Shirley Thomas

How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review

Background: The benefits of physical exercise in reducing clinically defined depression in the general population have been established, although a review of the evidence for older adults is needed. Objectives: To assess the efficacy of physical exercise for the treatment of depressive symptoms in older adults (>60 years). Data sources: We searched: MEDLINE (1966—May 2008); EMBASE (1980—May 2008); Cumulative Index to Nursing & Allied Health Literature (CINAHL; 1982—May 2008); PsycINFO (1966—May 2008), The Cochrane Library (Issue 2, 2008), and National Research Register (NRR; Issue 2, 2008). Review methods: Randomized controlled trials and quasi-experimental studies of physical exercise interventions for depression were included where 80% or more of participants were >60 years. Abstracts were assessed to determine whether they met specified inclusion criteria. Primary analysis focused on the prevalence of diagnosable depressive disorder following intervention. Secondary outcome was depression or mood scores on standardized scales. Results: Eleven randomized controlled trials with a total of 641 participants were included in the review. Short-term positive outcome for depression or depressive symptoms was found in nine studies, although the mode, intensity and duration of intervention varied across studies. Medium- to long-term effects of intervention were less clear. Conclusion: Physical exercise programmes obtain clinically relevant outcomes in the treatment of depressive symptoms in depressed older people. Exercise, though not appropriate for all in this population, may improve mood in this group. Further research is needed to establish medium- to long-term effects and cost-effectiveness.

Factors relating to depression after stroke.

OBJECTIVES Depression is common after stroke and can impede rehabilitation. The aim of this study was to determine which factors predicted the severity of depression at the time of recruitment to a treatment study and depression 6 months later. DESIGN A questionnaire-based longitudinal study. METHODS A total of 123 depressed stroke patients who were between 1 and 6 months post-stroke and had mild to moderate disabilities were recruited to a randomized controlled trial of cognitive behavioural psychotherapy (CBT) to treat depression (Lincoln & Flannaghan, 2003). At recruitment and at 6 months follow-up, patients (N=112) were assessed on the Beck Depression Inventory (BDI), General Health Questionnaire-28 (GHQ-28), Wakefield Depression Inventory (WDI), Barthel index, Extended activities of daily living scale (EADL), Sheffield Screening Test for Acquired Language Disorders (SST) and Recovery locus of control scale (RLOC). RESULTS Logistic regression showed that greater communication impairment on the SST at recruitment was predictive of severe depression on the BDI at recruitment (OR=0.72, p=.01). Patients with greater communication impairment (OR=0.69, p<.05) and a more external locus of control (OR=0.89, p<.05) at recruitment were more likely to remain depressed at follow-up. Patients who remained depressed at follow-up were more severely depressed at recruitment (p=.001). CONCLUSIONS Locus of control and communication impairment were related to depression. Communication impairment was the strongest predictor of depression severity and prognosis. Mild depression was more likely to resolve. The regression models only accounted for a small proportion of the variance in depression scores. Therefore, further studies of psychosocial factors in a more representative sample are required.

Predictors of Emotional Distress After Stroke

Background and Purpose— The aim of this prospective longitudinal study was to identify factors relating to emotional distress in the first 6 months after stroke in a sample including patients with aphasia. Methods— One hundred patients who were in hospital at 1 month after stroke were recruited and assessed on measures of communication impairment (Sheffield Screening Test), personal activities of daily living (Barthel Index), and emotional distress (Visual Analogue Self-Esteem Scale). Demographic and stroke characteristics were recorded. Patients (n=92) were reassessed on the same measures 6 months after stroke, in addition to assessing extended activities of daily living (Nottingham Extended Activities of Daily Living Scale). Results— Patients were aged 44 to 86 years (51 men), and 21 were classified as having aphasia. Multiple linear regression showed that expressive communication impairment and dependence in personal activities of daily living were significant predictors of emotional distress at 1 month after stroke (R2=24%). Expressive communication impairment, emotional distress at 1 month after stroke, and having a more severe stroke were significant predictors of emotional distress at 6 months after stroke (R2=55%). Distress levels were similar at 1 month and 6 months after stroke. Demographic characteristics and side of lesion were unrelated to distress. Conclusions— Expressive communication impairment and level of disability in personal activities of daily living were related to distress. Distress was persistent in the first 6 months after stroke. Appropriate treatment strategies need to be developed and evaluated for patients who have communication impairments.

Communication and Low Mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia

Objective: The aim was to evaluate behavioural therapy as a treatment for low mood in people with aphasia. Design: A randomized controlled trial comparing behavioural therapy plus usual care with a usual care control. Potential participants with aphasia after stroke were screened for the presence of low mood. Those who met the criteria and gave consent were randomly allocated. Setting: Participants were recruited from hospital wards, community rehabilitation, speech and language therapy services and stroke groups. Subjects: Of 511 people with aphasia identified, 105 had low mood and were recruited. Interventions: Behavioural therapy was offered for up to three months. Outcomes were assessed three and six months after random allocation. Main measures: Stroke Aphasic Depression Questionnaire, Visual Analog Mood Scales ‘sad’ item, and Visual Analogue Self-Esteem Scale. Results: Participants were aged 29 to 94 years (mean 67.0, SD 13.5) and 66 (63%) were men. Regression analysis showed that at three months, when baseline values and communication impairment were controlled for, group allocation was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), visual analogue ‘sad’ (P = 0.03), and Visual Analogue Self-Esteem Scale (P < 0.01). At six months, group alone was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), and remained significant when baseline values were controlled for (P = 0.02). Mean Stroke Aphasic Depression Questionnaire 10-item hospital version scores decreased from baseline to six months by six points in the intervention group as compared with an increase of 1.9 points in the control group. Conclusions: Behavioural therapy seemed to improve the mood of people with aphasia.

Clinical evaluation of a non-immersive virtual environment in stroke rehabilitation

Background and purpose: We describe our attempts to evaluate the effectiveness of a virtual environment developed to rehabilitate stroke patients in the task of making a hot drink. Methods: Single case studies were performed in 13/138 (9%) stroke patients undergoing rehabilitation in a UK stroke unit. Participants in AB/BA (n = 5) and ABA (n = 2) design studies received 5 one-hour sessions of attention control training (A phase) and 5 one-hour sessions of virtual environment training (B phase). An AB design with random duration of A and B phases (minimum duration of A and B phases 3 and 5 days respectively, with total duration of 3 weeks) was used in 6 participants. Results: Visual inspection of scores across all cases showed a trend towards improvement over time in both real and virtual hot drink making ability in both control and intervention phases. There was no significant difference (Wilcoxon, p > 0.05) in the improvements in real and virtual hot drink making ability during all control and intervention phases in the 13 cases. Ceiling effects limited the evaluation of effectiveness in 5 of the 8 cases in which daily performance measures were used. Conclusions: Few people in this setting were suitable for this intervention. The case studies showed no evidence of a strong effect of this intervention, but we had great difficulty in performing single case studies. We conclude that more testing and development of this system is required before it is subjected to rigorous testing of clinical effectiveness.

Cognitions and post-stroke depression.

OBJECTIVES Studies investigating the efficacy of cognitive-behavioural treatment for post-stroke depression have produced contradictory results (Flannaghan, 2000; Lincoln, Flannaghan, Sutcliffe, & Rother, 1997). This study aimed to assess whether depressed stroke patients experienced more negative and less positive cognitions than non-depressed stroke patients in order to ascertain whether post-stroke depression is suitable for cognitive-behavioural therapy. DESIGN A questionnaire-based study compared stroke patients who were assessed as depressed or not depressed. METHODS A Cognitions scale was developed from transcripts of cognitive-behavioural therapy sessions with depressed stroke patients. A total of 50 stroke patients, the majority of whom were still in hospital, were assessed on the Beck and Wakefield Depression Inventories and the Cognitions scale. RESULTS The prevalence rate for depression was similar to that found in previous studies. The internal reliability and construct validity of the scale were found to be acceptable. Significantly more negative cognitions and less positive cognitions were found in stroke patients who were depressed as compared with stroke patients who were not depressed. CONCLUSIONS The study suggests that post-stroke depression does not differ qualitatively from general depression and that general theories and thus treatments for depression may be valid within this population.

The assessment of low mood in stroke patients with aphasia: reliability and validity of the 10-item Hospital version of the Stroke Aphasic Depression Questionnaire (SADQH-10)

Objective: To assess the psychometric properties of an observational screening measure of depressive symptoms (SADQH-10; 10-item Hospital version of the Stroke Aphasic Depression Questionnaire) for use in stroke patients with aphasia and to determine the convergent and divergent validity of the SADQH-10. Design: Cross-sectional cohort. Setting: Hospital and community. Participants: Stroke patients with aphasia (n = 165) were recruited through hospital wards and community services as part of a randomised controlled trial. Participants were aged 29 to 94 years (68.6 ± 12.1) and 65% were men. Results: The SADQH-10 demonstrated good internal consistency (α = 0.77). Factor analysis revealed the SADQH-10 to be measuring three constructs (social interaction and physical pain, tearfulness, loss of interest and motivation). Significant correlations were found between scores on the SADQH-10 and VAMS ‘sad’ item (rs = 0.297, P < 0.01) but not with the VASES ‘depression’ item (rs = 0.064, P = 0.590) or measures of physical and language abilities. Conclusions: The SADQH-10 is both a valid and reliable observational screening measure of depressive symptoms for stroke patients with aphasia.

Psychometric properties of a revised version of the Visual Analog Mood Scales

Objective: To assess the internal consistency, validity and factor structure of a revised version of the Visual Analog Mood Scales (VAMS-R) in healthy older adults and aphasic stroke patients. Design: Cross-sectional study. Participants: Fifty healthy older people and 71 aphasic stroke patients. Setting: Community and hospital. Measures: The healthy participants were asked to complete the Hospital Anxiety and Depression Scale (HADS) and the VAMS-R. The aphasic stroke patients completed the VAMS-R and Visual Analogue Self Esteem Scale (VASES) and the Stroke Aphasic Depression Questionnaire 21 (SADQH-21) was completed by a nurse or carer. Results: The internal consistency of the scale was high (healthy adults alpha 0.74, aphasic stroke patients alpha 0.80). The VAMS-R correlated significantly with the HADS in healthy participants (HADS Anxiety rs = 0.59, P < 0.001, HADS Depression rs = 0.49, P = 0.001) and the VASES (rs = −0.69, P < 0.001) and SADQH-21 (rs = 0.43, P = 0.001) in stroke patients. Exploratory factor analysis identified three factors in the scale: negative mood states, energy levels and happiness. The three factors accounted 73% of the variance in healthy participants and 70% of the variance in aphasic stroke patients. Conclusions: The VAMS-R showed better psychometric properties than the original VAMS. Reversing the happy and energetic items improved the ability of the scale to assess mood states.

Validation of the Stroke Aphasic Depression Questionnaire using the brief assessment schedule depression cards in an acute stroke sample

OBJECTIVE To validate the Stroke Aphasic Depression Questionnaire (hospital version: SADQ H10), an observer-rated measure of depression, against the brief assessment schedule depression cards (BASDEC) in acute stroke. METHOD This naturalistic audit utilized a cross-sectional design. As part of routine care, 125 patients on an acute in-patient stroke unit were assessed with the BASDEC and SADQ H10. RESULTS The BASDEC classified 40 patients as depressed and 85 as non-depressed. The SADQ H10 and BASDEC significantly correlated. An ROC (receiver operating curve) analysis showed that the SADQ H10 discriminated between depressed and non-depressed acute stroke patients. CONCLUSIONS The results support the use of the SADQ H10 as a depression screen in acute stroke.

Prevalence of traumatic events and PTSD symptoms among secondary school students in Baghdad.

Background People in Iraq have been more or less continually exposed to war for more than three decades. Studies with Iraqi participants report high prevalence rates of posttraumatic stress disorder (PTSD) and related problems. Methods The aim of this study is to measure the prevalence of traumatic events and to screen the prevalence of PTSD symptoms among Iraqi secondary school students. Four self-report scales were administered to 403 secondary school students, aged 16–19 (61% male and 31% female). These scales were Baghdad Trauma History Screen, the Scale of Posttraumatic Stress Symptoms (SPTSS), Social Support Scale, and Scale of Religious Coping. Results The results showed that 84% of participants experienced at least one traumatic event. Of these, 61% fully met the criteria for PTSD; 65% of the females and 58% of the males. PTSD symptoms were correlated with 20 positive religious coping but not with social support. Conclusions It’s clear that traumatic events were speared widely among the participants and the result showed that the vast majority of participants were exposed to different types of traumatic events. In addition, many of the participants have met full PTSD criteria and others had partial PTSD.