Mood screening after stroke: for
people with and without
communication difficulties
Guidelines, tools and methods and practical issues in
screening after stroke
Aims of the session
•
To outline national guidelines for screening patients
for issues of mood after experiencing a stroke.
•
To explore why we screen and assess mood after a
stroke: the functions and purpose of screening tool &
assessments.
•
To explore mood screening measures and
assessment techniques for people with and without
communication problems after stroke.
Aims of the session
• This session is recommended for those who regularly screen
within their role. It covers items in section 5 of the Stroke
Specific Skills and Competencies framework, Early and
Continuing Rehabilitation:
• 5.1.2 Complete screening assessments for (cognitive function)
and emotional difficulties, interpret the results and develop
intervention plans within the MDT;
• 5.1.3 Understand and interpret results of the assessments and
feedback the results to the person, the family and the team;
• Further in depth assessment approaches are covered in the
cognitive section of the training package and in sessions on
working with depression and anxiety.
Why do we screen?
• We screen for mood problems because want to help people!
We have learned that untreated psychological problems lead to
poor outcomes, including higher mortality rates.
• The purpose of screening is therefore to identify those with
potential problems who can then be evaluated and monitored
further.
• A more in depth understanding of the nature of the mood would
then be carried out in order to plan treatment. For this a
screening tool helps to determine the severity of the problem;
• Intervention plans to assist change will be developed based on
assessment, preferably with the patient and their family;.
• By keeping the patient’s mood under review (RCP, 2012), we
can check if the intervention is working;
National Guidelines
• The RCP national clinical guidelines for stroke 2008
recommends screening and treatment for depression,
anxiety and emotionalism, and for cognitive and memory
impairment.
• National Service Framework for Depression in adults with a
chronic health problem (2009) incorporate standards for
assessing low mood.
• The National Institute for Health and Clinical Excellence
(NICE) stroke quality standard 2010 requires that:
'All patients after stroke are screened within 6 weeks of
diagnosis, using a validated tool, to identify mood
disturbance and cognitive impairment'.
National Guidelines
• RCP National Clinical Guidelines for Stroke (2012) 4th ed.
Recommend that:
• Services should adopt a comprehensive approach to the
delivery of psychological care after stroke, which should be
delivered by using a ‘stepped care’ model from the acute stage
to long-term management.
• Patients and their carers should have their individual practical
and emotional support needs identified before they leave
hospital, when rehabilitation ends or at their 6-month review,
and annually thereafter. Patients with stroke should be
routinely screened for depression anxiety and cognition and
intervention plans made and reviewed.
Mood Scales
There are different types of scales that we can consider for screening,
many of which have been validated in stroke. These can include:
•
•
•
Mood measures
Mood and Anxiety Measures
Anxiety measures
The tools include some that are designed for people without
communication and cognitive problems, and some for people with
communication problems. Most scales will be found in the PAAST
toolkit. Some tools are presented here as examples.
Some scales are self report which can be done as an interview, some
are observational. All have scoring criteria.
There are many other tools that measure that are available to measure
psychological problems such as self esteem, anger, post traumatic
reactions. Examples of these are also available in your toolkit but
will not be covered here.
Screening tools for depression after
stroke: Burton 2011
Tools for people without communication
problems:
Burton 2011
Assessing depression, people with
communication problems:
Burton 2011
Choosing the tool to suit you?
• Has the tool been validated for use with patients with stroke?
Sensitive and specific?
• How long does it take to administer and score the tool?
• What funds are required to purchase the tool? Initial purchase? Cost
of record forms?
• What level of training is required to administer the tool?
• Which tools do other local services use? ESD, IAPT, GPs
• Is the tool acceptable and relevant to patients?
• Quality standard: Every service should have a protocol across
the stroke pathway.
Example of a short depression scale:
Yale question
Two questions:
•
1. Prior to your stroke, have you ever felt sad or depressed?
(Yes/No)
•
2. Since your stroke, have you been feeling sad or
depressed?
•
A further clinical assessment should follow if these two are
affirmative, in line with national guidance.
•
Also be mindful of the range of psychological problems we
may face: I might not be depressed but I may be very
stressed, or anxious, or angry.
Scale example: A depression measure
for people with language problems
• Depression Intensity Scale Circles (DISCS)
If the patient points
to this circle (a
score of 2), or any
higher- this would
indicate low mood.
SADQ-H: Observation measure for depression
for people with language problems
The SADQ-H10 requires the rater to score the patient on 10 different behaviours,
shown below:
1.
Did he/she have weeping spells this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
2.
Did he/she have restless disturbed sleep this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
3.
Did he/she avoid eye contact when you spoke to him/her?
Every dayOn 4-6 day
On 1-4 days
Not at all
4.
Did he/she burst into tears this week?
Every dayOn 4-6 days
On 1-4 days
5.
Not at all
Did he/she complain of aches and pains this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
Depression measures for people with
language problems: observation measure
6.
Did he/she get angry this week?
Every day
On 4-6 days
On 1-4 days Not at all
7.
Did he/she refuse to participate in social activities this week?
Every day
On 4-6 days
On 1-4 days
Not at all
8.
Was he/she restless and fidgety this week?
Every day
On 4-6 days
On 1-4 days
Not at all
Did he/she sit without doing anything this week?
Every day
On 4-6 days
On 1-4 days
Not at all
9.
10.
Did he/she keep him/herself occupied during the day?
Every day
On 4-6 days
On 1-4 days
Not at all
Anxiety Scales
• A well used scale for measuring anxiety as well as
depression is the Hospital Anxiety and Depression Scale
(HAD-S) which has items for Anxiety and Depression.
• Lincoln, Kneebone, McNiven & Morris, (2012) suggest that a
cut off score of 8 on the HADS is more useful for detecting
symptoms in patients after stroke.
• Scales for anxiety symptoms such as the Beck Anxiety Scale
(BAI) can measure the type and severity of anxiety symptoms.
• The following slide shows a behavioural observation tool for
people with communication problems with norms in
development but available to use.
Screening for anxiety for those
with communication problems
Table: Behavioral Outcomes of Anxiety (BOA). Kneebone et al 2012
Often
1. Does he/she appear particularly tense
or on edge?
2. Does he /she have a strained face?
3. Does he/she avoid activities or social
engagements without good reason?
4. Does he/she appear fearful of falling?
5. Does he/she have trouble falling or
staying asleep?
6. Is he/she jumpy or easily startled?
7. Is he/she restless or constantly on the
move (e.g. do they pace)?
8. Is he/she easily tired?
9. Does he/she appear anxious?
10. Does he/she appear to panic, or have
unusual episodes of breathlessness or
hyperventilation?
Sometimes
Rarely
Never
Some considerations to bear in mind when we are
screening for mood after stroke
• Be mindful that some symptoms of stroke such as
fatigue, sleep and appetite changes can overlap with
mood problems. If these are in your screening tool ask
people whether they feel that issue is attributable to the
stroke or their mood.
• Be aware that you will not get the picture of a persons
mood from one screening tool, or on one day: you may
have picked them on a “good day” yet the day after that
they may be down. People may also be embarrassed to
tell you about their mood, and may minimise their
symptoms.
Further considerations
•
Stroke-specific cut off points may be required to detect stroke
patients who need further evaluation. See Psychological
Management of Stroke Lincoln et al, (2012) Wiley-Blackwell.
•
After a positive screen for mood (if someone is scoring
significantly), interview and follow up measures should be
used to clarify the nature of the problem and to begin to inform
what treatment plans may be followed. This helps people to
talk about how they see the problem.
•
Screening people with aphasia using tools and interviews
where possible may be the best approach.
•
Management plans are crucial, as screening alone does
not improve outcome!
Good practice when screening
people:
•
Have privacy to talk.
•
Explain the reasons for assessment and gain consent.
•
Leave enough time to properly explore the issues, to have an honest
conversation about how someone may truly be feeling.
•
Remember your core listening and communication (warmth,
genuineness and empathy) when asking a patient about they are
feeling.
•
Use your clinical judgement to supplement the results.
The personal perspective: what is causing the
person distress?
• If the person can express their opinions it is always a good
idea to ask the person how they are feeling, and what is going
on for them. That often gives us a bit of an idea of possible
problems. You may wish to speak to family members about
what is going on and what helps a person.
Asking specific questions to identify how someone is feeling at
specific times can uncover what they are thinking.
• “You/they just looked really worried/down/angry. Can you tell
me what went through your mind?”
• “Are there any times when you/they particularly anxious or
down and when you experience these symptoms?”
• “Does anything help?”
Good Practice in assessing mood
in people with aphasia
• Be prepared! (Girl guides), take pen and paper etc
• SADQ- asks for observations over the past week
• Read the communication assessment results and strategy
from SLT
• Be aware of the cognitive impression or assessment (OT
initial assessment/ SLT assessment results)
• Take pictures and scales- e.g. sleeplessness;
embarrassment; depression
• For questions relating to what makes it better pictures and
scales- e.g. music; bath; TV
• Use the Top tips for aphasia
Mood scale (no visual neglect)
I’m feeling…
happy
okay
unhappy
I
I
I
0
5
10
In the last week, I have been mostly…
happy
okay
unhappy
I
I
I
0
5
10
Summary
•
•
•
•
•
•
Screening informs treatment by measuring mood. Where
problems are indicated further assessment/monitoring is
needed;
Remember to share the results with the patient/family and
with the rehab team, getting ideas from them as to what may
help;
Discuss the effects of mood on engagement with
rehabilitation, possibly changing rehab goals for a while or
where/how we deliver rehab;
Develop intervention plans and monitor effectiveness of
treatment;
Have referral and signposting pathways;
Give information as to how people can get back in touch or
access services for mood related problems when needed.
This bears in mind psychological needs can arise at different
times post stroke.
Pathways can be helpful:
•
All stroke services should have a mood pathway for screening and
providing psychological, using validated screening tools and
following national guidance;
See: Accelerated Stroke Improvement website: Psychological
Care After Stroke for information on screening, protocols adopted
by services around the country in assessing mood.
http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstro
ke/tabid/177/Default.aspx
Further reading/information
•
Psychological Management of Stroke Lincoln, Kneebone,
McNiven & Morris, (2012) Wiley-Blackwell
•
Aphasia Alliance Top Tips for 'Aphasia Friendlier' Communication
(Conversations; Public Speaking; Written Communication and Using
Pictures)
http://www.aphasiatavistocktrust.org/aphasia/alliance/toptips.asp
•
PAAST manual and toolkit. NECVN.