Original Research Reports Detection of Depression in the Stroke Patient DANIEL S.P. SCHUBERT, M.D., PH.D., CYNTHIA TAYLOR, D.O. SUK LEE, M.D., ASKIN MENTARI, M.D. WILBERFORCE TAMAKLO, M.D.
The literature sURRests the hypothesis that nonpsychiatrists will underrecoRnize depression in el'Oluations ofstroke patients. On a medical rehabilitation ward. 15 stroke patients were naluatedfor depression by psychiatric interview and self-report. Charts were examinedfor detection of depression by the rehabilitation team. The hypothesis was supported: in contrast to psychiatric interview (68% depressed) and self-report (Beck Depression Inventory. 50% depressed). none of the patients were described as depressed in chart notes by the rehahilitationteam (excludinR the psychiatrists). Psychiatrists should develop ongoing interactions with primary care physicians 10 improve detection of poststroke depression and other depressions on medical wards.
P
oststroke depression has been well documented by Robinson and colleagues (see reviews by Robinson and Starkstein)1.2 and other investigators. J - 14 Robinson and Price l5 found about one-third of their stroke patients were depressed. whereas Sinyor et al. 12 found nearly half (47%) of their stroke patients had clinically significant depression. Other investigators. however. have found lower rates of depression. 16.17 Prior investigators agree that poststroke depression is most frequent in the acute poststroke phase while the patient is in the hospital (i.e.• the first weeks after stroke).2.6 Over the next 6 months after stroke. the rate of depression decreases slightly in some studies6 but up to 20% in others. 2 The rates of poststroke Received May 21. 1991; revised August 19. 1991; accepted September 4. 1991. From the School of Medicine. Case Western Reserve Universily and MetroHealth Medical and Rehabilitation Cenler. Cleveland. OH. Address reprint requests to Dr. Schubert. Department of Psychiatry. MetroHealth Medical Center. 3395 Scranton Road. Cleveland. OH 44109. Copyright © 1992 The Academy of Psychosomatic Medicine. 290
depression at different times vary with the criteria used for defining depression. nature of the sample. etc. 2•6 Because significant depression has been found in stroke patients. depression should be detected by the nonpsychiatric physician. Several studies have found that nonpsychiatric physicians underdiagnose depression. Depression was undetected by nonpsychiatric physicians in 70%-80% of patients who were diagnosed as depressed by Research Diagnostic Criteria. 18-20 Depression in tum may be associated with decreased physical functioning. 21 Other studies of detection of depression are considered in greater detail in another article (Schubert DSP. unpublished observations). This literature (Schubert DSP. unpublished observations) suggests that depression will be underrecognized in evaluations of stroke patients by nonpsychiatrists. The aim of our study was to assess detection of depression in stroke patients by a nonpsychiatric rehabilitation team and to compare this with patients' self-reports and diagnoses by psychiatrists. PSYCHOSOMATICS
Schubert et al.
METHODS
RESULTS
Subjects were 15 patients ages 47-72 who were admitted to MetroHealth Medical and Rehabilitation Center for rehabilitation. All were transferred to a physical medicine and rehabilitation ward after acute treatment for stroke at other Cleveland area acute hospitals. All had CT evidence of a stroke. Subjects and setting are described further in a previous article. 21
Rating of Depression by Rehabilitation Team
Measures In addition to a psychiatric interview using DSM-III-R 22 for diagnosis, all subjects completed the Beck Depression Inventory (BDI)23.24 (see House et at. 25 and Dam et at. 26 for use of BDI in stroke patients) and the Mini-Mental State Exam. 27 DSM-III-R diagnoses were made using an unstructured interview. 22 Clinical interview reliability of DSM-III-R diagnoses has been described as "extremely good" by Hyler et at. 28 The psychiatrist (W.T.) who gave the unstructured interview was blind to BDI results.
Detection of Depression All admission and progress notes were examined by the physical medicine and rehabilitation physician authors (C.T., S.L., or A.M.) for the words "depressed" or "depression" to indicate depressed mood or diagnosis of depression. 29 All members of the rehabilitation team documented evaluations and progress in the progress notes. In addition, team meeting summary notes were written in the chart by a recorder. Neither the discharge summary nor old records from other admissions were included in this chart evaluation. The only notes not searched for in the chart evaluation were those of the psychiatric consultants. None of the nonpsychiatric team was interviewed about presence of depression in the patients. The psychiatrist was not present on rounds. VOLUME 33· NUMBER 3· SUMMER 1992
Chart evaluation revealed no notation of depression, possible depression, use of the term "depressed," or similar documentation by the rehabilitation team for any of the subjects during the index admission. As indicated above, notes by all members of the rehabilitation team were searched for notation of depression with the exception of the psychiatrists' notes. The authors (A.M., C.T., S.L.) who attended combined staff rounds recalled occasional discussion of possible depression, but these were never noted in the chart. The rehabilitation team seemed to have evaluated these discussed depressions as normal, transient parts of the poststroke syndrome. Psychiatric Evaluation of Depression and Comparison With Rehabilitation Team As indicated above, the psychiatrists used the standard psychiatric diagnostic criteria of DSM-III-R 22 for diagnosis. Thirteen of the subjects received psychiatric diagnoses with some form of depression. Of these, eight received a diagnosis of adjustment disorder with depressed mood and five received a diagnosis of major depression. The total rate of psychiatrist-diagnosed depression was 68% (13/19) with major depression accounting for 26% and adjustment disorder with depressed mood accounting for 42%. (Percents are all rounded to the nearest percentage.) This total rate (68%) of psychiatrist-diagnosed depression was significantly higher than the rate of 0% diagnosed by the rehabilitation team excluding the psychiatrist (X 2 = 16.5, df= I, P
The literature sURRests the hypothesis that nonpsychiatrists will underrecoRnize depression in el'Oluations ofstroke patients. On a medical rehabilitation ward. 15 stroke patients were naluatedfor depression by psychiatric interview and self-report. Charts were examinedfor detection of depression by the rehabilitation team. The hypothesis was supported: in contrast to psychiatric interview (68% depressed) and self-report (Beck Depression Inventory. 50% depressed). none of the patients were described as depressed in chart notes by the rehahilitationteam (excludinR the psychiatrists). Psychiatrists should develop ongoing interactions with primary care physicians 10 improve detection of poststroke depression and other depressions on medical wards.
P
oststroke depression has been well documented by Robinson and colleagues (see reviews by Robinson and Starkstein)1.2 and other investigators. J - 14 Robinson and Price l5 found about one-third of their stroke patients were depressed. whereas Sinyor et al. 12 found nearly half (47%) of their stroke patients had clinically significant depression. Other investigators. however. have found lower rates of depression. 16.17 Prior investigators agree that poststroke depression is most frequent in the acute poststroke phase while the patient is in the hospital (i.e.• the first weeks after stroke).2.6 Over the next 6 months after stroke. the rate of depression decreases slightly in some studies6 but up to 20% in others. 2 The rates of poststroke Received May 21. 1991; revised August 19. 1991; accepted September 4. 1991. From the School of Medicine. Case Western Reserve Universily and MetroHealth Medical and Rehabilitation Cenler. Cleveland. OH. Address reprint requests to Dr. Schubert. Department of Psychiatry. MetroHealth Medical Center. 3395 Scranton Road. Cleveland. OH 44109. Copyright © 1992 The Academy of Psychosomatic Medicine. 290
depression at different times vary with the criteria used for defining depression. nature of the sample. etc. 2•6 Because significant depression has been found in stroke patients. depression should be detected by the nonpsychiatric physician. Several studies have found that nonpsychiatric physicians underdiagnose depression. Depression was undetected by nonpsychiatric physicians in 70%-80% of patients who were diagnosed as depressed by Research Diagnostic Criteria. 18-20 Depression in tum may be associated with decreased physical functioning. 21 Other studies of detection of depression are considered in greater detail in another article (Schubert DSP. unpublished observations). This literature (Schubert DSP. unpublished observations) suggests that depression will be underrecognized in evaluations of stroke patients by nonpsychiatrists. The aim of our study was to assess detection of depression in stroke patients by a nonpsychiatric rehabilitation team and to compare this with patients' self-reports and diagnoses by psychiatrists. PSYCHOSOMATICS
Schubert et al.
METHODS
RESULTS
Subjects were 15 patients ages 47-72 who were admitted to MetroHealth Medical and Rehabilitation Center for rehabilitation. All were transferred to a physical medicine and rehabilitation ward after acute treatment for stroke at other Cleveland area acute hospitals. All had CT evidence of a stroke. Subjects and setting are described further in a previous article. 21
Rating of Depression by Rehabilitation Team
Measures In addition to a psychiatric interview using DSM-III-R 22 for diagnosis, all subjects completed the Beck Depression Inventory (BDI)23.24 (see House et at. 25 and Dam et at. 26 for use of BDI in stroke patients) and the Mini-Mental State Exam. 27 DSM-III-R diagnoses were made using an unstructured interview. 22 Clinical interview reliability of DSM-III-R diagnoses has been described as "extremely good" by Hyler et at. 28 The psychiatrist (W.T.) who gave the unstructured interview was blind to BDI results.
Detection of Depression All admission and progress notes were examined by the physical medicine and rehabilitation physician authors (C.T., S.L., or A.M.) for the words "depressed" or "depression" to indicate depressed mood or diagnosis of depression. 29 All members of the rehabilitation team documented evaluations and progress in the progress notes. In addition, team meeting summary notes were written in the chart by a recorder. Neither the discharge summary nor old records from other admissions were included in this chart evaluation. The only notes not searched for in the chart evaluation were those of the psychiatric consultants. None of the nonpsychiatric team was interviewed about presence of depression in the patients. The psychiatrist was not present on rounds. VOLUME 33· NUMBER 3· SUMMER 1992
Chart evaluation revealed no notation of depression, possible depression, use of the term "depressed," or similar documentation by the rehabilitation team for any of the subjects during the index admission. As indicated above, notes by all members of the rehabilitation team were searched for notation of depression with the exception of the psychiatrists' notes. The authors (A.M., C.T., S.L.) who attended combined staff rounds recalled occasional discussion of possible depression, but these were never noted in the chart. The rehabilitation team seemed to have evaluated these discussed depressions as normal, transient parts of the poststroke syndrome. Psychiatric Evaluation of Depression and Comparison With Rehabilitation Team As indicated above, the psychiatrists used the standard psychiatric diagnostic criteria of DSM-III-R 22 for diagnosis. Thirteen of the subjects received psychiatric diagnoses with some form of depression. Of these, eight received a diagnosis of adjustment disorder with depressed mood and five received a diagnosis of major depression. The total rate of psychiatrist-diagnosed depression was 68% (13/19) with major depression accounting for 26% and adjustment disorder with depressed mood accounting for 42%. (Percents are all rounded to the nearest percentage.) This total rate (68%) of psychiatrist-diagnosed depression was significantly higher than the rate of 0% diagnosed by the rehabilitation team excluding the psychiatrist (X 2 = 16.5, df= I, P
