Which is the best screening tool for Post-Stroke Depression:
  - Evidence Based Meta-Analysis




        Alex Mitchell   ...
Contents

 Background

 Emotional complications of Stroke

 Scales and tools

 Reexamining the concept of PSD vs PD
1. Background
Stroke: Definition
 A syndrome characterized by acute onset of a
 neurologic deficit that persists for at least 24 hours,
...
Stroke Subtypes

                                    Lacunar
                                      19%
                   ...
Healthy life years lost (YLL) to disease Worldwide

                       1990                                 2020
     ...
Not Just




Function




           DSMV
PSD associated with:
 Poor functional recovery (in 9 of 12 studies)
 Reduced quality of life
 Increased cognitive impairme...
Carson et al, 2000
PSD Prevalence by DSMIV (n=1200)


                                                   Major %    Minor % total
Burvill et ...
PSD by Meta-analysis (n=2000)


 major depressive disorder   19% (12.1%, 25.6%)

 minor depressive disorder   17% (4.1%, 2...
2. Antidepressants and treatments
Treatment of Post-Stroke Depression
                  Individual Studies
                  • Placebo Controlled
          ...
Jorge et al (2003) Am J Psychiatry
N=104; 9 year follow up
Nortriptyline, fluoxetine, placebo (RCT)
Prophylactic treatment with Sertraline
Poulsen, et al, 2003 Stroke Patients Randomly Assigned to 12 Months of Double‐Blind...
Antidepressant Prevention – Meta-analysis
Cochrane 2008 Update
•   Sixteen trials (17 interventions)
•   N= 1655 participants,
•   13x pharmaceutical agents
•   4x ...
3. Scales and Tools of PSD

    How

    When

    By who?
Issues in screening tools for PSD                   Gaete, et al. 2008)




 Are staff always available for “observer” sca...
Other Guidelines
 RCPhycians on the National Clinical Guidelines for Stroke (UK)
 recommend that
 ‘patients should be scre...
Which Approach?
General                         Physical

                                                                                ...
Self-Report Scales
Concordance with DSMIV and ICD10
Interview Scales
• YALE
• “Are you depressed”? PPV 30-50%
Visual-Analogue
Figure 4: The Depression Intensity Scale
          Circles (DISCs)
                                                       ...
Figure 3: The Numeric Graphic Rating                    Instructions for administration
           Scale (NGRS)
          ...
Smiley Scale
Smiley Scale
Which Approach Works (Validity)?
Meta-analysis –Meader & Mitchell
 18 studies possibly eligibility criteria, providing data on
 2,045 participants

 Level ...
As of Sept 09
 HADS-D                                6x

 HAM-D/HDRS                            5x

 CES-D                ...
Preliminary Results
Preliminary Results 2
1.00                               Comment: Slide illustrates that there is

           Post-test Pr...
Comment: All methods compared
1.00                               regardless of quality of the study


           Post-test...
Interpretation
 Simple tools work surprisingly well but data is weak

 BDI, HADS and GDS are not especially strong



 Acc...
4. Comorbid Depression

   Why BDI/HADS not successful?

   Back to Basics
Lipsey (1986) PSD vs PD
Stroke (n=41) vs MI (n=26) on HAMD17
 Verhey et al (2009)

  loss of interest, psychomotor
 retardation, and gastro-
 inte...
Approaches to Somatic Symptoms of Depression
 Inclusive
 Uses all of the symptoms of depression, regardless of whether the...
Comment: Slide illustrates concept of
phenomenology of depressions in
medical disease




                                ...
Study: Somatic symptoms study
  N= 4500; Pooled database study; All comparative
  studies

  Physical illness+comorbid dep...
Comment: Slide illustrates actual
phenomenology of depressions in
medical disease




                                    ...
Summary
  Questions
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
Agm10   screening for depression in stroke (v4medium)
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Agm10 screening for depression in stroke (v4medium)

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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. 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
  2. 2. Contents Background Emotional complications of Stroke Scales and tools Reexamining the concept of PSD vs PD
  3. 3. 1. Background
  4. 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. 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. 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
  7. 7. Not Just Function DSMV
  8. 8. PSD associated with: Poor functional recovery (in 9 of 12 studies) Reduced quality of life Increased cognitive impairment Increased mortality 4 studies suggest Rx depression improves stroke outcomes (all since 1998) 3 studies suggest Ads post stroke reduce depression
  9. 9. Carson et al, 2000
  10. 10. PSD Prevalence by DSMIV (n=1200) Major % Minor % total Burvill et al (1995) Community 294 PSE-DSM-III 15 8 23 15 8 23 Fedoroff et al (1991) Acute hosp 205 PSE-DSM-III 22 19 41 22 19 41 Castillo et al (1995) Acute hosp 291 PSE-DSM-III 20 18 38 20 18 38 Pohjasvaara et al (1998) Outpatient 277 PSE- DSM-III-R 26 14 40 26 14 40 Vataja et al (2001) Outpatient 275 PSE-DSM-III-R 26 14 40 26 14 40 21.7 14.3 36
  11. 11. PSD by Meta-analysis (n=2000) major depressive disorder 19% (12.1%, 25.6%) minor depressive disorder 17% (4.1%, 29.4%) any depressive disorder 30% (20.9%, 39.1%) respectively
  12. 12. 2. Antidepressants and treatments
  13. 13. 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
  14. 14. Jorge et al (2003) Am J Psychiatry N=104; 9 year follow up Nortriptyline, fluoxetine, placebo (RCT)
  15. 15. 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
  16. 16. Antidepressant Prevention – Meta-analysis
  17. 17. 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”
  18. 18. 3. Scales and Tools of PSD How When By who?
  19. 19. 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
  20. 20. 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.”
  21. 21. Which Approach?
  22. 22. General Physical Trained Self-Report Confident Skilled Clinician Alone Signs of DS 6 Depression DISCS Observation Screening Stroke Aphasic In Stroke Visual Depression Scale 21/10 VA-SES SMILEY ET/DT YALE Interview HAMD-D 17 MADRAS 10
  23. 23. Self-Report Scales
  24. 24. Concordance with DSMIV and ICD10
  25. 25. Interview Scales • YALE • “Are you depressed”? PPV 30-50%
  26. 26. Visual-Analogue
  27. 27. 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.
  28. 28. 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
  29. 29. Smiley Scale
  30. 30. Smiley Scale
  31. 31. Which Approach Works (Validity)?
  32. 32. Meta-analysis –Meader & Mitchell 18 studies possibly eligibility criteria, providing data on 2,045 participants Level 1 - robust meta-analysis requires 4x studies (STATA) Level 2 - 3x studies Non-meta-analytic – 1x study
  33. 33. As of Sept 09 HADS-D 6x HAM-D/HDRS 5x CES-D 4x GDS 4x Zung, BDI fast screen, PHQ-2, PHQ-9 1x Yale / BDI-II / NGRS / DISCS / SMILEY (1x)
  34. 34. Preliminary Results
  35. 35. Preliminary Results 2 1.00 Comment: Slide illustrates that there is Post-test Probability NO ADVANTAGE to scales without somatic symptoms 0.90 0.80 0.70 0.60 HDRS+ 0.50 HDRS- Baseline Probability 0.40 HADS+ HADS- GDS30+ 0.30 GDS30- CES-D+ 0.20 CES-D- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  36. 36. Comment: All methods compared 1.00 regardless of quality of the study Post-test Probability 0.90 0.80 0.70 0.60 Smiley+ 0.50 Smiley- Baseline Probability DISCS+ DISCS- 0.40 NGRS+ NGRS- Yale+ Yale- 0.30 HDRS+ HDRS- HADS+ HADS- 0.20 CES-D+ CES-D- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  37. 37. Interpretation Simple tools work surprisingly well but data is weak BDI, HADS and GDS are not especially strong Acceptability is key
  38. 38. 4. Comorbid Depression Why BDI/HADS not successful? Back to Basics
  39. 39. Lipsey (1986) PSD vs PD
  40. 40. Stroke (n=41) vs MI (n=26) on HAMD17 Verhey et al (2009) loss of interest, psychomotor retardation, and gastro- intestinal complaints more common
  41. 41. 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
  42. 42. Comment: Slide illustrates concept of phenomenology of depressions in medical disease Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  43. 43. Study: Somatic symptoms study N= 4500; Pooled database study; All comparative studies Physical illness+comorbid depression Vs Physical illness alone Vs Primary depression alone
  44. 44. Comment: Slide illustrates actual phenomenology of depressions in medical disease Primary Depression Secondary Depression Weight loss Agitation Retardation Medically Unwell
  45. 45. Summary Questions

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