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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