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Running Head: DEPRESSION-RISK SCREENING POST STROKE

Enhancing Depression-Risk Screening Among Post-Stroke Patients During Acute

Hospitalization

Tracey L. Collins

Doctorate of Nursing Practice Program Capstone

Simmons College

© 2014, Tracey L. Collins

DEPRESSION-RISK SCREENING POST-STROKE ii

DEPRESSION-RISK SCREENING POST-STROKE iii

Abstract

Providers frequently fail to identify depressive symptoms in elderly patients.

National guidelines recommend routine formal depression screening for high risk adult

populations such as those with any chronic condition; however, this is not consistently

performed. The literature has identified that individuals with a history of major depression

may have a 34% higher risk for developing a stroke compared to the general population.

Therefore, based on high rates of undetected depression in the general elderly and higher

stroke rates among adults with major depression, this project aimed to implement depression-

risk screens during acute hospitalization to identify and initiate treatment for elderly patients

admitted for a stroke or transient ischemic attack (TIA).

For this project, focus groups were conducted to explore approaches staff nurses

would propose to integrate a depression-risk screening tool into their electronic health record

(EHR) and workflow. Based on results from the focus groups and a review of the literature,

both education and system changes were implemented to support adult depression-risk

screening and mental health referrals. As a result of this intervention, acute stroke and TIA

patients were screened every shift by staff nurses, with the Patient Health Questionnaire-2

(PHQ-2) depression-risk screening tool, within 24 to 48 hours post-acute hospital admission.

Patients with a PHQ-2 score of 2 or greater were offered a referral to a mental health

counselor for further evaluation of depression.

The focus groups identified seven themes to facilitate integrating a depression-risk

screen into the nurse assessment and workflow. In the education intervention, 110 nurses

completed web-based education of which 103 nurses also received face-to-face education.

Test scores increased significantly between the pre-education (M=55.27, SD=15.5) and post-

DEPRESSION-RISK SCREENING POST-STROKE iv

education tests (M=89.91, SD=11.3, t(109)=20.649, p=0.001. During the depression-risk

screening intervention, 80% (n=36) of the nurses screened as indicated and 86.7% (n=26) of

adult-hospitalized stroke patients received at least one depression-risk screen within the

electronic health record. Of the patients screened, 15.4% (n=4) had positive results, 50%

(n=2) accepted a mental health counselor referral, 50% (n=2) were prescribed an

antidepressant at discharge, and 25% (n=1) declined referral or treatment, but accepted a

chaplain consult for support.

This project identified barriers and implemented interventions to facilitate the use of

a depression-risk screen within the EHR for adult stroke and TIA patients in the acute

hospital setting. As a result of this project, 86.7% of acute hospitalized adult stroke patients

were screened, 15.4% had positive results, and 75% accepted an intervention. Of note, the

positive results were lower than expected, thus further study should be conducted to evaluate

staff nurse data collection methods.

DEPRESSION-RISK SCREENING POST-STROKE v

Acknowledgments

This practice inquiry project was made possible due to the support from student

colleagues, co-workers, and through the support of Simmons College faculty. My passion for

neuroscience patients began at Duke University Medical Center (DUMC) where I worked on

neuroscience units. During my graduate studies at Duke University, my graduate project

improved neuroscience patient outcomes through implementation of evidence-based-

practices surrounding aggressive fever management in neuro-critical care patients.

Upon leaving DUMC, my passion for neuroscience continued to grow. At Portsmouth

Regional Hospital, I was supported in obtaining my certification in neuroscience (CNRN),

serving as the Neuroscience Services Coordinator and leading the hospital to achieve Primary

Stroke Accreditation from The Joint Commission. Throughout this project, support was given

by all levels of the organization including senior leaders, physicians, stroke committee

members, directors, professional development educators, quality management professionals,

nursing informatics, staff nurses, and mental health counselors. Of note, I would like to thank

Bonnie Fossett for her guidance and support as a member of my capstone committee.

Everyone’s support, constructive feedback, and vested interest to strengthening patient care

were greatly appreciated.

Lastly, the educational experience at Simmons College has been enlightening. Many

discussion posts, papers, and exploration of online resources opened a world of nursing that

had been previously unfamiliar to me. I thank and acknowledge the doctoral students and

faculty at Simmons College. Of note, I would like to thank Rebecca Koeniger-Donohue for

her consistent guidance as my advisor and committee chairperson, Shelley Strowman for her

support on my capstone committee and for teaching me statistics in a manner that allowed

DEPRESSION-RISK SCREENING POST-STROKE vi

me to apply that knowledge during my project’s analysis, and Pat White, Patricia Rissmiller,

and Susan Duty who provided greatly appreciated academic guidance throughout the

program. This journey has created a strong foundation for my future professional endeavors.

Dedication

To anyone who can relate to having “unbelievably dark moments” where one “can’t

see the tunnel, much less the light at the end” (stroke survivor). I hope this project can make

an impact.

To Jake, thank you for your consistent support and for partaking in your educational

journey with me! To my children, thank you for your support and understanding. I love all of

you and could not be prouder!

DEPRESSION-RISK SCREENING POST-STROKE vii

Table of Contents

Abstract..........................................................................................................................................iii

Acknowledgments...........................................................................................................................v

Dedication.......................................................................................................................................vi

Table of Contents..........................................................................................................................vii

List of Figures..................................................................................................................................x

List of Tables...................................................................................................................................x

The Clinical Problem.....................................................................................................................11

Description of the Problem........................................................................................................11

Background................................................................................................................................12

Purpose of Study............................................................................................................................13

Practice Inquiry Questions.........................................................................................................13

Specific Aims of the Project......................................................................................................14

Project Significance.......................................................................................................................14

Policy Implications....................................................................................................................15

Review of the Literature................................................................................................................15

Stroke Prevalence Among Depressed Adults............................................................................16

Depression Prevalence...............................................................................................................17

Depression within adults........................................................................................................17

Depression within elderly adults............................................................................................17

Depression post-stroke...........................................................................................................18

Patient Outcomes and Depression..............................................................................................18

Functional recovery................................................................................................................19

Social role functioning...........................................................................................................19

Mortality.................................................................................................................................19

Barriers to Depression Screening...............................................................................................20

Informal screening practices..................................................................................................20

Lack of time............................................................................................................................21

Mental health proficiency.......................................................................................................21

Patient disclosure of feelings..................................................................................................22

Post-Stroke Depression Tool Selection......................................................................................22

DEPRESSION-RISK SCREENING POST-STROKE viii

Timing of Assessments to Maximize Detection........................................................................24

Workflow and Electronic Clinical Decision Support................................................................25

Staff Education Models..............................................................................................................25

Gaps in the Literature.................................................................................................................26

Theoretical Framework..................................................................................................................27

Methods.........................................................................................................................................28

Overview....................................................................................................................................28

Setting........................................................................................................................................28

Ethics..........................................................................................................................................29

Sample........................................................................................................................................29

Intervention and Implementation...............................................................................................30

Nurse focus groups.................................................................................................................30

Nurse education intervention..................................................................................................31

Patient depression screen and referral intervention................................................................32

Method of Evaluation.................................................................................................................34

Nurse focus groups.................................................................................................................34

Nurse education intervention..................................................................................................34

Patient depression screen and referral intervention................................................................35

Analysis.........................................................................................................................................35

Results............................................................................................................................................36

Capstone Question #1................................................................................................................36

Subjects..................................................................................................................................36

Analysis..................................................................................................................................37


Subjects..................................................................................................................................40

Analysis..................................................................................................................................40


Subjects..................................................................................................................................41

Analysis..................................................................................................................................42

Discussion......................................................................................................................................43

Limitations.................................................................................................................................47

DEPRESSION-RISK SCREENING POST-STROKE ix

Conclusion.....................................................................................................................................48

Recommendations for Future Research.....................................................................................49

Appendices....................................................................................................................................51

Appendix A: Consent Form.......................................................................................................51

Appendix B: Moderator Guide..................................................................................................52

Appendix C: Nurse Education – Web-Based PowerPoint.........................................................54

Appendix D: Nurse Education...................................................................................................69

Appendix E: Patient Education..................................................................................................71

Appendix F: Nurse Planex.........................................................................................................73

Appendix G: EHR Order Entry Prompt Before File Documentation........................................74

Appendix H: PARS (Mental Health Counselor) in Paper Stroke Provider Orders...................75

Appendix I: Nurse Education Pre and Post-Test.......................................................................76

References......................................................................................................................................79

DEPRESSION-RISK SCREENING POST-STROKE x

List of Figures

Figure 1: Theory of Planned Behavior (TPB)...............................................................................27

Figure 2: Patient Health Questionnaire – 2 (PHQ-2).....................................................................32

Figure 3: EHR Clinical Decision Support (CDS) for Depression Screenings and Referrals........33

List of Tables

Table 1: Demographics and Descriptive Features of Registered Nurses Participating in Focus Groups............................................................................................................................................36

Table 2: Focus Group Themes to Facilitate Integrating PHQ-2 into Nurse Assessment and Workflow.......................................................................................................................................37

Table 3: Patient Demographics, Pre versus Post Intervention Subjects........................................41

Table 4: PHQ-2 Screening Times and Score Breakdown.............................................................42

Table 5: Positive Depression-risk Screen Interventions................................................................43

DEPRESSION-RISK SCREENING POST-STROKE 11

The Clinical Problem

Description of the Problem

Among the elderly population, depression is an under-diagnosed problem. A variety

of provider and patient factors have led to insufficient depression detection and treatment.

Furthermore, rates of depression increase among elderly with acute and chronic health

problems, including stroke (Dennis, Kadri, & Coffey, 2012).

Depression diagnoses can include major depressive disorder (MDD) or minor

depression. For a diagnosis of depression, an individual must have symptoms present for two

weeks or longer. A diagnosis of MDD is made by a trained professional when a patient

exhibits five or more of the following symptoms (one of which must include depressed mood

or loss of interest in activities): depressed mood, loss of interest in most activities, significant

change in weight or appetite, change in sleeping patterns, decreased concentration, decreased

energy, feelings of guilt or worthlessness, agitation or slowed mental processing, or suicidal

ideation (APA, 1994). Minor depression is diagnosed when a patient exhibits four or fewer of

these symptoms and does not exhibit suicidal thoughts. Failure to detect and treat minor

depression in a timely manner can result in the development of MDD.

Federal organizations and national guidelines have identified the problem of under-

detecting depression among adults. The Centers for Disease Control and Prevention (2012)

endorse that depression is not a “normal part of growing old.” The U.S. Preventative Services

Task Force (2009) published a clinical guideline recommending routine screening of adults,

with mental health referrals when indicated. The U.S. Department of Health and Human

Services (2012) published a national guideline regarding the management of major

depression in adults in primary care, recommending the use of standardized instruments. This


guideline endorsed use of a two-question depression-risk screening tool for patients with

chronic illness and high risk for depression. Though these federal organizations and national

guidelines have recommended these routine depression-risk screenings for high-risk patients,

screening has been inconsistently implemented into practice.

This practice inquiry project explored Portsmouth Regional Hospital (PRH) staff

nurse attitudes regarding screening for depression risk, subjective norms related to social

pressures that support or hinder detection and referral of depression, perceived behavioral

control to facilitate patients receiving timely mental health referral and treatment of

depression, and intention to conduct depression-risk screens if adequate support were

provided. Based on results of the exploration, tailored education was provided and a two-

question depression-risk screening tool was embedded into the nurses’ electronic health

record (EHR) and workflow.

Background

Depression has been discussed for centuries, but was first referenced in medical

dictionaries in the 1860s (Berrios, 1988). In 1980, the American Psychiatric Association

(APA) differentiated major depressive disorder from bipolar disorder for the first time in the

Diagnostic and Statistical Manual (DSM) third edition. In 1994, the APA published the DSM

fourth edition, which changed criteria for diagnosing major depressive disorders to current

standards, including the requirement that symptoms must create distress and negatively

impact social, occupation, or other important aspects of daily living (Gruenberg, Goldstein,

& Pincus, 2005).

Several screening tools have been developed to assist non-mental health providers

with detecting depression, including the Patient Health Questionnaire-9 (PHQ-9) depression


screening tool validated in 1999. Benefits of this tool include brevity and the ability to

diagnose depression as well as grade the severity of the depressive symptoms (severe,

moderately severe, moderate, mild, or minimal) (Spitzer, Kroenke, & Williams, 1999). In

2002, the U.S. Preventive Services Task Force (USPSTF) made the first recommendation

regarding screening adults for depression. In 2005, the first two questions of the PHQ-9 were

validated for major depression-risk screening (Williams, 2005), enhancing the ease of

incorporating depression-risk screening into routine practice. Despite clarified definitions,

national guideline recommendations, and validated brief depression-risk screening tools,

opportunities still exist for incorporating formal depression-risk screening practices into

healthcare settings where mental health services are available for support.

Purpose of Study

The purpose of this practice inquiry project was three-fold: 1) to conduct focus

groups to explore methods staff nurses would propose to integrate a depression-risk

screening tool into their EHR and workflow; 2) to provide education and implement system

changes based on results of the focus groups and literature; and 3) to embed a two-question

depression-risk screening tool into the nurses’ EHR to be completed on stroke patients within

24 to 48 hours after acute hospitalization, with mental health counselor referrals offered

when positive screen results occur.

Practice Inquiry Questions

Questions to be answered by this practice inquiry project:

1. What methods will nurses at PRH propose to facilitate the integration of a depression-risk

screening tool into stroke patient assessment and nurses’ workflow in the EHR?


2. What effect does an education intervention have on nurses’ knowledge at PRH of

depression and key process changes?

3. After integrating a PHQ-2 depression-risk screening tool into the nurse’s electronic

patient assessment, how frequently will patients be screened within 24 to 48 hours post

admission and referred to mental health counselors when indicated?

Specific Aims of the Project

This practice inquiry project specifically determined what impact staff nurse

education and electronic clinical decision support would have on completion of depression-

risk screens within the EHR and mental health counselor referrals when indicated. In

addition, this project identified organizational and nurse workflow barriers that needed to be

overcome to achieve successful screening and referral practices.

Project Significance

Advanced practice registered nurses (APRNs) are leaders in translating research into

practice (Schramp, Holtcamp, Phillips, Johnson, & Hoff, 2010). Implementation of national

guidelines through the use of validated tools is a critical aspect of advanced practice nursing.

The impact of unrecognized depression on patients, families, and the healthcare system is

significant, and warrants quality improvement projects to strengthen care and outcomes.

According to the World Health Organization (2014), 350 million people live with

depression, which is considered a leading cause of disability. Patients with chronic illness or

disability, such as stroke, have an especially high risk for developing depression. Unmanaged

depression can have significant consequences, including suicide, which is highest among

elderly over the age of 85 (National Institute of Mental Health, n.d.). By recognizing the

inconsistencies that exist in depression-risk screening by non-psychiatric physicians and


negative consequences if depression goes unidentified in this patient population, screening

for the presence of depression that existed before stroke onset can lead to detection and

treatment to reduce the negative impact post-discharge.

Policy Implications

National guidelines recommend depression-risk screening in primary care settings;

however, these guidelines are inconsistently implemented. Within government-managed

healthcare systems, such as the U.S. Veterans Affairs primary care clinics (Williams, 2011)

and across the United Kingdom (National Institute of Health and Clinical Excellence, 2009),

depression screening is mandated. The Centers for Medicare and Medicaid Services (2011)

have supported depression screening in primary care offices by offering Medicare

reimbursement for annual depression screens for adults. The importance of detection and

treatment of depression, and the significant social burden of unmanaged depression, may lead

to mandatory depression screenings when patients have any encounter with healthcare

providers that can support mental health services, including hospitals.

Reviewing the Healthy People 2020 objectives surrounding mental health, healthcare

improvement objectives include “MHMD-4.2 Reduce the proportion of adults aged 18 years

and older who experience major depressive episodes” and “MHMD-9.2 Increase the

proportion of adults aged 18 years and older with major depressive episodes (MDEs) who

receive treatment” by 10% (Healthy People 2020, 2013). Current objectives focus on

increasing depression screening in primary care practices. However, recognizing that many

patients inconsistently seek primary care, the burden for detecting depression may fall to

acute-care hospitals.

Review of the Literature


The literature review was conducted using CINAHL® and MEDLINE® as the

primary online search databases. Guideline searches were completed on the Agency for

Healthcare Research and Quality (AHRQ). In addition, statistics from the National Institute

of Mental Health and Centers for Disease Control and Prevention were retrieved. The key

words included the following, both singularly and in combination: (a) assessment, (b)

computerized reminders, (c) depression, (d) disclosure, (e) general hospital, (f) inpatient,

(g) meta-analysis, (h) mortality, (i) nurses, (j) outcome, (k) post-stroke, (l) prevalence, (m)

primary care, (n) recovery, (o) referral, (p) risk factors, (q) screening, (r) stroke, (s)

systematic review, and (t) validity.

Searches focused on peer-reviewed journals. Fifty-six peer-reviewed articles were

included, eight of which were systematic reviews. Seventy-three references were used in

total, with publication dates ranging from 1988 to 2014. Articles that addressed post-partum

depression and strokes within pediatric populations under the age of 18 years were excluded.

After reviewing all sources, findings were organized into several categories focusing

on depression significance, screening barriers and tools, and methods to support staff

education and process change. Specific categories included (a) patient outcomes and

depression, (b) depression and stroke risk, (c) barriers to depression screening, (d) post-

stroke depression tool selection, (e) timing of assessments to maximize detection, (f)

workflow and electronic clinical decision support, and (g) staff education models.

Stroke Prevalence Among Depressed Adults

Annually, approximately 2.8% of the general adult population experiences a stroke

(American Heart Association, 2013). One study showed that individuals with major

depressive disorders may have a higher risk for stroke, with a 3.9% to 4.3% prevalence rate


(Li, 2012; Pan, 2011). A second study, which conducted a meta-analysis of 17 prospective

studies, concluded that patients with a history of depression may have a 34% higher risk of

developing a stroke. A relationship was identified, but cause and effect could not be validated

(Dong, Zhang, Tong, & Qin, 2012). Finally, a third study further explored the correlation

between depression and increased stroke risk. This study determined that major depressive

disorders only increased risk for stroke for individuals below 75 years of age (Kohler 2013).

Depression Prevalence

Stroke patients in the acute hospital setting are at risk for depression. Contributing

risk factors for depression include situational life events and an age over 65 years.

Depression within adults

Annually, approximately 6.7% of all adults in the U.S. suffer from major depressive

disorder (National Institute of Mental Health, 2008). When depression is identified and

treated, short-term remission of depressive symptoms occurs in 67% of adult patients within

one year (U.S. Preventative Services Task Force, 2009). However, recurrence of symptoms is

common. Research shows that only 8% of patients who achieve one-year remission from

depressive symptoms will remain symptom-free for up to five years, which is often related to

inconsistent monitoring (Wells, 2005).

Depression within elderly adults

Elderly depression rates range from 6% to 9%. These rates can increase based on life

events such as medical illness, bereavement, cognitive decline, and transitions to institutional

residencies. Depression rates increased to 11.5% among hospitalized elderly and 13.5%

among elderly requiring home health services (Center for Disease Control, 2012).


Depression post-stroke

The prevalence of post-stroke depression (PSD) most consistently ranges from 26%

to 39% within the first three months (Ayerbe, Ayis, Rudd, Heuschmann, & Wolfe, 2011;

Berg, Lonnqvist, Palomaki & Kaste, 2009; Damush, 2008; Jia, 2010; Ostir, Berges,

Ottenbacher, & Ottenbacher, 2011). In addition, research showed that at five years after a

stroke the rate of depression was 27% to 34% (Ayerbe, 2011).

Individuals with a history of any type of depression have the highest risk for

developing post-stroke depression (PSD) (Carod-Artal, 2010; Paolucci, Gandolfo,

Provinciali, Torta, & Toso, 2006). In addition, several factors place stroke patients at higher

risk for developing depression. These include severe disabilities resulting from the stroke that

require moderate assistance or greater (Kouwenhoven, Kirkevold, Engedal, & Kim, 2011;

Paolucci et. al., 2006), recurrent stroke at any time, aphasia, female gender (Appelros,

Stegmayr, & Terent, 2010; Paolucci, 2006; Zhang, Zhou, Zhang, Zhang, & Xu, 2011), lack

of social support to meet physical or cognitive needs, and low income (Zhang, 2011). Risk

factors with the highest odds of contributing to depression include a history of depression,

stroke severity, and recurrent strokes.

Patient Outcomes and Depression

Strokes can have lasting physical and social effects on patients. Besides the

possibility of resulting in long-term disability, strokes are the fourth leading cause of death in

the United States. In 2010, it was estimated that direct and indirect costs in the United States

resulting from strokes equaled $36.5 billion (American Heart Association, 2013).

Unmanaged depression resulting from strokes can contribute to high healthcare expenditure,


reduced functional recovery, altered social role functioning, and increased possibility of

mortality (Pan, Sun, Okereke, Rexrode, & Hu, 2011).

Functional recovery

Many individuals experience residual disability after a stroke. Studies hypothesize that

depression may negatively affect post-stroke functional recovery; however, they have failed

to demonstrate statistical significance. Ostir’s study (2011) examined Functional

Independence Measure (FIM) scores among 544 stroke patients from different centers in the

United States. This study identified that FIM scores are higher for non-depressed patients at

discharge and three months post-discharge from inpatient rehabilitation. Another study by

Weaver, Page, Sheffler, and Chae (2013) identified a negative correlation between

depression and upper extremity function.

Social role functioning

When a patient suffers a stroke, social role functioning such as socializing with

friends and family or participating in out-of-home entertainment and other leisure activities

may be significantly altered. Research demonstrates that managing depression can enhance

social role functioning, which increases satisfaction and quality of life for patients and

families (Achten, Visser-Meily, Post, & Schepers, 2012; Bergstrom, Eriksson, Tham, & von

Koch, 2011; Salter, Bhogal, Teasell, Feloy, & Speechley, 2012). It was also determined that

full remission of depressive symptoms was not required to observe an improvement. Results

showed that reducing depressive symptoms by 50% could significantly increase social role

functioning (Schmid, 2012).

Mortality


The literature showed that post-stroke depression was associated with increased risk

for mortality by at least 1.5 years (Salter, 2012) and a 1.31 hazard ratio (Köhler, 2013). Also,

reducing depressive symptoms may yield a 0.7% reduction in mortality over 12 months

(Cully, Zimmer, Khan, & Petersen, 2008).

Barriers to Depression Screening

Depression is under-diagnosed within the elderly population due to low provider

detection and patient disclosure; an estimated 25% of patients with major depressive

disorders are not diagnosed by primary care providers (Barbui & Tansella, 2006). Low

provider detection often occurs due to the similarity of depressive symptoms and somatic

symptoms associated with physical illness, including decreased appetite, weight loss, fatigue,

and altered sleep. Among stroke patients, detection of depression is further challenged by

post-stroke physical, cognitive, and psychosocial changes (Dennis, 2012). In addition to

physical assessment challenges, barriers to detection include informal screening practices by

healthcare providers, limited physician and nurse time, limited healthcare provider comfort

with mental health, and limited patient comfort with disclosing feelings.

Informal screening practices

Consistent screening for depression improves identification (U.S. Preventative

Services Task Force, 2009) and is encouraged for patients with diseases that have a high rate

of depression comorbidity (U.S. Department of Health and Human Services, 2012).

Unfortunately, informal approaches for depression screening are commonly used which lead

to inconsistent assessments and reduce detection and treatment.

Several studies examined recognition of depression in adult primary care patients.

Research by Edwards (2006) identified that 8% of stroke patients have depression detected


through informal approaches, compared to 31% when formal screenings were performed.

Cepoiu (2007) conducted a systematic review of 36 studies that explored depression

recognition by non-psychiatric physicians, which identified a sensitivity of 36.4% and

specificity of 83.7% for detecting any type of adult depression. Of note, for adults over 55

years old, the sensitivity decreased to 28.7% with a specificity of 85.1%.

Lack of time

Finding time to change clinical practice to adopt evidence-based recommendations is

a challenge. Literature shows that increased patient complexity without a proportional

increase in time to care results in physicians and nurses struggling to address all patient

problems during the patient encounter. Therefore, despite healthcare providers recognizing

the importance of detecting depression, other health problems may receive prioritization,

resulting in inadequate time for depression screenings (de Man-Van Ginkel, 2011;

Dickinson, 2008).

Mental health proficiency

Physicians and nurses receive only general mental health exposure during their

didactic and clinical education. Limited knowledge and inconsistent system infrastructure to

support depression screening and referral contribute to reduced detection and management of

mental health patients (Bern-Klug, Kramer, & Sharr, 2010; de Man van Ginkel, 2011;

O’Connor, Whitlock, Beil, & Gaynes, 2009; U.S. Preventive Services Task Force, 2009).

Research showed that healthcare provider comfort with mental health problems may

negatively impact detection even when formal screening tools are available. One qualitative

study evaluated physician and nurse perceptions regarding formal depression-risk screening

tools, finding that 12% percent of nurses and 10% of physicians stated they would use a


formal depression-risk screening tool. Several physicians and nurses stated that they

preferred to answer the screening questions using information patients provided when

answering other questions versus asking the depression-risk screening questions verbatim

(Hammond, 2004).

Nurses and physicians shared several reasons for not screening. The top reasons cited

included the perception that the questions were “too negative,” “people wouldn’t answer

honestly,” questions were “too non-specific/insensitive,” and questions were “too repetitive”

(Hammond, 2004, p. 190).

Patient disclosure of feelings

Research shows that detection of depression may also be challenged by inconsistent

patient disclosure of symptoms to primary care physicians. A research study by Bell (2011)

revealed that in a follow-up survey of 1,054 adults, 43% reported at least one barrier to

talking to a primary care physician regarding depression. Individuals with higher depressive

symptoms, no family history of depression, a belief that a diagnosis of depression is

stigmatizing, and individuals with a need for emotional control had reduced disclosure of

depressive feelings. Individuals at risk for under-disclosure often also came from lower-

income backgrounds and had less education.

Post-Stroke Depression Tool Selection

Several tools are available to screen for PSD. Within the hospital setting, the

Geriatric Depression Scale (GDS) and Patient Health Questionnaire (PHQ) were frequently

cited (Dennis, 2012).

The GDS screening tool was used in research studies that examined depression

among hospitalized elderly patients. The GDS-30 includes 30 questions, using a cutoff score


of 10 or 11, with 85% sensitivity and 82% specificity in the general elderly population

(Dennis et al, 2012). When administered to stroke patients, the tool had 85% sensitivity and

64% specificity, with a cutoff of 11. The GDS-15, which only requires 15 questions, is also

available; however, it has not been validated in stroke patients. One limitation of the GDS

depression screening tool was the finding that it may be less reliable in individuals with

cognitive impairment (Salter, 2007). The high number of questions and limitations with

cognitively impaired patients make this a less desirable tool for stroke patients.

The PHQ has both a nine- and two-question validated depression-risk screening tool.

Both tools have high sensitivity and specificity for detecting major depression among

patients with post-stroke physical and cognitive changes. The PHQ-9 using a cutoff score of

10 or greater has a 78% to 80% sensitivity and 78% to 96% specificity for detecting major

and minor depression (Williams et. al., 2005; de Man-van Ginkel, 2011; de Man-van Ginkel,

2012). The PHQ-2 includes the first two questions of the PHQ-9, using a cutoff score of 2 or

greater, has a sensitivity of 75% to 86% and a specificity of 76% to 84% for major

depression post-stroke (Arroll, 2010; de Man-van Ginkel, 2011).

Brevity is imperative to support use of a formal depression-risk screening tool. In a

research study by Sowden, Mastromaura, Januzzi, Fricchione, & Huffman (2010), the PHQ-2

depression-risk screening tool was calculated to require 1.4 minutes (+/- 1.1 minutes) to

complete in hospitalized cardiac patients. In addition, the National Institute of Health and

Clinical Excellence (2009) and the U.S. Preventative Services Task Force (2009) support the

use of a two-question depression-risk screening tool in general, and research by Osorio,

Carvalho, Fracalossi, Crippa, and Loureiro (2012) demonstrated effectiveness in an acute

hospital-setting.


Timing of Assessments to Maximize Detection

Studies exploring the benefits of depression-risk screening in the acute hospital post-

stroke were not available in the literature; therefore, literature regarding depression-risk

screenings in acute hospitals for other patient populations was reviewed. For a new

depression diagnosis, a patient should exhibit specific signs and symptoms for at least two

weeks. As such, screening in a hospital setting 24 to 48 hours post admission would not

detect depression that developed as a result of the acute stroke. Instead, it would detect

patients with undiagnosed or under-treated depression prior to the stroke to facilitate

treatment before transitioning to their next level of care.

Six research articles that implemented depression-risk screening practices during an

acute hospitalization were reviewed, five of which were performed on general medical

patients and one on cardiac patients. Four studies implemented depression-risk screening as

part of the admission process (Hammond, O’Keefe, & Barer, 2000; Koenig, Meador, &

Cohen, 1988; Koenig, Meador, Cohen, & Blazer, 1992; Sowden et al, 2010), one on day

three of hospitalization (Cullum, Tucker, Todd, & Brayne, 2006), and one when “medically

stable” (Jackson & Baldwin, 1993).

Despite most of the studies incorporating depression-risk screenings on admission,

the Sowden et.al (2010) study, which screened 3,504 subjects, identified that depression may

be detected less frequently during this time, related to subject reluctance to discuss mental

health issues upon admission. Therefore, assessing later in a patient’s admission may yield

higher detection rates.


Workflow and Electronic Clinical Decision Support

To implement change in a nursing process within the EHR, it is imperative that

process changes incorporate end-user feedback (Aarts, Doorewaard, & Berg, 2003;

Amatayakul, 2011; Sicotte, Denis, & LeHoux, 1998; Stevenson, Nilsson, Petersson, &

Johansson, 2010). Through dialog with direct care providers, a plan for intervention

development can be created that reflects current workflow and culture (Currie, 2005).

Electronic clinical decision support (CDS) “provides clinicians with knowledge or

specific information that is intelligently filtered or presented at appropriate times, to enhance

health and healthcare. Tools may include clinical practice guidelines, alerts and reminders,

order sets, patient data report…, [and] diagnostic support” (Hebda & Czar, 2013, p. 130).

CDS can facilitate identification of patients that would benefit from further assessment and

treatment (Persell, 2012).

A study by Williams (2011) analyzed physician documentation of post-stroke

depression screenings with the use of CDS. Within the healthcare setting of study, physicians

were expected to screen all post-stroke patients with the PHQ-9 within six months of a new

stroke. Relying on physician memory, 50% of patients were screened and 31.9% had positive

results. After implementation of CDS within the EHR, screening increased to 86%, with

42.5% of patients having a positive screen. This study illustrated that implementing a formal

depression screen in conjunction with CDS within the EHR can enhance depression

screening and detection of depressive symptoms.

Staff Education Models

When providing education, different approaches should be used to meet diverse

learning styles. Learning styles can be viewed from a global perspective as right brain versus


left brain learning preferences; right-brain individuals are more creative, while left-brain

individuals are more logical. To enhance learning for those who are right-brain, it is

important to present the big picture first, followed by details with visuals of changes that they

can expect to see. In contrast, left-brain dominant individuals flourish with understanding

how the pieces achieve the final goal. These individuals also benefit from having an

opportunity to discuss information to assist with learning (Avillion, Holtschneider, & Puetz,

2010).

Web-based training and face-to-face content reviews are two approaches for

providing education. Web-based training is beneficial in that it is available 24/7, self-paced,

user-friendly, cost-effective, and consistent in content. However, it also lacks human

interaction, which can be a major disadvantage (Avillion et.al., 2010).

Face-to-face content reviews support individual needs for human interaction and

allow for discussion to enhance understanding (Avillion et.al., 2010). This method of staff

education has been shown to increase satisfaction (odds ratio of 2.07) (Smith, Forster, &

Young, 2008) and contribute to higher retention of new information (Commodore-Mensah &

Dennison-Himmelfard, 2012). One disadvantage of this method, however, includes lack of

time during a work shift to attend (Avillion et.al., 2010).

Gaps in the Literature

Three limitations in the literature were identified. First, the current literature primarily

focuses on detection of depression in general elderly hospitalized or cardiac patients.

Additional confounding factors associated with changes post-stroke and their impact on

development of depression would benefit from further research. Second, the PHQ-2 has a

high sensitivity for detecting major depression. Research studies conducted during acute


hospitalization did not differentiate between major depressive disorders and minor

depression, which have different effects on patient outcomes. Finally, rates of undetected

depression were influenced by healthcare provider practice and patient disclosure of

symptoms. More research is needed regarding how to support patient comfort with disclosing

depressive symptoms.

Theoretical Framework

The Theory of Planned Behavior (TPB) originates from social sciences, and is used to

assist with explaining four key concepts that should be addressed to achieve a clinical

practice change: attitude, subjective norms, perceived behavioral control, and intention.

Figure 1: Theory of Planned Behavior (TPB)

Source: Hankins, M., French, D., & Horne, R. (2000). Statistical guideline for studies of the theory of reasoned action and the theory of planned behavior. Psychology and Health, 15, 151-161.

Attitude is defined as a person’s belief about a practice, positive or negative.

Subjective norm is defined as social pressures that support performance or non-performance.

Perceived behavioral control is defined as the ease or difficulty of performing a practice

change, based on the power an individual possesses to achieve the desired outcome.

Intention is defined as the willingness to perform a practice change.


This theory proposes that an individual’s intention to perform a task is based on

attitude, subjective norms, and perceived behavioral control. Changes in behavior are

influenced by intention and perceived behavioral control. Therefore, not only would an

individual need to have the willingness to change practice, but he or she would also need to

know they had the ability or authority to as well (Godin, 1996; Hankins, French, & Horne,

2000; Houme, Abdeljelil, & Gagnon, 2012).

Methods

Overview

This project implemented two interventions based on results from staff nurse focus

groups and the literature, with the goal of strengthening screening for depression in

hospitalized stroke patients during the period of 24 to 48 hours post-admission. The

effectiveness of the interventions were analyzed through the perspective of the Theory of

Planned Behavior, which states that behavior change occurs when attitudes, subjective

norms, perceived behavioral control, and intentions align.

First, focus groups were conducted with registered nurses to explore current practices

and perceptions regarding screening for depression and nurse workflow, and to gain insight

regarding nurses’ attitudes, subjective norms, perceived behavioral control, and intention to

change practice. Second, web-based and face-to-face staff nurse education was provided,

guided by the feedback from the focus groups and a review of current literature. Third, the

depression-risk screen PHQ-2 was embedded into the EHR and nurses’ routine workflow.

Setting

This project took place at Portsmouth Regional Hospital (PRH), a 209-bed for-profit

community hospital in Portsmouth, NH. The hospital received Primary Stroke Accreditation


in January 2013 and identified depression recognition post-stroke as an area in which to

improve care processes. Stroke patients involved in the project were cared for on five

different units: two cardiac, one intensive care, one medical, and one surgical. All patient

rooms were private with telemetry capability. Physician and mental health counselor support

was available 24 hours per day, seven days a week.

Ethics

Approval from the Simmons College Institutional Review Board (IRB) and the PRH

IRB was obtained for the nurse focus groups. The nurse education and patient depression

screen interventions were quality improvement methods, and thus exempt from IRB

oversight.

The rights of nurses and patients were protected within this study. To protect nurses’

rights during the focus groups, they were asked to provide written consent prior to

participating (see Appendix A). In addition, the nurses’ names were not included on the tape

or transcript. During the nurse education intervention, results of the pre- and post-education

test were accessed only by the principal investigator. To ensure patient privacy and

confidentiality, personal information was removed from the data collected during chart

reviews and replaced with identification numbers.

Sample

Registered Nurses (RNs) working on five separate units (two cardiac, one intensive

care, one medical, and one surgical) were eligible for inclusion. To participate in the focus

groups, nurses were required to have a minimum of three months of experience in their

current unit and work a minimum of eight hours per week. Upon completion of the focus


groups, educational materials were developed and all RNs from the above units received

education.

For the patient intervention, patient electronic health records were accessed to collect

data regarding depression-risk screenings. Patient records were included in the project if the

following inclusion criteria were met: (a) patient admitted to one of the aforementioned five

inpatient units with a diagnosis of new onset Transient Ischemic Attack (TIA), ischemic, or

hemorrhagic stroke established by brain imaging or physician documentation; (b) minimum

of 24-hour length of stay and discharged in 14 days or fewer; and (c) capacity to

communicate with a minimum of “yes” or “no” answers appropriately. Patients with

impairments that prohibited reliability of information (i.e., advanced dementia or intubation)

and palliative or end-of-life patients were excluded.

Intervention and Implementation

Nurse focus groups

Two separate nurse focus groups were conducted to assist with this portion of the

project. Nurse participants were recruited by posting flyers on the unit and via hospital and

home email.

A different moderator was used for each focus group, both of whom were Bachelor of

Science in Nursing (BSN) prepared professional development educators with experience

facilitating meetings. They received training from the principal investigator regarding the

purpose of the focus group and their role as moderators. They were also provided a focus

group interview script to facilitate probing for key concepts of the Theory of Planned

Behavior, including attitude, subjective norms, perceived behavioral control, and intention to


support a change in behavior. Results from the first focus group led to modifications in the

interview guide for the second focus group (see Appendix B).

Focus groups were audio recorded and field notes were taken. Discussions lasted until

the respondents had nothing new to add, which occurred in approximately 60 minutes for

each session. At the end of each session, the moderator summarized the main points from the

discussion to capture nurses’ comments and assist with clarification and additional insights.

Nurse education intervention

The nurse education intervention was designed to affect nurse attitudes and align

subjective norms and perceived behavioral control to foster positive intentions in regards to

performing the depression-risk screening as indicated. A PowerPoint educational

presentation (see Appendix C), which took 10 to15 minutes to complete, was created in the

hospital’s web-based staff education program and assigned to all nurses on the five inpatient

units. Nurses were given 14 days to complete the education at home or during a routine work

shift; they were compensated by the hospital for either completion option selected. In

addition, 103 nurses that worked at least eight hours per week also received a five-minute

face-to-face education during a normally scheduled work day.

The web-based education material included a PowerPoint presentation and two

handouts that could be printed for reference. The presentation provided depression statistics,

screen shots of new EHR screens, and electronic CDS embedded in the EHR to facilitate

completion (see Appendix C). The first one-page handout provided staff education

summarizing key points of the depression screen intervention as well as a copy of the

verbatim PHQ-2 depression-risk screening questions (see Appendix D). The second one-page

handout provided patient education to assist in explaining the risk of depression for stroke


patients and the meaning of the screening tool results (see Appendix E), which nurses were

encouraged to provide to every stroke patient. These handouts were reviewed during the

face-to-face education.

Patient depression screen and referral intervention

This intervention embedded the depression-risk screen PHQ-2 into the EHR used on

the designated five inpatient units. The PHQ-2 (see Figure 2) was selected because it had

been successfully used in a wide variety of inpatient and outpatient settings with stroke

patients as outlined in the literature review, was simple and brief, and correlated well with

formal interviews for major depressive disorder.

Figure 2: Patient Health Questionnaire – 2 (PHQ-2)“Over the past two weeks, how often have you been bothered by any of the following problems:”

Not at all Several days

More than half the days

Nearly every day

Little interest or pleasure in doing things

0 1 2 3

Feeling down, depressed, or hopeless

0 1 2 3

(de Man-van Ginkel, 2012; Williams, 2005)

PHQ-2 scores are computed by summing responses to the two items. A PHQ-2 score

of two or greater was chosen as the cutoff for a positive depression screen based on a review

of the literature. Among stroke patients, this cutoff had been shown to have a sensitivity of

75% to 86% and specificity of 76% to 84% for post-stroke major depression (Arroll, 2010;

de Man-van Ginkel, 2011).

Based on the focus group feedback, several changes were implemented to support

completion of the depression-risk screens within 24 to 48 hours. First, the PHQ-2 was

embedded within the nurses’ electronic shift assessment based on feedback that a separate


documentation screen would be overlooked. Second, four electronic clinical decision support

(CDS) triggers were added to the EHR to facilitate depression-risk screening and referrals

when indicated (see Figure 3).

Figure 3: EHR Clinical Decision Support (CDS) for Depression-Risk Screenings and Referrals

1 Admission Database

If a nurse answered “Yes” to a patient “admitted for stroke or stroke-like symptoms,” the nurse was prompted to complete the PHQ-2 depression-risk screening tool in the EHR shift assessment.

2 Nurse Planex Results of the previous depression screen and actions taken were added to the nurse planex (a computer-generated summary of patient information that included orders, medications, allergies, risk screen results, etc., that was reviewed when a new nurse assumed responsibility for a patient) (see Appendix F).

3 Documented Actions

Positive screen results: Nurse would document if a patient wanted a “mental health clinician,” “chaplain,” or if “patient declined” referrals.Negative screen results: Documented as “risk not identified”Inability to screen: Documented as “patient unable to complete.”

4 Referral Order Nurse submitted a mental health clinician or chaplain electronic referral order prior to finalizing shift assessment documentation (see Appendix G)

Nurses were provided prompts from the admission database, during nurse hand-off-reports,

and within the EHR nurse shift assessment to facilitate depression-risk screening and referral

when indicated. Finally, to overcome delayed mental health counselor referrals related to

needing a physician order, a mental health counselor order was added to the ischemic/TIA

and hemorrhagic stroke paper admission order sets (see Appendix H).


Method of Evaluation

Nurse focus groups

The audio tapes from the focus groups were transcribed verbatim by the principal

investigator. The transcripts were reviewed by the principal investigator and a graduate

student independently to extract and compare themes based on the Theory of Planned

Behavior to answer research question one: “What methods will nurses propose to facilitate

the integration of a depression-risk screening tool into stroke patient assessment and nurse’s

workflow in the EHR?”

Nurse education intervention

A 10-question computerized pre- and post-education test (see Appendix I) was

developed to evaluate the effectiveness of the educational intervention. To evaluate question

clarity, the test was administered to three nurses not included in the intervention. Feedback

was received regarding the questions and responses, and adjustments to the test were made.

The modified test was administered to another three nurses, who confirmed interpretation of

the questions and response choices.

Before starting the web-based education, nurses completed the validated computer-

based 10-question test. Upon completion of education, nurses re-took the same test to

evaluate the effectiveness of education. Nurses were included in the data analysis if the pre-

and post-education tests were completed before the EHR intervention was implemented.

The nurses’ understanding of the education regarding the new process was also

evaluated through chart reviews. Nurses were expected to complete a PHQ-2 depression-risk

screen at least once a shift 24-48 hours post-admission for stroke patients. Each patient could

have one to three depression-risk screens documented in the EHR during this timeframe. The


number of screens completed varied based on a nurse’s work shift (12 hours versus 8 hours)

and the patient’s hospital length of stay.

Patient depression screen and referral intervention

Evaluation of depression-risk screening results and mental health referrals were

performed through chart reviews. In total, 60 patient records were reviewed for this project,

from which patient demographic, depression-risk screening, and interventions after positive

screen results were collected. Pre-intervention data was obtained starting with discharges in

March 2013 and ending once 30 patients met the inclusion and exclusion criteria (August

2013). Post-intervention data collection started in September 2013 and ended once 30

patients met the inclusion and exclusion criteria (December 2013).

Analysis

The nurses’ focus group transcripts were analyzed for similarity of themes, identified

by two separate reviewers. From there, major themes were compiled and included in the

findings. To analyze the education intervention, the difference in nurse test scores (pre- and

post-) was assessed using a paired t-test. Descriptive statistics were used to analyze nurse

screening documentation in the EHR.

The data from stroke patients eligible for depression-risk screening and referrals was

also analyzed. An independent t-test was used to compare the age and length of hospital stay

pre- and post-intervention. Cross-tabulations and chi-square were used to analyze pre- and

post-intervention data regarding gender, race, admit stroke type, admit National Institute of

Health Stroke Scale (NIHSS), depression documented on the physician’s admission history

and physical (H&P), and antidepressant medication prescribed prior to admission. Frequency

descriptive statistics were used to analyze depression-risk scores, and a mean was computed


for the number of hours post-admission each screen was performed. An additional post-

intervention analysis was performed, comparing age and length of stay for patients with

positive versus negative screens. In addition, interventions received were described.

Results

Capstone Question #1

What methods will nurses at PRH propose to facilitate the integration of a depression-risk

screening tool into stroke patient assessment and nurse’s work flow in the EHR?

Subjects

Different perspectives were obtained during two focus groups (n=9 unique

respondents). The first focus group recruited three staff nurses from the medical and cardiac

unit. The second focus group, after expanding eligible participants, recruited six staff nurses.

Of note, all of the participants were Caucasian women (99% of the hospital’s staff nurses

were Caucasian), and the majority of the nurses’ education level was an associate degree

(67%) (55% of the hospital’s staff nurses held an associate degree). See Table 1 for

additional demographic data.

Table 1: Demographics and Descriptive Features of Registered Nurses Participating in Focus Groups

N MeanAge (years) 9 44.4Hours Worked/Wk. 9 34.2RN Experience (years) 9 10.6Worked Current Unit (years) 9 6

N PercentUnitCardiac 1 11Medical 6 67Surgical 1 11ICU 1 11ShiftDays (7a-3p) 7 71Off-Shift (3p-7a) 2 29


Gender Male 0 0Female 9 100RaceCaucasian 9 100EducationAssociate degree in nursing 6 67Bachelor degree in nursing 1 11Master’s degree in nursing 2 22

Analysis

A qualitative analysis of themes was conducted from the transcripts of the nurse focus

groups. Six major themes were identified in relation to the Theory of Planned Behavior. Two

themes reflected nurse attitudes regarding practice and one emerged regarding subjective

norms associated with positive screen results. Additionally, one barrier and one solution

theme were revealed with respect to perceived behavioral control. Finally, one theme was

identified in relation to system changes needed to support nurse intention to complete the

new screening process (see Table 2).

Table 2: Focus Group Themes to Facilitate Integrating PHQ-2 into Nurse Assessment and Workflow

Themes Number of Responses*Uncomfortable asking sensitive questions 5Screening tools not helpful 3

Screening tools helpful when action oriented 3Positive screen warrants timely consult order 11Physician order required 9Nurse-initiated mental health counselor consults 6Documentation Triggers 4

* A subject could receive credit for statements more than once.Based on the focus groups, two themes reflected nurse attitudes regarding screening.

First was the theme of uncomfortable asking sensitive questions. Nurses expressed feeling

“awkward and uncomfortable” asking sensitive screening questions to patients, and shared

that they might “reframe questions” depending on the patient and whether they perceive the

patient is at risk for a positive result. One nurse admitted that she “may not even ask suicide


screening questions to an 85 year old elderly patient.” The second theme was screening tool

helpfulness. On three separate occasions, nurses expressed screening tools were “not

particularly helpful” and found them “redundant” to their routine assessment. In contrast,

three other responses expressed that screening tools can be helpful when the action required

from a positive screen can be executed. Nurses expressed that “You have to have a follow-up

or a road to go down when you ask ‘brief’ questions,” thus indicating that adding work to

their day is perceived as beneficial if actions will occur that benefit the patient.

A consistent subjective norm theme emerged that a positive screen warrants timely

consult orders. Nurses shared “we screen, but what’s the outcome” and “leave …note for

physicians, might not get addressed at all.” Throughout the focus groups, this concern was

expressed in different manners, resulting in more responses than subjects. The responses

reflected that nurses consistently understood the expectation that a positive screening result

should lead to additional assessment for the presence of disease. However, nurses expressed

concern that in the current state, their requests for mental health counselors are not

consistently acknowledge by physicians, either through a written order or explanation of why

an order was not written. As a result, unless the current process was changed, the nurses

expressed concern that positive screen results may not be consistently acted upon in a timely

manner.

Perceived behavioral control relates to whether an individual believes adequate

support exists to foster a practice change. A perceived barrier to executing timely referrals

after screening was physician order required. Nurses shared they “need physician order for

PARS [mental health counselor],” as this is the current practice at PRH. They also expressed

that receiving an order “depends on the doctor.” To overcome this barrier, nurses proposed


nurse-initiated mental health counselor consults. Suggestions included adding a “pre-

check” on the paper stroke order sets so a mental health counselor order was written for all

stroke patients, and allowing a nurse to “consult PARS [mental health counselor] on their

own; create protocol.”

The final concept evaluated was nurse intention to complete screens. The nurses

made consistent statements demonstrating support for incorporating depression-risk

screening into practice, including that screening tools tell “a lot… [but] you have to have a

follow-up or a road to go down when you ask ‘brief’ questions.” Nurses also recognized that

screening tools assist to “jog your memory.” However, a theme of documentation triggers

emerged as a key element for practice change to occur. Nurses recommended having

information “pulled from what already obtained from admission” as they “need a trigger” to

remind them to complete and refer when indicated.

Within the focus groups, nurses also provided feedback regarding educational

resources to facilitate the process change. Brief education lasting no longer than 15 minutes,

for example, was consistently requested. Preference regarding web-based or face-to-face

education had mixed responses, but one of these methods was perceived to meet needs across

the board. Nurses also proposed developing a one-page summary of the process change with

a copy of the PHQ-2 verbatim questions as well as the patient education sheet to be provided

to all stroke patients.


What effect does an education intervention have on nurse’s knowledge at PRH of depression

and key process changes?


Subjects

Of the 130 eligible subjects, 110 nurses completed the web-based education and

electronic pre- and post-education test, and 103 received face-to-face education. The 20

nurses who did not complete the web-based education worked an average of less than eight

hours per week. All nurses who worked an average of eight hours per week or more received

the face-to-face education.

Analysis

The test score change (pre- and post-) had a normal distribution. Scores increased

significantly between the pre-education (M= 55.27, SD=15.5) and post-education test (M=

89.91, SD=11.3), t(109)=20.649, p=0.001, with a 95% confidence interval that the increase

in score post-education ranged from 31.31 to 37.96. Of note, the correlation between pre- and

post- test data was only 0.165, indicating that nurses did not maintain their relative standing

within the group. This variability could be related to nurses completing the tests at work,

which may have resulted in distractions.

The effect of education to change nurse behavior was evaluated through chart reviews

of nurses’ screening documentation. Of the 130 eligible RNs, 45 nurses cared for stroke

patients and had at least one opportunity to perform a PHQ-2 depression-risk screen. Eighty-

five nurses did not have an opportunity to care for a stroke patient during the project. Of the

45 nurses, 80% (N=36) screened and documented the PHQ-2 depression-risk score in the

EHR at least once. However, 20% (N=9) of the nurses bypassed the EHR clinical decision

support (CDS) prompts resulting in the patient not being screened for depression risk. These

nurses had one screening opportunity each.



After integrating a PHQ-2 depression-risk screening tool into the nurse’s electronic patient

assessment, how frequently will patients be screened within 24 to 48 hours post admission

and referred to mental health counselors when indicated?

Subjects

Thirty pre- and post-intervention patients were compared for similarities in screening

and treatment practices (see Table 3). Independent sample t-tests and chi-square tests were

used to test for differences. The sample demographics including age, gender, race, admission

stroke type, length of stay, NIHSS, and antidepressant medication prescribed prior to

admission were not statistically different between the pre- and post- intervention samples.

The majority of both samples experienced mild strokes, defined as an NIHSS score between

one and five (Brott & Adams, 1989; Rehabmeasures, 2013). The pre-intervention sample had

a statistically higher frequency of depression documented on admission, 23.3% versus 3.3%

post-intervention (p < 0.05) (see Table 3). Reason for this variation between the subject

groups is unclear.

Table 3: Patient Demographics, Pre versus Post Intervention SubjectsPre-Intervention Post-Intervention p-value

Number of Subjects 30 30Age (years) 74.9 73.5 0.572Gender Male: 66.7%

Female: 33.3%Male: 66.7%Female: 33.3% 1.00

Race 100% White, Non-Hispanic

100% White, Non-Hispanic 1.00

Admit Stroke Type Ischemic TIA Hemorrhagic TIA/Ischemic

70%20%10%0%

50%23.3%20%6.7%

0.253

LOS (days) 3.8 3.4 0.509LOS (hours) 92.3 82 0.509Admit NIHSS Mean: 6 Mean: 3.3 0.139


Median: 4Mode: 0Range: 0-28

Median: 2Mode: 0,2,3Range: 0-18

Depression documented on admission H&P 23.3% 3.3% 0.023

Antidepressant prescribed PTA

30% 16.7% 0.222

Analysis

Pre-intervention, 3.3% (n=1) of patients were screened for depression, indicated by

documentation of a mental health counselor visit. Post-intervention, 86.7% (n=26) of patients

were screened at least once with the PHQ-2 depression-risk screen within 24 to 48 hours

post- admission. Based on patient length of stay and nurse shift length (8 versus 12-hour

shifts), 23% of the patients had one PHQ-2 screen opportunity, 50% had two screening

opportunities, and 26.7% had three screening opportunities. Therefore, 76.7% of the patients

had more than one depression-risk screening opportunity within the intervention window.

The first depression-risk screen was completed 76.7% of the time when indicated,

with a mean timeframe of 27.4 hours post-admission. The second depression-risk screen was

completed 91.3% of the time when indicated, with a mean time of 38.6 hours post-admission.

The third depression-risk screen was completed 75% of the time when indicated, with a mean

time of 44.4 hours post-admission (see Table 4). Upon review of the record, documentation

was not present to justify not screening, and may be attributable to nurse variability.

Table 4: PHQ-2 Screening Times and Score BreakdownMean Hours

Post-AdmissionPHQ-2 Score Breakdown

N Screen Completed when Indicated

Screen 1 27.4 0 = 91.3%3 = 4.3%6 = 4.3%Missing

21117

76.7%(23 out of 30 opportunities)

Screen 2 38.6 0 = 81%2 = 4.8%3 = 4.8%5 = 4.8%

17111

91.3%(21 out of 23)


6 = 4.8%Missing

12

Screen 3 44.4 0 = 66.7%3 = 16.7%6 = 16.7%Missing

4112

75%(6 out of 8)

Reviewing the patients who received at least one depression-risk screen, 15.4% (n=4)

had a positive depression-risk screen result, ranging from a PHQ-2 score of 2 to 6. Upon

analyzing the four patients with a positive screen, they were older (M=84.5, SD=2.5)

compared to patients with negative screens (M=71.8, SD=10.7). Patients with a positive

screen also had a longer length of stay (M=6.4, SD=4.1) compared to patients with negative

screens (M=2.97, SD=1.8).

As a result of depression-risk screenings, patients with positive screen results were

consistently offered a mental health counselor (MHC) referral. Two patients accepted a MHC

referral; one was diagnosed with depression and prescribed a new antidepressant upon

hospital discharge, the other was negative for depression. One patient with a history of

depression prior to admission declined a MHC referral but accepted an additional

antidepressant medication prescription at discharge. Finally, one patient declined mental

health referral and treatment, but accepted a chaplain consult for support (see Table 5).

Table 5: Positive Depression-Risk Screen InterventionsPatient Accepted MHC

ReferralDeclined MHC

ReferralNew

Antidepressant at Discharge

Chaplain Visit

1 X X2 X X3 X X4 X

Discussion


Within this practice inquiry project, two interventions – staff nurse education and

PHQ-2 embedded into the nurses’ EHR and workflow – were implemented based on insights

gained during focus groups and the literature. In addition, electronic CDS was used to

facilitate depression-risk screening on stroke patients within 24 to 48 hours after acute

hospitalization, with mental health counselor referrals or other support provided when

positive screen results occurred.

The first practice inquiry question required exploration of methods proposed by the

nurses at PRH to facilitate integration of a depression-risk screening tool into stroke patient

EHR assessment and nurse’s workflow. The focus groups revealed that nurse attitudes

supported the use of depression-risk screening as long as timely action could be executed as a

result of the findings; despite some nurses sharing that they felt uncomfortable asking

sensitive mental health questions. Nurses understood that a positive depression screen should

result in therapeutic mental health action. However, requiring a physician order for a mental

health counselor referral was a perceived barrier. To overcome this barrier, a physician order

for mental health counselor referrals was added to paper stroke order sets, supporting nurse-

driven mental health counselor referrals based on results of the PHQ-2.

Nurse discomfort with asking sensitive mental health questions was identified within

the literature and reaffirmed as a problem for PRH staff nurses. During the focus groups,

nurses expressed concern regarding “lack of control” to facilitate mental health counselor

services for patients in a timely manner. This perception related to the infrastructure at PRH,

which required a physician order for mental health services. In addition, 67% of the focus

group participants were Associate Degree RNs, which may have also influenced these

perceptions. In sum, by providing a physician order for a mental health counselor referral and


incorporating electronic CDS within the EHR, nurses expressed a positive intention to

complete the PHQ-2 depression-risk screen and refer to mental health counselors when

indicated.

The second practice inquiry question explored the impact of education on nurses’

knowledge and understanding of key process changes. Education was provided in a two-step

manner in an effort to support limited time and different learning styles of the nurses. After

staff nurses completed a brief web-based education, face-to-face education was provided to

review and reinforce key process changes. The post-education test results significantly

increased from the pre-education test results. However, there was a low correlation (0.165)

for unknown reasons. Of note, the majority of nurses completed the pre- and post-education

test during a routine work shift. This could have resulted in nurses completing the tests too

quickly, related to the need to return to patient care activities, leading to inconsistent changes

in pre- and post-test scores. Allowing nurses uninterrupted time to complete the pre- and

post-test may have yielded a higher correlation. In addition, the web-based education

program provided global test-question analysis. Pre- and post-education test analysis at the

nurse level would have been beneficial.

In addition to changes in test scores, effectiveness of the nursing education was

evaluated through nurse depression screen performance. Of 130 nurses, only 34.6% (n=45)

of these nurses cared for a stroke patient during this project. Among these, 80% (n=36)

screened for depression and documented correctly as outlined in the education. The

remaining 20% (n=9) had bypassed the depression-risk screen. Reasons for bypassing this

mandatory screen were unclear. It could indicate a need for more education and further

reinforcement to facilitate work flow; however, there would have been a benefit in


interviewing the nurses to identify why the screen was not performed. One shortcoming that

exists within the EHR system used at PRH is that a “mandatory” screen can be skipped by

pressing the <escape> key on the keyboard. To date, nurses have not been consistently held

accountable for this practice, which negatively impacted the outcome of this practice change.

Within the next few months, a new EHR nurse documentation platform will be implemented

which will hopefully address this shortcoming.

The third practice inquiry question explored how frequently stroke patients would be

screened within 24 to 48 hours post-admission and referred to mental health counselors when

indicated. Despite the ability to bypass a mandatory screen, 86.7% of patients were screened

at least once during this timeframe; however, only 70% of patients were screened at every

opportunity. Within this project, 15.4% (n=4) of patients yielded a positive screen.

The positive screen results from this practice inquiry project were higher than the

CDC’s hospitalized elderly depression rate estimates, but lower than expected for stroke

patients. The Center for Disease Control (2012) estimates that 11.5% of elderly hospitalized

patients experience depressive symptoms. A systematic review conducted by Dennis et al.

(2012) summarized that positive depression screen detection rates among elderly patients

admitted to an acute hospital range between 8% and 45%. Based on Dong et al.’s (2012)

meta-analysis, which identified that adults with depression may have a 34% higher risk of

stroke, a higher rate of positive screen results were expected during this practice inquiry

project. Lower detection could relate to the small sample size, lower stroke severity, or the

significantly lower patient history of depression prior to admission in the post-intervention

sample (3.3%) compared to the pre-intervention sample (23.3%). In addition, the methods


nurses used to collect the PHQ-2 data was not evaluated, thus if the nurses failed to ask the

verbatim questions, detection rates would be lower.

Clinical decision support was embedded within the EHR to facilitate timely

interventions when positive depression-risk screens were identified. Among the four patients

with positive screens, 100% were offered a mental health counselor, which was higher than

the literature, 85.9% (Williams et al., 2010). Of those offered a referral, 50% (n=2) of the

patients accepted a mental health counselor referral; one patient was discharged on an

antidepressant and the other patient was negative for depression upon further evaluation. A

third patient with a history of depression declined the mental health counselor referral but

accepted an additional antidepressant prescription upon hospital discharge. Therefore, 50%

(n=2) of patients with positive screen results accepted a new antidepressant medication upon

discharge. Finally, one patient (25%) declined additional evaluation or treatment, but

accepted a chaplain consult for support. Rationale for this patient’s refusal for further

evaluation or treatment was unclear from the medical record documentation. Compared to

the literature, more patients accepted mental health counselor referral and antidepressant

medication versus declining services (Williams et al., 2010). However, the findings are

limited based on the small sample size.

Limitations

Five limitations were identified within the practice inquiry project, two of which were

identified during the focus group intervention. First, neither moderator had experience in this

specific role, which resulted in limited probing during the focus groups. Second, recruitment

was challenging due to an increased patient census and nurses’ planned summer vacations.

One limitation to the nurse education intervention was scant support for staff education


outside the nurse’s regular work schedule. Thus, education primarily occurred during a

nurse’s work shift, which could have led to distractions. Within the patient depression screen

and referral intervention, two limitations existed. First, Portsmouth Regional Hospital has a

low volume of stroke patients, which resulted in an average of 10 patients meeting inclusion

criteria per month, leading to a small sample size. Second, despite establishing electronic

CDS within the EHR for timely screening post-stroke, the EHR still allowed nurses to bypass

mandatory electronic documentation screens, reducing compliance.

Conclusion

This practice inquiry project incorporated nurse insights before embedding the PHQ-2

depression-risk screening tool in the nurses’ EHR at Portsmouth Regional Hospital. Web-

based and face-to-face staff nurse education and electronic clinical decision support were

implemented to strengthen depression-risk screening and referral when indicated.

Pre-intervention, 3.3% of stroke patients were screened for depression, compared to

86.7% of patients post-intervention. In addition, 15.4% (n=4) of the post-intervention

patients had a positive screen. Of these patients, 50% (n=2) agreed to further assessment by a

mental health counselor, 50% (n=2) accepted an additional antidepressant prescription at

discharge, and 25% (n=1) only agreed to speak with a chaplain for support. As a result of this

practice inquiry project, depression-risk screening significantly increased leading to

increased surveillance and potential mental health referrals by the nurse. The project results

suggest further investigation is warranted to probe the theoretical perspectives of attitudes,

subjective norms, perceived behavior control, and intentions that support nurses in screening

and referral.


Recommendations for Future Research

During this project inquiry project, three opportunities for future research were

identified. First, explore if degree level impacts nurses’ perceived behavioral control for

depression-risk screening and initiating needed mental health services. Potential strategies to

conduct this research could include interviews or surveys, reducing the influence of peer

pressure that can develop within focus groups.

A second area for exploration is nurse attitudes and perceptions regarding

documentation. Despite education and electronic CDS prompting completion of the

depression-risk screen, several patients were not screened. More research is needed to

understand why some nurses do not complete screenings despite real time EBP

recommendation availability. Research could be performed to determine if there is an

association between a nurse’s education level, experience, and perceived purpose of

documentation with documentation compliance. Potential strategies to conduct this research

include a combination of chart reviews and nurse surveys, comparing demographics of

nurses completing the screen as indicated, versus nurses that bypassed the mandatory

documentation screen.

A final area for future research includes validation of depression screen results. The

literature and focus groups identified that nurses may complete screening tools based on

information received during their general assessment versus asking screening questions

verbatim. Failure to ask depression-risk screening questions verbatim can result in lower

detection and treatment. Therefore, research could be performed to evaluate how screening

tool data is collected by staff nurses; comparing their results to screens completed

independently by a nurse researcher. Potential strategies to conduct this research include


patient interviews, nurse interviews, and chart reviews; comparing nurse researcher and staff

nurse results for consistency.

Depression has a significant impact on a patient’s recovery post-stroke. Early

detection of depressive symptoms while in the hospital setting may help reduce the severity

of depressive symptoms experienced post-hospital discharge. To maximize depression

detection, use of a PHQ-2 depression-risk screening tool within the nurses’ EHR and

electronic CDS can enhance screening and mental health referrals when indicated.


AppendicesAppendix A: Consent Form

Focus Groups of Hospital Employees

I am asking you to participate in a quality improvement project about depression after stroke. This consent form should give you the information you need to decide whether to be in the quality improvement project. I welcome your questions about the purpose of the project, what you would be asked to do, the possible risks and benefits, your rights as a volunteer, and anything else about the project or this form that is not clear. When I have answered all your questions, you can decide if you want to be in the project. This process is called “informed consent.” I will give you a copy of this form for your records.

PURPOSE OF THE PROJECT

The goal of this project is to develop a nursing work flow process where stroke patients are screened for depression in the electronic health record 24-48 hours after acute hospitalization and through telephone interview 28-35 days post-discharge, with appropriate referrals made based on screening results. The purpose of the focus group is to gain insights regarding how to proceed with nurse education and the best method for integrating the screening tool into shift assessment and nurse’s work flow.

STUDY PROCEDURES

There will be a focus group for RNs who work a minimum of 8 hours per week. The focus groups will take 60 to 90 minutes, depending on the number of people. I would like to tape the focus group so it can be transcribed. No names will be attached to the focus group, and the tape will be destroyed as soon as it is transcribed, or within three months, whichever comes first.

RISKS, STRESS, OR DISCOMFORT

I do not anticipate that the questions will be difficult to answer, but some may cause you to share your knowledge and areas where knowledge deficits may exist, which may cause emotional discomfort. You may refuse to answer any question at any time, leave the focus group at any time, and may withdraw from the project at any time without penalty.

CONFIDENTIALITY

No findings in this study will be linked to individual respondents. I will ask participants to respect each other’s confidentiality, but we cannot ensure this.

Portsmouth Regional Hospital leadership or Simmons College faculty will not have access to interview notes. Data will be handled by Tracey Collins, Simmons College DNP student.

Tracey Collins, MSN Printed name of individual obtaining consent Signature Date

If you have questions about the project or your rights you should contact Tracey Collins at 603-433-6926 and/or the Human Protections Administrator in the Office of Sponsored Programs at 617-521-2414.

Participant’s statement

This project has been explained to me. I volunteer to take part in this project. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the resources listed above.

I agree to

Participate in a focus group.

Have the focus group taped.

Printed name of participant Signature Date


Appendix B: Moderator Guide

1. What are verbal and nonverbal signs of depression?

2. Would you interpret your assessments differently if a patient had a stroke? How?

* I’m going to ask a few questions about screening tools and PARS consults

3. What is the purpose of screening tools, such as the suicide screen you complete on

admission?

4. When a patient has a “positive” result, what does that mean?

5. What is your opinion about screening tools?

6. When asking screening questions, do you ask the patients these questions as written or

based on information you obtain?

7. How would you support a patient when they express having problems with depression or

extreme sadness?

8. Are you familiar with the PHQ-2 depression-risk screening tool? Have you ever used it?

9. What criteria are you currently using to decide if a patient would benefit from a mental

health counselor (PARS) referral?

*I’m going to ask a few questions about nursing documentation

10. What is the best way to incorporate a 2-question screening tool into Meditech if it should

be completed within 24 to 48 hours after admission?

11. If a reminder were to be placed on status board, what would you find helpful?

12. What are advantages and disadvantages of stand-alone screens, like the sedation vacation

screen?

* Last section – A few questions regarding how you prefer to learn new information


13. How do you like to receive new information? Healthstream, face-to-face, flyers, e-mail,

etc.?

14. When you receive education during your work day, when is the best time? How long

should it last?

15. What are your thoughts regarding pre-test and post-tests?

16. Anything else that would help with staff education, offering support to patients, or incorporating screening into practice that you feel would be beneficial


Appendix C: Nurse Education – Web-Based PowerPoint


Appendix D: Nurse Education

1. Stroke patients should be asked the following questions (as Written) every shift for the first 48 hours after admission:

“Over the past 2 weeks, how often have you been bothered by any of the following problems:”

Not at all Several Days

More than half the

days

Nearly Every Day

“Little interest or pleasure in doing things” 0 1 2 3

“Feeling down, depressed, or hopeless” 0 1 2 3

Score of 2 or Greater: Refer to Mental Health Counselor

2. Document depression screen results in Meditech shift assessment3. If indicated and patient approves, place mental health clinician consult

a. Provider order for mental health clinician (PARS) included in stroke order sets4. If patient declines mental health clinician, offer chaplain for support 5. If patient declines both support services, document in Meditech 6. Provide patient education pamphlet

NOTE:

Administer depression screen every shift for first 48 hours after admission unless:◦ Patient with significant cognitive impairment/intubated◦ Patient screens positive and mental health clinician consult made (Consult shown on planex)

Read screening questions verbatim Positive depression screen does NOT diagnose depression If Mental Health Clinician needed sooner than 24 hours – call X4952 in addition to placing order in

Meditech OE (IE: Marked anxiety, panic attacks, or suicidal thoughts)

Depression Screening for Stroke Patients


Special Considerations◦ Patients with current depression treatment should still be screened – to evaluate for presence of

depressive symptoms◦ Communication deficits (IE: aphasia) –

Consider showing patient screening tool and asking patient to point to response (or) Seek assistance from speech therapist

Dealing with stroke rehabilitation while also handling the normal stresses of everyday life can be overwhelming.


Appendix E: Patient Education

A stroke can be a life-changing event that can cause physical, mental, and emotional changes.

Signs of Depression (feeling sad or unhappy)

While recovering from your stroke, your body will begin to experience physical and mental changes.

Mental changes, like physical changes, are important to identify and manage.

No matter how good your progress, you could experience depression while recovering.

During your admission you may be asked the following questions to see if you could benefit from additional support:

Over the past 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things Feeling down, depressed, or hopeless

Response options include:

Not at all Several Days More than half the days Nearly every day

Mood Changes Associated with Stroke


** This screening does not diagnose depression; it identifies when more support could be helpful**

Talk With Your Doctor or Nurse

If you are worried that you may be having symptoms of anxiety (frequent worrying), depression, or other emotional changes speak with your doctor or nurse

Mental Health Clinicians can assist with identifying if your symptoms are related to stress, expected changes after a stroke, or need treatment.

Chaplains can also assist with offering spiritual and non-spiritual support if desired.


Appendix F: Nurse Planex


Appendix G: EHR Order Entry Prompt Before File Documentation


Appendix H: PARS (Mental Health Counselor) in Paper Stroke Provider Orders


Appendix I: Nurse Education Pre and Post-Test

*Answers in bold

1. What percentages of patients with depression are identified when depression screening occurs through routine assessment?

a. 20% to 30%b. 30% to 50%c. 40% to 50%d. 75% to 86%

2. What percentages of patients with depression are identified when a 2-question depression-risk screening tool is used?

a. 20% to 30%b. 30% to 50%c. 40% to 50%d. 75% to 86%

You are working on an inpatient unit. You are assisting J.B., an 86-year-old man admitted with a stroke, with ambulating to the bathroom. During this time, J.B. tells you his wife died 9 months ago. He proceeds to become tearful when telling you about his loneliness. He tells you he feels sad much of the time, hasn’t been involved in his normal activities, has had difficulty sleeping for over a month, and has been drinking alcohol daily.

3. What symptoms could BEST indicate depression?a. Crying, feeling sad much of the time, decreased activity, difficulty sleepingb. Crying, wife died 9 months agoc. Crying, feeling sad much of the time, decreased activityd. Crying, feeling sad much of the time, difficulty sleeping

4. Based on the scenario in question 3, which of the following symptoms would place the patient at highest risk for suicide?

a. Frustration over lack of sleepb. Loss of wifec. Drinking alcohol d. Advanced age


You are caring for K.C., a 65 year old ischemic stroke patient. K.C. shows little interest or pleasure in doing things, and shares she has felt this way for weeks. She complains of pain in her unaffected side with no known cause, and requires discharge to an acute rehabilitation center related to severe fatigue, and slow functional recovery.

5. Which of the following symptoms BEST indicates risk of depression?a. Unexplained painb. Little interest or pleasure in doing things for weeksc. Severe fatigued. Slow functional recovery

6. To administer the 2-question depression-risk screening tool, a patient is asked “Over the past 2 weeks, how often have you been bothered by any of the following problems”?

a. Feeling down, depressed, or hopeless AND Feeling bad about yourself — or that you are a failure or have let yourself or your family down

b. Have little interest or pleasure in doing things AND Feeling down, depressed, or hopeless

c. Little interest or pleasure in doing things AND Poor appetite or overeatingd. Feeling down, depressed, or hopeless AND Trouble falling or staying asleep, or

sleeping too much

7. The depression-risk screening tool questions should be completed in the following manner:

a. Perform routine physical assessment, then answer screening questions based on verbal and non-verbal information collected

b. Pull up the computer screen and read questions verbatim, with back to patientc. By asking the patient or family member if they have felt depressed within the

past 2 weeksd. As part of routine assessment, incorporate asking screening tool questions

as written, every shift, for the first 48 hours after admission

8. The patient has a “positive” depression-risk screening score. How would you explain what this means to the patient?

a. “Your depression-risk screening score was 2 or greater. This means that you have depression, and may benefit from starting an antidepressant. I will notify the provider to request orders.”

b. “Your depression screening shows that you might be at risk for depression, which is common for stroke patients. Would you like to speak with a mental health counselor, who can assist with offering you support?”


c. “Your depression-risk screening score was 2 or greater. Because you had a stroke, your feelings are expected. We will continue to check you every shift to continue to monitor how you are feeling.”

You are caring for K.C., a 65 year old ischemic stroke patient. K.C. shows little interest or pleasure in doing things, and shares she has felt this way for weeks. She complains of pain in her unaffected side with no known cause, and requires discharge to an acute rehabilitation center related to severe fatigue, and slow functional recovery.

9. Would this patient warrant an urgent or routine mental health counselor consult if their depression-risk screen was positive? Within what time frame would you expect the mental health evaluation to occur?

a. Non-urgent, patient seen within 12 hoursb. Non-urgent, patient seen within 24 hoursc. Urgent, patient seen within 12 hoursd. Urgent, patient seen within 24 hours

10. In addition to feeling hopeless and having suicidal thoughts, which patient characteristic are urgent and would warrant calling a mental health counselor to facilitate a consult as soon as possible?

a. Patient repeatedly declines to participate in rehabilitationb. Patient suffers from mood disorder, PTSD, or alcohol/substance abusec. Patient exhibits marked anxiety or panic attacksd. Altered sleep/wake cycle for over two weeks


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