A Nurses Guide
Presented by Rachel Lambert
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
If not treated PSD can affect
Quality of Life
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
Age 60 or younger
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.
Incidence and Recovery
Effect on Brain Function
Duration of two years
Response to treatment
Risk of double depression
Sign and Symptoms of PSD
Significant lack of energy
Lack of motivation
Difficulty finding enjoyment in anything
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
What are some tools to Identify PSD?
Self –report scales
Hamilton Rating Scale for Depression
Beck Depression Inventory
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
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
Treatments that have been proven to be effective include:
Selective Serotonin reuptake Inhibitors (SSRIs)
First line medication choice
Dosage/Side Effects/ Drug Interactions
thoughts lead to moods
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
Utilizing pre-existing coping techniques
Repetitive Transcranial Magnetic Stimulation
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
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
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
An empowered patient able to participate in their recovery process!
Brodaty, 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