Screening stroke patients to
offer support for mood
disturbance in acute and
community settings
Sara Banks
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
East of England Stroke Forum Annual Conference
March 14th 2013
Objectives
• To know more about national and local context of screening for mood
disturbance
• To be up-to-date in knowledge about mood disturbance in stroke
• To be able to select measures to screen for mood disturbance
• To more confidently interpret results of screens for mood disturbance
• To have a framework by which to begin to offer further support
• To have time to be able to discuss the above and related issues with
colleagues across the region
National context
• British Psychological Society (2010)
Psychological services for stroke survivors and their families
• NHS Improvement (2011a)
Psychological care after stroke: Improving stroke services for people with cognitive and mood
disorders
• NHS Improvement (2011b)
Accelerating stroke improvement
• Royal College of Physicians (2012)
National clinical guideline for stroke: Fourth edition
• NHS Improvement (2012)
Psychological care after stroke: Economic modelling of a clinical psychology led team approach
NHS Improvement (2011a)
Local context
• NHS East of England (2011)
Psychological support for stroke: A guide for commissioners
• Anglia Stroke and Heart Network, Beds and Herts. Stroke and Heart
Network, Essex Cardiac and Stroke Network (2012)
Stroke-specific multi-professional competency framework
• NHS Midlands and East (2012)
Stroke services specification
• Anglia Heart and Stroke Network
Psychological service implementation group
Adjustment to stroke
• A process of adaptation to disability
• Holbrook (1982) Social and emotional outcomes of stroke
o
o
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Crisis - Shock, confusion and anxiety
Rehabilitation - Expectation, denial, grieving
Emotional response - Anger, depression, despair
Acceptance - Reality of changed lifestyle
• Patterns for phases of adjustment to stroke and related emotional
experiences
o
o
Kirkevold (2002)
Eilertsen (2010)
• When/how does ‘adjustment’ become ‘mood disturbance’?
Depression
Prevalence
• Occurs in around 30% of people post-stroke (Hackett and Anderson, 2005)
Definition (Diagnostic and Statistical Manual of Mental Disorders Fourth Edn)
• Five or more symptoms in two-week period with a change from previous functioning
• Causes clinically significant distress or impairment in social, occupational/other function
Neurobiology
• Structures in the prefrontal and limbic areas of the brain are involved in affective regulation
• Biological factors important in the acute stage
Psychosocial factors
• Disability, pre-stroke depression, cognitive impairment, stroke severity and anxiety are
predictors of depression post-stroke (Ayerbe at al., 2013)
Anxiety
Prevalence
• A range of conditions - can occur in up to 30% of people post-stroke (Lincoln et al., 2012)
Definition (Diagnostic and Statistical Manual of Mental Disorders Fourth Edn)
• GAD: Frequent and excessive anxiety/worry for at least six months alongside at least three:
o Restlessness, feeling ‘on edge’, easily fatigued, difficulty concentrating
o Mind going blank, irritability, muscle tension, sleep disturbance
• Causes clinically significant distress or impairment in social, occupational/other function
Neurobiology
• The amygdala and hypothalamus
Psychosocial factors
• Associated with dependence, vulnerability, inability to meet expectations, (Lander, 2009)
Anger
Prevalence
• In acute stages up to around 35% report ‘significant aggressiveness’ (Santos et al., 2006)
Definition (Diagnostic and Statistical Manual of Mental Disorders Fourth Edn)
• Personality change due to a general medical condition – Aggressive type
• Causes clinically significant distress or impairment in social, occupational/other function
Neurobiology
• The amygdala and thalamus. Anger in different types of strokes.
Psychosocial factors
• Associated with history of depression (Aybek et al., 2005)
• Control of anger related to motor dysfunction, dysarthria, emotional lability (Kim et al., 2002)
• Reporting of anger as ‘personality changes’ (Stone et al., 2004)
Selecting measures for mood disturbance
• Validity
• Reliability
• Sensitivity and specificity
• Why screen?
o Identifying a problem for further assessment
o Understanding the nature and extent of problem to plan intervention
o To monitor changes across course of recovery
• Which measures?
o Considering ability to communicate
o Considering stage of care pathway
o Considering how findings might be used in practice
Offering further support
Based on a stepped care model:
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Knowledge, skills and confidence to assess and manage psychological issues
Using clinically significant cut-offs
Using descriptive knowledge from caregiver and staff team
Knowledge of services available in locality
The King’s Lynn approach
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Outline of model
Using guidelines as a framework
Development according to team strengths (and limitations)
Development according to willingness of external organisations to participate
An ongoing project!
Questions and discussion...
References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington DC: American
Psychiatric Association.
Aybek, S., Carotal, A., Ghika-Schmid, F. et al. (2005). Emotional behaviour in acute stroke: The Lausanne emotion in stroke study.
Cognitive and Behavioural Neurology, 18, 37-44.
Ayerbe, L., Ayis, S., Wolfe, C. D. A. & Rudd, A. G. (2013). Natural history, predictors and outcomes of depression after stroke: systematic
review and meta-analysis. The British Journal of Psychiatry, 202, 14-21.
Bennett , L. & Marsden-Smith (2012). Stroke-specific multi-professional competency framework. Anglia Stroke and Heart Network.
British Psychological Society (2010). Psychological Services for Stroke Survivors and their Families. Leicester: Division of Clinical
Psychology , Division of Neuropsychology.
Eilertse, G., Kirkevold, M & Bjork, I. (2010). Recovering from stroke: A longitudinal, qualitative study of older Norwegian women. Journal
of Clinical Nursing, 19, 2004-2013.
Hackett, M.L. & Anderson, C.S. (2005) Predictors of depression after stroke: A systematic review of observational studies. Stroke, 36,
2296-2301.
Holbrook, M. (1982). Stroke: Social and emotional outcome. Journal of the Royal College of Physicians of London, 16, 100-104.
Kirkevold, M. (2002). The unfolding illness trajectory of stroke. Disability and Rehabilitation, 24, 887-898.
References continued...
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Lander Z. (2009). A qualitative analysis of the phenomena stroke survivors associate with post-stroke anxiety. Leicester: D.Clin.Psy., University of
Leicester.
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Lincoln, N. (2012). Psychological management of stroke. Oxford: John Wiley & Sons Ltd.
•
Naylor, C., Parsonage, M., McDaid, D., Knapp, M, Fossey, M. and Galea, A. (2012). Long-term conditions and mental health: The cost of co
morbidities. London: The Kings Fund and Centre for Mental Health.
•
NHS East of England (2011). Psychological support for stroke: A guide for commissioners. NHS East of England.
•
NHS Midlands and East (2012). Stroke service specification . NHS Midlands and East.
•
NHS Improvement (2011a). Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders. Leicester:
NHS Improvement.
•
NHS Improvement (2011b) Accelerating stroke improvement. NHS Improvement.
•
NHS Improvement (2012). Psychological care after stroke: Economic modelling of a clinical psychology led team approach. Leicester: NHS
Improvement.
•
Royal College of Physicians (2012).National Clinical Guidelines for Stroke. London: Royal College of Physicians.
•
Santos, C. O., Caeiro, L., Ferro, J. M., et al. (2006). Anger, hostility and aggression in the first days of acute stroke. European Journal of
Neurology, 13, 351-358.
•
Stone, J., Townend, E., Kwan, J. et al. (2004). Personality change after stroke: Some preliminary observations. Journal of Neurology,
Neurosurgery and Psychiatry, 75, 1708-1713.