Background

Every year, 15 million people experience a stroke,1 making it the leading cause of death and disability worldwide.2 In the United States alone, there are at least 795 000 people who experience a stroke,3 and it is expected that 246 000 of those will experience some degree of depression.2 With depression being a major cause of disability worldwide and an estimated 30% of patients with stroke experiencing poststroke depression (PSD),2 one would assume that patients with stroke are routinely being screened for depression in our healthcare facilities. Sadly, however, this is not the case.2 Many patients with stroke are never screened for depression, and their moods are not assessed during hospitalization.2 This is contrary to the stroke standard because it is recommended to screen all patients with stroke for depression.

Depression is one of the most serious complications after a stroke and has been identified as a significant poststroke comorbidity for the past 2 decades.4 Yet, in the poststroke population, depression remains overlooked and untreated in clinical practice despite the high prevalence after a stroke.5 More than 50% of patients with stroke with depression suffer daily with the disorder because they are never given a diagnosis and treated.6 As neuroscience nurses, we often see patients who have been physically and mentally devastated by this disease. Our job, as patient advocates, is to screen patients with stroke for depression in a timely manner, providing the best care and quickest recovery possible. This executive summary addresses the researched evidence on the significance of PSD, guidelines, screening barriers, and screening tools.

Significance

According to the World Health Organization, depression is a major health issue that contributes to disability rates throughout the world.7 Depression after a stroke may lead to extended hospital stays, decreased quality of life, and increased mortality rates. It restricts and delays physical, verbal, and cognitive rehabilitation after a stroke.8 Poststroke depression increases the mortality rate by 3.4% in a 10-year period, compared with nondepressed patients with stroke.5 In the United States, it is estimated that strokes amount to $34 billion each year in economic costs, with a large share of these costs due to secondary disability or PSD.3 One solution that can be significant in recognizing PSD is clinical PSD screening. Administering a depression screening tool to patients with stroke helps decrease the chances of depression going undiagnosed and untreated, therefore speeding up recovery and providing the best care possible.

Guidelines for Screening

Screening is conducted to detect and delay the progression of an illness by providing care early in its course.9 In the United States, Australia, and the United Kingdom, screening for depression is a standard for stroke care credentialing.2 Although it is recommended by national guidelines, in many health facilities, PSD screening compliance is very low.10 The US Department of Veterans Affairs and the Department of Defense Clinical Practice Guidelines for the Management of Stroke Rehabilitation "recommend that all patients be screened for depression[horizontal ellipsis]by appropriately trained clinicians using standardized and valid screening tools. If depression [is] found on initial screening assessment, patients should be formally assessed by the appropriate clinician."11 It is recommended by the Joint Commission to screen all hospitalized patients with stroke for depression before discharge.2 The National Institute of Healthcare and Excellence quality standards recommend PSD screening within 6 weeks of a stroke.12 Each guideline differs, which may be contributing to the reason PSD screening compliance is low in US healthcare facilities. The guidelines are unclear as to when to screen the patient for PSD, who should be screening the patient, and which screening tool is the most appropriate.

Barriers to Screening

There are many barriers to PSD screening including concerns about screening instruments, the time it takes to administer screening tools, deficits in knowledge about the tools, and who should administer the tools because it is not an established routine in some clinical areas.10 A 2008 study by Hart and Morris10 investigated different stroke units and the compliance of PSD screening by the staff. The study showed that compliance may increase with additional knowledge and skills through training, understanding the evidence of the screening tool, and knowing the guidelines. According to the authors, making depression screening a routine practice in medical facilities and having support from nursing colleges and health professionals will increase compliance.10 Language barriers also interfere with screening as patients having a stroke commonly have some degree of receptive or expressive aphasia, making it difficult to assess PSD with interview questions.13 Other barriers, such as the stigma associated with depression and mental illness, may make patients less likely to mention depression symptoms to the care provider.9 Another issue that may be contributing to why screening is not being conducted is the normalization of depression symptoms, which include depressed mood, lack of interest, loss of energy, decreased appetite, and much more. Care providers and patients may be treating depression symptoms as an expected part of the stroke instead of treating depression and stroke as 2 different conditions.9 Of the multiple providers in hospitals, rehabilitation facilities, and primary care practices, there is no standard of care as to who should screen for PSD. There are studies that have shown speech therapists, occupational therapists, nurses, and social workers all screening patients for depression. A study by Karamchandani et al14 discussed the feasibility of the Patient Health Questionnaire (PHQ) being self-administered in the hospital setting and the social worker collecting the results. Other studies, such as the one by de Man-van Ginkel et al,15 discussed the clinical usefulness and brevity of the administration of a modified PHQ by the nursing staff in the hospital setting.

Screening Tools

There are many different depression screening tools used in clinical practice. Because of the various screening tools, it has become difficult for the clinician to distinguish which one is the easiest to administer and most accurate for diagnosing depression symptoms in patients with stroke.2 There is no 1 specific tool recommended for PSD screening. Depending on the location, time frame, and the language deficits of the patient, the screening tool will vary. There is no abundance of research in this particular area, and further research is needed to determine the best and most accurate screening tool in different poststroke patient populations. A meta-analysis16 suggested 3 scales-the Center of Epidemiological Studies Depression Scale, the Hamilton Depression Rating Scale, and the PHQ-9-as the best options for screening for PSD. The most commonly used tools by nurses and in stroke research are the single-item screen, the 30- or 15-item Geriatric Depression Scale, Montgomery-Asberg Depression Rating Scale, and the PHQ-2 and PHQ-9.2 When screening aphasic patients, a visual emoticon scale has shown adequate sensitivity and specificity and can be rapidly administered.17

When considering a screening tool, feasibility in clinical practice is very important. The PHQ-2 and PHQ-9 are suggested for clinical nursing use because they take less time to administer and are easy to score.15 Because of the time constraints that exist in most healthcare settings, it is recommended that all patients be screened with the PHQ-2 and then screen only those patients who have screened positive on the first test with the PHQ-9.18 A prospective study by de Man-van Ginkel et al15 found that the PHQ-2 and PHQ-9 showed good validity with respective sensitivities and specificities for major depression. The PHQ-2 and the PHQ-9 are preferred over other screening tools because they are easily obtained, brief, and suitable to patients.18 The American Stroke Association has stated that the PHQ-2 performed adequately in the population with stroke when compared with other depression screening tools and is recommended for a single screening.19

For time management, it is recommended to first screen with the PHQ-2 and only proceed with the remaining 7 questions of the PHQ-9 if the patient scores greater than 3 on the PHQ-2.17 Patient scoring of 0 to 4 on the PHQ-9 does not require further intervention because this score indicates no depression.15 The health provider administering the screening tool should notify the physician whether the patient screens greater than 5 on the PHQ-9 because this scoring indicates some level of depression, with the severity of depression increasing with the score.15 The patient should be assessed by the physician and/or have a mental health consult if they answer anything other than "not at all" to question 9 on the PHQ-9 because this screens for suicide ideation.2

Conclusions

Depression is a chronic illness that can be treated and is present in 1 of 3 patients with stroke. It is imperative that our healthcare facilities recognize PSD screening as a standard of stroke care because it is recommended by major guidelines. The most accurate and easiest tool to administer in the inpatient setting is the PHQ-2 and the PHQ-9. This screening tool can be administered by multiple health professionals from the nurse to the therapist. Overall, it is important to screen patients for PSD because depression is a major disabling disease that can be treated but is often overlooked in patients with stroke. Further studies should focus on system improvement efforts to screen for PSD such as standardizing who to screen and what hospital day to screen for PSD and a screening tool for our acute hospitalized patients, primary care patients, and aphasic patients to adhere to the national standards for screening in our healthcare facilities and to provide the best care possible.

References