Evidence based practice for post stroke depressive symptoms and/or anxiety symptoms: issues and interventions in an acute rehabilitation setting in Singapore

Abstract

Background: Post-stroke depression (PSD) and post stroke anxiety (PSA) are associated with poor recovery, increased disability and they are often underdiagnosed and/or undermanaged. Study aim: This study explored the evidence base relating to PSD and/or PSA psychosocial management in acute and post-acute rehabilitation from the perspective of existing literature, practitioners’ beliefs, influence on function, and a psychosocial intervention for acute patients with PSD and/or PSA. Methods: A five-study series was conducted: a scoping review of published literature on psychosocial management of PSD/PSA focussed on the acute/post-acute period (within six months post stroke); an audit of published stroke clinical practice guidelines (CPGs) to identify those with PSD/PSA information and what practice recommendations were (within six months post stroke); a cross sectional cohort study using in-patient report on PSD and PSA symptoms and observational measures on patients’ activities of daily living function (ADL) within two weeks of stroke; a cross sectional self-report survey with health professionals regarding their awareness and their self-reported practice of mood assessment with stroke survivors; and an evaluation of an occupational therapist designed intervention program for PSD and/or PSA which was conducted over a six month period using an existing data set from a randomised controlled trial. The cohort study, survey and intervention study were all conducted at Changi Hospital Singapore. Results: The scoping review revealed 36 papers presenting evidence about psychosocial management of PSD and/or PSA including assessments and intervention strategies. Problem-solving, and educational intervention approaches had the most evidence, and the Hospital 3 Anxiety Depression Scale was the most frequently used mood measure. The audit of CPGs revealed all 10 included information about psychosocial aspects of PSD but only five included information about PSA. Assessment and intervention recommendations in CPGs were brief and not specific. The observational cohort study revealed 28.4% and 39.6 % of N=134 patients met criteria for PSD and PSA respectively. Of these, self-reported pre-stroke level of exercise and PSD were the factors that accounted for most variance in ADL function. The survey of 394 health professionals revealed a majority thought PSD/PSA were common and this was associated with participant characteristics of being older age or having more work experience increasing this perception. Doctors were least and Occupational Therapists (OTs) most likely to ask mood related questions of stroke patients. The evaluation of an occupational therapy intervention delivered in addition to standard care found participants had significantly more improvement in mood outcomes and a superior recovery rate compared to patients in standard care. Conclusion: PSD/PSA was common in the patient sample. PSD/PSA levels are associated with ADL function. CPGs provide little guidance on screening or psychosocial intervention strategies that can be used. There is emerging evidence on assessment and intervention for PSA/PSD, with more on PSD. The most commonly used assessment is the HADS, and a variety of psychosocial intervention approaches are used including problem solving and patient education. Although there is awareness of PSA/PSD by health professionals, most do not ask mood related questions in their practice. Occupational therapists are most likely to do so. Emerging evidence exists to inform recommendations for PSD/PSA psychosocial assessments and intervention approaches, but more work is needed to translate research knowledge into practice and to investigate effectiveness of psychosocial interventions for these patients.