This is a talk from a symposium on screening for depression in neurological disease. Topic is what screener works best in stroke given the communication and cognitive difficulties that may be present.
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Agm10 screening for depression in stroke (v4medium)
1. Which is the best screening tool for Post-Stroke Depression:
- Evidence Based Meta-Analysis
Alex Mitchell ajm80@le.ac.uk
Consultant in Liaison Psychiatry & Psycho-oncology
RCPsych Symposium 24-June-2010
4. Stroke: Definition
A syndrome characterized by acute onset of a
neurologic deficit that persists for at least 24 hours,
reflects focal involvement of the central nervous
system, and is the result of a disturbance of the
cerebral circulation.
Transient Ischemic Attack (TIA)
Reversible Ischemic Neurologic Deficit (RIND)
Stroke in Evolution (Progressive Stroke)
Completed Stroke
5. Stroke Subtypes
Lacunar
19%
Thromboembolic
6%
SAH
13% Cardioembolic
14%
Hemorrhagic
Ischemic
26%
71%
ICH
13%
Unknown
32%
Other 3%
Data from NINCDS Stroke Data Bank: Foulkes et al. Stroke. 1988;19:547.
6. Healthy life years lost (YLL) to disease Worldwide
1990 2020
Rank Cause % Rank Cause %
1 Lower respiratory infections 8.2 1 Ischaemic heart disease 5.9
2 Diarrhoeal diseases 7.2 2 Major depression 5.7
3 Perinatal conditions 6.7 3 Road traffic accidents 5.1
4 Major depression 3.7 4 Cerebrovascular disease 4.4
5 Ischaemic heart disease 3.4 5 COPD 4.2
6 Cerebrovascular disease 2.8 6 Lower respiratory infections 3.1
7 Tuberculosis 2.8 7 Tuberculosis 3.0
8 Measles 2.7 8 War 3.0
9 Road traffic accidents 2.5 9 Diarrhoeal diseases 2.7
10 Congenital abnormalities 2.4 10 HIV 2.6
Global Burden of Disease Study, 1996
14. Treatment of Post-Stroke Depression
Individual Studies
• Placebo Controlled
–Lipsey (1984) n = 34
–Reding et al (1986) n= 27
–Andersen et al (1994) n=66
–Grade et al (1998) n = 21
• Head-to-Head
–Lauritzen et al (1994) n = 20
–Dam et al (1996) n =52
–Robinson et al (2000) n = 56
–Jorge et al (2003) n=104
15. Jorge et al (2003) Am J Psychiatry
N=104; 9 year follow up
Nortriptyline, fluoxetine, placebo (RCT)
16. Prophylactic treatment with Sertraline
Poulsen, et al, 2003 Stroke Patients Randomly Assigned to 12 Months of Double‐Blind
Treatment With Sertraline or Placebo with GDS >16
18. Cochrane 2008 Update
• Sixteen trials (17 interventions)
• N= 1655 participants,
• 13x pharmaceutical agents
• 4x trials of psychotherapy.
• “some evidence of benefit of pharmacotherapy in terms of
a complete remission of depression and a reduction
(improvement) in scores on depression rating scales, but
there was also evidence of an associated increase in
adverse events.
• There was no evidence of benefit of psychotherapy”
21. Issues in screening tools for PSD Gaete, et al. 2008)
Are staff always available for “observer” scales
Can all patients “self report?”
Do somatic symptoms contaminate?
Cognitive impairment and delirium (50%; 20% troubling)
Special deficits (5-10%)
Speech and language deficits
Anosognosia
Visual impairment
Neglect
22.
23. Other Guidelines
RCPhycians on the National Clinical Guidelines for Stroke (UK)
recommend that
‘patients should be screened for depression within the first month following a
stroke and their mood kept under review’
SIGN 64 recommended
“all stroke patients should be screened for mood disturbance. Some form of
screening should occur initially and at three month intervals or key stages
of the rehabilitation process and after rehabilitation support has been lost.
Also
“All screening measures have limitations (in specificity and sensitivity) so that
some patients. problems will be missed or overestimated. Current
measures may include items concerning, for example, activity or
concentration, which may be directly affected by stroke. Screening does
not constitute a diagnosis of depression and cannot provide insight into the
complexity of the individual.s problems.”
31. Figure 4: The Depression Intensity Scale
Circles (DISCs)
Instructions for administration
Most severe
depression • This is a scale to measure depression
Please point to each of the circles in turn to
make sure that you can see them all.
• The black circles show how depressed you feel.
[Indicate the clear circle at the bottom]
• The bottom circle shows no depression.
[Indicate the fully shaded circle at the top]
• The top circle shows depression as bad as it can
be.
[Pointing at each circle in ascending order]
• As you go from the bottom circle to the top, you
can see that depression is becoming more and
more severe.
• Which of these circles shows how depressed you
feel today?
No To the administrator:
In your opinion was the person able to
Depression understand this scale?
Yes No
The DISCs is displayed on a laminated card.
• Each circle is 2 cm in diameter. Comment
• The scale measures 15 cm from the centre of
the bottom circle to the centre of the top circle.
• A pictorial version also available.
32. Figure 3: The Numeric Graphic Rating Instructions for administration
Scale (NGRS)
• This is a scale to measure depression.
• Please point to
Indicates
Most severe
10 • The Highest score [should indicate 10]
depression ………
9 • The Mid-point [should indicate 5]
………
8 • The Lowest score [should indicate 0]
………
7
6 • The numbers show how depressed you feel.
5 [Indicate 0]
• The bottom of the scale shows no depression.
4
[Indicate 10]
3 • The top shows depression as bad as it can be.
2
[Pointing at each number in ascending order]
1 • As you go from the bottom of the scale to the top,
you can see that depression is becoming more
0 No depression and more severe.
• Which point on the scale shows how depressed
you feel today?
The NGRS is displayed on a laminated card
It measures 10 cm, with numbered increments every 1 cm To the administrator
In your opinion was the person able to
understand this scale?
Yes No
48. Stroke (n=41) vs MI (n=26) on HAMD17
Verhey et al (2009)
loss of interest, psychomotor
retardation, and gastro-
intestinal complaints more
common
49. Approaches to Somatic Symptoms of Depression
Inclusive
Uses all of the symptoms of depression, regardless of whether they may or
may not be secondary to a physical illness. This approach is used in the
Schedule for Affective Disorders and Schizophrenia (SADS) and the Research
Diagnostic Criteria.
Exclusive
Eliminates somatic symptoms but without substitution. There is concern that
this might lower sensitivity. with an increased likelihood of missed cases (false
negatives)
Etiologic
Assesses the origin of each symptom and only counts a symptom of
depression if it is clearly not the result of the physical illness. This is proposed
by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule
(DIS), as well as the DSM-III-R/IV).
Substitutive
Assumes somatic symptoms are a contaminant and replaces these additional
cognitive symptoms. However it is not clear what specific symptoms should be
substituted
50. Comment: Slide illustrates concept of
phenomenology of depressions in
medical disease
Primary Depression Alone
Fatigue
Anorexia
Insomnia
Concentration
Secondary
Medically Unwell Alone Depression
51. Study: Somatic symptoms study
N= 4500; Pooled database study; All comparative
studies
Physical illness+comorbid depression
Vs
Physical illness alone
Vs
Primary depression alone
52. Comment: Slide illustrates actual
phenomenology of depressions in
medical disease
Primary Depression
Secondary
Depression
Weight loss
Agitation
Retardation
Medically Unwell