F Clegg

The Depression Intensity Scale Circles (DISCs): a first evaluation of a simple assessment tool for depression in the context of brain injury

Objective: To assess the validity, responsiveness, and test–retest reliability of DISCs (Depression Intensity Scale Circles) as a simple screening tool for depression in patients with cognitive or communicative deficits following acquired brain injury. Design: Cohort analysis of consecutive patients entered into an integrated care pathway for screening and management of depression in the context of rehabilitation. Setting: Regional neurological rehabilitation service in the UK. Participants: 114 patients with complex disabilities caused by acquired brain injury (mean (SD) age, 42.8 (14.5) years). Main outcome measures: DISCs (a graphic rating scale depicting six circles with increasing proportion of dark shading), Numbered Graphic Rating Scale (NGRS), Yale single question (“Do you often feel sad or depressed”), Beck Depression Inventory-II (BDI-II), DSM-IV criteria for depression. Results: At initial assessment the DISCs correlated with total BDI-II scores (Spearman ρ = 0.66, p<0.001), NGRS (ρ = 0.87, p<0.001), and DSM-IV (ρ = 0.59, p<0.001). A DISCs score ⩾2 identified depression (major or minor) according to DSM-IV criteria with 60% sensitivity, 87% specificity, 75% positive predictive value, and 77% negative predictive value. Test–retest reliability after 24 hours (n = 66) showed “excellent” level of agreement (weighted κ = 0.84). In 45 patients who received intervention for depression, the DISCs showed a significant change in response to treatment (Wilcoxon; p<0.001). Conclusions: DISCs had acceptable convergent validity, reliability, and responsiveness as a simple graded tool for screening and assessment of depression in patients with complex disabilities following acquired brain injury. It warrants further investigation in patients with more profound language and cognitive deficits for which it is primarily intended.

Managing depression in brain injury rehabilitation: the use of an integrated care pathway and preliminary report of response to sertraline

Aims: To use data generated from an integrated care pathway (ICP) to describe the characteristics of patients presenting with depression in a brain injury rehabilitation programme and to assess their response to treatment with sertraline. Setting: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16–65) with severe complex disabilities. Design: Prospective cohort study of 82 patients admitted to the unit during the 15-month period between between 1 September 1999 and 1 December 2000. Response to sertraline was assessed in an open-label, before-andafter study design Methods and design: All admissions were screened and included in the ICP if there was clinical suspicion of depression, past or present. Anti-depressant medication was prescribed, where appropriate, according to the ICP protocol. Depression was diagnosed on clinical grounds against DSM-IV criteria, and measured where feasible using the Beck Depression Inventory (BDI-II) administered by interview, pretreatment and at 6–8 weeks. Results: Of 82 admissions 41 (50%) were managed using the ICP and 27 (64%) were either started on or changed to sertraline – 21 for depression ± lability and six for emotional lability only. All of the depressed patients improved clinically at some level and no signi”cant side-effects were observed. The BDI-II was assessable in 17/21 who showed a mean improvement of 14.5 ± 9.7 (con”dence interval (CI) 9.3–19.7, p < 0.001). Eleven patients (52%) had previously failed to respond with a different selective serotonin re-uptake inhibitor (SSRI) agent but still made a signi”cant response when changed to sertraline with a mean reduction in BDI-II of 16.3 ± 10.9 (CI 8.4–24.11, p < 0.001). Conclusions: The ICP was practical to use and provided systematic data on assessment of depression and response to treatment in ‘real-life’ clinical practice in a brain injury rehabilitation setting. Sertraline appears to be useful and well-tolerated in this context. A full placebo-controlled study is now required.

A completed audit cycle and integrated care pathway for the management of depression following brain injury in a rehabilitation setting

Objective: To develop an evidence-based multidisciplinary integrated care pathway (ICP) for the management of depression following brain injury in a rehabilitation setting, and to assess its impact on standards of care and documentation. Setting: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16–65) with complex disabilities mainly resulting from brain injury. Methods and design: A completed cycle of audit including: standards set for documentation, assessment, management and review; L an initial retrospective audit of documented patient management against those standards during a five-year period (26 patient records); ICP development by a multidisciplinary team of doctors, psychologists and nurses based on clinical opinion and systematic review of the literature; re-audit from the ICP documentation (48 patient records) over a period of 15 months. Results: The initial audit demonstrated borderline acceptable documentation of baseline mood state and start of medication (54–61%), but poor documentation of review (29%) and subsequent treatment (27%). Introduction of the ICP improved all standards of documentation to 94–100%, except for assessment using a validated measure (84%) and follow-up assessment (76%). Conclusions: This ICP raised staff awareness of depression, leading to improved documentation and possibly also standards of care.