The smiley as a simple screening tool for depression after stroke: A preliminary study

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Abstract

In Hong Kong, there is a paucity of evidence to support which tool is superior in measuring depression after stroke (DAS). A simple, non-language-based, culturally neutral, non-verbal and easy to apply tool that is not highly dependent on training will be desirable.

Objectives

The present study aimed to examine the clinical utility of three smiley pictures in detecting DAS for older Chinese patients at 1 month after first-ever ischemic stroke.

Methods

This was a cross-sectional study. A total of 253 stroke patients were interviewed by a research nurse at 1-month follow-up.

Results

Taking Diagnostic and Statistic Manual (DSM IV) as the gold standard, the measurement properties of emoticon (sad) in terms of sensitivity, specificity, positive and negative predictive values, as well as Kappa's value were found comparable to Geriatric Depression Scale (GDS). The emoticon (happy) demonstrated a highly significant inverse relationship with all depression assessment tools (p<0.001). It was also found that the emoticon (flat) could capture 98% of all depressed subjects identified by DSM IV, although its predictive values were less satisfactory.

Conclusions

The smiley pictures seemed to fulfil the requirements for early and prompt screening among older patients. Cultural implication regarding emotions dissipation among Chinese patients should be further studied.

Section snippets

What is already known about the topic?

  • Depression after stroke (DAS) might impact on rehabilitation and clinical outcomes.

  • Detecting depression in the elderly patients is important but often difficult due to factors relating to patients, healthcare professionals and assessment tools.

  • A valid and user-friendly assessment tool is indicated for early and prompt screening of DAS.

What this paper adds

  • The degree of agreement between DSM IV and the emoticon (sad) is moderately high and comparable with that of Geriatric Depression Scale (Chinese).

  • Smiley diagrams being a simple, non-language-based, culturally neutral, less time consuming and easy to apply tool might be suitable for preliminary screening of DAS.

  • Cultural specificity in moderating emotions dissipation among Chinese heeds careful interpretation of DAS assessment results.

Background

The lack of a biological marker for depression has been the major barrier to prompt clinical diagnosis. A variety of assessment tools for depression and DAS have been reported previously. Commonly accepted across different countries and cultures are the Diagnostic and Statistical Manual fourth edition (DSM IV) (Aben et al., 2003; Cassidy et al., 2004; Rao et al., 2001) and the GDS (Agrell and Dehlin, 1989; Johnson et al., 1995; Leeds et al., 2004; Mast, 2004; Nannetti et al., 2005; Nir et al.,

Aims

The aims of this study were to: (1) examine the clinical utility of the smiley pictures in detecting DAS for older Chinese patients at 1 month after first-ever ischemic stroke, (2) compare the performance of the smiley pictures with DSM IV as the gold standard, as well as the Chinese version of GDS.

Design

The study of smiley diagrams in assessing DAS adopted a cross-sectional design. A personal interview by a research nurse was undertaken at 1 month at a rehabilitation unit or outpatient clinic during

Demographics of participants

A total of 253 patients completed the depression assessment at 1 month after first stroke. About 66% of female subjects aged 70 years or over were compared to 57% of males (p=0.423). The males had received significantly more education and attained higher levels compared with the females (p<0.001). About 44% of females had not received any education, while only about 15% of males were illiterate (p<0.001). Slightly over half of both male and female subjects stayed in hospital for about 2 weeks

Discussion

Depression after stroke is a triple burden in itself (depression, stroke and old age) for older clients (Lee et al., 2007). Early detection might help to alleviate the burden and tremendous suffering due to a compromised quality of life (Moon et al., 2004; Sturm et al., 2004). Existing Western diagnostic and rating scales are often lengthy and assume a certain level of literacy. While necessary for research and classification purpose, these tools are impractical for frontline healthcare workers

Conclusion

This paper reports a tentative attempt to use a simple visual and language-independent tool to facilitate early detection of DAS. Application of this tool by front-line healthcare workers may help to raise the index of suspicion among susceptible subjects and lead to a more detailed assessment targeted at diagnosis and suitable treatment. The performance of such a visual tool seems promising and justifies further research, in particular among needy groups such as those with expressive aphasia,

Acknowledgments

We would like to express gratitude to the stroke patients and their families, all clinical partners who had actively participated in this study. This study was supported by a seed funding grant from the University of Hong Kong.

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