HHS Public Access Author manuscript Author Manuscript
Stroke. Author manuscript; available in PMC 2017 January 01. Published in final edited form as: Stroke. 2016 January ; 47(1): e1–e3. doi:10.1161/STROKEAHA.115.008362.
Nursing Assessment of Depression in Stroke Survivors Pamela H. Mitchell, PhD, RN
Keywords post-stroke depression; assessment; depression screening; nursing
Author Manuscript
Stroke is a leading cause of death and disability world-wide.1,2 Because depression is the second leading cause of disability in the world,3 stroke complicated by depression is doubly disabling. Thirty-one percent of stroke survivors are estimated to be clinically depressed (95% confidence interval 28–35%).4 Thus, at any given time between 28 and 35 percent of stroke survivors are likely to be living with depression. With an annual incidence of 795,000 new or recurrent strokes in the United States,1 we might expect 246,000 will be depressed.
Author Manuscript
Post-stroke depression (PSD) is associated with poorer recovery, reduced health related quality of life5 and with a higher risk of subsequent stroke and mortality.6, 7 We also know that many people hospitalized with stroke have not had their mood assessed by discharge.8 Because depression in chronic illness, including stroke, can be successfully treated, it becomes imperative that we assess for depression for all stroke survivors in our health systems. Indeed, this has become a standard for credentialing stroke care in Australia, the United Kingdom and the United States.8–12 Nurses are the health professionals most in contact with stroke survivors and their families during an acute episode, and are therefore key to assessing the presence of clinical depression. The purpose of this paper is to review the screening and diagnostic assessment tools available to health professionals, with emphasis on clinically feasible instruments that can be used by staff nurses.
Method
Author Manuscript
A literature search was conducted in MEDLINE with a secondary search in PsycINFO and CINAHL to ascertain any papers relevant to nursing missed by the MEDLINE search. The search terms included stroke and depression, post-stroke depression, assessment, measurement, diagnosis. Sub-collections of systematic reviews, diagnosis and nursing journals were followed until there were no new and relevant papers retrieved.
Corresponding Author University of Washington, Biobehavioral Nursing & Health Systems Box 356266, University of Washington, Seattle WA 98195-7266 Fax: 206-543-3624; Telephone 206-221-7674; [email protected].
Mitchell
Page 2
Author Manuscript
Definition of Clinical Depression in Stroke
Author Manuscript Author Manuscript
Screening instruments assess for depressive symptoms but are not designed to diagnose depression disorder without a confirming clinical interview. The gold standard for diagnosis of depression is a clinical interview ascertaining that the person meets the criteria for depression set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychiatric Association. The manual is now in its fifth iteration,13 but the criteria for symptoms to reach a diagnosis of depression are the same as earlier editions: persistent feelings of sadness or depressed mood, marked and persistent loss of pleasure in most activity, persistent feelings of worthlessness or excessive guilt, or frequent thoughts of death or suicide, frequent or recurrent thoughts of dying, or of suicide plus one or more of what are often called vegetative or psychomotor signs: increased or decreased sleep, increased or decreased motor activity, increased or decreased eating and weight gain or loss, difficulty in concentrating and thinking. Persistent means nearly every day, nearly all day for two weeks or more. Depressive disorder may be episodic or persistent. In fact, PSD may be, for some people, an exacerbation or recurrence of a previous episode of depression.4 The clinical interview by a trained mental health professional to confirm the diagnosis may include structured interviews such as the Structured Clinical Interview for Depression (SCID)14, or for people with medical conditions, the Depression Interview and Structured Hamilton (DISH).15 Screening tools include questions about all of the components listed above, scored either yes or no or with frequency (none to nearly all day). Most have a cut-off score that has been validated as correctly classifying those whose depressive symptoms are or are not confirmed by a diagnostic interview. The ideal screening tool does not mistake motor deficits caused by stroke for the `motor retardation' of depression, can be used with patients who may have some degree of abnormal speech and has high sensitivity (identifies all the depression that is confirmed with a diagnostic interview) and high specificity (does not include those without depression).
Screening Tools
Author Manuscript
For nearly 30 years nurses have been admonished to be alert for depression in people who have survived acute stroke.16–18 However, the plethora and length of various screening and diagnostic tools available has made it hard to know which instruments are both efficient and accurate in detecting depressive symptoms, particularly in the face of medical illness. More recently a variety of screening instruments used with stroke patients have been evaluated against each other and against the reference standard of clinical interview. Meta-analyses of these studies have provided concrete guidance for clinicians and researchers to use during either the acute or chronic phase of stroke.14, 19–29 Options for assessing depression in aphasic patients have also been validated.30, 31
Nursing Use of Tools Screening tools used most often in stroke nursing research and practice include the singleitem screen,32 the 30 or 15 item Geriatric Depression Scale,21 Montgomery-Asberg Depression Rating Scale (MADRS) 26 and the Patient Health Questionnaire (PHQ-2 and PHQ-9). 21, 22, 28
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 3
Author Manuscript
The single-item screen (do you often feel sad or depressed?) has been validated against the MADRS (a structured clinical interview) and found to have sensitivity and specificity greater than 80% as well as considerable ease of use by research psychology assistants and nurses. The investigators noted that patients do not need to be able to read, write or have normal speech to respond, thus potentially making this a good screen for stroke patients.32 These same investigators had earlier established that nurses trained to administer the MADRS attained a high degree of sensitivity and acceptable specificity, compared to psychiatrist diagnosis.26
Author Manuscript
Lee and colleagues propose a visual emoticon scale (the `Smiley') that can be used with patients who are aphasic or have a language barrier. Patients are asked how frequently they experienced a happy, sad or neutral `face' (emoticon) over the past week. The sad face had adequate sensitivity and specificity in comparison with the 15 item GDS. It had the advantage of rapidity of administration and ease with a low literature or aphasic group.31
Author Manuscript
The PHQ 2 item and 9 item versions are increasingly used in research and in primary care clinical practice.33, 34This tool is comprised of the first two or first nine items of the Brief Patient Health Questionnaire. 33, 35 Patients are asked “Over the last two weeks, how often have you been bothered by a) little interest or pleasure in doing things, b) feeling down, depressed, or hopeless” Responses are scored zero for not at all, 1 for several days, 2 for more than half the days and 3 for nearly every day. The PHQ-9 adds items about sleep, fatigue, appetite, feeling bad about self, concentration, slow movement and thoughts about death or hurting self. De Man-van Ginkel and colleagues recently tested staff nurse administration of both the 2 item and 9 item tools in stroke patients in acute care and in rehabilitation in the Netherlands, with the 15-item GDS as the reference test. Test-retest reliability, interrater reliability and sensitivity-specificity were excellent. They recommend this screening tool for clinical nursing use due to its ease of use, high reliability and validity. They also recommend training for nurses using this tool.21 The Joint Commission recommends that all stroke patients be screened for depression before discharge: the most likely tools to recommend would either be the single-item screen (do you often feel sad or depressed?) or the PHQ 2 (little interest or pleasure in doing things; feeling down depressed or hopeless). A yes answer to the single-item or a score of more than 2 for the PHQ-2 would indicate need for further evaluation by a social worker, psychosocial nurse practitioner or other mental health personnel as dictated by the hospital policy.
Author Manuscript
The PHQ-9 can also be recommended for stroke nurses' use with some training.18 Nurses using the full 9 item tool would need to know how to score the questionnaire, what referral sources are available for patients who score 5 or more and how to proceed with patients who have “thoughts that you would be better off dead or hurting yourself” on any occasion. All nurses should inquire of such patients if they have thought about how they might accomplish killing or hurting themselves (is there a plan?) and if they have the means to do so. If there is both a plan and means, there should be an immediate referral to mental health resources.36
Take-Away Points There are several short tools that are valid in screening for depression. Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 4
Nurses can successfully screen for depression in stroke survivors.
Author Manuscript
The PHQ 2 and PHQ 9 are easy to use and can rapidly identify those who should be referred on for further evaluation and treatment.
Acknowledgments Disclosures: Dr. Mitchell received grant support from the NIH relevant to this paper (R01 NR007755, Psychosocial-Behavioral Intervention in PSD) 1999–2015; she is also a member of the American Heart Association/American Stroke Association scientific statement writing group on Post-stroke depression. This paper is completely independent of that writing group.
References Author Manuscript Author Manuscript Author Manuscript
1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: A report from the American Heart Association. Circulation. 2015; 131:e29–322. [PubMed: 25520374] 2. Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, et al. The state of US health, 1990–2010: Burden of diseases, injuries, and risk factors. JAMA. 2013; 310:591–608. [PubMed: 23842577] 3. Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJ, et al. Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Med. 2013; 10:e1001547. [PubMed: 24223526] 4. Hackett ML, Pickles K. Part 1: Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014; 9:1017–1025. [PubMed: 25117911] 5. Zikic TR, Divjak I, Jovicevic M, Semnic M, Slankamenac P, Zarkov M, et al. The effect of post stroke depression on functional outcome and quality of life. Acta Clin Croat. 2014; 53:294–301. [PubMed: 25509239] 6. Robinson RG, Spalletta G. Poststroke depression: A review. Can J Psychiatry. 2010; 55:341–349. [PubMed: 20540828] 7. Kouwenhoven SE, Kirkevold M, Engedal K, Kim HS. Depression in acute stroke: Prevalence, dominant symptoms and associated factors. A systematic literature review. Disabil Rehabil. 2011; 33:539–556. [PubMed: 20690858] 8. Intercollegiate Stroke Working Party, Royal College of Physicians. National sentinel stroke audit 2010, round 7. Roya l College of Physicians; London: May. 2012 9. National Stroke Foundation. Clinical guidelines for stroke management 2010. National Health and Medical Research Council; Melbourne, Australia: Aug. 2010 10. NHS Improvement. Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders. National Health Service Improvement web site; http:// www.improvement.nhs.uk/stroke [accessed May 20, 2015] 11. NICE. Stroke quality standard, quality statement 9: Mood disturbance and cognitive impairments. NICE Guidance website; Jun. 2010 http://www.nice.org.uk/guidance/QS2/chapter/Qualitystatement-9-Mood-disturbance-and-cognitive-impairments [accessed May 20, 2015] 12. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, et al. Recommendations for comprehensive stroke centers: A consensus statement from the brain attack coalition. Stroke. 2005; 36:1597–1616. [PubMed: 15961715] 13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Association; Washington DC: 2013. 14. Pettersson, A.; Bostrom, KB.; Gustavsson, P.; Ekselius, L. [accessed May 29, 2015] Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review. Nord J Psychiatry. 2015. published online ahead of print March 5, 2015http:// informahealthcare.com/doi/abs/10.3109/08039488.2015.1008568
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 5
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
15. Freedland KE, Skala JA, Carney RM, Raczynski JM, Taylor CB, Mendes de Leon CF, et al. The depression interview and structured hamilton (DISH): Rationale, development, characteristics, and clinical validity. Psychosom Med. 2002; 64:897–905. [PubMed: 12461195] 16. Vogel CH. Assessment and approach to treatment in post-stroke depression. J Am Acad Nurse Pract. 1995; 7:493–497. [PubMed: 8695289] 17. Schneider MA, Schneider MD. Recognizing poststroke depression. Nursing. 2012; 42:60–63. [PubMed: 23172068] 18. Pfeil M, Gray R, Lindsay B. Depression and stroke: A common but often unrecognized combination. Br J Nurs. 2009; 18:365–369. [PubMed: 19329901] 19. Allen, J.; Annells, M. J Clin Nurs. Vol. 18. England: 2009. A literature review of the application of the geriatric depression scale, depression anxiety stress scales and post-traumatic stress disorder checklist to community nursing cohorts; p. 949-959. 20. Berg A, Lonnqvist J, Palomaki H, Kaste M. Assessment of depression after stroke: A comparison of different screening instruments. Stroke. 2009; 40:523–529. [PubMed: 19074478] 21. de Man-van Ginkel JM, Gooskens F, Schepers VP, Schuurmans MJ, Lindeman E, Hafsteinsdottir TB. Screening for poststroke depression using the patient health questionnaire. Nurs Res. 2012; 61:333–341. [PubMed: 22710475] 22. Turner A, Hambridge J, White J, Carter G, Clover K, Nelson L, et al. Depression screening in stroke: A comparison of alternative measures with the structured diagnostic interview for the diagnostic and statistical manual of mental disorders, fourth edition (major depressive episode) as criterion standard. Stroke. 2012; 43:1000–1005. [PubMed: 22363064] 23. Benaim C, Decavel P, Bentabet M, Froger J, Pelissier J, Perennou D. Sensitivity to change of two depression rating scales for stroke patients. Clin Rehabil. 2010; 24:251–257. [PubMed: 20097722] 24. Kang HJ, Stewart R, Kim JM, Jang JE, Kim SY, Bae KY, et al. Comparative validity of depression assessment scales for screening poststroke depression. J Affect Disord. 2013; 147:186–191. [PubMed: 23167974] 25. Lees R, Stott DJ, Quinn TJ, Broomfield NM. Feasibility and diagnostic accuracy of early mood screening to diagnose persisting clinical depression/anxiety disorder after stroke. Cerebrovasc Dis. 2014; 37:323–329. [PubMed: 24903316] 26. Lightbody CE, Baldwin R, Connolly M, Gibbon B, Jawaid N, Leathley M, et al. Can nurses help identify patients with depression following stroke? A pilot study using two methods of detection. J Adv Nurs. 2007; 57:505–512. [PubMed: 17284278] 27. Meader N, Mitchell AJ, Chew-Graham C, Goldberg D, Rizzo M, Bird V, et al. Case identification of depression in patients with chronic physical health problems: A diagnostic accuracy metaanalysis of 113 studies. Br J Gen Pract. 2011; 61:e808–820. [PubMed: 22137418] 28. Meader N, Moe-Byrne T, Llewellyn A, Mitchell AJ. Screening for poststroke major depression: A meta-analysis of diagnostic validity studies. J Neurol Neurosurg Psychiatry. 2014; 85:198–206. [PubMed: 23385849] 29. Williams LS, Brizendine EJ, Plue L, Bakas T, Tu W, Hendrie H, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke. 2005; 36:635–638. [PubMed: 15677576] 30. Cobley CS, Thomas SA, Lincoln NB, Walker MF. The assessment of low mood in stroke patients with aphasia: Reliability and validity of the 10-item hospital version of the stroke aphasic depression questionnaire (SADQH-10). Clin Rehabil. 2012; 26:372–381. [PubMed: 22023890] 31. Lee, AC.; Tang, SW.; Yu, GK.; Cheung, RT. Int j nurs stud. Vol. 45. England: 2008. The smiley as a simple screening tool for depression after stroke: A preliminary study; p. 1081-1089. 32. Watkins CL, Lightbody CE, Sutton CJ, Holcroft L, Jack CI, Dickinson HA, et al. Evaluation of a single-item screening tool for depression after stroke: A cohort study. Clin rehabil. 2007; 21:846– 852. [PubMed: 17875564] 33. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA. 1999; 282:1737–1744. [PubMed: 10568646] 34. Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41:1284–1292. [PubMed: 14583691]
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 6
Author Manuscript
35. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001; 16:606–613. [PubMed: 11556941] 36. Valente S. Assessing patients for suicidal risk. Nursing2010. 2010; 40:36–40.
Author Manuscript Author Manuscript Author Manuscript Stroke. Author manuscript; available in PMC 2017 January 01.
Stroke. Author manuscript; available in PMC 2017 January 01. Published in final edited form as: Stroke. 2016 January ; 47(1): e1–e3. doi:10.1161/STROKEAHA.115.008362.
Nursing Assessment of Depression in Stroke Survivors Pamela H. Mitchell, PhD, RN
Keywords post-stroke depression; assessment; depression screening; nursing
Author Manuscript
Stroke is a leading cause of death and disability world-wide.1,2 Because depression is the second leading cause of disability in the world,3 stroke complicated by depression is doubly disabling. Thirty-one percent of stroke survivors are estimated to be clinically depressed (95% confidence interval 28–35%).4 Thus, at any given time between 28 and 35 percent of stroke survivors are likely to be living with depression. With an annual incidence of 795,000 new or recurrent strokes in the United States,1 we might expect 246,000 will be depressed.
Author Manuscript
Post-stroke depression (PSD) is associated with poorer recovery, reduced health related quality of life5 and with a higher risk of subsequent stroke and mortality.6, 7 We also know that many people hospitalized with stroke have not had their mood assessed by discharge.8 Because depression in chronic illness, including stroke, can be successfully treated, it becomes imperative that we assess for depression for all stroke survivors in our health systems. Indeed, this has become a standard for credentialing stroke care in Australia, the United Kingdom and the United States.8–12 Nurses are the health professionals most in contact with stroke survivors and their families during an acute episode, and are therefore key to assessing the presence of clinical depression. The purpose of this paper is to review the screening and diagnostic assessment tools available to health professionals, with emphasis on clinically feasible instruments that can be used by staff nurses.
Method
Author Manuscript
A literature search was conducted in MEDLINE with a secondary search in PsycINFO and CINAHL to ascertain any papers relevant to nursing missed by the MEDLINE search. The search terms included stroke and depression, post-stroke depression, assessment, measurement, diagnosis. Sub-collections of systematic reviews, diagnosis and nursing journals were followed until there were no new and relevant papers retrieved.
Corresponding Author University of Washington, Biobehavioral Nursing & Health Systems Box 356266, University of Washington, Seattle WA 98195-7266 Fax: 206-543-3624; Telephone 206-221-7674; [email protected].
Mitchell
Page 2
Author Manuscript
Definition of Clinical Depression in Stroke
Author Manuscript Author Manuscript
Screening instruments assess for depressive symptoms but are not designed to diagnose depression disorder without a confirming clinical interview. The gold standard for diagnosis of depression is a clinical interview ascertaining that the person meets the criteria for depression set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychiatric Association. The manual is now in its fifth iteration,13 but the criteria for symptoms to reach a diagnosis of depression are the same as earlier editions: persistent feelings of sadness or depressed mood, marked and persistent loss of pleasure in most activity, persistent feelings of worthlessness or excessive guilt, or frequent thoughts of death or suicide, frequent or recurrent thoughts of dying, or of suicide plus one or more of what are often called vegetative or psychomotor signs: increased or decreased sleep, increased or decreased motor activity, increased or decreased eating and weight gain or loss, difficulty in concentrating and thinking. Persistent means nearly every day, nearly all day for two weeks or more. Depressive disorder may be episodic or persistent. In fact, PSD may be, for some people, an exacerbation or recurrence of a previous episode of depression.4 The clinical interview by a trained mental health professional to confirm the diagnosis may include structured interviews such as the Structured Clinical Interview for Depression (SCID)14, or for people with medical conditions, the Depression Interview and Structured Hamilton (DISH).15 Screening tools include questions about all of the components listed above, scored either yes or no or with frequency (none to nearly all day). Most have a cut-off score that has been validated as correctly classifying those whose depressive symptoms are or are not confirmed by a diagnostic interview. The ideal screening tool does not mistake motor deficits caused by stroke for the `motor retardation' of depression, can be used with patients who may have some degree of abnormal speech and has high sensitivity (identifies all the depression that is confirmed with a diagnostic interview) and high specificity (does not include those without depression).
Screening Tools
Author Manuscript
For nearly 30 years nurses have been admonished to be alert for depression in people who have survived acute stroke.16–18 However, the plethora and length of various screening and diagnostic tools available has made it hard to know which instruments are both efficient and accurate in detecting depressive symptoms, particularly in the face of medical illness. More recently a variety of screening instruments used with stroke patients have been evaluated against each other and against the reference standard of clinical interview. Meta-analyses of these studies have provided concrete guidance for clinicians and researchers to use during either the acute or chronic phase of stroke.14, 19–29 Options for assessing depression in aphasic patients have also been validated.30, 31
Nursing Use of Tools Screening tools used most often in stroke nursing research and practice include the singleitem screen,32 the 30 or 15 item Geriatric Depression Scale,21 Montgomery-Asberg Depression Rating Scale (MADRS) 26 and the Patient Health Questionnaire (PHQ-2 and PHQ-9). 21, 22, 28
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 3
Author Manuscript
The single-item screen (do you often feel sad or depressed?) has been validated against the MADRS (a structured clinical interview) and found to have sensitivity and specificity greater than 80% as well as considerable ease of use by research psychology assistants and nurses. The investigators noted that patients do not need to be able to read, write or have normal speech to respond, thus potentially making this a good screen for stroke patients.32 These same investigators had earlier established that nurses trained to administer the MADRS attained a high degree of sensitivity and acceptable specificity, compared to psychiatrist diagnosis.26
Author Manuscript
Lee and colleagues propose a visual emoticon scale (the `Smiley') that can be used with patients who are aphasic or have a language barrier. Patients are asked how frequently they experienced a happy, sad or neutral `face' (emoticon) over the past week. The sad face had adequate sensitivity and specificity in comparison with the 15 item GDS. It had the advantage of rapidity of administration and ease with a low literature or aphasic group.31
Author Manuscript
The PHQ 2 item and 9 item versions are increasingly used in research and in primary care clinical practice.33, 34This tool is comprised of the first two or first nine items of the Brief Patient Health Questionnaire. 33, 35 Patients are asked “Over the last two weeks, how often have you been bothered by a) little interest or pleasure in doing things, b) feeling down, depressed, or hopeless” Responses are scored zero for not at all, 1 for several days, 2 for more than half the days and 3 for nearly every day. The PHQ-9 adds items about sleep, fatigue, appetite, feeling bad about self, concentration, slow movement and thoughts about death or hurting self. De Man-van Ginkel and colleagues recently tested staff nurse administration of both the 2 item and 9 item tools in stroke patients in acute care and in rehabilitation in the Netherlands, with the 15-item GDS as the reference test. Test-retest reliability, interrater reliability and sensitivity-specificity were excellent. They recommend this screening tool for clinical nursing use due to its ease of use, high reliability and validity. They also recommend training for nurses using this tool.21 The Joint Commission recommends that all stroke patients be screened for depression before discharge: the most likely tools to recommend would either be the single-item screen (do you often feel sad or depressed?) or the PHQ 2 (little interest or pleasure in doing things; feeling down depressed or hopeless). A yes answer to the single-item or a score of more than 2 for the PHQ-2 would indicate need for further evaluation by a social worker, psychosocial nurse practitioner or other mental health personnel as dictated by the hospital policy.
Author Manuscript
The PHQ-9 can also be recommended for stroke nurses' use with some training.18 Nurses using the full 9 item tool would need to know how to score the questionnaire, what referral sources are available for patients who score 5 or more and how to proceed with patients who have “thoughts that you would be better off dead or hurting yourself” on any occasion. All nurses should inquire of such patients if they have thought about how they might accomplish killing or hurting themselves (is there a plan?) and if they have the means to do so. If there is both a plan and means, there should be an immediate referral to mental health resources.36
Take-Away Points There are several short tools that are valid in screening for depression. Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 4
Nurses can successfully screen for depression in stroke survivors.
Author Manuscript
The PHQ 2 and PHQ 9 are easy to use and can rapidly identify those who should be referred on for further evaluation and treatment.
Acknowledgments Disclosures: Dr. Mitchell received grant support from the NIH relevant to this paper (R01 NR007755, Psychosocial-Behavioral Intervention in PSD) 1999–2015; she is also a member of the American Heart Association/American Stroke Association scientific statement writing group on Post-stroke depression. This paper is completely independent of that writing group.
References Author Manuscript Author Manuscript Author Manuscript
1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: A report from the American Heart Association. Circulation. 2015; 131:e29–322. [PubMed: 25520374] 2. Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, et al. The state of US health, 1990–2010: Burden of diseases, injuries, and risk factors. JAMA. 2013; 310:591–608. [PubMed: 23842577] 3. Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJ, et al. Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Med. 2013; 10:e1001547. [PubMed: 24223526] 4. Hackett ML, Pickles K. Part 1: Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014; 9:1017–1025. [PubMed: 25117911] 5. Zikic TR, Divjak I, Jovicevic M, Semnic M, Slankamenac P, Zarkov M, et al. The effect of post stroke depression on functional outcome and quality of life. Acta Clin Croat. 2014; 53:294–301. [PubMed: 25509239] 6. Robinson RG, Spalletta G. Poststroke depression: A review. Can J Psychiatry. 2010; 55:341–349. [PubMed: 20540828] 7. Kouwenhoven SE, Kirkevold M, Engedal K, Kim HS. Depression in acute stroke: Prevalence, dominant symptoms and associated factors. A systematic literature review. Disabil Rehabil. 2011; 33:539–556. [PubMed: 20690858] 8. Intercollegiate Stroke Working Party, Royal College of Physicians. National sentinel stroke audit 2010, round 7. Roya l College of Physicians; London: May. 2012 9. National Stroke Foundation. Clinical guidelines for stroke management 2010. National Health and Medical Research Council; Melbourne, Australia: Aug. 2010 10. NHS Improvement. Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders. National Health Service Improvement web site; http:// www.improvement.nhs.uk/stroke [accessed May 20, 2015] 11. NICE. Stroke quality standard, quality statement 9: Mood disturbance and cognitive impairments. NICE Guidance website; Jun. 2010 http://www.nice.org.uk/guidance/QS2/chapter/Qualitystatement-9-Mood-disturbance-and-cognitive-impairments [accessed May 20, 2015] 12. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, et al. Recommendations for comprehensive stroke centers: A consensus statement from the brain attack coalition. Stroke. 2005; 36:1597–1616. [PubMed: 15961715] 13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Association; Washington DC: 2013. 14. Pettersson, A.; Bostrom, KB.; Gustavsson, P.; Ekselius, L. [accessed May 29, 2015] Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review. Nord J Psychiatry. 2015. published online ahead of print March 5, 2015http:// informahealthcare.com/doi/abs/10.3109/08039488.2015.1008568
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 5
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
15. Freedland KE, Skala JA, Carney RM, Raczynski JM, Taylor CB, Mendes de Leon CF, et al. The depression interview and structured hamilton (DISH): Rationale, development, characteristics, and clinical validity. Psychosom Med. 2002; 64:897–905. [PubMed: 12461195] 16. Vogel CH. Assessment and approach to treatment in post-stroke depression. J Am Acad Nurse Pract. 1995; 7:493–497. [PubMed: 8695289] 17. Schneider MA, Schneider MD. Recognizing poststroke depression. Nursing. 2012; 42:60–63. [PubMed: 23172068] 18. Pfeil M, Gray R, Lindsay B. Depression and stroke: A common but often unrecognized combination. Br J Nurs. 2009; 18:365–369. [PubMed: 19329901] 19. Allen, J.; Annells, M. J Clin Nurs. Vol. 18. England: 2009. A literature review of the application of the geriatric depression scale, depression anxiety stress scales and post-traumatic stress disorder checklist to community nursing cohorts; p. 949-959. 20. Berg A, Lonnqvist J, Palomaki H, Kaste M. Assessment of depression after stroke: A comparison of different screening instruments. Stroke. 2009; 40:523–529. [PubMed: 19074478] 21. de Man-van Ginkel JM, Gooskens F, Schepers VP, Schuurmans MJ, Lindeman E, Hafsteinsdottir TB. Screening for poststroke depression using the patient health questionnaire. Nurs Res. 2012; 61:333–341. [PubMed: 22710475] 22. Turner A, Hambridge J, White J, Carter G, Clover K, Nelson L, et al. Depression screening in stroke: A comparison of alternative measures with the structured diagnostic interview for the diagnostic and statistical manual of mental disorders, fourth edition (major depressive episode) as criterion standard. Stroke. 2012; 43:1000–1005. [PubMed: 22363064] 23. Benaim C, Decavel P, Bentabet M, Froger J, Pelissier J, Perennou D. Sensitivity to change of two depression rating scales for stroke patients. Clin Rehabil. 2010; 24:251–257. [PubMed: 20097722] 24. Kang HJ, Stewart R, Kim JM, Jang JE, Kim SY, Bae KY, et al. Comparative validity of depression assessment scales for screening poststroke depression. J Affect Disord. 2013; 147:186–191. [PubMed: 23167974] 25. Lees R, Stott DJ, Quinn TJ, Broomfield NM. Feasibility and diagnostic accuracy of early mood screening to diagnose persisting clinical depression/anxiety disorder after stroke. Cerebrovasc Dis. 2014; 37:323–329. [PubMed: 24903316] 26. Lightbody CE, Baldwin R, Connolly M, Gibbon B, Jawaid N, Leathley M, et al. Can nurses help identify patients with depression following stroke? A pilot study using two methods of detection. J Adv Nurs. 2007; 57:505–512. [PubMed: 17284278] 27. Meader N, Mitchell AJ, Chew-Graham C, Goldberg D, Rizzo M, Bird V, et al. Case identification of depression in patients with chronic physical health problems: A diagnostic accuracy metaanalysis of 113 studies. Br J Gen Pract. 2011; 61:e808–820. [PubMed: 22137418] 28. Meader N, Moe-Byrne T, Llewellyn A, Mitchell AJ. Screening for poststroke major depression: A meta-analysis of diagnostic validity studies. J Neurol Neurosurg Psychiatry. 2014; 85:198–206. [PubMed: 23385849] 29. Williams LS, Brizendine EJ, Plue L, Bakas T, Tu W, Hendrie H, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke. 2005; 36:635–638. [PubMed: 15677576] 30. Cobley CS, Thomas SA, Lincoln NB, Walker MF. The assessment of low mood in stroke patients with aphasia: Reliability and validity of the 10-item hospital version of the stroke aphasic depression questionnaire (SADQH-10). Clin Rehabil. 2012; 26:372–381. [PubMed: 22023890] 31. Lee, AC.; Tang, SW.; Yu, GK.; Cheung, RT. Int j nurs stud. Vol. 45. England: 2008. The smiley as a simple screening tool for depression after stroke: A preliminary study; p. 1081-1089. 32. Watkins CL, Lightbody CE, Sutton CJ, Holcroft L, Jack CI, Dickinson HA, et al. Evaluation of a single-item screening tool for depression after stroke: A cohort study. Clin rehabil. 2007; 21:846– 852. [PubMed: 17875564] 33. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA. 1999; 282:1737–1744. [PubMed: 10568646] 34. Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41:1284–1292. [PubMed: 14583691]
Stroke. Author manuscript; available in PMC 2017 January 01.
Mitchell
Page 6
Author Manuscript
35. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001; 16:606–613. [PubMed: 11556941] 36. Valente S. Assessing patients for suicidal risk. Nursing2010. 2010; 40:36–40.
Author Manuscript Author Manuscript Author Manuscript Stroke. Author manuscript; available in PMC 2017 January 01.
