Improving Psychological Care After Stroke

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Improving Psychological Care After Stroke

• Dr Steve Margison
• Consultant Clinical Neuropsychologist
• South Devon Healthcare NHS Foundation Trust

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Accelerated Stroke Improvement (ASI)
Joining Up Prevention
Implementing Best Practice in Acute Care
Improving Post Hospital and Long Term Care.
Domains

• Early Supported Discharge
• Joint Care Plans using Single Assessment Process
• 6/12 review
• Psychological Support

Key Areas of Focus

• Direct Admission to a Stroke Unit
• Timely Brain Scan
• (1 Hour and 24 Hour)

• AF Detection and Treatment
• Timely and effective management of TIA

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ASI 6 Timely Access to Psychological Support
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Psychological Services for Stroke Survivors and
their Families

• Key Recommendation
• Psychological Screening for both cognitive
  impairment and mood disorder should become
  routine within all hospitals admitting stroke
  patients
• Also provides recommendations on Service
  Specifications, structure and staffing

January 2010 Edition
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How do we know who to be concerned about?

• West et al (Stroke, 2010, 41, 1723-1727)
• Investigated trajectory of psychological symptoms
  and their impact on functional recovery.
• 444 patient assessed at 2-6 weeks, then followed
  up at 9, 13, 26 52 weeks.
• Used GHQ to look at psychological symptoms and
  modified Barthel Index for function.

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West et al (2010)

• Strong association between trajectory of
  psychological symptoms and functional outcome.
• Four classes or groups of patients identified
  based on GHQ.
• Groups show a gradual decrease in psychological
  distress over time.
• Cluster 37 scored above the WHO threshold for
  1st 3 months and continued to have problems.

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West et al (2010)

• Cluster 37 had more pre-morbid depression.
• Higher dep. lt-gt poorer Barthel scores but there
  was wide variation in this group.
• One high score does not predict poorer outcome
  but trajectory does seem to.
• Poorer functional outcome actually associated
  with
• Psychological symptoms
• More severe disability early on
• Age

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How to assess?

• Depression and distress are not the same.
• Measures of depression are similar in content -
  dont produce different results.
• Ask questions as well as doing questionnaires
  e.g. previous problems?
• It matters more that we ask and do something with
  the results.

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What should we do with patients who are
depressed? - On a Stroke Unit or Ward

• Keep relevant notes
• Watchful waiting
• Refer to mental health professional e.g.
  psychiatric liaison.
• Consider anti-depressant medication
• (Kneebone et al, British Journal of Occupational
  Therapy, February 2010)
• Pass on your concerns on discharge.

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What should we do with patients who are depressed?

• Stepped care suggests interventions based on need
  not one size fits all.
• Sub-threshold problems are everyones
  responsibility - all staff and peer support?
• Mild-moderate problems should be dealt with by
  designated staff - Stroke Ward, Rehab,
  Re-Ablement etc.
• Severe or persistent problems need to be managed
  by specialist services - Mental Health
  professionals.

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What should we do with patients who are depressed?

• Cochrane review
• Anti-depressants are most effective if used for
  people who are moderately to severely depressed
  (15).
• Cognitive behaviour therapy isnt useful.
• BUT there is significant criticism of the
  Cochrane review which points out that it was
  based on a study with poor protocols for doing
  CBT.
• In reality IAPT services will be important.

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What could we do in Stroke Services.

• Brief interventions that are strong on engagement
  and acceptability are important.
• Activity Scheduling
• Problem Solving
• Active Listening
• Motivational Interviewing?
• Staff need supervision and training.

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South Devon

• Devising a stepped care model.
• Engaging the stakeholders.
• Working with resources we have.
• Training as many staff as possible to be aware of
  psychological issues.
• Agreeing which assessment, when, by whom.
• Exploring referral pathways.

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Some things to remember.

• Not all psychological disorder post stroke arises
  from the stroke. At least half of all depression
  post-stroke arises from depression before stroke
  (Prof. Allan House, Liaison Psychiatrist).
• Mental and physical health needs should be of
  equal importance.
• Targeting interventions isnt possible without
  on-going monitoring.
• Do something to get started.