Implementation and Evaluation of Depression Improvement Program in Stroke Care (Dips)

Background: Post-stroke depression (PSD) is a serious complication of stroke. It often goes undetected and untreated. Purpose: The primary objective was to evaluate utilization of the Patient Health Questionnaire-9 (PHQ-9), depression treatment algorithm and development of a treatment plan. Secondary objectives were to (1) evaluate timing of PHQ-9 (2) compare the relationship between PSD, severity of stroke, functional disability and discharge location and (3) evaluate patient reported PHQ-9 and proxy family member caregivers results and (4) determine staff satisfaction with project implementation. Methods: In an observational study, 85 consecutive ischemic stroke (IS), hemorrhagic stroke (ICH), subarachnoid (SAH), and transient ischemic attack (TIA) patients consented to participate during admission between March and August 2017. Patients and proxy caregivers completed the PHQ-9 within the first 48 hours of admission, post-discharge day 7, and post-discharge day 30 to assess for depression. The modified Rankin Score (mRS) assessment tool was used to evaluate functional disability pre-stroke and at discharge. Results: Subjects were diagnosed with IS (n=68), ICH (n=15), SAH (n=1) and TIA (n=1). During admission, 47.1% reported depression symptoms. There were 16 (p=0.053) incident cases at day 7 and 13 (p=0.0046) incident cases at day 30. 37.5% were treated during admission based on the initial PHQ-9 score, p=0.0005. Forty-two percent were treated by discharge, p=0.0002. 43.6% were treated by day 7, p=0.0007 and 40.5% treated by day 30, p=0.0002. A significant increase in reported PHQ-9 score from baseline admission occurred later during admission, p=0.0046 and a moderately positive relationship existed between patient reported PHQ-9 and proxy, p<0.0001. A significant relationship occurred between reported minor depression and discharge to a skilled nursing facility (p=0.0163). Conclusions: This study suggests that implementation of an evidenced-based depression screening and treatment algorithm can improve detection of depression symptoms and treatment of PSD during the acute phase of hospitalization. Patients reported a significant increase in depression symptoms later in the admission and there is moderately positive relationship between patient reported PHQ-9 scores and proxy caregiver. Assessment and treatment of PSD during acute hospitalization with follow-up after discharge should be standard of care for all stroke sub-types.