Understanding problems with low mood and depression after stroke Mood issues after stroke
Low mood and Depression • Many people will experience a range of emotions after a stroke in line with making sense and beginning to come to terms with (“adjusting”) to having the stroke and its effects on their life. • This session looks specifically at the topic of low mood, exploring what the symptoms of low mood are, how it feels to experience low mood at different severity levels. • It looks at classifications for depression and what characteristics may be seen in depression which may aid our understanding of the impact of low mood for patients. This includes the impact on their rehabilitation. • The session is aimed at helping us to conceptualise (make sense of) the symptoms of low mood, and to appreciate how someone is feeling to begin to help them.
Learning objectives • Screening measures for mood are included in a separate presentation, as is the management of mood. • Each of these sessions are recommended for all levels of staff working across the stroke pathway, with the screening presentation optional to unqualified staff. • Case studies and reflective exercises are included throughout.
Depression is a common problem • Depression affects many of the general population. Each year about 1 in 16 will be diagnosed with depression. • When we consider people who have two or more chronic physical health problems, nearly one in four (23%) suffer from depression. • After people experience a stroke depression is experienced by a significant amount of people. Family members may also experience low mood or clinical depression. • The figures of how many people experience depression after stroke vary, though studies suggest that as many as 35% (one in 3) experience depression at some point.
The impact of Depression on Stroke Rehabilitation • The impact of the depression on rehabilitation is significant. Depressed patients often lack motivation to engage in the rehabilitation process, have longer stays and may not engage in leisure and social activities. • There is also a strong relationship between psychological recovery in the short and long term.
The long term impact • A major study in to depression after stroke (House et al 2011) looked in to the impact of depression on long term outcome: • They found that people with depression at 1 month after a stroke were more likely to have increased predicted mortality at 12 months after a stroke, and: • Psychological symptoms in the first 6 months after stroke were found to be associated with substantially poorer physical outcomes at one year. • Therefore identification and treatment of depression in order to improve outcomes for patients and their families is crucial.
The personal impact • The personal impact for the individual who is suffering from low mood is the most significant. • Take a minute to think how someone may feel when they are experiencing a depressed mood after a stroke, for example when they are in hospital or if they have returned home. • Describe how might they feel? What may be running through their mind? How might this impact on what they feel able to, or want to do?
The personal experience of low mood after stroke • Here Dorothy who has mild depression after stroke explains how she feels: “ I just feel down some days, not weepy all the time but like “something is missing”. That “something” is the more cheerful, optimistic me. Since the stroke I feel that every day is a struggle and I’d rather not have to bother. I feel less confident and less interested in myself, and others. I feel that I’m not as good as anyone else and some days just wish that I could be alone”.
John is severely depressed, this is how he feels • “For me, it feels like I'm just stuck. It feels like a big black hole has been placed into my life, and everything that did or would make me feel better is just sucked into it. There's this blanket of hopelessness that covers me all the time, thoughts that I'm not good enough, I'll never do anything right or that I will never succeed now in life. Also that since the stroke I am a burden and my wife and family would be better off without me. I think that I wish I wasn’t here, that the stroke had taken me but I keep trying, more for others than myself. Every day I wake feeling terrible and every night I feel lonely and tired. I can’t think of the future as I can’t even cope with the present. I only hope I can get better than this”.
The impact of suffering from depression • This description gives us an insight into how far reaching the symptoms of depression are; they are psychological, physical and social. Depression can be quite overwhelming, and this might explain why people find it hard to just ‘pull themselves together’. • The table on the next slide highlights the different dimensions of depression that we need to look out for.
Adjustment? Low mood? Depression? • Depression can sometimes be difficult to discriminate, say from adjustment reactions or to “low mood”. • Depression is diagnosed when low mood is persistent and a deterioration in people’s functioning lasts for weeks rather than days, significantly affecting people’s well-being. The levels of depression and the diagnostic criteria for depression are outlined next.
Levels of depression • It is important to recognise that there are different severity levels to depression and there are different treatment approaches for mild, moderate and severe depression. Determining the severity of the depression is important and may be addressed by the use of screening measures and interviewing or talking to the person. • People who are severely depressed are more at risk and require more assessment such as suicidal intent and often more concrete work, with direction coming from others rather than being self generated, until such a time that they improve. Remember back to how awful John feels with the severe depression he is experiencing.
NICE guidelines • It is acknowledged in these guidelines that comprehensive assessment is needed if someone has depressed mood. Some people are so depressed that they consider suicidal ideas and plans to harm oneself- therefore this is included in further assessment. • Physical health problems are also considered as they can affect mood. Life problems outside stroke, emotions in significant others, and lack of support are also important as these too can affect mood and coping. • Ultimately assessment and measurement of mood should aid our understanding of a persons symptoms, and experience of depression. This enables us to begin to help the person by understanding their situation and making plans for managing heir mood.
The symptoms of depression • As the quote from John demonstrates, people who are experiencing depression will respond to day to day events in a variety of ways. • They will have changes to their feelings, their physiological responses, often experiencing negative, automatic patterns of thinking. They also may change their behaviour when responding to things, for example by avoiding situations.
Case Study: Burt • Imagine Bert, who seems to have become quieter over the past 2 weeks. He does not seem to put a lot of effort into the physio and OT sessions. When you tell him you have to re-arrange a session, he seems to deflate. He now spends most time lying on his bed. When his family visit, he smiles but he seems to be even flatter when they leave. • Can you think of what Burt may have been feeling or thinking at this point?
Interpretations, thoughts, feelings, emotions and actions • You will notice that there is quite a range of thoughts Bert might be having, from not being liked to being a hopeless case. It is worth asking Bert about this, for example: • “You just looked really upset. Can you tell me what that was about?” • Bert tells you that he thinks that he will not get any better, and that he will be a burden to his wife and children. One way of making sense of what is going on is using a cognitive behavioural framework as displayed below. This shows how our thoughts, feelings, physical sensations and behaviours are linked in depression.
Burt • Let us have a look how this model looks like for Bert: his therapy session has been re-arranged, and he thinks this means he is not getting better. He is feeling down, his energy seems to drain away from him.
Listening for someone’s low mood is part of all of our role • “Listening” to a person’s mood and asking how they are feeling can help people to begin to express how they are feeling with regards to their mood. • Asking specifically about someone’s thoughts and feelings and how this impacts on their actions (for example motivation to see people) can help us to start to understand the personal impact of their patterns of low mood/depression. • Validating that it is difficult to have low mood, or depression can help someone to feel understood and less alone. Telling people that we want to support them to improve their mood and that there are a number of treatment options for doing so (including talking therapy, medication) can often help people to begin to move forward.
Approaches for helping • Our approaches need to help people who have suffered a stroke to them feel worthwhile and useful again, their future worth working towards and should provide some hope to them. • Approaches will be offered (including psychological, social, medication) depending on the severity of the depression. These are covered in the next session: helping with Low mood and Depression after stroke.
Summary • Depression is a common issue after stroke • The identification of this is important to enable intervention plans to be put in place • Screening tools assist in the identification of depressive symptoms • Further assessment and diagnosis will identify whether someone meets “clinical caseness” and whether, and what type of intervention they require • We all should understand the components of low mood (physical, psychological: feelings, thoughts, behavioural changes, and social changes in depression. • Understanding the experience of depression for each person helps us to work with them more effectively.