Nadina Lincoln University of Nottingham

Transcription

1 Nadina Lincoln University of Nottingham

2 Screening for emotional distress How do we screen? Prevention of distress

3 Detect distress Distress impedes progress Refer for further evaluation Consider for intervention Distress affects quality of life Important that screening leads on to action

4 Large numbers of patients Hospital and community Choice of measure depends on: Type of patient When Where Who? No single measure will be suitable for all

5 Screening measures should be: sensitive, detect 80% of those with problem specific, of those without the problem 60% should be identified supported by evidence in stroke short and practical

6 Hospital Anxiety and Depression Inventory General Health Questionnaire Beck Depression Inventory Beck Anxiety Inventory Beck Depression Fast Screen Brief Assessment Schedule for Depression Cards Geriatric Depression Scale...

7 Mood is considered People are asked about how they feel Provides structure to ensure questions are asked Give an indication of when to act But... Do not tell you what to do...

8 HADS depression 4/5 (Johnson et al 1995) 6/7 (O Rourke et al 1998) 8/9 (Aben 2002) Cut-offs provide a guide and should not be applied rigidly

9 Healey et al stroke patients BASDEC, BDI Fast Screen Structured Clinical interview Major depression BASDEC sensitivity 1.0, specificity 0.95 BDI-FS sensitivity 0.71 specificity 0.74 Minor depression BASDEC sensitivity 0.69, specificity 0.97 BDI-FS 0.62, specificity 0.78

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13 Visual analogue VAMS DISCS VASES Observer-rated SODS SADQ ADRS

14 Stern (1997)

15 Afraid, confused, sad, angry, energetic, tired, happy, tense Convergent and discriminant validity (Arruda et al, 1999) Bennett et al. (2006) in relation to HADS: Modest correlation with HADS-total (r=0.45) Internal consistency increased when happy and energetic removed (0.71 to 0.81)

16 Turner-Stokes et al (2005)

17 Evaluated in sample of younger adults with ABI (n=114; mean age 42.8 years) Correlated with BDI-II Cut-off >2: sensitivity 0.60, specificity 0.87 Excellent test-retest reliability (k=0.84) Showed change in response to treatment Needs further evaluation in stroke sample

18 Brumfitt & Sheeran (1999)

19 10 bipolar pictures with 5 point response scale Depression as practice item Bennett et al. (2006) Correlated with HADS total (r=-0.57) Internal consistency increased when depression included in total score ( ) No suitable cut-off identified

20 6 items Yes/No (present or absent) Lightbody et al. (2007) using SCID: Sensitivity when completed by nurses was low Does the patient sometimes look sad, miserable or depressed? Does he/she seem withdrawn, showing little interest in the surroundings?

21 Hospital and community versions 21 and 10 item versions Behaviours associated with mood Did he/she have weeping spells? Every day On 4-6 days On 1-4 days Not at all this week this week this week this week Did he/she take interest in events around him/her? Every day On 4-6 days On 1-4 days Not at all this week this week this week this week

22 HADS Depression Screening Measure Optimum* Cut-off Sensitivity SODS 1/ SADQ-H 17/ SADQ-H 10 5/ VAMS 223/ VASES 32/ Specificity

23 Observer Early Frequent Questionnaire Later Less repeatable

24 OK for depression but what about other mood states?

25 MOOD ASSESSMENT CARE PATHWAY Is the person CONFUSED? (i.e. in PTA, reduced alertness/awareness; in delirium/delirious? ) If concerns about suicidal ideation see steps to take section, alert staff and contact psychology/psychiatry YES YES NO Does the person have a language problem? YES NO Does the person have visual impairment? Do you need a Depression / Anxiety measure? YES NO YES NO SoDs (at MDT) SADQ-H10 (at MDT) DISCS HADS Wimbledon - Information gained from measure Patient level of Independence +

26 MOOD ASSESSMENT CARE PATHWAY Is the person CONFUSED? (i.e. in PTA, reduced alertness/awareness; in delirium/delirious? ) If concerns about suicidal ideation see steps to take section, alert staff and contact psychology/psychiatry YES YES NO Does the person have a language problem? YES NO Does the person have visual impairment? Do you need a Depression / Anxiety measure? YES NO YES NO SoDs (at MDT) SADQ-H10 (at MDT) DISCS HADS Wimbledon Information gained from measure - Patient level of Independence +

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29 Stroke Units Activity Music therapy Distress Management System Family Support Services Problem Solving Motivational interviewing Anti-depressants

30 Stroke Units Activity Music therapy Distress Management System Family Support Services Problem Solving Motivational interviewing Anti-depressants

31 GHQ 28 Median p 1 year SU 17 CW Juby et al 1996 Cerebrovasc Dis 5 year SU 17 CW Lincoln et al 2000 BMJ

32 Observational studies indicate over 50% of the day is spent in isolated disengagement Collaborative Evaluation of Rehabilitation in Stroke across Europe

33 Time (min.) Total therapy Physiotherapy Occup.- therapy Speech therapy Neuro. training Nursing care Medical Care Sports Autonom. exercise Belgium Great Britain Switzerland Germany Other therapy

34 overall 72% of the time (7 hours per day) was spent on nontherapeutic activities

35 Särkämö et al MCA stroke patients Random allocation Music Language Usual care control Music group less depressed on POMS

36 House et al 2000 Early after stroke Problem solving Attention Placebo No intervention Problem solving sig. lower GHQ28

37 Watkins et al 2007 Stroke 38: consecutive patients 4 individual, weekly sessions MI Normal mood at follow up 81/207 (39.1%) control group 100/204 (49.0%) intervention group Significant benefit of MI over usual stroke care (OR: 1.60, 95% CI: 1.04 to 2.46, P0.03) Benefits maintained at one year follow-up

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39 May et al. (2002) followed up 2,201 men aged over 14 years fatal and non-fatal strokes occurred more often in people with high GHQ-30 scores comparison was significant only for fatal stroke (risk ratio 3.36). Surtees et al (2008) 20,627 participants, aged 41 to 80 years stroke free at enrolment. Mental Health Inventory Score > 1 SD below mean increased stroke risk significantly, by 11%..

40 Staged approach All Consider mood Identify distress Specifically trained staff Specific techniques to prevent distress with supervision Psychological expertise Deliver specific interventions Train other staff to deliver interventions Deal with unusual

41 Screening measures are available They need to be used with care Prevention of distress is better than cure Motivational interviewing is promising Reducing distress may also prevent further stroke Limited supporting evidence

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