Cerebrovascular accidents (CVAs), commonly known as strokes, are the fourth most common cause of death in the United States.1 Patients who survive stroke face many challenges. One significant challenge is trying to maintain mental stability and a positive outlook in the midst of a health crisis.
Incidence and Prevalence
Approximately one-third of stroke survivors experience depressive symptoms after the event.2 With more than 795,000 strokes occurring each year in the United States,1 the number of people experiencing post-stroke depression (PSD) is comparable to the population of a small city. As a neuroscience nurse specializing in stroke care, this means that one-third of the patients I care for on a daily basis could be experiencing despair and hopelessness that may go unnoticed. In my experience, mental illness and physical illness are so intertwined that treatment of one without the other makes for a harder, longer road to recovery.
Overlooked and undiagnosed PSD can potentially affect the patient and lead to significant healthcare resource utilization. Recent statistics disclose a stroke rehabilitation cost of more than $58 billion a year in the United States.3 With healthcare in the midst of many changes, ensuring the holistic health of stroke survivors should be at the core of treatment in order to decrease costs, ensure quality outcomes, decrease stroke-related morbidity and prevent re-hospitalization.
In a quest to better prepare patients and their families with the education necessary to physically and mentally recover after a stroke, I performed a literature search focusing on the prevalence of PSD and its associated risk factors, as well as any treatment methods to decrease the incidence of the disorder.
One study explored the incidence and determinants of PSD among Chinese patients at Bejing Tiantan Hospital.4 This quantitative study used screening to assess severity of symptoms, global cognition, degree of functional handicap and depressive ideation. The subjects were assessed immediately after their CVA/TIA, then again at 14 weeks and 3 months post-stroke. Results showed that 45 out of 165 patients (27.3%) displayed symptoms of PSD at 3 months after the event, and 21.2% of them were diagnosed with major depression according to World Health Organization criteria. The study also identified as independent risk factors female gender, marital status, depression history and degree of handicap at 14 days post-stroke.
A quantitative study conducted in the Netherlands5 explored the frequency of PSD and its associated risk factors. However, unlike the Chinese research, this study excluded patients with a depression diagnosis prior to their stroke. The researchers thought it could be a limitation to the study. Data were collected using standardized questionnaires and physical assessment of deficits, including the National Institutes of Health Stroke Scale. Results showed that PSD affected 13% of the total sample. When it was further broken down into TIA (10% PSD) and CVA (15% PSD) patients, the prevalence of PSD did not significantly differ between the two, suggesting that even a threat to a person’s health can lead to depression.
A study by neurological research nurses pulled data from 7,643 patients in Canada.6 The researchers included only subjects who had experienced a first stroke. They reviewed physical assessments and progress notes, as well as demographic, medical and hospitalization information. They determined that only 4.8% of patients had a clinical diagnosis of PSD. This low incidence, related to the study’s specific inclusion criteria of a psychiatry consultation and a prescribed antidepressant, suggests that PSD is likely underdiagnosed and unrecognized in the acute-care setting. Patients who were admitted to a stroke unit were more likely to receive treatment for depression.
A rehabilitation physician studied 51 patients over a 1-year period and looked at the prevalence of PSD and its relationship with disability.7 As determined by a psychiatrist, 35.29% of the subjects were diagnosed with PSD as defined by the ICD-9. Multiple risk factors were identified through the use of various assessment tools and standardized data collection. These included a higher degree of disability in cognition, balance, walking ability and ADL dependence. The diagnosis of PSD decreased as post-stroke duration increased to 2 years.
Another study identified depressive complications after stroke and their association with quality of life.8 Starting 72 hours after their initial stroke and continuing every 14 days for 6 months, 65 subjects received assessment tools measuring stroke impairment and quality of life. Depression was a significant determinant of quality of life up to 6 months after stroke, supporting the ongoing evidence of PSD and its lasting effects. Clinical predictors of poor quality of life were stroke severity at onset and a greater amount of co-morbidities, while sociodemographic factors improved quality of life. These included marital status and spousal support, highest educational attainment, older age and degree of social support.
Another study explored racial and ethnic disparities in PSD detection.9 This study collected data on 5,825 patients through the review of the VA national medical database and Medicare claims. Results showed that the prevalence of PSD was 39%, with major risk factors, including younger age, more comorbidities and a higher priority of VA care. Interestingly, the researchers found that race is a contributing determinant of PSD, using the subgroups of white, black, Hisupic and all others. The chance of non-Hisupic white veterans being diagnosed with PSD is 1.75 times that of the black subgroup, and 1.56 times that of all the other subgroups, suggesting that the white subgroup is at the highest risk for stroke.
SEE ALSO: Earn CE: Neurologic
A study of treatment methods for PSD evaluated the effectiveness of an integrated care model.10 The researchers created a control group who received standard stroke discharge education and follow-up with their primary care provider at 2 weeks and 12 months post-stroke, and an integrated care (IC) treatment group. The IC group received further education on modifiable risk factors, as well as aid in the appointment of a health accountability partner before leaving the hospital. Their outpatient care was managed by a study coordinator and included appointments with the patient’s PCP at 2 weeks, 3 months, 6 months and 12 months post-stroke. In addition, a week before and after each appointment, the coordinator made a follow-up phone call to assess changes in care and the subject’s degree of depression. At the end of 12 months, 44% of the total sample was diagnosed with PSD. Results showed a significant decrease in PSD incidence for subjects receiving integrated care (33%) as compared to the control subgroup (55%). A higher degree of disability and more severe stroke were the highest risk factors for PSD.
Many risk factors for PSD have been identified, most of which relate to the degree of disability experienced. As patients begin to heal and accept their diagnosis and residual symptoms, close follow-up and early intervention are essential. It is imperative for nurses to recognize and educate patients and their support systems about PSD, a diagnosis that threatens the independence of the patient and can in turn prolong hospital stays, impair quality of life and increase mortality.4
In my institution, we have refined a stroke program that stretches from public education through acute and post-acute care, ensuring a multidisciplinary approach. This continuum of care has improved the patient experience in our community. It has been my goal to highlight the prevalence of PSD and integrate patient and family education into our piece of the continuum, the acute care setting. From posters and bulletin boards to unit- and hospital-wide presentations, I continue to work on my goal of improving outcomes and ensuring the holistic health of all my patients.
1. American Stroke Association. Impact of Stroke. Stroke statistics. http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp
2. Hackett ML, et al. Frequency of depression after stroke: A systematic review of observational studies. Stroke. 2005;36(6):1330-1340.
3. Fralick-Ball S. Post-Stroke depression: early assessment and interventions can promote optimal recovery. ADVANCE for Nurses. 2010;7(2):16-20.
4. Zhang T, et al. A prospective cohort study of the incidence and determinants of post-stroke depression among the mainland Chinese patients. Neurol Research. 2010;32(4):347-352.
5. Snaphaan L, et al. Post-stroke depressive symptoms are associated with post-stroke characteristics. Cerebrovasc Dis. 2009;28(6):551-557.
6. Herrmann N, et al. Detection and treatment of post stroke depression: results from the registry of the Canadian stroke network. Int J Geriatr Psychiatry. 2011;26(11):1195-1200.
7. Srivastava A, et al. Post-stroke depression: prevalence and relationship with disability in chronic stroke survivors. Ann Indian Acad Neurol. 2010;13(2):123-127.
8. Gbiri CA, et al. Prevalence, pattern and impact of depression on quality of life of stroke survivors. Int J Psychiatry Clin Pract. 2010;14(3):198-203.
9. Jia H, et al. Racial and ethnic disparities in post-stroke depression detection. Int J Geriatric Psychiatry. 2010;25(3):298-304.
10. Joubert J, et al. The positive effect of integrated care on depressive symptoms in stroke survivors. Cerebrovascular Dis. 2008;26(2):199-205.
Brittany Cherry is a nurse at Lancaster General Hospital in Lancaster, Pa.