Transcript Slide 1

Depression among Community Living
Stroke Survivors Using Home Care
Services
Maureen Markle-Reid, Gina Browne, Camille Orridge,
Stacey Daub, Mary Lewis, Robin Weir, Jacqueline Roberts,
Lehana Thabane, Amiram Gafni
11th Annual Stroke Collaborative
October 20th, 2008
Toronto, Ontario
THE PROBLEM OF DEPRESSION
AFTER STROKE
• Depression is common among stroke survivors and is
associated with poor health outcomes and increased
cost;
• Despite the potential benefit associated with the
identification and treatment of post-stroke depression, it
often remains unrecognized and untreated;
• Untreated depression is associated with slower recovery,
lower quality of life, increased mortality, increased use of
health services and early institutionalization;
• Recognition, prevention and treatment of post-stroke
depression are critical to achieving optimal patient
outcomes after stroke.
2
OUTLINE
•
•
•
Background
Research Questions
Methods
– Design, setting and participants
– Study variables
•
Results
– Recruitment/participants
– Characteristics of community living stroke survivors using
home care services
– Prevalence of depression
– Risk factors and costs of depression
•
•
•
Summary
Implications
Conclusions
3
THE PROBLEM OF STROKE: THE FACTS
• Stroke is the third leading cause of mortality in
Canada and is the most common disabling
chronic condition;
• 40,000 to 50,000 people in Canada experience
a stroke each year, and 80% of these people
survive;
• 60% of stroke survivors are left with permanent
disability, and 12% to 25% will have another
stroke within the first year;
• 50% of people with strokes have other chronic
conditions.
4
THE PROBLEM OF DEPRESSION AFTER
STROKE: THE FACTS
• Post-stroke depression occurs in 30-50% of all
stroke survivors in the year following stroke;
• Period of greatest risk is within the first few
months of onset;
• Depression can be caused by biochemical
changes in the brain caused by the stroke or a
normal psychological reaction to the losses from
stroke;
• High incidence of relapse.
5
ONSET AND DURATION OF
POST-STROKE DEPRESSION
• Post-stroke depression is long-lasting: 50-60%
of those depressed in first month post-stroke are
still depressed at 1 year;
• Average duration is 9-12 months; may last up to
3 years;
• Delayed onset: between 3 months and 2 years;
about 30% who were not initially depressed
become depressed.
6
THE PROBLEM OF DEPRESSION AMONG STROKE
SURVIVORS USING HOME CARE SERVICES
• Increasing demand for home care services;
• Only 20% of stroke survivors require institutionalization
and most (up to 80%) eventually return to their homes;
• Average of 20% of stroke survivors are referred to CCAC
services following acute hospitalization or inpatient
rehabilitation;
• Stroke is one of the top three reasons for admission to
the Toronto Central Community Care Access Centre
(CCAC);
• Of seniors with a stroke, 35% received home care, as
opposed to 9% of non-stroke survivors.
7
THE PROBLEM OF DEPRESSION AMONG STROKE
SURVIVORS RECEIVING HOME CARE SERVICES
• Stroke survivors receiving home care services
are at high risk for depression compared to
general community living stroke survivors;
• Multiple risk factors:
Lower functional ability and related quality of life
> 65 years of age
Reduced life satisfaction
Poor social support
Higher prevalence of cognitive impairment
8
WHY IS THIS RELEVANT?
• Depression is an important complication of
stroke that may impede rehabilitation, recovery,
quality of life, and caregiver health;
• Stroke-associated depression may reduce
survival and increase the risk of recurrent stroke;
• Depression among older people, in general, is
associated with poor functional outcomes and
dependency, diminished quality of life, mortality,
higher use of drugs and alcohol, increased use
of healthcare resources, and poor compliance
with treatment of co-morbid health conditions.
9
WHY IS THIS RELEVANT?
• In 1998, depression cost Canadians
approximately $14.4 billion dollars per
year
• These costs are compounded by indirect
costs to unpaid caregivers and society
related to providing informal care
10
RELATED WORK
• Most studies are based on surveys of the
general population of community living seniors
or general home care population;
• Studies exclude people with cognitive
impairment or other co-morbid health conditions;
• Little is known about the prevalence of
depression among community living stroke
survivors using home care services or the risk
factors for depression;
• Little information on the characteristics of stroke
survivors using home care services.
11
MOOD DISTURBANCES
ANXIETY
Generalized Anxiety Disorder
DEPRESSIVE
Panic Disorder
Major Depressive Disorder
Dysthymia
Cyclothymia
Manic Depression
PHOBIAS
Simple Phobia
Social Phobia
SUBSTANCE ABUSE
Agoraphobia
Alcohol
Drugs
12
What is DEPRESSION???
DEPRESSION IS A SERIOUS ILLNESS
--A Bio-Chemical Imbalance
13
BEHAVIOURS ASSOCIATED WITH
DEPRESSION
•Sadness
•Feelings of worthlessness
•Frequent crying
•Negative outlook
•Withdrawal
•Over sensitive
•Difficulty
concentrating
•Feelings of
hopelessness
•Difficulty making
decisions
•Recurrent thoughts of
death or suicide
•Difficulty sleeping
•Weight loss or weight
gain (10lbs either way)
•Lack of energy
14
DSM IV SYMPTOMS OF DEPRESSION
Depressed,
…most of the day
Irritable,
…more days than not
Volatile Mood,
…greater than 2 weeks + 5 symptoms = Major
Depression
Worry and/
…greater than 2 years + 2 symptoms = Dysthymia
or Anxiety
a)
Over/under eating
b)
Over/under sleeping
c)
Fatigue, tiredness
d)
Low self-esteem
e)
Poor concentration/decisionmaking
f)
Hopelessness/pessimism
g)
Guilt, brooding and worry
15
DISTINGUISHING FEATURES
…WEIGHING THE EVIDENCE
Emotional Response
Versus
Mood disturbance
•Feeling is Specific to Situation
•Generalized
•Focused Object of  Feelings
(one person/event)
•Everyone (thing) (variety of
people/events)
•Appropriate/Timely
•Excessive/Unwarranted
•Short Duration (days/weeks)
•Long Duration (months/years)
•Definite Onset
•Insidious Onset (“I don’t
know”)
16
TREATMENT FOR POST-STROKE
DEPRESSION
• Depression in stroke survivors should not be
regarded as inevitable or untreatable;
• Prognosis is good with early identification and
treatment;
• 80-90% of depressive disorder can be treated;
• Reducing just one depression-related risk factor
can reduce the frequency and morbidity of
depression.
17
RESEARCH QUESTIONS
1. What are the characteristics of stroke survivors
referred to CCAC services?
2. What is the prevalence of depression in
community living stroke survivors using home
care services?
3. What are the risk factors for depression in
community living stroke survivors using home
care services?
4. What is the 6-month cost of use of health
services for depressed community living stroke
survivors using home care services?
18
DEFINITIONS
•
Prevalence of depression is the measure of the
proportion of stroke survivors with depression at
baseline:
– Depressive symptoms: CES-D > 21
– Taking antidepressant medication
•
Prevalence of recognized depression: whether a
stroke survivor identified as depressed is receiving any
treatment (taking an antidepressant medication)
•
Prevalence of adequately treated depression:
whether a stroke survivor identified as depressed is
displaying depressive symptoms: CES-D > 21
19
METHODS
•
Design: Cross-sectional survey using baseline data from a
randomized controlled trial on the effects and costs of an
interdisciplinary team approach to stroke rehabilitation for
community living stroke survivors
•
Setting: Toronto Central CCAC
•
Participants:





•
Confirmed diagnosis of stroke
Up to 18 months post-stroke
Eligible for home care services through the Toronto Central CCAC
Able to speak and understand English or an appropriate translator
is available
Living at home in the community in the Toronto Central CCAC
catchment area
Study Period: October 2005 – September 2008
20
STUDY VARIABLES
Data Sources: In-home interview, CCAC data, RAI-HC
Dependent Variable: Presence of depressive symptoms (CES-D > 21)
Independent Variables (known risk factors for depression):
Physical
Female gender
Cognitive impairment
Prior stroke
0-6 months post-stroke
Medical co-morbidities
Functional impairment
Increased age
Use of prescription
medications
Recent hospital stay
Psychosocial
History of depression
Living alone
Poor social support
Family caregiver with
depression
Widowed, divorced or
separated
Low income
6-Month Cost of Use of Health Services
21
RESULTS
Assessed for Eligibility:
Referred to CCAC with a Stroke Diagnosis
(n = 655)
Excluded (n=554):
Did not meet inclusion criteria (n = 308)
Refused to participate (n = 153)
Deceased (n = 3)
Unable to contact (n = 90)
Baseline
Measures
Randomized
(n = 101)
Allocated to Intervention Group
(n = 52)
Allocated to Control Group
(n = 49)
22
CHARACTERISTICS OF COMMUNITY LIVING STROKE
SURVIVORS USING HOME CARE SERVICES (N = 101)
•
75% had their first-ever stroke
•
70% were within their first six months post-stroke
•
73% with a hospital admission within the last 6
months: 47% in-patient rehabilitation; 26% acute
care hospital,
•
53% had one or more risk factors for stroke: 44%
hypertension; 19% hypercholesterolemia; 15%
diabetes; 5% smoking, obesity, alcohol
•
Average age was 74 years
•
54% were male
•
35% had four or more chronic health problems
23
CHARACTERISTICS OF COMMUNITY LIVING STROKE
SURVIVORS USING HOME CARE SERVICES (N = 101)
•
Taking an average of 6 prescription
medications daily
•
70% had physical discomfort, limiting bathing
and dressing
•
74% had physical or emotional problems
limiting socialization
•
20% were cognitively impaired
•
77% reported unsteadiness on their feet
•
40% lived alone
•
18% had a family caregiver with depression
24
PERCENTAGE OF STROKE SURVIVORS WITH
DEPRESSION (0-18 MONTHS POST-STROKE)
(n=101)
100%
90%
80%
57.4%
70%
60%
50%
38.0%
n=58
40%
30%
n=38
20%
20.0%
n=20
10%
0%
CES-D ≥ 21
Antidepressant Use
TOTAL
25
PREVALENCE OF DEPRESSION AMONG
STROKE SURVIVORS BY SUBGROUP
Population Rates
Primary Care
20-25%
25-30%
Secondary Care 35%
Hospital
50%
Home Care 57%
26
PERCENTAGE OF STROKE SURVIVORS WITH
DEPRESSIVE SYMPTOMS (CES-D > 21) BY NUMBER
OF MONTHS POST-STROKE (n=101)
100%
90%
Percentage (%)
with Depression
80%
70%
60%
50%
40%
30%
37%
n=71
39%
n=18
42%
n=12
20%
10%
0%
0 - 6 months
7 - 12 months
> 12 months
Num ber of Months Post-Stroke
27
PERCENTAGE OF DEPRESSION DETECTED AND TREATED
(n=101)
100%
Non-Depressed
n=43
Percent
57%
Depression Not Detected
and Not Treated
(n = 20)
Depression Detected but
Inadequately Treated
(n = 18)
0%
Depressed
n=58
Depression Detected and
Adequately Treated
(n = 20)
28
PERCENTAGE OF DEPRESSION DETECTED AND
TREATED IN STROKE SURVIVORS WITH
DEPRESSION (n=58)
100%
35%
Depression Not Detected
and not Treated
(n = 20)
31%
Depression Detected but
not Adequately Treated
(n = 18)
Percent
35%
0%
Depression Detected and
Adequately Treated
(n = 20)
29
PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE
SYMPTOMS (CES-D > 21) USING ANTIDEPRESSANTS BY
NUMBER OF MONTHS POST-STROKE (n=38)
100%
80%
90%
80%
70%
Percentage (%)
Taking
Antidepressants
50%
60%
50%
40%
30%
20%
14%
N=4
n=13
10%
n=1
0%
0-6 Months
7-12 Months
>12
Number of Months Post-Stroke
30
DEPRESSION RISK FACTORS (n = 101)
PROPORTION
OR
First-ever stroke
84.2%
2.3
Taking > 4 prescription
meds
97.3%
8.5
Family caregiver with
depression
23.7%
5.1
Physical discomfort
limiting bathing or
dressing
89.5%
7.3
Physical or emotional
problems limiting social
activities
97.3%
4.6
FACTORS
31
6-MONTH PER PERSON COST OF USE OF HEALTH
SERVICES FOR STROKE SURVIVORS WITH AND
WITHOUT DEPRESSION
$50,000
$48,875
$45,000
$41,885
$40,000
Dollars
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
Depressed
(CES-D ≥ 21)
Non-Depressed
(CES-D < 21)
32
SUMMARY
•
Depression is highly prevalent among community
living stroke survivors using home care services in
the first 1½ years following stroke;
•
Only 35% of depression was recognized and
adequately treated;
•
Rate of depressive symptoms increases in the 18
months after stroke;
Antidepressant use among those with depressive
symptoms varies from 14%-80% in the first 1½ years
following stroke;
Depression is associated with first-ever stroke; poor
health, low social support; higher use of prescription
medications; having a family caregiver with
depression; and increased cost of use of health
services.
33
•
•
MYTHS
 Depression is a character flaw
Depressed people can just snap out of it if
they want to
Asking a depressed person about suicidal
thoughts is dangerous
34
BARRIERS TO DETECTION AND TREATMENT
1. Individual doesn’t realize they
are depressed
2. Health care practioner doesn’t
recognize or diagnose
depression
3. Stigmas associated with having
depression
4. Concerns that medication or
treatment will alter personality or
cause other side effects
35
ASSESSING POST-STROKE DEPRESSION:
UNDERDIAGNOSIS
• Overlap with stroke symptoms;
• Under-reporting of symptoms due to stigma;
• Assumed to be a normal sign of aging;
• Assumed to be a normal reaction to losses;
• Difficult to assess in patients with severe language and
memory impairments and those lacking insight;
• Inadequate training of health professionals.
36
BARRIERS TO DETECTION AND TREATMENT
IN HOME CARE ARE MULTIFACTORIAL:
•
Eligibility for home care is determined primarily by
physical needs;
•
Access to professional services is limited;
•
Use of standardized, evidence-based approach for
screening, assessment and management;
•
Limited communication and collaboration between
home care providers;
•
Short-term follow-up and support;
•
Little information on the best way to provide home care
services for prevention and management of
depression
37
IMPLICATIONS: WHAT CAN BE DONE?
Home care occupies a strategic position in the identification
and treatment of depression among stroke survivors
Key Components:
• Assessment and screening
• Referral for treatment
• Ongoing monitoring and support
38
RECOGNIZING DEPRESSIVE SYMPTOMS
Kessler-10 Screening Scale for Depressive Symptoms and Anxiety
During the past 30 days, about how often did you feel…
a.
tired out for no good reason?
b.
nervous?
c.
so nervous that nothing could calm you down?
d.
hopeless?
e.
restless or fidgety?
f.
so restless that you could not sit still?
g.
depressed?
h.
that everything was an effort?
i.
so sad that nothing could cheer you up?
j.
worthless?
A score of 16-29/50 indicates medium risk for anxiety and depression;
30-50/50 indicates high risk for anxiety and depression.
39
With Dr. _____________________________
Re Patient: ___________________________
DOB: _______________________________
I have had the pleasure of meeting your patient
.
During one of our conversations,
displayed some of the
following symptoms and behaviours:















Sadness
Irritability
Poor self esteem
Feels misunderstood, victimized, picked on
Worry
Guilt
Anger
Trouble concentrating
Trouble focusing
Disorganized
Indecisive, procrastinates
Trouble sleeping
Over/under eating
Weight gain/loss
Substance use
More days than not 
More of the day than not 
For the past ________________ week/months/years
Your review of this situation and consideration of medication will be
most appreciated. I will continue my visits with
and
support them in the following areas.
___________________
___________________
___________________
Sincerely,
40
TREATMENTS
ANTIDEPRESSANTS
•SSRI’s (Prozac, Zoloft,
Paxil, Luvox)
+
COUNSELING
•Interpersonal
Therapy (IPT)
=
•Tricyclics
•Cognitive Behavioral
•MAO’s
•Marital
MOST
EFFECTIVE
TREATMENT
•Herbal remedies i.e., St.
John’s Wort
41
MOST EFFECTIVE INTERVENTIONS ARE:
PROACTIVE
INTENSIVE
TARGET HIGH RISK
COMPREHENSIVE – MULTIFACETED
EVIDENCE-BASED
COORDINATED – INTERDISCIPLINARY
COLLABORATION
42
ONGOING MONITORING AND SUPPORT
• Structured and planned contacts
• Regular follow-up to address risk factors, assess
clinical outcomes and adherence to treatment
• Regular assessment of antidepressant and other
medication therapy to assess response, side
effects and compliance
• Increased attention to education and support for
family caregivers of stroke survivors
43
POLICY IMPLICATIONS
Allocation of resources for depression
screening and delivery of prevention
strategies:
– Development of processes, protocols
– Training, monitoring and support
– Change attitudes and perceptions
44
CONCLUSIONS
• Depression is highly prevalent among stroke
survivors receiving home care services in the
first 1½ years post-stroke, and is associated with
poor health outcomes and increased cost of use
of health services;
• Recognition and treatment of depression in
stroke survivors using home care services is
suboptimal;
• Home care programs have the potential to play
a major role;
• Coordinated, multifaceted interventions to
improve recognition and treatment of depression
in home care need to be widely implemented. 45
You can make a difference!
46
ACKNOWLEDGEMENTS
(2005 – 2008) Funded by:
• CIHR Institute of Health Services and Policy
Research
• CIHR Knowledge Translation Branch
• Ontario Ministry of Health and Long-Term Care
• Toronto Central Community Care Access Centre
• Bridgepoint Health
• McMaster University, System-Linked Research Unit
on Health and Social Services Utilization
• Heart and Stroke Foundation of Ontario
• Greater Toronto Area Rehabilitation Network
47
PARTNERS
• Toronto Central Community Care Access
Centre
• Bridgepoint Health
• Saint Elizabeth Health Care
• VHA Home HealthCare
• VON
• COTA Health
• Ontario Ministry of Health and Long-Term Care
• McMaster University, System-Linked Research
Unit on Health and Social Services Utilization
48
THANK YOU!
Maureen Markle-Reid, RN, MScN, PhD
Principal Investigator
Career Scientist, Ontario Ministry of Health and Long-Term Care
Associate Professor, School of Nursing, McMaster University
1200 Main Street West, HSC 3N28H
Hamilton, Ontario L8N 3Z5
Tel: 905-525-9140, ext. 22306
Fax: 905-521-8834
E-mail: [email protected]
49