1. Helping with low mood and depression after stroke
Ways to help someone with mood problems after stroke

2. Introduction and learning objectives
This session looks at an overview of understanding someone who may suffer from with low mood after a stroke.
The session is recommended for all levels of staff working across the stroke pathway.
The session will cover:
Recap of depression
RCP tiered framework for interventions for psychological problems, including depression
Management approaches that all staff can use: core therapeutic skills, activity scheduling, problem solving, motivational interviewing and managing thoughts and feelings.
Pathways for referral on for moderate to severe depression.

3. Recap on depression 1
We discovered in the last session that depression is a common problem after a stroke, affecting possibly one in 3 people who have experienced a stroke at some point.
It is not always clear when someone may get depressed. It may be immediately after stroke or later on, around 6 months when full functioning may not have been achieved.
In relation to depression we are aware that issues such as pain can contribute to depression. Other life events such as bereavements and lack of support can also make life difficult. Some people may have had periods of depression before and may be more vulnerable to episodes of depression.
There are varying levels of depression, from mild to severe and diagnostic categories can help to clarify this.

4. Recap on depression 2
We also learned that there are certain characteristics, or patterns of feeling, thinking and acting, as well as physiological responses that people encounter when they are depressed. There is also the social impact of depression.
This holistic (bio-psychosocial) is the most helpful framework for understanding depression.
Empathising with how somebody feels, what their thoughts are and how that affects what they feel able and willing to do is important.
By understanding this we can begin to support a person emotionally, as well as to problem solve any “blockers” in the way of a person’s progress.

5. The tiered approach and levels of intervention
How we assist people with depression depends on the severity of the problem to a large extent. Referral on to mental health professionals will be necessary in some cases, for example in the case of an individual experiencing major depression, or someone who displays depression with psychotic symptoms.
We should all recognise the symptoms of depression and we all can, and do, offer some form of support, particularly for mild to moderate levels of depression.
The tiered model adopted for stroke is presented on the next slide. This helps us to look at core skills expected for all staff to deliver.

6. Stepped Care/Tiered Model

7. Ways to help: core skills
This section refers to the interventions that all staff should use to help an individual who is suffering from the effects of depression.
Core counselling skills including warmth, genuiness and empathy are key to our work. Being sensitive and open to asking why a person is low can open the door to understanding the individual.
By using our core counselling skills we can help people to feel truly acknowledged and they will believe that you are genuine in your quest to help them, thereby they can feel understood and supported.

8. Take a minute to understand the person’s experience of depression
We heard some patient accounts oh how it feels to have depression in the previous presentation from ”Dorothy” and “John”.
A good exercise in trying to understand the person whom we are helping, before we rush in to suggest ways to help is to take a moment to “step in to their shoes”. Imagine how it might feel to have their difficulties, to be that person, coping, 24 hours a day; 7 days a week. This is called “internalising the other”; being able to understand how it may feel to be that person and what their current difficulties are.
Remember that when people are down they often feel that they are worthless, the world is hostile and the future hopeless. The person who you may be thinking of may have some thoughts relating to these beliefs.
Think back to “John” who was severely depressed, how he described what really was going on beneath the surface of his day to day life.

9. A shared understanding.
Any intervention should be based upon a shared understanding of the symptoms of depression for the person, the personal impact of the depression and the problems that the low mood is causing.
This is turn helps us to begin to help the person.
Sometimes simply talking about the depression helps a person to let go of some of feelings and fears, and can itself often be therapeutic. Think of the last time that this happened for you- when someone seemed to really acknowledge how you were feeling when you were upset and where you felt listened to and understood. Getting things out in the open can help.
Giving people an explanation of depression and how it affects people can often help them to understand themselves and their situation. Information booklets can explain depression in more detail, and may introduce techniques to help.
People may then be able to work collaboratively with us looking at what may help them, step by step.

10. You can use assessment templates to pick the key symptoms of depression for a person. Here is a generic one as a guide.

11. Psychological techniques to help with depression
Once we have understood someone is suffering from depression we aim to challenge some of the areas where depression is impacting on their functioning, for example someone giving up on activities. We also aim to challenge the most unhelpful thoughts.
Ultimately whilst we acknowledge that it is difficult coping with the stroke and the psychological issue of depression, we want to offer some strategies to make a person feel worthwhile and useful again and their future worth working towards, thereby giving a glimmer of hope.
Many of the psychological interventions try to change a persons behaviour and function, whilst others look at challenging unhelpful and distressing thoughts. These are considered next.

12. Ways to help: Scheduling Activity
Activity Scheduling is a simple behavioural intervention that is often used with patients who are depressed. It can help people to re-engage in things they like doing or to re-establish routines.
We can also use it to “test” some of the patient’s negative assumptions (for example, “I don’t enjoy anything these days”, “I can’t do anything anymore”).
One way to look at this is by asking people about their current level of activity, and what might be helpful to add in to a day or a week. Trying to introduce activity which gives the person a sense of mastery and pleasure (however small) each day is a good start as it can improve mood.

13. Ways to help: increasing positive activity
The overall aim of an Activity Schedule is to identify behaviours and activities that make an individual feel better, and then to increase the frequency of these activities, thereby decreasing the amount of time that somebody is feeling depressed. By focussing on mastery or pleasure, we might be able to help the person being more active even with tasks that they do not enjoy very much.
You can find blank Activity Schedules in the PAAST toolkit.

14. Ways to help: problem solving
When people are depressed they often feel that there are no, or limited solutions to their problems.
Take Alice, who had been in hospital for 2 months following a stroke. She was making progress but could not walk unaided. Despite the progress in her rehabilitation staff saw Alice’s mood seem to deteriorate. They asked Alice about this and she reported that she was fed up of being in hospital and she felt that she would never get out. The staff asked her if anything could help and Alice thought that there probably wasn’t. The staff pursued this further, asking if Alice may like to get off the ward? Alice’s family had offered this many times but she had said no as she felt that she was a burden.

15. Problem solving
The staff reflected this back to Alice: her problem appeared to be that she was getting down and felt that she was never going to get out of hospital. However Alice was not taking offers up of going out as she felt a burden (although this may have been Alice’s rather than her family’s view).
The staff took the lead in suggesting that it would be a good plan to work towards getting Alice out more as this could improve her mood. They suggested that they see Alice with her family to explore this option and to ascertain all possible options; selecting an option that would suit everybody. This also moved the rehab goals forward, staff would train Alice’s family in car transfers and outdoor safety.

16. Key steps to problem solving

17. Goals
Problem solving often leads to us setting a goal with the person who is feeling low after a stroke.
In making SMART goals (Specific, Measurable, Achievable, Realistic and Targeted) with someone who is depressed we need to make the goal attainable as success experiences are needed. Eliciting support from others can also help, so as to give support when people are at a low point.
In the case of Alice she and her family set a very small and realistic goal to begin with and evaluated the outcome as a successful. Building from this Alice tried other goals and she began to see that she would get out again.
As part of good collaborative goal setting we have to let the person set their goals, with our support. The next slide looks at motivational interviewing.

18. Ways to help: motivational interviewing
Motivational interviewing is a technique used by many health professionals to aid us when we are working with rehabilitation goals or promoting behaviour/ lifestyle changes. When working with an individual who is low in mood, you might find that they lack motivation to take part in therapy or work towards their goals.
Motivational interviewing is all about getting people to want to change for themselves, rather than us simply telling them what they should or should not do.
Within this people will have “internal debates” as to whether they should or shouldn’t do something.

19. Internal debates
Have you ever had an internal argument with yourself where it almost feels as though you have a miniature devil on one shoulder and a miniature angel on the other one? Perhaps one part of you is saying “eat a second slice of cake”, when the other part is saying “you’re supposed to be trying to eat healthily this week”.
These will be some of the types of arguments that your patients will be dealing with:
“Should I go to the OT group this morning, or can I not be bothered?”
“Is there any point in having physiotherapy today as I did terribly yesterday…. then again it might help if I can only get myself motivated”

20. How we help
Sometimes we fall in to the role of the miniature angel, telling people about all the positive changes they have to make and how they should go about doing it. This however means that the patient does not own these arguments, and is left with the role of the miniature devil – defending their choices and putting forward the other point of view.
Through motivational interviewing, we try to ask the right questions to get the patient to take control of both sides of the argument so that they are the ones coming up with reasons why they should change or why they should take part in an activity or goal. Someone is much more likely to run with an idea/plan of action if they came up with it themselves, than they are if you are just telling them what to do.

21. Getting started
Sometimes when people are depressed they know what may help but simply can’t get started.
Try working on the premise that doing a little of something is better than doing nothing, and may make people feel, even say 10% better at that time if they engage in something. This may take 5 minutes of our session time to negotiate this however a person will feel better when they say they have done a session with you rather than avoided it.
Sell action plans as an experiment, something to try with an exit point if it isn’t working. Think about Alice who wasn’t keen about going out. She tried the experiment of going out, and in time she was able to get to the hospital café, then later out to a pub for lunch and she thoroughly enjoyed it when it happened.

22. Recap on things to consider when working with someone who is depressed
Bear in mind that like Alice, when any of us are having a down day our emotions are closer to the surface and we feel less optimistic of the results of most things we do. Or we try to get out of doing things completely.
In any approach for someone with depression we must be aware of this, therefore it can take longer to engage somebody in to any activity (even talking) that day.
Weighing up the pros and cons from trying an activity, or talking, that particular day may help.
For people who are more depressed they may need more encouragement and goals should be small and concrete, with feedback given for how well they did even to try, given the extent of their depression.
Utilising support: people who the person most trusts (including staff) can be a good way to help move people forward.

23. Ways to help: identifying the thoughts in depression
Cognitive behavioural therapy (CBT) is recommended for post-stroke depression. Although trained staff may help to deliver psychological therapy, we can all help to understand a person, using basic CBT techniques. Take the example below:
George has a “script” in his mind which mirrors the symptoms of depression he is experiencing. He wakes up and tells himself “there’s no point in doing anything today as I’m useless and it will not make me feel any better”. That day he refused to do much. At the end of the day he felt dissatisfied, unfulfilled, and a little cross. His day had turned in to a no-win situation. He got no sense of pleasure or sense that he had mastered anything in his day, making him feel yet lower.

24. Helping George
All staff can help George by listening out for what is going through his mind, to his negative thoughts. This helps us to empathise with how he is feeling that day and the impact of his depressed mood on his thinking. Validating that when we are down we can feel bad and have negative thoughts may help him to acknowledge that depressive thinking is present.
Offering options for George to do something that day to see if this changes his mood, even to a small degree, may help. Offering an alternative opinion to his worst thoughts may also be useful: you may want to ask George when he suggests that he is useless if his family would see him that way or whether they have a different perspective on things?

25. Challenging key “down” thoughts
George's Unhelpful Down Thought
Helpful thought
“There is no point in doing anything today as I am useless and it will not make me feel any better”
“I am feeling a bit low today and this feels hard. However I will try something as it might help, or at least will distract my mind. I feel useless but people tell me that I am not, I am recovering from a stroke. I shouldn’t dwell on this as it doesn’t help. Come on let’s get on with the day”

26. Helping George
Feedback that the team working with George tells him that they have a different view of him to his own. They tell him that George is making good progress and would certainly not see him as useless, nor want him to give up! They tell him that they respect him for his efforts and the effort he is making.
Encouraging mastery and pleasure every day and involving others to set goals with George also helps greatly. They speak to his wife about what can help when she comes in. She brings some things from home and their son takes him out in the wheelchair around the hospital grounds whenever he comes in.
Talking to George about what is important to him, for example seeing his family and friends, and planning that he can get out even more yet might help him to feel more hopeful.

27. Pathways of care
The stepped care model of assisting people with more severe or complex depression advises that there are clear pathways for approaching specialist staff in mental health to assist in the assessment and treatment of more moderate to severe, or complex difficulties with depression.
Specialist staff will additionally consider past mental health issues, psychiatric history, personality functioning, substance abuse and a host of interconnecting issues such as family functioning. They will value your opinions in such assessments as you know the person well.
Interventions such as talking therapy or medication that can help with the depression will be offered and evaluated as to their effectiveness; the details of which should be written in a mood management plan.

28. Summary 1
Depression is a common consequence of stroke but a difficult problem to face.
Screening and assessment of depression is important and can help us to gauge severity of depression and can start a conversation about how someone really feels inside.
Identification of depression should lead to treatment.
Understanding how somebody feels in their environment, their thoughts and feelings and how this impacts on their functioning can help us to step in to their shoes and to begin to help them.

29. Summary 2
Educating people about depression can make it feel more understandable and therefore controllable.
Applying techniques to manage depression can help: this may include support, ways to encourage mastery and pleasure and goal setting, in addition to challenging negative thoughts.
Have a referral process for those who are moderately to severely depressed. Check if the person has been depressed in the past and what helped at this time.
Your understanding and support will be key to recovery. Compassion and support for the person experiencing depression will make all the difference.