Dr Jenni White

Background: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results. Objective: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of =10. Methods: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview. Results: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of =10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88). Conclusions: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.

Background. Impaired health-related quality of life (HRQoL) post stroke is common, though prevalence estimates vary considerably. Few longitudinal studies explore post-stroke patterns of HRQoL and factors contributing to their change over time. Accurately identifying HRQoL after stroke is essential to understanding the extent of stroke effects. Objectives. This study aimed to assess change in levels of, and identify independent predictors of, HRQoL over the first 12-months post-stroke. Methods. Design. A prospective cohort study. Setting and participants. Community-dwelling stroke survivors in metropolitan Newcastle, New South Wales (NSW), Australia. Consecutively recruited stroke patients (n = 134) participated in face-to-face interviews at baseline, 3, 6, 9 and 12 months. Outcome measure. HRQoL (measured using the Assessment Quality-of-life).Independent measures. Physical and psycho-social functioning, including depression and anxiety (measured via Hospital Anxiety and Depression Scale), disability (Modified Rankin Scale), social support (Multi-dimensional Scale Perceived Social Support) and community participation (Adelaide Activities Profile).Analyses. A linear mixed model was used to establish the predictors of, change in HRQoL over time. Results. On multivariable analysis, HRQOL did not change significantly with time post-stroke. Higher HRQoL scores were independently associated with higher baseline HRQoL (P = 0.03), younger age (P = 0.006), lower disability (P = 0.003), greater community participation (P = 0.001) and no history of depression (P = 0.03). Conclusion. These results contribute to an understanding of HRQoL in the first year post-stroke. Community participation and stroke-related disability are potentially modifiable risk factors affecting post-stroke HRQoL. Interventions aimed at addressing participation and disability post-stroke should be developed and tested.

Background: Depression in stroke survivors is common, leads to poorer outcomes and often not treated. A group cognitive behavioural therapy (CBT) program (Brainstorm) for stroke survivors with depression, and their carers has been running as part of usual care since 2007. Objective: To evaluate the implementation and acceptability of Brainstorm, a closed group intervention consisting of up to 10 sessions of education, activity planning, problem solving and thought challenging. Methods: Participating stroke survivors and their carers complete assessment measures at baseline, posttreatment and 1-month and 6-months follow-up. A mixed models for repeated measures data was conducted with depression and anxiety scores for stroke survivors (Beck Depression Inventory-II; Hospital Anxiety and Depression Scale) and the assessment of depression, anxiety and carer burden for carers. Acceptability was assessed by session attendance and written and open participant feedback upon completion of the program. Results: Forty-eight community dwelling stroke survivors and 34 carers attended Brainstorm, with a median attendance of 88% of sessions. Follow-up assessments were completed by 77% (post-treatment), 46% (1-month) and 38% (6-month) of stroke survivors. Stroke survivors¿ depression scores decreased from baseline to posttreatment (p<.001); maintained at 1-month (p<.001) but not at 6-month (p=.056). Anxiety scores decreased between baseline and 1-month (p=.013). Carer burden, depression and anxiety scores at 1-month and 6-month follow-up, for carers, were all reduced when compared with baseline (p<.05). Conclusion: The Brainstorm group intervention for depression in stroke survivors appears to have been effectively implemented and is acceptable to stroke survivors and carers.

Background: Data highlight the importance of undertaking intense and frequent repetition of activities within stroke rehabilitation to maximise recovery. An enriched environment (EE) provides a medium in which these activities can be performed and enhanced recovery achieved. An EE has been shown to promote neuroplasticity in animal models of stroke, facilitating enhanced recovery of motor and cognitive function. However, the benefit of enriching the environment of stroke survivors remains unknown. Aim: To qualitatively explore stroke survivors' experience of implementation of exposure to an EE within a typical stroke rehabilitation setting, in order to identify facilitators and barriers to participation. Methods: Semi-structured interviews with 10 stroke survivors (7 females and 3 males, mean age of 70.5 years) exposed to an EE for a 2-week period following exposure to routine rehabilitation within a stroke rehabilitation ward. An inductive thematic approach was utilised to collect and analyse data. Results: Qualitative themes emerged concerning the environmental enrichment paradigm including: (1) "It got me moving"-perceived benefits of participation in an EE; (2) "You can be bored or you can be busy."-Attenuating factors influencing participation in an EE; (3) "I don't like to make the staff busier"-limitations to use of the EE. Conclusions: This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective. Reported benefits included (1) increased motor, cognitive and sensory stimulation, (2) increased social interaction, (3) alleviation of degree of boredom and (4) increased feelings of personal control. However, participants also identified a number of barriers affecting implementation of the EE. We have previously published findings on perceptions of nursing staff working with stroke survivors in this enriched rehabilitation environment who identified that patients benefited from having better access to physical, cognitive and social activities. Together, results contribute to valuable evidence for future implementation of an EE in stroke rehabilitation settings.Implications for RehabilitationStroke survivor access to an enriched environment (EE):Results identified that participation in both individual and communal forms of environment enrichment within the stroke rehabilitation ward resulted in increased access to activities providing increased opportunities for enhanced motor, cognitive and sensory stimulation.Increased access to and participation in activities of the environmental enrichment (individual and communal) interrupted the ongoing cycle of boredom and inactivity experienced by many participants.This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective.

Background: Clinician interest in the role of tablet technology in commercially available tablet devices (i.e. iPads) following stroke is rising. Tablets have the potential to encourage engagement in therapeutic activities. We aimed to explore stroke survivor acceptability of and experience of tablet use during the first three months of stroke recovery. Design: A qualitative study using an inductive thematic approach incorporating the process of constant comparison was utilized to collect and analyse data. Setting: Community dwelling stroke survivors in metropolitan Newcastle, New South Wales, Australia. Participants: Twelve stroke survivors (8 male, 4 female; median age of 73 (IQR 58-83) years). Main outcome measures: Qualitative outcomes were participants' perceptions using in-depth, semi-structured interviews. Results: Participants' found tablets easy to use and beneficial. Most stroke survivors used the tablet to engage in therapeutic and leisure activities on most days during the three months. Three key themes emerged: (1) Getting established on the iPad: "It just became easier and easier", (2) Technology as a means for increased stimulation: "Something to keep me interested", and (3) Personal experiences of access to an iPad: "It's been very helpful". Conclusions: Incorporating tablet technology into the delivery of stroke rehabilitation appears to be feasible and acceptable at a patient level. This process has the potential to improve participation in therapeutic and or leisure; however further evaluation towards the impact of tablet technology on patient outcome and quality of life is required.

Purpose: Few longitudinal studies explore post-stroke patterns of psychological morbidity and factors contributing to their change over time. We aimed to explore predictors of post-stroke depression (PSD) and post-stroke anxiety over a 12-month period. Methods: A prospective cohort study. Consecutively recruited stroke patients (n=134) participated in face-to-face interviews at baseline, 3, 6, 9, and 12 months. Primary outcome measures were depression and anxiety (measured via Hospital Anxiety and Depression Scale). Independent variables included disability (Modified Rankin Scale), Quality-of-life (Assessment Quality-of-life), social support (Multi-dimensional Scale Perceived Social Support) and community participation (Adelaide Activities Profile (AAP)). Secondary outcomes were predictors of resolution and development of PSD and anxiety. Results: Anxiety (47%) was more common than depression (22%) at baseline. Anxiety (but not depression) scores improved over time. Anxiety post-stroke was positively associated with baseline PSD (p<0.0001), baseline anxiety (p<0.0001) and less disability (p=0.042). PSD was associated with baseline anxiety (p<0.0001), baseline depression (p=0.0057), low social support (p=0.0161) and low community participation (p<0.0001). The only baseline factor predicting the resolution of PSD (if depressed at baseline) was increased social support (p=0.0421). Factors that predicted the onset of depression (if not depressed at baseline) were low community participation (p=0.0015) and higher disability (p=0.0057). Conclusion: While more common than depression immediately post-stroke, anxiety attenuates while the burden of depression persists over 12 months. Clinical programs should assess anxiety and depression, provide treatment pathways for those identified, and address modifiable risk factors, especially social support and social engagement.Implications for RehabilitationPsychological distress post stroke is persisting.Multi-disciplinary teams that establish goals with patients promoting social and community engagement could assist in managing psychological morbidity.A shift towards promoting longer-term monitoring and management of stroke survivors must be undertaken, and should consider the factors that support and hinder psychological morbidity.