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Depression among Community Living Stroke Survivors Using Home Care Services

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. 11 th Annual Stroke Collaborative October 20 th , 2008 Toronto, Ontario.

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Depression among Community Living Stroke Survivors Using Home Care Services

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  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

  2. 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.

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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

  9. 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.

  10. 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

  11. 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.

  12. MOOD DISTURBANCES ANXIETY DEPRESSIVE Generalized Anxiety Disorder Panic Disorder Major Depressive Disorder Dysthymia Cyclothymia Manic Depression PHOBIAS Simple Phobia Social Phobia Agoraphobia SUBSTANCE ABUSE Alcohol Drugs

  13. What is DEPRESSION??? DEPRESSION IS A SERIOUS ILLNESS --A Bio-Chemical Imbalance

  14. BEHAVIOURS ASSOCIATED WITH DEPRESSION • Sadness • Frequent crying • Withdrawal • Difficulty concentrating • Difficulty making decisions • Difficulty sleeping • Lack of energy • Feelings of worthlessness • Negative outlook • Over sensitive • Feelings of hopelessness • Recurrent thoughts of death or suicide • Weight loss or weight gain (10lbs either way)

  15. DSM IV SYMPTOMS OF DEPRESSION Depressed, Irritable, Volatile Mood, Worry and/ or Anxiety …most of the day …more days than not …greater than 2 weeks + 5 symptoms = Major Depression …greater than 2 years + 2 symptoms = Dysthymia • Over/under eating • Over/under sleeping • Fatigue, tiredness • Low self-esteem • Poor concentration/decision-making • Hopelessness/pessimism • Guilt, brooding and worry

  16. DISTINGUISHING FEATURES…WEIGHING THE EVIDENCE Emotional Response Versus Mood disturbance • Feeling is Specific to Situation • Focused Object of  Feelings (one person/event) • Appropriate/Timely • Short Duration (days/weeks) • Definite Onset • Generalized • Everyone (thing) (variety of people/events) • Excessive/Unwarranted • Long Duration (months/years) • Insidious Onset (“I don’t know”)

  17. 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.

  18. RESEARCH QUESTIONS • 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?

  19. 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

  20. 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

  21. 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): 6-Month Cost of Use of Health Services

  22. 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)

  23. 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

  24. 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

  25. PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSION (0-18 MONTHS POST-STROKE) (n=101) n=58 n=38 n=20

  26. PREVALENCE OF DEPRESSION AMONG STROKE SURVIVORS BY SUBGROUP Population Rates 20-25% Primary Care 25-30% Secondary Care 35% Hospital 50% Home Care 57%

  27. PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE SYMPTOMS (CES-D > 21) BY NUMBER OF MONTHS POST-STROKE (n=101)

  28. 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 Depressed n=58 (n = 18) Depression Detected and Adequately Treated (n = 20) 0%

  29. 100% Depression Not Detected and not Treated 35% (n = 20) Depression Detected but not Adequately Treated 31% (n = 18) Depression Detected and Adequately Treated 35% (n = 20) 0% PERCENTAGE OF DEPRESSION DETECTED AND TREATED IN STROKE SURVIVORS WITH DEPRESSION (n=58) Percent

  30. PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE SYMPTOMS (CES-D > 21) USING ANTIDEPRESSANTS BY NUMBER OF MONTHS POST-STROKE (n=38) N=4

  31. DEPRESSION RISK FACTORS (n = 101)

  32. 6-MONTH PER PERSON COST OF USE OF HEALTH SERVICES FOR STROKE SURVIVORS WITH AND WITHOUT DEPRESSION

  33. 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.

  34. 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

  35. BARRIERS TO DETECTION AND TREATMENT • Individual doesn’t realize they are depressed • Health care practioner doesn’t recognize or diagnose depression • Stigmasassociated with having depression • Concerns that medication or treatment will alter personality or cause other side effects

  36. 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.

  37. 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

  38. 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

  39. RECOGNIZING DEPRESSIVE SYMPTOMS Kessler-10 Screening Scale for Depressive Symptoms and Anxiety During the past 30 days, about how often did you feel… • tired out for no good reason? • nervous? • so nervous that nothing could calm you down? • hopeless? • restless or fidgety? • so restless that you could not sit still? • depressed? • that everything was an effort? • so sad that nothing could cheer you up? • worthless? A score of 16-29/50 indicates medium risk for anxiety and depression; 30-50/50 indicates high risk for anxiety and depression.

  40. TREATMENTS + = MOST EFFECTIVE TREATMENT ANTIDEPRESSANTS • SSRI’s (Prozac, Zoloft, Paxil, Luvox) • Tricyclics • MAO’s • Herbal remedies i.e., St. John’s Wort COUNSELING • Interpersonal Therapy (IPT) • Cognitive Behavioral • Marital

  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: mreid@mcmaster.ca

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