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 o o 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: • • • • 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 • • • • • 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... • Lander Z. (2009). A qualitative analysis of the phenomena stroke survivors associate with post-stroke anxiety. Leicester: D.Clin.Psy., University of Leicester. • 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.