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.

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. Contents
Background
Emotional complications of Stroke
Scales and tools
Reexamining the concept of PSD vs PD

3. 1. Background

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

8. Not Just
Function
DSMV

9. 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

10. Carson et al, 2000

11. 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

12. 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

13. 2. Antidepressants and treatments

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

17. Antidepressant Prevention – Meta-analysis

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”

20. 3. Scales and Tools of PSD
How
When
By who?

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

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.”

24. Which Approach?

25. 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

26. Self-Report Scales

28. Concordance with DSMIV and ICD10

29. Interview Scales
• YALE
• “Are you depressed”? PPV 30-50%

30. Visual-Analogue

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

34. Smiley Scale

35. Smiley Scale

37. Which Approach Works (Validity)?

38. 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

40. 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)

41. Preliminary Results

42. 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

43. 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

44. Interpretation
Simple tools work surprisingly well but data is weak
BDI, HADS and GDS are not especially strong
Acceptability is key

45. 4. Comorbid Depression
Why BDI/HADS not successful?
Back to Basics

47. Lipsey (1986) PSD vs PD

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

53. Summary
Questions