A Survey of the Management of Mood Problems after Stroke by Clinical. a Professor of Clinical Psychology, University of Nottingham

Transcription

1 A Survey of the Management of Mood Problems after Stroke by Clinical Psychologists Nadina B Lincoln a, Esme Worthington b & Karyn Mannix c a Professor of Clinical Psychology, University of Nottingham b Research Associate, University of Nottingham c Trainee Clinical Psychologist, University of Nottingham Correspondence address: Nadina Lincoln, Professor of Clinical Psychology, Institute of Work, Health and Organisations, University of Nottingham, International House, Jubilee Campus, Wollaton Road, Nottingham, NG8 1BB, UK Fax: +44 (0) Telephone: +44 (0) nadina.lincoln@nottingham.ac.uk 1

2 Summary The management of mood problems after stroke was audited for 140 patients across 10 services. Most patients were screened using clinical interviews. The most common outcomes of assessment were monitoring and advice. Only 42% received psychological treatment. Introduction Stroke is the third leading cause of death in the UK, affecting an estimated 150,000 people every year (The Stroke Association, 2010). A third of patients suffer from post-stroke emotional difficulties, particularly depression and anxiety (Hackett, Yapa, Parag & Anderson, 2005). Existing studies have focused largely on depression, which has a reported prevalence of 20-50%, and persists 3 6 months post-stroke (Hosking, Marsh & Friedman, 2000). In contrast, anxiety has received less attention, with studies suggesting a prevalence of 4-28% (Barker- Collo, 2007). Both depression and anxiety can have significant negative implications, affecting patients mortality and quality of life, progress in rehabilitation, and discharge (Hackett et al., 2005). Despite this, both have been under-recognised and under-treated in routine clinical practice. According to the National Sentinel Stroke Audit (2008), although it was recommended that all patients were screened for low mood, only 65% were being screened (Royal College of Physicians (RCP), 2009). Furthermore, there currently remains a severe shortage of clinical psychology input in stroke 2

3 services (RCP, 2009, p.18). Of the 92% of hospitals with stroke units, just 36% have clinical psychologists, and in those units where a service is provided this is often minimal, with few patients receiving on-going treatment, especially following discharge (RCP, 2009). These findings may be explained by the limited evidence base for psychological interventions after stroke. Although cognitive behaviour therapy has a strong evidence base in the treatment of depression (NICE, 2006), the results are mixed for depression after stroke. Whilst some evidence for its efficacy has been reported (Fiske, Wetherell & Gatz, 2009), a randomized controlled trial (Lincoln & Flannaghan, 2003) found no significant differences between cognitive behaviour therapy, a placebo intervention, or standard care. This limited research base has resulted in a Cochrane review concluding that there is currently no evidence to support or refute the effectiveness of psychotherapy in reducing symptoms of depression after stroke (Hackett, Anderson, House & Xia, 2009). The Stroke Research Network Rehabilitation Clinical Studies Group have encouraged clinical psychologists to evaluate the effectiveness of mood interventions in order to justify the development of clinical services. The Organisation for Psychological Research in Stroke group (OPSYRIS) has also discussed the need for this information. Although workshops have been held to encourage research proposals in this area, it is difficult to plan any research when the services currently being delivered are an unknown. It is not clear what types of psychological interventions are being provided, or the outcome 3

4 measures being used in clinical practice. This audit was undertaken to gather this information. The aim was to document the nature and provision of clinical psychology services for patients with mood problems after stroke across UK stroke services. Method Clinical psychologists working in stroke services were contacted through the Organisation for Psychologists Researching in Stroke (OPSYRIS) and invited to take part in a survey of services provided. Those clinical psychologists who agreed were provided with a survey form (copies available on request) and asked to complete the information on every patient referred to the service between 1 st January 2009 and 31 st March This included information on patient demographics. Stroke type was classified according to the Bamford classification, derived from information in patients medical notes. Information was requested on the process of screening for and assessment of mood problems (e.g. method, outcomes), and the provision of psychological treatment (e.g. treatment type, outcome). Where standardised scales were used, contributors were asked to specify the measure and the preand post-treatment scores. Services were asked to provide subjective judgments of the effect of intervention. 4

5 At the end of the three month period each participating centre was asked to return completed forms as soon as all included patients had been discharged from hospital. A questionnaire was then sent to the service to obtain information about the setting of the survey, including the type of service and the level of psychology provision. Ethical approval was granted by the Institute of Work, Health and Organisations, University of Nottingham Ethics Committee. For National Health Services (NHS) purposes, the study was registered as an audit in each of the participating sites. Results The data were analysed using SPSS Version Fourteen UK stroke services, members of OPSYRIS, originally agreed to take part in this study. However, due to service relocation and staff shortages, ten services took part. Service Configuration Six of the ten services returned questionnaires providing information about their service. All six were inpatient units, with bed numbers ranging from Only 5

6 one service also had an outpatient unit. Most services offered acute and rehabilitation care, with one offering rehabilitation only. Only two services had community provision. All six services had one clinical psychologist (wte ranged from 0.2 to 1.0) and varying trainee and assistant psychologist support. All services held formal multidisciplinary meetings (MDT) ranging from once to six times a week. Patient Characteristics Information was available for 140 stroke patients with a mean age of 69.8 years (SD = years, range 18 95), and 72 (51%) of these were male. Most had partial anterior circulation strokes, but information was missing on type of stroke for 56 (40%) participants. There were more patients included with left hemisphere strokes (n=59, 42%) than right (n=46, 33%). These results are summarized in Table 1. Table 1 about here. Mood Screening and Assessment Most patients (n=125, 89.3%) were screened for mood difficulties. The initial assessment was generally carried out by a clinical psychologist (n=96, 68.6%), an assistant psychologist (n=36, 25.7%), or a trainee clinical psychologist (n=7, 6

7 5.0%). Patients were referred to psychologists by allied health professionals (OT/PT/SALT) (n=37, 26.4%), nursing staff (n=33, 23.6%), and medical staff (n=25, 17.9%). In some (n=21, 15%), mood assessment was carried out routinely, and therefore no information on referral source was available for these cases. About half of patients were found to have mood problems (n=79, 56.4%), with the remainder having cognitive (n=22, 15.7%) or other (n=13, 9.3%) difficulties as their main presenting problem. The most common mood problem reported was depression, occurring (either alone or in conjunction with anxiety) in 74 (52.9%) patients. Anxiety was a problem on its own for six patients (4.3%), but also cooccurred with depression in a further 27 (19.3%). For 26 patients (18.6%), information regarding their main presenting problem was not provided. The majority of assessment took place by clinical interview (n=98, 70.0%). Questionnaire measures were administered for 77 patients (55.0%), and in most cases (n=63, 45.0%) these patients had also been interviewed. In addition, discussions took place between hospital staff and patients family members regarding patients mood (n=10, 7.1%), and observations were carried out by staff members (n=14, 10.0%). The Hospital Anxiety and Depression Scale was the most frequently used questionnaire (n=43, 30.7%). Most services used just one questionnaire and used this for most of their patients. 7

8 Table 2 about here. The most common outcomes of assessment were monitoring (n=67, 47.9%) and advice (n=63, 45.0%). 59 patients (42.1%) received psychological treatment and 23 (16.4%) were prescribed anti-depressant medication. Often a combination of approaches was used (e.g. monitoring together with advice). Results are shown in Table 2. Of the 59 who received psychological treatment, 44 (74.6%) were treated by a clinical psychologist, 5 (8.5%) by an assistant psychologist, and 5 (8.5%) by a trainee psychologist. A further 5 (8.5%) were identified as having been treated by an other (nursing staff or unspecified ). The types of treatment offered are summarized in Table 3. Cognitive and behavioural therapies were the most commonly used. The number of therapy sessions offered ranged from 1 to 17 (with a median of 1 session). Sometimes more than one approach to treatment was used concurrently. Table 3 about here. Pre-treatment questionnaire scores were provided for 71 (50.7%) patients, and post-treatment scores for only 18 (12.9%). Thus, the information on outcomes of treatment was primarily based on clinicians subjective opinions of patients 8

9 progress. These indicate that for 38 (64.4%) patients the problem had resolved or improved. There were 11 (18.6%) who showed no change, and 1 (1.7%) worsened. Discussion The survey aimed to identify the nature and provision of clinical psychology services for mood problems across UK stroke services. Results indicated that the majority of patients referred to clinical psychologists were screened for depression and anxiety. Assessments were based primarily on clinical interview, with questionnaires used for some patients. In line with guideline recommendations, all of these questionnaires were valid measures of mood difficulties and easily administered. Other methods (e.g. observation) were sometimes used due to patients communication difficulties or other impairments which complicated the assessment of mood. Advice and monitoring were the most frequent outcomes of mood assessments. The high percentage of advice and monitoring and relatively low provision of other psychological treatments may be related to the severity of patients mood problems (mild, rather than moderate or severe). However, because the severity was not recorded, this is not possible to ascertain. It may also be that services did not have the adequate resources to offer treatment to all patients who may have benefitted from it. Some services also had a policy of advise and monitor before instigating psychological treatment, as mood problems are known to 9

10 improve quite quickly in the early stages after stroke (Lincoln & Flannaghan, 2003). Pre- and post-treatment scores were rarely provided, thus it was not possible to obtain an objective indication of improvement with treatment. The majority of patients showed some improvement following treatment on the basis of the subjective report of the treating therapist. There are a number of limitations to this study. It is not known whether participating services were representative of UK clinical practice or whether they represent those which had the best resources and organisation to complete the audit. They also represent those services with some clinical psychology provision, whereas in some areas there is no clinical psychology service for stroke patients. There was also a high proportion of missing data. For example, standardized scores for treatment outcomes were rarely provided. The findings indicated that participating stroke services were not meeting the recommendations of current stroke guidelines, such as universal screening and early identification of post-stroke mood problems. Several aspects of management are not supported by research evidence. For example, it is not known the extent to which clinical interview in the acute stage is able to detect all mood problems. The policy of advise and monitor was commonly used, but the justification for this is not clear. CBT was the most commonly used psychological 10

11 treatment, but evidence for its effectiveness in this population is not available. Clinical psychology services are able to address cognitive and emotional problems after stroke, but the level of service provision suggests that in some centres the service provided does not meet even the minimum standards required. 11

12 References Barker-Collo, S. (2007). Depression and anxiety 3 months post stroke: Prevalence and correlates. Archives of Clinical Neuropsychology, 22, Department of Health (2007). National Stroke Strategy. London, UK: Author. Fiske, A., Wetherell, J. & Gatz, M. (2009). Depression in older adults. Annual Review of Clinical Psychology, 5, Hackett M.L., Anderson, C.S., House, A.O. & Xia, J. (2009). Interventions for treating depression after stroke. Stroke, 40, Hackett, M.L., Yapa, C., Parag, V. & Anderson, C.S. (2005). Frequency of depression after stroke: A systematic review of observational studies. Stroke, 36, Hosking, S.G., Marsh, N.V. & Friedman, P.J. (2000). Depression at 3-months post-stroke in the elderly: Predictors and indicators of prevalence. Aging Neuropsychology & Cognition, 7,

13 Lincoln, N.B. & Flannaghan, T. (2003). Cognitive behavioural psychotherapy for depression following stroke: A randomized controlled trial. Stroke, 34, National Institute for Health and Clinical Excellence (2006). Computerised cognitive behaviour therapy for depression and anxiety. London, UK: Author. National Institute for Health and Clinical Excellence (2008). Diagnostic and initial management of acute stroke and transient ischaemic attack (TIA). London, UK: Author. Royal College of Physicians (2009). National Sentinel Stroke Audit. Phase II (clinical audit) London, UK: Author. Royal College of Physicians (2008). National Clinical Guideline for Stroke. Third Edition. London, UK: Author. The Stroke Association (2010). Facts & figures about stroke. Retrieved January 15, 2009, from 13

14 Table 1: Stroke type classification Frequency Percent Type of stroke PACS TACS LACS POCS Other/unknown Hemisphere affected Left Right Both Unknown PACS = partial anterior circulation stroke TACS = total anterior circulation stroke LACS = lacunar stroke POCS = posterior circulation stroke 14

15 Table 2: Mood screening, assessment, and outcomes of assessment (n=140) Frequency Percent Referrer Nurse Doctor Physiotherapist OT SALT Other Data unavailable Mood problem Depression Anxiety Both Other None Data unavailable Method of assessment Interview Questionnaire HADS WDI

16 BASDEC DISCS BAI BDI-FS SADQ Problems Checklist BDI VAMS VASES GDS IES-R Other Observation by staff Discussion with family/mdt Review of medical notes Visual analogues Unspecified Outcomes of assessment Monitoring Advice given Psychological treatment Anti-depressant

17 medication Other Family/carer support Referral to another service Other Key: HADS: Hospital Anxiety and Depression Scale; WDI: Wakefield Depression Inventory; BASDEC: Brief Assessment Schedule Depression Cards; DISCS: Depression Intensity Scale Circles; BAI: Beck Anxiety Inventory; BDI-FS: Beck Depression Inventory (Fast Screen); SADQ: Stroke Aphasic Depression Questionnaire; BDI: Beck Depression Inventory; VAMS: Visual Analogue Mood Scale; VASES: Visual Analogue Self-Esteem Scale; GDS: Geriatric Depression Scale; IES-R: Impact of Events Scale Revised. 17

18 Table 3: Delivery and subjective outcomes of psychological treatments (n=59) Frequency Percent Treating clinician Clinical psychologist Assistant psychologist Trainee psychologist Other Type of treatment Cognitive behaviour therapy Behavioural Systemic therapy Psychotherapy Other Outcome of treatment Problem resolved Improved No change Worsened Data unavailable