists.
7.1.2 Assessment for Post stroke Depression:
- Patients identified as being at risk for depression during screening should be managed by a healthcare professional with expertise in diagnosis and management of depression in stroke patients. If required, a referral should be made to an appropriate mental health specialist (e.g., psychiatrist or psychologist) [Evidence Level C].
- Further assessment by the mental healthcare professional may include:
- More in-depth interview for the purpose of assessment and diagnosis based on accepted diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders) [Evidence Level B];
- Population-specific assessment measures (e.g., children, elderly, persons with co-morbid neuropsychiatric conditions) [Evidence Level C];
- Determination of appropriate course of treatment and individualized management plan;
- Post-treatment assessment and follow-up as needed.
7.1.3 Treatment and Management Modalities:
- Patients with mild depressive symptoms or those diagnosed with minor depression may initially be managed by “watchful waiting”* (Evidence Level B].
- Pharmacological treatment should be considered/started if the depression is persistent and interferes with clinical goals, or worsens [Evidence Level B].
- Patients diagnosed with a depressive disorder following formal assessment should be considered for a trial of antidepressant medication [Evidence Level A].
- No one drug class has been found to be superior for PSD treatment. Side effect profiles, however, suggest that some selective serotonin reuptake inhibitors may be favoured in this patient population. [Evidence Level A]. Please refer to Pharmacology profile (Medications Table) Table 7.1B. (to come)
- Choice of an antidepressant medication will depend upon symptoms of depression, potential known side effects of the medication, particularly in the child or older adult, drug interactions with other current medications and underlying disease conditions. (Medications Table to come)
- Response to treatment should be monitored regularly by a health professional with expertise in mental healthcare. Monitoring should include evaluation of any changes in the severity of depression, review of potential side effects, and update of ongoing management plans [Evidence Level C].
- If a good response is achieved, treatment should be continued for a minimum of six months before slowly withdrawing the antidepressant [Evidence Level C].
- Examples of a ‘good response’ may be indicated by positive changes in thoughts and self-perceptions (e.g., hopelessness, worthlessness, guilt), emotional symptoms (e.g., sadness, tearfulness), and improved motivation to carry out daily activities.
- Following initial treatment for PSD, patients should continue to be monitored for recurrence of depressive symptoms, as part of ongoing comprehensive stroke management [Evidence Level C]. The involvement and feedback of family and caregivers can be an important component of ongoing monitoring.
* Watchful waiting is defined as a period of time when the patient who displays mild depressive symptoms is monitored closely without additional therapeutic interventions to determine whether the mild depressive symptoms will improve. The timeframe for watchful waiting varies in the literature somewhere between 2 to 4 weeks. It is often described as including suggestions to the patient for self-help strategies and participation in exercise.
B. Non-Pharmacological and Adjunct Treatment
- There is inadequate evidence at present to support the use of psychotherapy as monotherapy in the treatment of PSD [Evidence Level C].
- Treatment for PSD may also include psychotherapy as an adjunct in combination with antidepressants and/or longer-term option to prevent relapse. This approach, while supported by evidence in other populations, requires more research in stroke populations [Evidence Level C].
- Different options that have been explored in small studies have included cognitive behavioural therapy (CBT) and problem solving therapy, although the methodological details of the therapies have not been well described. These therapies could be considered where appropriate at the discretion of the mental health expert [Evidence Level C].
- Other approaches to adjunctive treatment of PSD that are emerging, but require more research, include other forms of Repetitive Transcranial Magnetic Stimulation (rTMs), CBT, physical exercise, and acupuncture [Evidence Level C].
C. Other Mood Symptoms (Anxiety)
- Patients with marked anxiety should be offered psychotherapy [Evidence level B].
- Although evidence is limited in stroke patients, pharmacotherapy may be considered as an adjunct to psychotherapy [Evidence Level C].
D. Post Stroke Emotional Incontinence (PSEI)
- In cases of severe, persistent or troublesome tearfulness, patients may be given a trial of antidepressant medication [Evidence Level A]. Side effect profiles suggest that some selective serotonin reuptake inhibitors may be preferred over others for this patient population. Please refer to Pharmacology profile (Medications Table) Table 7.1B. (to come)
7.1.4 Prevention of Post Stroke Depression
- Although, emerging data on the use of pharmacotherapy as a preventive intervention for post stroke depression is encouraging, routine use of prophylactic antidepressants is not recommended in post-stroke patients, at this time [Evidence Level A].
- Further research is required to define at risk patients, choice of antidepressant agents, optimal timing and duration of intervention [Evidence Level A].
- Non-pharmacological, talk-based interventions including problem-solving therapy and motivational interviewing may be used to enhance rehabilitation and prevent depression post stroke [Evidence Level B].
- Engaging patients in activities such as exercise or music therapy may also have a beneficial effect on mood post-stroke [Evidence Level C].
7.1.5 Ongoing Monitoring, Support and Education
- Patients should be given information and education about the potential impact of stroke on their mood and that of family and caregivers; patients and families should be provided with the opportunity to talk about the impact of stroke on their lives at all stages of care [Evidence level C]. Refer to Chapter 6 for more recommendations on patient education and caregiver support.
- Patients and their caregivers should have their psychosocial and support needs assessed and reviewed on a regular basis (at least annually) as part of long-term stroke management [Evidence level C] by primary care practitioners and consulting specialists.
- For patients who experience some degree of communication challenge or deficits following stroke, appropriate strategies for screening of possible PSD should be implemented to ensure adequate assessment and access to appropriate treatment [Evidence Level C].
Approximately one-third of all individuals who experience stroke will exhibit symptoms of depression at some time following the stroke event (acute, sub-acute and at long-term follow-up). The majority of cases of post-stroke depression (PSD) may develop in the first 3 months of stroke, and incidence rates of depression tend to decline over time, although research reports have indicated symptoms have emerged up to two years after index stroke. Post-stroke depression (PSD) also was reported in 48% of 71 young stroke patients after at least 1 year of follow-up. PSD may prove to be persistent for as many as one-half of the individuals identified as depressed soon after stroke. Severity of functional limitations, stroke severity, cognitive impairment and a previous history of depression have all been identified as important risk factors for the development of PSD.
PSD is associated with poorer functional recovery, increased risk for dependence, poorer cognitive function and reduction in social participation. In addition, the presence of PSD has been associated with increased risk for mortality. Appropriate identification, diagnosis and treatment of PSD have been associated with improved outcomes.
Families and caregivers of patients who experience a stroke are also at risk for depression, with the reported incidence as high as 30% to 60% of caregivers experiencing depressive symptoms.
- Education for primary care practitioners and healthcare providers across the continuum of stroke care on recognition, assessment, and management of post-stroke depression.
- Timely access to appropriate mental health specialists as needed who are able to diagnose and evaluate severity of depression, and provide guidance for ongoing management.
- Timely access to specialized therapies to manage post-stroke depression, including medication, counseling and psychotherapy as required.
- Process for ongoing monitoring of any patient with positive screening for depression during screening and assessment process.
- Mechanisms to involve and support caregivers of stroke survivors. Processes should be in place to provide education and ensure that the caregivers’ emotional needs are monitored and addressed, ideally through involvement of the primary health care team.
- Optimization of strategies to prevent the recurrence of stroke.
- Proportion of acute stroke patients with documentation indicating initial screening for post-stroke depression was performed (either informally or using a formal screening tool) in the acute care, rehabilitation, long-term care and community settings (e.g., homecare) setting. (Core Indicator)
- Proportion of acute stroke patients referred for additional assessment or intervention for a suspected diagnosis of depression.
- Proportion of stroke patients diagnosed with PSD and treated with antidepressants at one month, three months, six months, and one year following the initial stroke event.
- Recommendation 7.1 and corresponding performance measures apply across the continuum of stroke care and should be considered in the acute, early rehabilitation and longer-term recovery phases and in all healthcare settings.
- When monitoring these performance measures it is important to record when and in what context (continuum of care) the measurement were conducted.
- Data for measurement may be found through primary chart audit. Data quality will be dependent on the quality of documentation by healthcare professionals.
- For patients referred to psychiatry, information may be available through provincial physician billing databases.
- For persons over 65 years old, information on medication prescriptions may be available through provincial and territorial senior drug benefit plan databases.
- For performance measure 3, the issue is not just increasing the use of antidepressants but increasing the number of patients with PSD who are adequately treated, and reducing the number of patients with depression who are untreated (depressive disorder + no antidepressant med) and undertreated (depressive symptoms + antidepressant med). This should be considered in the measurement and analysis plan.
- Click here to download the mood and cognition updates
- Table 7.1A: Selected Depression Screening Tools http://www.strokebestpractices.ca/wp-content/uploads/2013/03/Table71A-EN.pdf
- Table 7.1B: Summary Table for Selected Pharmacotherapy for Post-Stroke Depression (to come)
- Stroke Best Practices Teaching Slides: Mood and Cognition Following Stroke (to come)
- Evidence-based Review of Post-Stroke Depression (EBRSR). http://www.ebrsr.com/reviews_details.php?8
- StrokEngine http://strokengine.ca/
- A Patient's Guide to Canadian Best Practice Recommendations for Stroke Care http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5056519/k.C841/Stroke__A_Patients_Guide_to_Canadian_Best_Practice_Recommendations_for_Stroke_Care.htm
- Getting on With The Rest of Your Life After Stroke http://strokebestpractices.ca/wp-content/uploads/2010/11/Getting-on-with-the-Rest-of-Your-Life-After-Stroke.pdf
- HSF 10 warning signs of depression: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5482531/k.6ACA/Stroke__Mental_changes.htm
- The Heart & Stroke Living with Stroke™ program http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.7936265/k.94AE/Living_with_Stroke__Ontario_Locations.htm
- Let's Talk about Stroke http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3882223/k.3FC6/Stroke__Lets_Talk_about_Stroke.htm
- Life after Stroke website: http://www.lifeafterstroke.ca
- NHS Psychological care after stroke http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx
- HSF Ontario Tips and Tools: http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/ .6194819/k.FEB1/ Tips_and_Tools__2010.htm
- Coping with stress http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5590155/k.3B4A/Heart_disease__Coping_with_stress.htm
- APA: Diagnostic and Statistical Manual of Mental Disorders (DSM) http://www.psychiatry.org/practice/dsm
Although post-stroke depression (PSD) is a common consequence of stroke, risk factors for the development of PSD have not been clearly delineated. In a systematic review, Hackett and Anderson (2005) included data from a total of 21 studies. Of the many different variables assessed, physical disability, stroke severity and cognitive impairment were most consistently associated with depression. The authors noted that major methodological limitations within the available literature make it difficult to form a definitive conclusion. As part of the DESTRO study, a multicentre observational study of depression in stroke, Paolucci et al. (2005) identified female sex (OR=1.49), previous stroke (OR = 1.55), previous depression (OR=3.97) and severe disability (Modified Rankin Scale score >3, OR = 2.70) as factors likely to facilitate the development of depression following stroke. The risk for post-stroke depression was found to increase exponentially in individuals with more than one risk factor (Paolucci et al. 2005). In young adults with stroke, PSD risk factors are carotid localization of the infarct, severe disability, bad general outcome and absence of return to work (Neau et al., 1992). In a report from the Auckland Regional Community Stroke Study (Hackett and Anderson 2006), the authors described an attempt to create a simple, predictive tool for the identification of individuals most at risk for abnormal mood. Of the factors included in the model, only two were significant predictors of mood; prior treatment for depression (OR = 2.4, 95% CI 1.34 – 3.43) and requiring “much help” with activities of daily living (OR = 2.35, 95% CI 1.33 – 4.14). The ability of the model to predict risk for depression might be increased by the inclusion of other factors such as fatigue and performance of instrumental activities of daily living. However, Van de Port et al. (2007) demonstrated that use of these two predictors (prior treatment for depression and requiring much help with ADLs) in a multivariate model could correctly classify depression in 76% of patients 3 years post stroke.
Examination of the results of multiple meta-analyses (Mitchell and Kakkadasam 2011; Mitchell et al. 2011; Mitchell et al. 2010; Mitchell et al. 2009; Cepoiu et al. 2007) revealed that non-psychiatric physicians, nurses, and therapists demonstrate poor sensitivity relative to gold standard psychiatric interviews and standardized formal rating scales when using clinical observation to identify depression in individuals who have experienced stroke in both inpatient and community-based settings. Use of formal screening tools by direct comparison is associated with significantly greater sensitivity (Lowe et al. 2004). As in the recent CANMAT task force recommendations, it is noted that the use of formal instruments is a key component in the diagnostic process required to promote early detection of depression.
PSD in survivors of childhood stroke is not well studied but appears to be common based on preliminary evidence (Elbers, 2013). Depression and anxiety may also be increased in parents of children with stroke (Goodman 2000; Gordon, 2002).
In 2006, the Canadian Stroke Strategy and Heart and Stroke Foundation of Ontario supported a consensus process to identify a standardized basket of outcome assessment tools that could be used to across the stroke continuum of care. Included in the resulting basket of measures were the following screening tools for the identification of possible depression in individuals with stroke: The Hospital Anxiety and Depression Scale (HADS), the Geriatric Depression Scale (GDS) and the Stroke Aphasic Depression Questionnaire (SADQ-10). A brief description of each of these tools is provided in the accompanying table. Detailed reviews of the GDS, HADS and SAD-Q are available from www.ebrsr.com, www.strokengine.com, and/or in Salter et al. (2007).
Once diagnosed by a healthcare professional with appropriate expertise, the use of pharmacotherapy for the treatment of PSD has been associated with significant benefits in terms of reduction of depressive symptomatology (Chen et al. 2006, Hackett et al. 2008). However, these findings should be considered in light of reports of adverse effects associated with the use of antidepressant medications. While selective serotonin reuptake inhibitors are among the most commonly prescribed pharmacological agents for the treatment of PSD, they may also be associated with increased risk for mortality and stroke (Coupland et al. 2011, Wu et al. 2011). In addition, pharmacodynamic interactions between antidepressants and cardiovascular agents have been noted for several antidepressant classes including SSRIs, which may result in significant adverse events (Tuunainen et al. 2009).
Based on the results of available meta-analyses (Wilson et al. 2009, Hackett et al. 2008), there is insufficient evidence to support the use of talk-based, cognitive behavioural therapies (CBT) as monotherapy for the treatment of PSD. However, talk-based therapy, such as problem-solving therapy, when used in combination with pharmacotherapy may be an effective means to reduce symptoms of depression (Mitchell et al. 2009, Alexopoulos et al. 2012, Lincoln and Flanaghan 2003). The use of other, non-pharmacological strategies, such as light therapy (Tuuainen et al. 2009, Sondergaard et al. 2006), physical exercise (Graven et al. 2011) and music therapy (Jun et al. 2012, Sarkamo et al. 2008), acupuncture (Zhang et al. 2010) have all been demonstrated to have a positive effect on mood within the population of individuals with stroke.
For individuals who, following screening and appropriate follow-up assessment, experience mild symptoms of depression, watchful waiting may be the most appropriate strategy. While there is no direct evidence of the effectiveness of this approach as an intervention within the stroke population, it has been used with good results as part of interventions, such as stepped care management (van’t Veer-Tazelaar et al. 2009, Dozeman et al. 2012), undertaken in populations of older individuals. A single randomized controlled trial examined the use of pharmacotherapy for individuals with mild depression and found a significant reduction in depressive symptomatology associated with the use of antidepressant therapy; however, study participants were not drawn from the stroke population (Williams et al. 2000).
Given the high prevalence of PSD and the negative consequences associated with it, there has been increasing attention paid to strategies for its prevention. The most commonly studied strategy has been universal pharmacologic prophylaxis, although discussions have expanded to include selected or indicated prophylaxis, problem-solving therapy (Robinson et al. 2008) and motivational interviewing (Watkins et al. 2007, 2011). Results of recent meta-analyses have provided encouraging results in favour of pharmacotherapy for the prevention of post-stroke depression (Salter et al. 2012, Yi et al. 2010, Chen et al. 2007); however, little is known about optimal timing and duration of intervention, or the best approach (e.g. universal, selected or indicated) to take in offering such a strategy.
Post Stroke Emotional Incontinence (PSEI)
Reported frequency of PSEI ranges from 11%-35% depending upon the criteria used to define the condition and time elapsed since stroke onset (House et al. 1989, Kim and Choi-Kwon 2000). While there has been an association reported between PSEI and PSD, more individuals with emotionalism do not have significant or diagnosable depression (Kim and Choi-Kwon 2000, Tang et al. 2004). In a recent Cochrane review (Hackett et al. 2010), pooled analyses were reported for data gathered from 5 randomized controlled trials examining antidepressant therapy for PSEI. Large treatment effects in terms of emotionalism, reduced tearfulness, clinical impressions of change and Lability Scale scores were reported in favour of antidepressant treatment when compared to control conditions. Given methodological limitations, the authors conclude that the existing literature is suggestive, but not definitive, evidence that pharmacotherapy is effective in the treatment of PSEI.
Anxiety Following Stroke
Anxiety following stroke occurs more often in women than in men. In the Perth Community Stroke Study, it was reported that 20% of women who experienced stroke developed symptoms of anxiety following the event while, in the same sample, only 9% of men experienced post-stroke anxiety (Burvill et al. 1995). However, individuals who experienced post-stroke anxiety, often reported having anxiety or depression at the time of the stroke event (Burvill et al. 1995). Individuals with generalized anxiety disorder (GAD) after stroke may often experience co-morbid depression. Castillo et al. (1995) reported that, in a sample of individuals with post-stroke GAD approximately 75% were also depressed. Despite the prevalence of post-stroke anxiety, very few studies have evaluated the effectiveness of potential treatments. A recent Cochrane review (Campbell Burton et al., 2011) identified only 2 randomised trials suggesting a positive effect associated with the provision of pharmacotherapy with or without the addition of psychotherapy. However, further research in this area is certainly indicated in this population.