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Qualitative and Quantitative Measurement of Depression in Veterans Recovering from Stroke

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Qualitative and Quantitative Measurement of Depression in Veterans Recovering from Stroke Volume 42, Number 3, Pages 277–290 JRRDJRRD May/June 2005 Journal of Rehabilitation Research & Development Qualitative and quantitative measurement of depression in veterans recovering from stroke Christine L. Williams, DNSc, APRN, BC;1* Maude R. Rittman, PhD, RN;2 Craig Boylstein, PhD;2 Christopher Faircloth, PhD;2 Qin Haijing, MS2 1University of Miami, School of Nursing and Health Studies, Coral Gables, FL; 2North Florida/South Georgia Veterans Health System, Department of Veterans Affairs Health Services Research and Development/Rehabilitation Research and Development Rehabilitation Outcomes Research Center, Center of Excellence, Gainesville, FL Abstract—This analysis triangulates qualitative and quantita- This study describes early poststroke emotional tive data from interviews, Geriatric Depression Scale scores, recovery in a population of veterans and explores the and patient records to evaluate poststroke depression. Partici- extent to which the GDS agrees with narrative descrip- pants were veterans who were discharged home following a tions of negative mood experiences obtained from at- new stroke. Findings indicated underrecognition and treatment home interviews and clinical indicators of depression of depression. Narrative data uncovered a rich description of obtained from patient records. Two research questions respondents’ perceptions and emotional experiences during guided the qualitative component of the study: (1) “What stroke recovery. Key words: cerebrovascular accidents, culture, depression, geriatric, measurement, mental health, qualitative methods, rehabilitation, stroke recovery, triangulation. Abbreviations: DSM-III = Diagnostic and Statistical Manual of Mental Disorders, 3rd edition; GDS = Geriatric Depression Scale; MMSE = Mini-Mental State Examination; NUD*IST = Nonnumerical Unstructured Data Indexing Searching and The- INTRODUCTION orizing; PSD = poststroke depression; SD = standard deviation; VA = Department of Veterans Affairs. Depression is a significant problem in recovery from This material was based on work supported by the Depart- stroke because it has been linked to disability, caregiver ment of Veterans Affairs (VA) Health Services Research burden, institutionalization, and mortality [1–3]. Since and Development (HSR&D), Nursing Research Initiative depression frequently complicates stroke recovery, the (grant 98-183). The work was also supported with issue of measurement is critical to the development of resources and the use of facilities at the VA HSR&D/Reha- knowledge about prevalence, change over time, and treat- bilitation Research and Development Rehabilitation Out- ment [4]. Yesavage et al. describe the Geriatric Depression comes Research Center of the North Florida/South Georgia Scale (GDS) as a screening tool for depression [5], Veterans Health System and the Miami VA Medical Center although it has been used as an outcome measure as well Geriatric Research, Education and Clinical Center. [6]. The GDS has been determined to be reliable and valid *Address all correspondence to Christine L. Williams, DNSc, in many studies [7–8] and has been used with the poststroke APRN, BC; University of Miami, School of Nursing and population [9]. Although it has been widely used, less is Health Studies, 5801 Red Road, Coral Gables, FL 33124; 305- known about how GDS self-ratings compare to qualitative 284-6025; fax: 305-470-0104. Email: [email protected] descriptions of mood and clinical data from patient records. DOI: 10.1682/JRRD.2004.02.0017 277 278 JRRD, Volume 42, Number 3, 2005 are the emotional recovery experiences of veterans fol- physical symptoms of stroke [9]. Since older adults may lowing hospitalization for stroke?” and (2) “What is the not describe their mood in psychological terms, this relationship of GDS scores to descriptions of emotional emphasis may be problematic. recovery as related by veterans during at-home inter- In some studies, the GDS was an adequate screening views at the same point in time?” The following addi- measure in the poststroke population. For example, tional research question guided quantitative analyses: Johnson and associates compared the GDS to other (3) “What is the relationship between GDS scores, screening instruments and depression diagnoses using participant ethnicity, and clinical indicators of depres- Diagnostic and Statistical Manual of Mental Disorders, sion?” We hypothesized that no relationship would exist 3rd edition (DSM-III) criteria [24]. They reported that the between GDS scores and ethnicity. To address the rela- GDS performed satisfactorily for sensitivity (80%) but tionship between the GDS and clinical data, we hypothe- less so for specificity (66%). They found a prevalence of sized that the number of participants self-reporting 26 percent. Agrell and Dehlin compared the GDS to five depression (via the GDS) would be similar to the number other depression rating scales in a stroke population and diagnosed and treated for depression. found that the GDS and the Zung performed best of the six instruments [25]. Rao, Jackson, and Howard found that the performance of the 15-item GDS was satisfactory and BACKGROUND similar to the modified Hamilton Rating Scale for Depres- sion [26]. Lieberman and associates translated the GDS to Depression is common after stroke, occurring in over Hebrew and used it to measure depression in 276 individ- 50 percent of survivors [10–13], yet it is often undiag- uals receiving rehabilitation in Israel (126 poststroke and nosed [14]. Treating depression has been shown to 150 posthip fracture) [27]. They found a high prevalence improve functional ability [15–16]; therefore, appropriate of depression overall (41%) and no difference in preva- measurement is crucial to maximize remaining abilities. lence between the two groups. Depression was signifi- Detecting and treating depression early is important cantly related to independence and self-care ability before because depression predicts adverse health outcomes [15]. the event and improved over the course of hospitalization The older person who experiences a stroke is vulner- (mean = 23 days). able to depression from biologic causes such as hypoxia Other studies using the GDS in elders from minority and from psychosocial stressors due to the loss of physi- cultures have yielded mixed results. In a study of 41 older cal function and decline in quality of life. In the post- Mexican Americans diagnosed with PSD with the use of stroke period, depression is a strong predictor of quality the DSM-III criteria, Baker and Espino found only 39 per- of life and mortality [16–21]. Depression may occur up cent screened positive for depression with the recom- to 2 years following stroke and may worsen during stroke mended cutoff of 6 on the 15-item GDS Spanish version recovery [21]. Improvement in poststroke depression short form [28]. Baker and Espino recommended using a (PSD) is associated with better performance in activities cutoff of 4. They cautioned that Mexican Americans may of daily living [22] poststroke. Whether depression is be more likely to express mood in somatic symptoms than organic, reactive, or a combination of the two, intensity psychological symptoms. Since the GDS is designed to varies from major depression to subsyndromal depres- minimize somatic complaints, under-diagnosis may be sion. Major depression is the most serious and debilitat- more likely. ing, but mild depression may also adversely affect Fernández-San Martin and colleagues found the 30- physical function and quality of life [23]. Measurement item Spanish version of the GDS to be satisfactory for a scales, therefore, must be sensitive enough to detect a sample of 218 mostly female patients in primary care range of depressive symptoms. [29]. However, they recommended a lower cutoff (9/10) Standardized measures such as the GDS have been for primary-care patients (sensitivity 86.7% and specific- widely used in stroke patient populations; however, ques- ity 63.1%). They found no difference in mean scores for tions remain regarding the relevance of the GDS in PSD. those with and without cognitive impairment. One advantage of the GDS for this population is the Tang and colleagues used a Chinese version of the focus on psychological symptoms of depression to GDS short form to screen 127 older Chinese participants decrease the potentially confounding effects from the for depression 3 months after an acute stroke [30]. 279 WILLIAMS et al. Measurement of depression in stroke Although sensitivity and specificity were acceptable The recruitment process began when patients were (87% and 73%, respectively), they found a low positive hospitalized with a new stroke. Nurses introduced the predictive value (37%). They recommended the use of study and asked patients if they would be willing to speak additional methods for more accurate screening. to a member of the research team about participation. If In a study of African-American and Caucasian nurs- the patient expressed interest, a research team member ing-home residents, Harralson and associates found that visited the potential participant, provided detailed infor- Caucasian residents evidenced more depression than mation regarding the study, and requested consent. African-American residents [31]. African Americans Following consent, eligibility was determined according were less likely to be diagnosed with depression and less to the inclusion and exclusion criteria and initial screen- likely to be taking antidepressant medication, and also ing data were
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