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Practice comment

'Depression after stroke may be missed – nurses can spot it'

Stroke is the single largest cause of neurological disability in the UK. For some, the physical disability may not be as devastating as the emotional aspects

So good holistic nursing should focus not only on patients’ physical health but also their psychological wellbeing.

Following a stroke, psychological problems are common. These include depression, anxiety, emotionalism and post-traumatic stress disorder, with depression being the most common.

Many of these problems remain undiagnosed or inadequately treated. Only one in five hospital stroke teams in England include a clinical psychologist. Yet 33% of stroke survivors have depression, and the relationship between psychological problems and recovery is strong. Depressed stroke patients lack motivation to participate in rehabilitation, make less progress, and fail to engage in leisure and social activities.

Nurses are in an ideal position to detect depression in patients after stroke by active listening and asking open-ended questions that allow patients to express their feelings and alert nurses to possible depression.

But many signs of depression may appear to be physical symptoms of stroke. Health professionals may attribute these problems to the physical illness rather than depression, diagnosis is difficult.

Treatments are available so it is essential to recognise and attend to symptoms of depression, such as crying and prolonged low mood, at an early stage. The NICE Stroke Quality Standard suggests: “All patients after stroke are screened [for depression] within six weeks of diagnosis, using a validated tool.” Formal screening for depression can be time consuming, but nurses may consider asking patients if during the past month they have often been bothered by feeling down, depressed or hopeless or if they have had little interest or pleasure in doing things.

If they answer “yes” to either question, nurses should consider depression and follow the local recommendations for further assessment. The Yale single question: “Do you often feel sad or depressed?” is also accurate in identifying possible depression following a stroke. In patients with cognitive and communication problems, nurses may consider asking carers to complete the Signs of Depression Scale.

Nurses can form good therapeutic relationships and incorporate approaches to supporting patients’ adaptation and
readjustment. This psychological support can be achieved through active listening, education and referring them to support services. The criteria and patterns of referral will vary considerably from area to area, but may include GP, stroke liaison, clinical psychology, or Improving Access to Psychological Therapies services. In this way nurses can play a vital role in identifying and helping patients with psychological problems after stroke. NT

Caroline Watkins is professor of stroke and older peoples’ care; Liz Lightbody is a research fellow, in the clinical practice research unit, both at the School of Health, University of Central Lancashire. For course information see: www.ukstrokeforum.org and click on the UKFST logo

Readers' comments (10)

  • 'Depression after stroke may be missed – nurses can spot it'

    how patronising

    what is this all about? so many articles about what nurses can and should do I just wonder whether the new generations of nurses don't learn to 'do' holistic care anymore or even develop observational skills? I really wonder what the do do on the wards?

    depression is an obvious risk following stroke and always was and and its detection and management has always been included as an integral part of nursing care of this group of patients and besides any other patients who are depressed as well. Illness and undergoing any form of treatment is frequently accompanied by depression and nurses are more than able to detect these signs!

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  • "So good holistic nursing should focus not only on patients’ physical health but also their psychological wellbeing."

    contradiction in terms. It is not holistic nursing if it only focuses on physical health!!!!!!!!!!!!!!!!!!!!!

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  • for the author of this article

    definition from COED 11th ed.

    holistic
    n adjective
    1 chiefly Philosophy characterized by the belief that the parts of something are explicable only by reference to the whole.
    2 Medicine treating the whole person rather than just the physical symptoms of a disease.

    DERIVATIVES
    holistically adverb


    HOLISTIC NURSING

    A philosophy of nursing practice that takes into account total patient care, considering the physical, emotional, social, economic, and spiritual needs of patients, their response to their illnesses, and the effect of illness on patients' abilities to meet self-care needs. (From Mosby's Medical, Nursing, & Allied Health Dictionary, 4th ed, p745)
    http://www.reference.md/files/D018/mD018939.html


    Pflege. 1996 Sep;9(3):221-32.
    [Holistic nursing--definition and realization].
    [Article in German]
    Glaser J, Büssing A.
    Abstract
    Holistic nursing This article focuses on the current discussion on holistic nursing. Looking at holistic nursing from a work psychological perspective a classification of nursing models is presented. So far, the prevalence of holistic nursing models was overestimated in empirical studies since there was a lack of relevant criteria. The proposed classification allows to differentiate models of nursing along the two dimensions: design of nursing organization and nursing principle. Preconditions and prospects of holistic nursing are discussed with regards to the completed and the current implementation of projects.

    PMID:8949009[PubMed - indexed for MEDLINE
    http://www.ncbi.nlm.nih.gov/pubmed/8949009

    The first three posts are by the same Anonymous.

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  • I have worked with stroke patients for 21 years, and sadly many aspects of the problems from a stroke go undetected, not just depression. Hopefully, full implementation of the stroke strategy and an increase in direct admissions to a specialised stroke unit, if not all (being realistic, this may happen, bed availability, post-op stroke, etc.). Patient in a bed often over-rides the most appropriate bed still. In such a condition as stroke (and there are others) need an interdisiplinary approach is required, not just holistic nursing care.

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  • above..omit the word 'need' on the penultimate row

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  • Anonymous | 5-Jul-2011 11:56 pm

    perhaps they are better catered for on a general medical ward than in specialized units as we never had difficulties identifying
    the problems of the many stroke patients that we cared for or delivering individualized treatment.

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  • Anonymous | 6-Jul-2011 1:01 am

    Research shows that care on a specialised stroke unit saves lives, more lives than cardiac patients in a specialsed cardiac unit. Bravo, if on a general medical ward you can give the best researched care for a diverse group of medical patients, I applaud that, but don't believe you are in the majority. I hope you and your colleagues address all the agnosias, hemianopias, dysarthria, dyspasia, dysphagia, the dyspraxia - speech, dressing, mobiltity, etc, perceptual and cognition problems and have the appropriate level of SALT, OT and P/T input. Not to mention thrombolysis and the aftercare, and support the Stroke Strategy, RCP and NICE guidelines. Are your patients supported by Research Nurses offering portfolio studies adopted by the Stroke Research Network? If 'yes' to all, please tell me where you work.

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  • above: dyspasia, should read dysphasia...typo error

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  • Anonymous | 9-Jul-2011 1:32 am

    "...please tell me where you work."

    in an interdisciplinary specialist team in a university hospital outside the UK!

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  • Anonymous | 9-Jul-2011 7:26 am

    in an interdisciplinary specialist team in a university hospital outside the UK!

    Perhaps that explains my initial comments then.

    I am a little confused though, on one hand you refer to a 'general medical ward' delivering stroke care and above you refer to ' an ID specialised team'

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