Development, Implementation, and Outcomes of Post-stroke Mood Assessment Pathways: Implications for Social Workers

Figures & data

Table 1 Mood Assessment Screening Tools Considered for Inclusion into the Mood Assessment Pathway

Pathway	Context of use	Valid in stroke, efficient sensitivity	Benefits/issues	Included in pathways analysis
Hospital Anxiety Depression Scale—Anxiety (HADS-A)	It can be used for all adults. Initially developed for use in non-psychiatric hospitals however further research demonstrates it is reliable and valid in other settings (Snaith & Zigmond, 1994) Self-reported tool.	The sensitivity of the HADS-A is higher than the DASS-A (Dahm, Wong, & Ponsford, 2013). A cut-off of six recommended for stroke patients (Kneebone et al., 2012). Burton and Tyson (2015b) systematic review advises the HADS was the most effective tool to identify anxiety.	There is a copyright on the HADS-A resulting in a cost to implement it.	This tool was chosen for the pathway due to its proven validity in the stroke population and its efficiency (Aben, Verhey, Lousberg, Lodder, & Honig, 2002)
Patient Health Questionnaire-9 (PHQ-9)	Recommended as a clinically valid tool for stroke patients by the National Stroke Foundation (2010). This tool can be used regardless of age, gender, or ethnicity. It taps the nine diagnostic symptom criteria that define DSM-IV major depressive disorder (Lowe, Kroenke, Herzog, & Grafe, 2004). Self-reported tool.	It is quick to administer and has adequate reliability, validity, sensitivity, and specificity in stroke samples (Lowe et al., 2004). Good sensitivity for detecting severe depression and recommended as effective tool in stroke patients (Burton & Tyson, 2015b)	It can be used for patients without significant cognitive or communications problems (Kneebone et al., 2012). Freely available	This tool was chosen for the pathway due to its proven validity in the stroke population and its efficiency
Behaviour Outcomes for Anxiety (BOA)	Specifically designed to detect and monitor anxiety post-stroke for people with communication challenges. The BOA is an observational rated instrument that is completed by someone who knows the patient well (Linley-Adams, Morris, & Kneebone, 2014).	Eccles, Morris, and Kneebone (2017) suggest the BOA has adequate sensitivity and specificity in the stroke population.	It is the only tool screening for anxiety that has been developed for stroke patients who experience communication or cognitive problems. Limited research to date as the tool is relatively new. Freely available	This tool was chosen for the pathway as it is the only tool to specifically assess anxiety for stroke patients with significant communication or cognitive challenges.
Stroke Aphasic Depression Questionnaire-10 or H10 for hospital patients (SADQ-10 or SADQ-H10)	Specifically designed for stroke patients with significant communication challenges. It can be used for all age groups and is an observer rating scale that is completed by the primary nurse, key worker, or clinician who knows the patient best.	Kneebone et al. (2010) recommend a cut-off is six or more on the SADQ-H10 and 14 on the SADQ-10 (Kneebone et al., 2012). The clinician should assess suicidal ideation if patient scores six or more (if possible given communication challenges). Good psychometric and clinical utility for major depression and any depressive disorder (Burton & Tyson, 2015b).	This tool is recommended to screen for depression in stroke populations for patients who have cognitive and/or communication problems that preclude administration of the PHQ-9 (Kneebone et al., 2012). Freely available	This tool was chosen as it has the most research to support its use in detecting depression in stroke patients with significant communication challenges (Burton & Tyson, 2015b)

Table 2 Mood Assessment Screening Tools Not Considered for Inclusion into the Mood Assessment Pathway

Pathway	Context of use	Valid in stroke, efficient sensitivity	Benefits/issues	Not included in pathways analysis
Hamilton Depression Rating Scale	This is a clinically valid tool (Aben et al., 2002) that is recommended by the National Stroke Foundation (2010).	It has similar predictive validity as HADS and BECK, however requires trained staff to administer and is more time consuming (Aben et al., 2002).	Training required to implement tool (Aben et al., 2002). Takes 15–20 min to administer (Sharp, 2015). Freely available.	This screen was excluded from our pathway due to length and training requirements (Aben et al., 2002).
Geriatric Depression Scale 15-item (GDS)	The GDS is clinically valid in the stroke population for over-65s. It is recommended by the National Stroke Foundation (2010). There has been limited research conducted in < 65 years population, therefore researchers excluded this tool on the pathway as we ideally wanted a valid tool that could be used for all ages.	The researchers acknowledge that this is a valuable tool for patients with hearing impairments, expressive dysphasia, or mild cognitive difficulties. Some of the user rated scales have quite complicated response options that can be confusing for the user (Cinamon, Finch, Miller, Higgins, & Mayo, 2011). In such cases the GDS could be used as an alternative. (Roger & Johnson-Greene, 2009) recommend a cut off of 3 in the stroke population (usual cut off is 6). The GDS has high sensitivity and internal consistency in the elderly stroke patient cohort (Agrell & Dehlin, 1989).	The yes/no answers as opposed to scaling questions a good alternative for those with hearing or mild cognitive impairments. Freely available.	Not included in pathway as it targets > 65 years of age. The researchers do recommend this to be considered as a complimentary tool for its specific target group.
Brief Assessment Schedule for Depression Cards (BASDEC)	Recommended for use in the over 65 age group in noisy environments that lack privacy, such as hospital wards (Kneebone et al., 2010). It is a valid tool in the over 65 years of age stroke population (Healey, Kneebone, Carroll, & Anderson, 2008).	Acceptable internal consistency and reliability in older stroke survivors in an inpatient rehabilitation setting (Healey et al., 2008).	Tool unavailable therefore unable to be included.	The BASDEC cards were not chosen because the authors wanted to be able to use the tools across all ages. Additionally, unable to obtain them from the publisher at the time of writing.
Depression Intensity Scale Circles (DISCs)	The DISCs can be used for under and over 65 year olds if there is a major cognitive or communication difficulty (Kneebone et al., 2010).	Burton and Tyson (2015b) state the DISCs did not have adequate sensitivity and specificity in detecting any depression or major depression.	There is no suicide question, therefore Kneebone et al. (2010) recommend using the BASDEC suicide question. Freely available	Excluded due to lack of sensitivity and specificity in the stroke population.
Depression and Anxiety Stress Scale (DASS)	There has been limited research in using the DASS with the stroke population (Ownsworth, Little, Turner, Hawkes, & Shum, 2008).	Sukantarat, Williamson, and Brett (2007) conducted a comparative study between the DASS and HADS for patients who had experienced a recent critical illness. Both DASS and HADS emerged as reliable tools for detecting anxiety and depression in this patient group, however Dahm et al. (2013) found that the sensitivity of the HADS-A is higher than the DASS-A	Inadequate research to support its validity in the stroke population Freely available	The DASS was not chosen for the pathway due to the limited research conducted specifically with the stroke population
Hospital Anxiety Depression Scale –Depression (HADS –D)	It can be used for all adults. Initially developed for use in non-psychiatric hospitals, however further research demonstrates it is reliable and valid in other settings (Snaith & Zigmond, 1994).	Research suggests the PHQ-9 a superior tool for screening Post-Stroke Depression as it taps into the nine diagnostic symptom criteria that define DSM-IV major depressive disorder (Kneebone et al., 2012).	There is no suicide question in the HADS-D, which the researchers felt was important.	The HADS-D was not chosen for the pathway as the PHQ-9 had greater research to support its use in the stroke population.
Generalised Anxiety Disorder-7 (GAD-7)	The GAD-7 is a brief (7 item) tool to assess anxiety in the general population (Spitzer, Kroenke, Williams, & Löwe, 2006). The questions are scaling questions, therefore patient requires reasonable language and cognition to follow.	The GAD-7 has not been specifically evaluated in the stroke population (Eccles et al., 2017).	Requires further evaluation in regard to its effectiveness in the stroke population (Eccles et al., 2017).	Inadequate research using this tool in the stroke population existed at time of implementation.

Table 3 Mood Assessment Pathways Considered for Inclusion into the WBHHS Post-stroke Mood Assessment Pathways

Pathway name, (Weighting), Authors	Ease of use	Training required	Clinical utility	Time taken to administer (minutes)	Validity in stroke population yes/no	Score/10
Screening for depression and anxiety after stroke: Developing protocols for use in the community. (Weighting)	(2)	(2)	(1.5)	(2)	(2)	(9.5)
Kneebone et al. (2012)	Streamlined	HADS-A: Nil PHQ-9: Nil BOA: Nil SADQ 10: Nil	Straight forward	HADS-A <5 PHQ-9 < 5 BOA <5 SADQ-10 < 5	HADS-A: yes PHQ-9: yes BOA: yes SADQ-10: yes
Screening for depression after stroke: Developing protocols for the occupational therapist (Weighting)	(1)	(1.5)	(0.5)	(2)	(1.5)	(6.5)
Kneebone et al. (2010)	More complex/more variables	DISCS: Nil SADQ-H10: Nil BASDEC: minimal (unable to obtain) HADS: Nil	Unable to obtain the BASDEC from publisher at time of writing	DISCS <5 SADQ-H10 < 5 BASDEC 3–4 HADS <5	DISCS: yes* SADQ-H10: yes BASDEC: yes HADS: yes
Mood Pathway—Stroke Services (Weighting)	(1)	(1.5)	(0)	(2)	(1.5)	(6.5)
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (Clark & Taylor, 2010)	More complex/more variables	DISCS: Nil BADEC: (unable to obtain) SADQ-H10: Nil HADS: Nil	Unable to obtain the BASDEC from publisher at time of writing	DISCS <5 BASDEC 3–4 SADQ-H10 < 5 HADS <5	DISCS: yes* BASDEC: yes SADQ-H10: yes HADS: yes
G-Master (Weighting)	(2)	(1.5)	(2)	(2)	(1)	(8.5)
Greater Manchester Assessment of Stroke Rehabilitation (Burton, Tyson, & McGovern, 2013)	Streamlined	SADQ-H10: Nil DISCS: Nil PHQ-9: Nil GAD-7: Nil**	Straight forward	SADQ-H10 < 5 DISCS <5 PHQ-9 < 5 GAD -7 < 5**	SADQ-H10: yes DISCS: yes* PHQ-9: yes GAD 7: not specifically evaluated in the stroke population

Notes. Weighting Scale 0 = absent, 0.5 = low, 1 = medium, 1.5 = medium high, 2 = high

*valid with stroke patients though did not have adequate sensitivity and specificity in detecting any depression or major depression (Burton & Tyson, 2015b). **Authors unable to obtain published information. Tested in author’s research.

Figure 1 Post-stroke mood assessment pathway for patients without communication or cognitive difficulties (Adapted with permission from Kneebone et al., 2012)

Figure 2 Post-stroke mood assessment pathway for patients with communication or cognitive difficulties (Adapted with permission from Kneebone et al., 2012)

Table 4 The PARiHS Framework Applied to the Target Groups, the Activities, the Responsibilities and Goals of the Research

Target group	Activities	Health professional	Goal	PARiHS Framework
Stroke patients in the Wide Bay South Hospital and Health Service	Discussion of research project Consider aim and purpose Identify Australian PSMAPs	SW rehab SW community	Determine whether implementing a PSMAP would improve rates of mood screens in conjunction with clinical interview for patients who have had a stroke	E, C, F
SW rehab SW community	Literature review	SW rehab SW community	Identify clinically validated screening tools for stroke population	E, F
Stroke patients: Pre-implementation (2013–2014) Post-implementation (2014–2015)	Develop audit tool Chart audit WBHHS (South)	SW rehab SW community Allied health volunteers	Identify: Completion of mood screens Clinical interviews Interventions	E, F
SWs and OT	Stakeholders meeting	SW rehab SW community	Identify the health professionals who would conduct the PSMAP	E, C, F
OT acute SW sub-acute/rehab SW community	Staff training	SW rehab SW community	Complete survey Increase knowledge and skills Create readiness for change	E, C, F
OT and SWs in acute, sub-acute, rehab and community	Implement the PSMAP pathway	OT and SWs	Quality improvement Identify patients at risk of depression and/or anxiety	C, F
Speech therapists	Consultation re patients with aphasia/communication challenges	OT and SWs	Determine most effective screening tool to be used	E, F
Patient (in hospital) with their consent	Complete PSMAP in conjunction with clinical interview MDT input	OT acute SW sub-acute/rehab All MDT Mental health liaison	Identify patients at risk of depression/anxiety Intervention	E, C, F
Family/carer (for inpatients)	Attend family meeting	SW and MDT	Support patient and family/carers Discharge planning	E, C, F
Patients community with their consent	Complete PSMAP and/or review and repeat mood screen Ongoing intervention	SW community	SW support Intervention	E, C, F
Stroke patients in the Wide Bay Hospital and Health Service (South)	Evaluation	SW rehab SW community	To determine if implementing a PSMAP improved rates of mood screens in conjunction with clinical interview Improve psychological wellbeing of patients	E, C

Notes. PSMAP—Post-Stroke Mood Assessment Pathway; SW—social worker; OT—occupational therapist; MDT—multidisciplinary team. E—Evidence; C—Context; F—Facilitation

Table 5 Chart Audit Pre- and Post-implementation of Post-stroke Mood Assessment Pathways and Staff Training

Variable	Pre-implementation n =	Post-implementation n =
Charts audited (Hospital A discharges and transfers, Hospital B sub-acute discharges and rehabilitation discharges, Community Health discharges)	213	238
Hospital A: admissions	136	149
Hospital A: discharges (home or to Community Health)	65	75
Hospital A: transfers to subacute in Hospital B	71	74
Hospital B: direct admissions into sub-acute	3	5
Hospital B: discharges from sub-acute (home or to Community Health)	20	19
Hospital B: transfers from sub-acute to rehabilitation—discharge from rehabilitation	54	60
Hospital A: Community Health admissions post-discharge	2	0
Hospital B: Community Health admissions post-discharge	1	10

Table 6 Patient Demographics and Length of Stay by Service

Variable	Pre-intervention		Post-intervention		p
Charts audited N =	213		238
Males n = (%)	116 (54.5)		126 (53)
Age, mean (SD)	70 (12)		71 (11)		.49
Females n = (%)	97 (45.5%)		112 (47)
Age, mean (SD)	74 (13)		77 (11)		.07
	Male	Female	Male	Female
Days in Hospital A mean (SD)	7 (5)	6 (4)	6 (4)	6 (4)
Days in Hospital B (sub-acute and rehabilitation) mean (SD)#	29 (24)	37 (42)	29 (21)	32 (25)

Note. # Days in Hospital B unable to be split

Table 7 Post-stroke Mood Assessment by Service Location and Profession

Screening &/or interview and health professional	Mood assessment and service location	Audit 2013–2014 n =	Year 2014–2015 n =	Proportion change %	95% CI [LL, UL]	p
Charts audited		213	238
Formal mood screen used	Yes	8	42	13.85	[8.05, 19.69]	< .0001**
Evidence of discussion in notes only (i.e. no screening tool used)	Yes	23	21	1.99	[−3.79, 7.93]	.47
Total evidence of mood discussion	Yes	31	63	11.85	[4.10, 19.38]	.002**
Was low mood identified?	No	12	33	15.78	[−7.6, 36.8]	.15
	Yes	19	30	15.7	[−7.7, 36.73]	.15
Screen &/or interview	Hospital A no screen, no interview	124	147	7.5	[2.06, 13.7]	.003**
	Hospital A screen only	0	0	0	0	0
	Hospital A interview only	12	2	7.5	[2.11, 13.6]	.003**
	Hospital A screen and interview	0	0	0	0	0
	Hospital B sub-acute no screen, no interview	20	19	0	[−17.6, 16.8]	–
	Hospital B sub-acute screen only	0	0	0	0	0
	Hospital B sub-acute interview only	0	0	0	0	0
	Hospital B sub-acute screen and interview	0	0	0	0	0
	Hospital B rehab no screen, no interview	37	7	56.9	[39.1, 70.66]	<.0001**
	Hospital B rehab screen only	1	0	1.8	[−4.41, -9.8]	.29
	Hospital B rehab interview only	10	16	11.1	[−5.91, 27.2]	.16
	Hospital B rehab screen and interview	6	37	50.5	[32.78, 64.58]	<.0001**
Screen &/or interview in community	No community screen or interview	1	2	13.3	[−34.88, −73.16]	.64
	Community interview only	1	3	3.3	[−44.61, 65.12]	.91
	Community screen and interview	1	5	16.7	[−48.54, 61.78]	.62
Health profession who documented mood or discussion	Social worker	21	53	14.1	[−4.9, 35.07]	.0.11
	Doctor	2	0	6.6	[−1.52, 21.98]	0.04*
	Occupational therapist	6	0	20	[6.46, 38.56]	.0003**
	Alcohol Tobacco Other Drugs (ATODs)	1	1	1.72	[−5.92, 15.67]	0.59
	Community Team	0	9	14.2	[0.40, 25.29]	.03*
	Mental Health	0	0	0	0	0

Notes. * indicates p < .05, ** indicates p < .001

LL and UL indicate the lower and upper limits of a confidence interval respectively

Table 8 Interventions for Low Mood

Intervention	Audit year
	2013-2014 n =	2014-2015 n =	Proportion change %	95% CI [LL, UL]	Difference in proportions p
Low mood identified	19	30
Counselling	7	25	46.5	[15.81, 69.81]	.001**
Mental Health	3	13	27.6	[−2.1, 50.46]	.04*
Carer Support	0	0	0	0	0
Refer psychologist	0	2	6.6	[−11.97, 21.98]	.25
Increase social support	1	1	1.9	[−12.86, 22.88]	.74
GP follow-up	2	12	29.5	[1.11, 50.9]	.027*
Refer community SW	3	9	14.22	[−14.04, 37.24]	.26
Antidepressants	3	13	27.6	[−12.1, 50.4]	.46
Sunshine	0	4	13.3	[−6.77, 30.68]	.1
Education	0	4	13.3	[−6.77, 30.68]	.1
Diversional therapy	0	2	6.6	[−11.97, 21.98]	.25
Watchful waiting	0	1	3.3	[−14.63, 17.1]	.42
Pt declined intervention	1	0	5.2	[−7.43, 25.93]	.21
No intervention	9	1	44	[17.22, 67.99]	.0002**

Notes. * indicates p < .05, ** indicates p < .001

LL and UL indicate the lower and upper limits of a confidence interval respectively

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