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Section 7.3

Post-Stroke Depression

All patients with stroke should be considered to be at high risk for depression. During the first assessment, the clinical team should determine whether the patient has a history of depression or risk factors for depression [Evidence Level B].

  1. All patients with stroke should be screened for depression using a validated tool [Evidence Level A] (SCORE). Screening should take place at all transition points and whenever clinical presentation indicates. Transition points may include:
    1. upon admission to acute care, particularly if any evidence of depression or mood change is noted
    2. before discharge to the community from acute care or during early rehabilitation if transferred to inpatient rehabilitation setting
    3. periodically during inpatient rehabilitation
    4. periodically following discharge to the community
  2. Patients identified as being at risk for depression during screening should be referred to a healthcare professional with expertise in diagnosis and management of depression in stroke patients [Evidence Level B]. These patients should be referred to a psychiatrist or psychologist where available.
  3. Patients with mild depressive symptoms should be managed by “watchful waiting,” with treatment being started only if the depression is persistent [Evidence Level A].
  4. Patients diagnosed with a depressive disorder should be given a trial of antidepressant medication, if no contraindication exists. No recommendation is made for the use of one class of antidepressants over another; however, side effect profiles suggest that selective serotonin reuptake inhibitors may be favoured in this patient population [Evidence Level A].
  5. In adult patients with severe, persistent or troublesome tearfulness, selective serotonin reuptake inhibitors are recommended [Evidence Level A].
  6. Treatment should be monitored and should continue for a minimum of six months if a good response is achieved [Evidence Level A].
  7. Routine use of prophylactic antidepressants is not recommended in post-stroke patients [Evidence Level A].
  8. Patients should be given information and advice about the impact of stroke, and the opportunity to talk about the impact on their lives [Evidence Level B].
  9. Patients with marked anxiety should be offered psychological therapy [Evidence Level B].
  10. Patients and their caregivers should have their psychosocial and support needs reviewed on a regular basis as part of long-term stroke management [Evidence Level A].
    Rationale

    Post-stroke depression may affect as least one in every four individuals who have had a significant stroke event. The stroke patient is at greatest risk in the first six months after a stroke. Depression may affect a patient’s ability to participate in post-stroke therapy and is associated with slower progress in rehabilitation and increased length of stay. Clinicians need to be watchful and recognize depression before it interferes significantly with therapy and the patient’s well being. Standardized screening assessments for depression can indicate that depression exists and also can be used to monitor progress. However, there is no single, universally accepted tool for the assessment of post-stroke depression. An alternative to verbal scales to assess mood should be sought when assessing someone who is aphasic.11

    Anxiety should be assessed and treated, especially when found in conjunction with depressive symptoms. Antidepressant medications and counseling appear to be helpful in treating this condition. Aphasic patients provide a unique challenge for assessment and treatment.

    System Implications
    • Education for primary care practitioners and healthcare providers across the continuum of stroke care on assessment and recognition of post-stroke depression.
    • Timely access to appropriate clinicians who are able to evaluate severity of depression.
    • Timely access to specialized therapies to manage post-stroke depression, including medication and counseling as required.
    • Process for ongoing monitoring of any patient with positive screening for depression during referral process.
    • Mechanisms to support caregivers of stroke survivors.
    • Optimization of strategies to prevent the recurrence of stroke.
    Performance Measures
    1. Proportion of acute stroke patients with documentation indicating assessment or  screening for depression was performed either informally or using a formal assessment tool in the acute care or rehabilitation setting.
    2. Proportion of acute stroke patients referred for additional assessment or intervention for a suspected diagnosis of depression.
    3. Proportion of stroke patients treated with antidepressants at one month, three         months, six months, and one year following the initial stroke event.

    Measurement Notes

    • This recommendation 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.
    • When monitoring these performance measures it is important to record the measurement time frame and relevant stage of the stroke continuum.
    • 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, information on medication prescriptions may be available through provincial and territorial senior drug benefit plan databases.
    Implementation Resources and Knowledge Transfer Tools
    Summary of the Evidence

    Post-stroke depression may lead to adverse effects on the success of rehabilitation following a stroke event, suggesting the importance of early identification of symptoms early in the rehabilitation process.11Post-stroke depression has a negative impact on functional recovery and social activity. A reduction is social activity can also adversely affect mood. It is crucial to monitor the level of social activity and/or withdrawal from social events of stroke survivors. Risk factors associated with increased risk for post-stroke depression include being female, past history of depression or psychiatric illness, social isolation, functional impairment and cognitive impairment.555 It has been reported that 21.6 percent of patients were depressed when assessed within the first month of stroke. The proportion of incident cases increased to 5.1%, 6.0%, 5.6% and 7.1% at three, six, nine and 12-month assessments, respectively.556 While the incidence of major depression after stroke may decrease over the first 24 months following stroke, 557, 558 minor depression tends to persist or increase over the same time period. 558-560 In a recent study, approximately one-half of individuals identified as experiencing depression during the acute phase after stroke continued to experience depression at 18 months; however, more women than men were identified in the acute phase, while more men than women were identified as depressed at 18 months after stroke.560

    Every individual should be screened for depression following a stroke event using a standardized tool. Such tools include the Hospital Anxiety Depression Scale, the Beck Depression Inventory and the Geriatric Depression Scale.

    The Hospital Anxiety Depression Scale is a bidimensional scale divided into two subscales: anxiety and depression.25Bjelland and associates found a mean correlation of 0.56 between the subscales.561Teasell and collaborators previously summarized the sensitivity and specificity of this tool.28 O’Rourke and coworkers demonstrated a sensitivity of 80 percent and specificity of 79 percent with a cut-off of 6/7 on the depression subscale,562 while Bjelland and associates determined optimal sensitivity and specificity at a cut-off of 8/9 (sensitivity and specificity at approximately 80%).561 Of 24 papers reviewed by Bjelland and associates, only 1 included individuals who had experienced a stroke. Using a stroke population, Aben and collaborators determined an optimal cut-off of 11/12 for the Hospital Anxiety Depression Scale total, with sensitivity nearly 87 percent and specificity close to 70 percent. 556 The scale is quick, easy to use and well tolerated by patients; however, one item, “I feel as if I am slowed down,” has been identified as problematic.563

    The Beck Depression Inventory is used for the detection and assessment of severity of depression. The inventory includes 21 self-rated items and takes between 5 and 10 minutes to complete.564 It has been suggested that the Beck Depression Inventory may be the most suitable scale for assessing depression after stroke; however, despite the optimal cut-off for the presence of depression within the stroke population, there is concern with the high rate of misdiagnosis (approximately 31 percent) and the authors have noted difficulties completing the scale with a stroke population.556 In the Evidence-Based Review of Stroke Rehabilitation, Teasell and collaborators assessed the thoroughness with which the reliability, validity and responsiveness of the tool was presented within the literature. 28 The Beck Depression Inventory was given a rating of excellent on measures of rigour and results for reliability, while receiving poor ratings (i.e., minimal information available) on measures of rigour and results for responsiveness. No information relating to the Beck Depression Inventory was reported for the floor/ceiling component of responsiveness.

    The Geriatric Depression Scale is a self-rating screening tool with 30 items, which takes approximately five to seven minutes to administer.565 Using the aforementioned Evidence-Based Review of Stroke Rehabilitation assessment, the Geriatric Depression Scale was given a rating of excellent on measures of rigor and results for reliability (test–retest and internal consistency) and validity (excellent, meaning most major forms of testing were reported).28 There was no information available regarding the responsiveness of the tool. It is worth noting that the Geriatric Depression Scale has been reported to have better sensitivity and specificity among higher-functioning individuals.281 Of particular concern for use within a stroke population are the varied reports of this scale’s ability to detect depression in patients with moderate to severe cognitive impairment. As a result, it has been suggested that it should not be used for screening these patients.565

    Once screening has occurred, it is imperative that, when appropriate, patients be referred to a psychologist or psychiatrist with expertise for further assessment and diagnosis.39 There is no evidence that the provision of information alone helps resolve clinical depression in stroke patients.28 A systematic evidence-based review of counseling and psychologic therapies has looked at the level of expertise that is required for working with patients with depression. It concluded that generic counseling should only be offered to those with minor degrees of psychologic distress, and that patients with complex psychologic issues should be treated by staff with therapeutic expertise.34

    About 15 percent of post-stroke patients experience uncontrollable laughing or crying, and, if not treated, this can develop into clinical depression. When this lability interferes with the patient’s rehabilitation or complicates the patient’s relationship with family members, pharmacotherapy has been found to be beneficial.11 Literature suggests that post stroke depression is treatable with a variety of medications, with SSRIs and tricyclic antidepressants being the most frequently studied.28 When compared with placebo, heterocyclic antidepressant medications demonstrated a significant treatment effect.566, 567 Robinson and associates283 compared a heterocyclic antidepressant with an SSRI and found nortriptyline (a heterocyclic drug) to be more effective than the SSRI fluoxetine. Robinson and associates observed that nortriptyline improved the Hamilton Depression Scale scores significantly more than fluoxetine and/or placebo.567 In addition, the response rate of nortriptyline was significantly greater than those of both fluoxetine and placebo. While the results of the Lipsey and colleagues study were promising, the authors noted confusion, drowsiness and agitation were significant side effects that may pose risks to elderly patients. 566 Likewise, while the heterocyclic combination of imipramine and mianserin significantly improved melancholia scale scores, Lauritzen and collaborators noted that a significant number of patients with myocardial infarction were excluded.568 Furthermore, those with cardiac arrhythmia, heart block, urinary outlet obstruction and narrow-angle glaucoma were advised against the use of heterocyclic antidepressants. This relatively high incidence of side effects associated with heterocyclic antidepressants, especially in elderly patients, must be taken into account when deciding on their use.

    SSRIs selectively block serotonin reuptake rather than blocking both serotonin and norepinephrine reuptake. There is conflicting evidence (three positive studies, two negative studies) regarding the effectiveness of SSRIs in treatment for poststroke depression.569Fruehwald and associates found benefit with fluoxetine at 12 and 18 weeks after treatment initiation.570 The drug effect was found to be quicker than for the heterocyclic drugs, taking effect three weeks into the treatment. Furthermore, side effects were found to be mild and transient and significantly less severe than those associated with the heterocyclic drugs. SSRIs work faster and have fewer and less severe side effects than heterocyclic drugs. Efficacy of heterocyclic drugs in the treatment of post-stroke depression has strong evidence. However, side effects mean they should be used with caution in the elderly population.28

    The incidence of post-stroke delirium is high, but with variably reported incidence (between 7.6 percent and 48 percent).571, 572 The onset of delirium after stroke may lead to a significantly elevated risk of mortality, poor functional outcome, cognitive impairment and/or institutionalization.571 Several guidelines have discussed general management of delirium,39, 52 as have several Cochrane reviews.573, 574 These guidelines emphasize the current paucity of quality controlled data to guide interventions related to delirium after stroke, the pre-eminence of nonpharmacologic and preventive measures, the identification and treatment of occult reversible coexistent etiologies, as well as the time-limited, symptom- or sign-targeted use of pharmacologic treatments for management of agitation, use of sedation for normalizing the sleep–wake cycle and amelioration of psychotic symptoms that do not originate from neurologically mediated perceptual disturbances.

    Among the pharmacologic interventions, the strongest data exists for the safety and efficacy of very low dose haloperidol; however, controversy surrounds the association between haloperidol, other conventional antipsychotics and second-generation (atypical) antipsychotics, and increased vascular mortality. The warning related to increased stroke or vascular mortality risk for the class of atypical antipsychotics has been strongest for chronic institutional use versus the acute, low risk of glucose dysregulation, respiratory depression, but not acute vascular events after stroke or in general management of delirium. There is no evidence to support the use of benzodiazepine monotherapy, nor good evidence to support the use of cholinesterase inhibitors for individuals with delirium, unless superimposed on pre-existing dementia or cognitive impairment responsive to cholinesterase inhibitor therapy.29