Download Improving Psychological Care After Stroke

Improving Psychological Care
After Stroke
Dr Steve Margison
Consultant Clinical
Neuropsychologist
South Devon Healthcare NHS
Foundation Trust
Accelerated Stroke Improvement
(ASI)
Domains
Joining Up
Prevention
Key Areas of
Focus
 AF Detection
and Treatment
 Timely and
effective
management
of TIA
Implementing
Best Practice
in Acute Care
 Direct
Admission to
a Stroke Unit
 Timely Brain
Scan
(1 Hour and
24 Hour)
Improving Post
Hospital and
Long Term Care.
 Early Supported
Discharge
 Joint Care Plans
using Single
Assessment
Process
 6/12 review
 Psychological
Support
ASI 6 – Timely Access to
Psychological Support
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
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.
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.
West et al (2010)
 “Cluster 37” had more pre-morbid depression.
 Higher dep. <-> 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
How to assess?
 Depression and distress are not the same.
 Measures of depression are similar in content
- don’t 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.
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.
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 everyone’s
responsibility - all staff and peer support?
 Mild-moderate problems should be dealt with
by designated staff - Stroke Ward, Rehab, ReAblement etc.
 Severe or persistent problems need to be
managed by specialist services - Mental
Health professionals.
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 isn’t 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.
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.
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.
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 isn’t possible without
on-going monitoring.
 Do something to get started.