Post-Stroke Depression:

A Nurses Guide

Presented by Rachel Lambert

Objectives

• RN will understand the prevalence, roadblocks and importance of identifying PSD

• RN will be able to identify the risk factors and signs and symptoms of PSD

• RN will be familiar with the assessment tools used in identifying PSD

• RN will be familiar with treatments to combat PSD

Who does PSD affect?

• 1 out of every 3 post-stroke patients• Largely under-reported• If not treated PSD can affect– Rehabilitation– Recovery– Quality of Life– Caregiver health– Survival – Health Care System

Effect of PSD on Recovery

• Depression may jeopardize a patient’s ability to meet functional goals and to reintegrate into society

• The incidence of complications (e.g., skin breakdown, urinary tract infections), hospital length of stay, and medical costs expenses may all increase because of depression.

• PSD has been linked with higher mortality rate

Risk Factors for Post Stroke Depression• Female gender • Age 60 or younger • Divorced • Alcoholism • Non-fluent aphasia • Having a major motor or cognitive deficit• Nursing- home/Rehab placement• Lack of Social Support

Types of Post-Stroke Depression

• Major Depressive Disorder

• Dysthymic Reactive Depression

Diagnostic Criteria for Major Depressive Disorder

At least one cardinal symptom :• low mood or diminished interest in

almost all activities plus• three or four cluster symptoms for a

minimum total of five symptoms. Both the cluster and cardinal symptoms

should be present for at least 2 weeks and denote a change from a previous functioning condition.

Major Depression

• Incidence and Recovery

• Etiology• Effect on Brain

Function• Suicidal Ideation

Dysthymic Depression

• Prevalence• Duration of two years• Response to treatment– Antidepressants– Risk of double depression

Sign and Symptoms of PSD• Significant lack of energy• Lack of motivation• Problems concentrating• Difficulty finding

enjoyment in anything• Sleep disturbances

Why does PSD often go undiagnosed?

• Diagnosis of PSD is challenging in the acute and chronic aftermath of stroke

• Stroke symptoms can mask depression symptoms making it hard to distinguish the root of the impairments a patient is experiencing

Stroke Impairments

What are some tools to Identify PSD?Self –report scales• Hamilton Rating Scale for Depression

http://www.servier.com/App_Download/Neurosciences/Echelles/HDRS.pdf

• Beck Depression Inventoryhttp://www.ibogaine.desk.nl/graphics/3639b1c_23.pdf

Objective Data Scales:• Clinical Global Impression Severity Scale (CGI-S) • Signs of Depression Scale (SDSS)

Timing of Evaluation • Evaluation should occur the

first month following a stroke

• Patients should be monitored at regular intervals, depending on risk factors and presenting symptoms

• Families should be included in the evaluation process

Onset of PSD

• Occurs in all phases of stroke recovery

• Peak incidence and severity of depression occur between 6 months and 2 years after stroke

Apathy vs. Depression

• Apathy is a motivational disorder that can occur in the presence or absence of depression– Apathy associated with attention and processing

Speed deficits– Depression associated with memory and executive

function issues

By understanding the differences, the proper intervention can be determined

Crying Behaviors

• Identifying distinctions among crying behaviors is an important aspect of assessing post-stroke

• RN must be able to distinguish crying that's congruent with a mood of sadness from other crying behaviors

• Pathologic crying , Emotionalism, Catastrophic Reactions

Treatment

Treatments that have been proven to be effective include:

• Antidepressant medications• Behavioral therapy • Alternative therapy

Selective Serotonin reuptake Inhibitors (SSRIs)

First line medication choice

Dosage/Side Effects/ Drug Interactions

• Prozac• Zoloft• Paxil

Tricyclic and Teracyclic Antidepressants

Dosage/Side Effects/Drug InteractionsTCA’s• Elavil• Pamelor• Ludiomil

Novel Antidepressants

Dosage/Side Effects/Drug Interactions

• Wellbutrin• Effexor• Remeron

MAOI Inhibitors

Monoamine oxidase inhibitors (MAOIs)Dosage/Side Effects/Drug Interactions• Nardil• Marplan• Parnate

Behavioral Therapy

• Cognitive therapy– thoughts lead to moods

• Problem-solving therapy– mental health professionals meet with stroke

survivors to facilitate awareness of problems and help develop solutions

• Psychosocial behavioral intervention– stroke survivors are provided with opportunities

to interact with educational materials and interventionists

Alternative Therapy

• Utilizing pre-existing coping techniques

• Repetitive Transcranial Magnetic Stimulation

• Music Therapy• Acupuncture

RN’s Role• A multidisciplinary health team

is essential in PSD screening, diagnosis, treatment, monitoring and prevention of potential complications.

• RN plays an important role in – Identifying risk factors– Effectively Screening Patients – Educating patients and their

families on treatment options to combat PSD

Nursing Considerations

• A post-stroke patient may need spiritual support, counseling with a provider who has experience with the diagnoses, and support groups

• Providing resources including printed materials, websites, and organizations is helpful for the patient and family members

• Assess the patient’s and family’s perception of the diagnoses, and coping mechanisms

Nursing Considerations

• If the patient is intubated and unable to speak, identify alternative methods of communication

• Review prescribed medications (antidepressants) with patient and /or family members e.g. side effects and dosages

• Encourage patient and family to prioritize needs and learn to accept help

Desired outcome

An empowered patient able to participate in their recovery process!

ReferencesBrodaty, H Sachdev, P Withall A, Altendorf, A Valenzuela , MJ Lorentz, L. “Frequency and clinical, neuropsychological and neuroimaging

correlates of apathy following stroke - the Sydney Stroke Study.” Psychol. Med. 35(12), 1707-1716 (2005).

“Depression Trumps Recovery “-Excerpted and adapted from "Depression Trumps Recovery," appearing in Stroke Connection Magazine September/October 2003. (Science update May2008) http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/EmotionalBehavioralChallenges/Depression-Trumps-Recovery_UCM_309731_Article.jsp

Fralick-Ball, Susan. “Post-stroke depression: early assessment and interventions can promote optimal recovery.” ADVANCE Newsmagazineshttp://occupational-therapy.advanceweb.com/features/articles/post-stroke-depression.aspx?CP=2

Gaete, J and Bogousslavsky, J. "Post-stroke depression." Expert Review of Neurotherapeutics 8.1 2008 Jan: 75-92. Academic OneFile. Web. 15 Jan. 2011.

Hackett, M. L., et. al. “Management of Depression after Stroke; A Systematic Review of Pharmacologic Therapies.“ Stroke; 2005 May;36:1092-1097.

Lökk, Johan Delbari, A . “Management of depression in elderly stroke patients .“ Neuropsychiatric Disease and Treatment 2010:6 539–549 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938303/pdf/ndt-6-539.pdf

Melrose, Sheley PhD, RN. ”How to uncover post-stroke depression.” Nursing Made Incredibly Easy! 2010 July/Aug; 8 (4):31 - 37.

Mitchell ,PH Veith, RC Becker, KJ Buzaitis, A Cain, KC Fruin,M et al. “Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial.” Stroke 2009;40:3073-8.

Paolucci, Stefano. “Epidemiology and treatment of post-stroke depression.” Neuropsychiatric Disease Treatment. 2008 February; 4(1): 145–154. Published online 2008 February. PMCID: PMC2515899

Stradling, Dana RN, BSN, CNRN. September 25, 2009 .“Stroke and depression: continuing education course for the RN.”Published online 2009 September . http://dynamicnursingeducation.com/class.php?class_id=129