In the first two years after stroke approximately one-third of the patients suffer from depression, also referred to as post-stroke depression (PSD). Patients with PSD suffer from symptoms, such as a diminished interest or pleasure (anhedonia), depressed mood, sleep disturbances, loss of energy, changes in appetite, feelings of inappropriate guilt, concentration difficulties, psychomotor retardation or agitation, and suicidal thoughts. PSD aggravates the burden of physical, psychological and social disability after a stroke and hinders patient participation in rehabilitation, increasing the negative impact of associated impairments on recovery. However, despite the high prevalence, its impact on rehabilitation outcome and the current treatment options, post-stroke depression is not generally recognized in stroke patients. This poor recognition, along with a passive attitude of health care professionals towards therapy, leads to underdiagnosis and undertreatment of post-stroke depression. Therefore, the main aim of this thesis is to investigate proper strategies to early recognize patients at risk and to detect PSD in stroke patients, and to describe the role of nurses in PSD.
The first part of the thesis provides a review of the literature on the role of nurses in the daily care of depressed stroke patients with a focus on the early detection of PSD and therapeutic interventions that they can use. The findings of both studies showed that nurses distinguished a screening role from an intervening role. They recognized symptoms of depression, however, they experienced the assessment of psychological status as difficult because of a lack of knowledge, skills and training. Measurement scales supporting their observations were seldom used.
Furthermore the nature of post-stroke depression is investigated, addressing the question whether all nine symptoms of depression, irrespective of their somatic or psychological nature, should or should not be considered as a clinical manifestations of PSD. Comparing the symptom profile of depressed and non-depressed stroke patients, with depressed and non-depressed patients with symptomatic atherosclerotic diseases, and general practice patients demonstrated broadly similar symptom profiles in the three cohorts. However, the stroke patients suffered more severely from these symptoms than the patients with symptomatic atherosclerotic diseases or the patients in general practice. The findings show that PSD is not a different type of depression. This findings indicate that all depressive symptoms, including somatic symptoms, should taken into account when diagnosing depression in patients after stroke.
The main part of the thesis presents three studies focusing on the early detection of post-stroke depression in the daily care of stroke patients who were able to communicate adequately. First, the reliability, validity, and clinical utility of the nine-item and the two-item Patient Health Questionnaire (PHQ-9, PHQ-2) was investigated in daily nursing practice of hospitalized patients with stroke. These results suggest that the PHQ-9 and PHQ-2 are preferable instruments for the early detection of PSD in the daily care of stroke patients who are able to communicate adequately. Nurses judged the PHQ to be a brief and easy-to-use instrument in daily practice of nursing stroke care.
The timely detection of Post-Stroke Depression (PSD), however, is complicated by a decrease in the length of hospital stay, resulting in a large proportion of patients who are discharged within two weeks after stroke. This underscores the need to develop another strategy to detect PSD in the early stage after stroke. Therefore, the Post-Stroke Depression Prediction Scale (DePreS), which is a clinical prediction rule for the early identification of stroke patients at increased risk for PSD, was developed and validated. The DePreS enables clinicians to estimate the degree of the depression risk for an individual patient within the first week after stroke. The prediction could be used as the basis for a simple decision tree to guide a more selective screening process for PSD.
The challenge in the future will be to create a continuous process in which further research leads to ongoing development and testing of effective and efficient care for patients with stroke which may eventually decrease the burden of PSD and the negative impact on patients' recovery.