Managing depression after stroke Presented by Maree Hackett
After stroke Physical changes We can see these Depression Emotionalism Anxiety Confusion Communication problems
What is depression? Category A symptoms Depressed (dysphoric mood) OR Loss of interest/pleasure (anhedonia) Category B symptoms At least four present most days for 2 weeks Sleep disturbance Change in appetite Agitation Loss of energy Guilt or worthlessness Difficulty concentrating Thoughts of death These feelings are persistent and they start to interfere with peoples day-to-day lives.
Depression: classification Syndrome Constellation of signs & symptoms Semi-structured interview (DSM/ICD diagnosis) *Chinese menu style Symptom burden Affective, behavioural, somatic, negative cognitions Questionnaires, interviewer administered, self-completed *Symptoms only: not ill & don t seek help, +clinical impairment: ill & seek help
0-28 days 28 d 6 months > 6 months Hackett et al, Stroke 2005;36:1330-1340
Depression is poorly managed, why? Think it s normal after stroke Aren t aware of their symptoms Aware, but embarrassed to tell others (stigma) Unsure of treatment Think they are abnormal Doctor/health care professional/family don't recognise symptoms Doctor/health care professional doesn t have time to assess Doctor/health care professional/family don t know how to treat Put on treatment but never followed up
Why do we care? Poor progression through rehabilitation Worse physical function Impaired cognitive function Increased carer stress?greater risk of morbidity and mortality (suicide)
Q1: Screening for depression Should we check every person with stroke and assess them for symptoms of depression?
Does screening work (in non-mental health settings)? There is no impact on recognition, treatment or outcome of depression, unless Treating clinician is alerted to high scorers AND Treating clinician is supported by a programme of care (treatment is monitored with clear stopping rules) Gilbody et al, CMAJ 2008; 178 (8). doi:10.1503/cmaj.070281
What screening tool to use? Compared: Patient Health Questionnaire 2 item (PHQ-2) Patient Health Questionnaire 9 item (PHQ-9) Hospital Anxiety and Depression Scale (HADS) Beck Depression Inventory-II (BDI-II) Distress thermometer Kessler 10 (K-10) Against Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID): Major Depressive Episode [criterion standard] Turner et al, Depression screening in stroke: a comparison of alternative measures with the SCID (Major Depressive Episode) as criterion standard. Stroke 2012;43:1000-1005.
Management options: Conservative management (i.e. do nothing) Self management (e.g. alcohol) Herbal or natural remedies (e.g. St. Johns Wort) Support (e.g. all staff) Counselling (e.g. social workers) Psychotherapy/talking therapy (e.g. cognitive therapy) Antidepressants (e.g. SSRI, TCA)
Cochrane Reviews Pharmaceutical agent versus placebo Psychological intervention vs. usual care or attention control PREVENT depression after stroke (no depression at trial entry) TREAT depression after stroke (depressed at trial entry) All randomised controlled trials (RCTs) Stroke (WHO definition), excluding subarachnoid haemorrhage Original reviews 2004, updated 2008, 2013 updates underway!
Defining psychological interventions Includes information and education, advice, listening, emotional support direct patient-professional interaction therapist: trained, supervised develop social problem-solving skills, emotional impact of stroke structured, timetabled as a talking therapy Excludes information/education only evaluations of people and approaches unless there s a specific description of psychological therapy
Q2: Can we prevent depression after stroke?
Prevention: Psychotherapy (alone) 2004 (1 trial, 450 people) 1º No evidence of preventing depression 2º Evidence of response: mean change -1.41 (-2.64 to -0.18) 2º Evidence of response: mean difference -1.41 (-2.31 to -0.03) 2008 (4 trials, 902 people) 1º Evidence of preventing depression OR 0.64 (0.42 to 0.98) 2º Evidence of response: mean change -1.37 (-2.33 to -0.40) 2º Evidence of response: mean difference -1.41 (-2.31 to -0.03) Hackett et al, Cochrane Database of Systematic Reviews: 2008, Issue 1. Art. No.: CD003689.
Prevention: Pharmacotherapy 2004 (10 trials, 479 people + 1 psychostimulant, 21 people) 1º No evidence of preventing depression 2º No evidence of response 2008 (11 trials, 591 people + 1 psychostimulant, 21 people) 1º No evidence of preventing depression 2º No evidence of response Hackett et al, Cochrane Database of Systematic Reviews: 2008, Issue 1. Art. No.: CD003689.
Q3: Can we treat depression after stroke?
Treatment: Psychotherapy (alone) 2004 (2 trials, 121 people) 1º No evidence of remission of depression 2º No evidence of response on continuous measures 2008 (4 trials, 445 people) 1º No evidence of remission of depression 2º No evidence of response on continuous measures Hackett et al, Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003437
Treatment: Pharmacotherapy 2004 (7 trials, 615 people) 1º No evidence of remission of depression 2º Some improvement in mood scores but data not pooled 2008 (12 trials, 1121 people + 1 combination, 45 people) 1º Evidence of remission Odds Ratio 0.47 (95% CI 0.22 to 0.98) 2º Evidence of response (50% scores) OR 0.22 (0.09 to 0.52) 2º Evidence of harm (Adverse Events) OR 1.71 (1.34 to 2.18) Hackett et al, Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003437
Variation in trial quality Participants range in time since stroke, several days to 13 years Method of randomisation Seldom concealed Number of participants underpowered for more meaningful binary endpoints unable to control for confounders Interventions varied, treatment was generally short outcome assessors may know treatment allocation Analysis selective reporting of multiple outcomes, measured multiple ways high loss to follow-up, not intention-to-treat adverse events not systematically recorded or reported
Summary of use of antidepressants in psychiatric (not just stroke) research Most RCTs provide outcomes at 6-8 weeks Placebo response is 30-40% Antidepressant response is 50-60% with no clear difference between classes of antidepressant Total dropouts at 6-8 weeks are 30% for TCA, and 27% for SSRI Minimal or no response in mild or moderate depression but is substantial in severe depression (Fournier et al, JAMA. 2010;303:47-53)
Some options: NICE guidelines Watchful waiting (mild to moderate depression) 1/3 depressive episodes will recover spontaneously or with placebo treatment within a month Guided self help (mild depression), computerised CBT, exercise Short-term psychological treatment (mild and moderate depression), PST, CBT, counselling: 6-8 sesssion/10 weeks Antidepressants (for moderate and severe depression) Only use an antidepressant as part of a therapeutic programme Don t start an antidepressants without a clear (written) stopping protocol
Has our research had an impact? Our three Cochrane reviews on the management of depression and emotionalism following stroke, are cited in the Australian New Zealand United Kingdom Scottish & American stroke management guidelines and in the 2007 Lancet series on Global Mental Health.
Has our research had an impact? Australian guidelines 2010
FOCUS (UK) and AFFINITY (Aus) Assessment of Fluoxetine IN stroke recovery (AFFINITY) Fluoxetine Or Control Under Supervision (FOCUS) 1 To determine if taking fluoxetine, 20 mg, once daily, for 6 months, started 2-15 days post acute stroke improves participants functional outcome
Thank you for listening any questions?