Screening helps ensure psychosocial needs are identified early; this can facilitate well-being and improve people’s engagement and motivation in rehabilitation. Psychosocial well-being should be considered within the initial assessments of all disciplines and monitored in the weeks and months after stroke.

Psychosocial screening can occur through multiple means: conversation and observation, semi-structured interviews, validated screening tools, and diagnostic assessments. All members of the stroke team can screen for psychosocial needs with appropriate training and support. Diagnostic assessments need to be completed by appropriately qualified healthcare professionals (e.g. medical or mental health providers).

Ensuring screening processes are culturally responsive, culturally safe, and engaging is critical to improving equity and better health outcomes. This helps create positive and empowering interactions with the healthcare team, and can help achieve equity for whānau Māori.

Every person with stroke should have a validated mood screen in the first few weeks after stroke – although formal screening is not recommended in the first week after stroke. If there are any concerns about mood after this time, a validated screen should be completed. Key timepoints when screening may be particularly important are:

  • At point of transfer to, or during, inpatient rehabilitation
  • Before discharge to the community, or before discharge from community services
  • During routine follow-up in primary care or stroke review clinics [14, 15].
  • People who require further assessment or intervention should be identified early, provided with supports appropriate to their level of need, and referred for specialist support (if required) as soon as possible.

Psychosocial screening

Before screening, explain why screening is happening. Mood and well-being screens are more reliable and therapeutic when clients understand the rationale and feel they can trust their clinicians.

A possible script is: “As you know, a medical event like a stroke can impact not only our brain and body, but also our sense of self and our confidence. As well as monitoring how your body is adjusting to the stroke, we find it helpful to check how you are adjusting to your stroke to make sure we are supporting you as best we can. I would like to ask some questions about how you have been feeling lately – is this ok? Do you have any questions before we start?”

It is helpful to talk about how screening and supporting psychosocial well-being can support people’s goals and priorities.

Whanaungatanga is foundational and should be prioritised

Whanaungatanga is foundational and should be prioritised

Psychosocial screening – informal or through validated screening tools – occurs best in the context of a mutual relationship where people feel welcome, known, and have a sense of connection with the person they are working with.

Screening occurs in multiple ways and at multiple time points

Screening occurs in multiple ways and at multiple time points

Psychosocial screening is not a one-off event.

Screening processes should include a combination of screening approaches; conversations with the person and whānau, observation, structured questions, validated mood screens, and diagnostic assessments where indicated. These all need to be documented.

Mood screens need to be interpreted with caution: combining information from different sources is important for identifying issues and support needs.

Screening needs to be accessible for those with communication differences and impairments.

Screening needs to be accessible for those with communication differences and impairments.

A number of screening tools have been designed for people with post-stroke communication impairments. Involving speech-language therapists in screening can improve the screening process and outcome.

Whānau, interpreters, and/or cultural advisors should be included for people from culturally and linguistically diverse backgrounds.

Screening should consider people’s holistic well-being needs

Screening should consider people’s holistic well-being needs

Within screening, it is important to attend to the different ways psychosocial well- being can be impacted. Formal screening tools commonly focus on depression and anxiety, but other aspects such as adjustment and identity are important to consider as are cultural aspects of well-being.

Appropriate action plans should be developed and implemented

Appropriate action plans should be developed and implemented

Observations and results should be shared with the person with stroke, other team members, and with their whānau, if appropriate. These should be documented in discharge documentation.

Action plans need to be developed and implemented in a timely manner and need to be monitored over time

Informal screening: Supportive conversations and observations

Informal screening: Supportive conversations and observations

Psychosocial well-being should be considered at all times throughout stroke care. Well-being can be reviewed through conversations with the person with stroke, their whānau and friends, and via observation.

Supportive conversations or observations might be brief check-ins, short chats or extensive discussions. It might simply be a 30 second check in at the beginning of a nursing shift or medical review, a few questions during an initial assessment, an informal five-minute discussion before or after a rehab session, or a longer chat with them or whānau if it appears their mood and motivation is causing them difficulties. These should be two-way conversations, going beyond asking questions to having a conversation about how things are going.

It helps to be down-to-earth, demonstrating care for the person, and being non- judgemental of how they are adjusting to their stroke. You don’t need to ‘fix’ their mood; simply create an accepting and supportive space for them to share, ask questions, and reflect if they wish. Creating an environment where people feel safe to talk and to ask questions is invaluable.

Be mindful about how questions are framed. This may be particularly important for Māori, Pacific peoples, and those from non-English speaking backgrounds. Use interpreters if needed. Minimise technical words and use more everyday, informal language. More questions may need to be asked both to clients and whānau. When providing information, ensure this is shared in ways, and at times, that facilitate understanding and are responsive to the needs and priorities of the person and their whānau.

Pay attention to changes in mood and behaviour over time. The sooner that difficulties are noticed, or the sooner that improvements are noticed, the more proactive and supportive providers can be.

Checking in about well-being through conversation

Simple questions to explore how people are doing

Simple questions to explore how people are doing

Comment on your observation

Comment on your observation

Use people's own language

Use people's own language

Simple check-ins with whānau and friends

This has been a big change for you and whānau – how are you coping?

How do you feel [Person] is coping? Do you have any concerns about them?

Is this mood or behaviour (e.g, quiet, tearful, aggressive) normal for them or new since the stroke?

Observations

Observations

If concerns are raised:

If concerns are raised:

Screening with structured interviews

Initial assessments completed by any discipline or by an interdisciplinary team should include brief screening questions about client and whānau psychosocial well-being.

This ideally includes questions on adjustment, mood changes, emotional lability, behavioural/personality changes and carer stress, all of which are common post-stroke.

These should be documented in the patient’s clinical notes. 

Recommended questions for IDT initial assessments

Recommended questions for IDT initial assessments

Screening using validated screening tools

All stroke patients should be screened for depression and anxiety with a simple, brief, validated measure at least one time point after stroke. These measures cannot be used to diagnose mood disorders, but they provide a measure of symptoms and severity that can help guide further assessment and intervention.

Some validated screening tools require staff to be trained to administer them.

Things to consider when using validated screening tools

Mood screens should be interpreted with caution

Mood screens should be interpreted with caution

Mood screens should be interpreted with caution and guided by clinical judgement.

Several symptoms included in mood screens are not specific to mood disorders – they are also common following a stroke and other medical conditions.

For example, reduced energy, sleep, appetite and concentration may be symptoms of the stroke itself, or they may be a sign of a mood disorder.

Furthermore, people with cognitive or communication difficulties may provide less reliable responses – for example if they have difficulty remembering or monitoring their symptoms or understanding and expressing how they feel.

Take care to use the most appropriate mood screen, identify the best timing of screening, and use clinical judgement to interpret results. 

Places of screening: Face-to-face and private

Places of screening: Face-to-face and private

Considerations when screening via telehealth

Considerations when screening via telehealth

Whānau involvement in screening well-being

Whānau involvement in screening well-being

Supporting communication needs.

Supporting communication needs.

Screening people from linguistically diverse backgrounds

Screening people from linguistically diverse backgrounds

Screening for psychological risks

Healthcare professionals should:

  • Be aware of self-harm risk factors
  • Take expressions of self-harm seriously
  • Be familiar with simple risk questions
  • Follow protocol on managing self-harm
  • Ensure clear communication with team and senior/expert clinicians

If a clinician is worried about someone’s safety, they must inform the appropriate clinicians involved in the person’s care even if the person requests that they do not do this. This process should be discussed in a transparent and supportive manner. Information that is shared to others should be only on a ‘need-to-know’ basis, unless permission is given from the person.

How and when to ask about suicide

How and when to ask about suicide

The Hospital Anxiety and Depression Scale (HADS)

The Hospital Anxiety and Depression Scale (HADS)

Suicide risk factors post-stroke include:

Suicide risk factors post-stroke include:
  • younger age, post-stroke depression, previous mood disorder or self-harm, higher stroke severity, cognitive impairment, persistent and poorly controlled pain, substance use or withdrawal, and lower education or income [17].
  • Distress and thoughts of death and suicide are common as people process the reality of their stroke and consider how to resolve challenging situations. They may think or openly talk of death or suicide: ‘I’d rather be dead’, ‘I should’ve died’, ‘I’ve had enough’, ‘there’s no point’.

The risk of self-harm is on a continuum from low risk to imminent risk. Many people will have passive and fleeting thoughts post-stroke such as ‘I can’t cope’ and ‘I wouldn’t mind if I didn’t wake up’. Others can develop more serious considerations of self-harm – with active intent and plan of self-harm. Self-harm attempts can occur with preparation (e.g. stockpiling medications) but can also occur impulsively during a time of distress or helplessness.

Teams should have contact information for local mental health and crisis teams easily available, both for consultation and to provide to clients and their whānau.

Screening for broader well-being

Conversations about holistic well-being

Having conversations with patients and whānau about the wider domains of well-being may help normalise the psychosocial impacts for people and may help identify issues earlier. This means support can be offered in a timely manner. This section touches on four areas that people identify as important in well-being: adjustment, relationships, hope, and identity. The questions suggested here are not intended to be asked as part of a formal screening process. Instead, they may be interwoven into conversation at different times throughout care.

Adjustment

Adjustment

Relationships

Relationships

Having hope for the future

Having hope for the future

Having hope for the futurehe sense of well-being is enhanced when people feel hope and have a positive view of what their future may look like. Low hope can come from multiple areas including low mood, a sense of loss, changes in identity, and a loss of confidence in themselves and in the future. Hope can be built through re-establishing a view of a possible and desired future, positive relationships, and a sense of progress toward things that matter [19]. Processes such as goal-setting can help but it best supports hope when clinicians acknowledge people's hopes and connect short- term goals to people's broader aspirations. This also supports engagement [20].

Identity

Identity

Validated screens for holistic well-being

Validated screens for holistic well-being

The measures above have been used extensively to screen for mood disorders in people with stroke. However, broader measures of quality of life can provide understandings into other areas of well-being that are commonly impacted by stroke.

Measures that may be useful include:

Communicate with the person with stroke, whānau and team

It is important to share your observations and screening results with both the person and those involved in the persons’ care. Consider their confidentiality: only share information that is relevant to their care and goals.

Communicate with client and whānau

Communicate with client and whānau

Communicate with team

Communicate with team

Example of screening approaches

Counties Manukau Rehabilitation Service

Counties Manukau Rehabilitation Service

Counties Manukau’s Community Rehabilitation Service include the PHQ-4 as part of the initial IDT assessment.

It used to be recorded on a separate form, but they found that incorporating it into the initial assessment form prompted staff to do it routinely. 

Before implementing the PHQ-4 into routine practice, their psychologist provided training about how to ask questions and score responses and gave information about what would trigger a referral to psychology.

The PHQ-4 is supported by a wide-ranging initial assessment which prompts providers to explore people’s general well-being and to ask about carer stress and well-being, and by providers’ observations of the person and their whānau.

Staff use a range of strategies to adjust screening for people with aphasia or significant cognitive issues.

These include joint sessions with the SLT, use of Talking MatsTM resources to aid understanding and expression, and use other communication supports such as whiteboards to write key words and to help people communicate their responses. When working with Māori stroke patients, staff involve whānau in screening.

These initial screenings are discussed at the regular IDT meeting. The template for the meeting also reminds staff to identify people’s cultural needs and to discuss sex and intimacy with the person.

Waitematā - Early Discharge and Rehabilitation Service (EDARS)

Waitematā - Early Discharge and Rehabilitation Service (EDARS)

The Early Discharge and Rehabilitation Service (EDARS) at Waitematā screens well-being at multiple points during a person’s six-week rehabilitation programme.

The referral form for the services requires referrers to provide information about psychosocial well-being. Whilst this was primarily intended as a safety screener, it helps highlight issues around vulnerability, isolation and social supports, prompting and prompts the referrer to identify issues and consider these before the person is discharged home. It also means that the EDARS team have a better picture of who is coming into their services and who may be particularly vulnerable. The questions ask if the person is a primary carer for others, if they are a vulnerable adult or at risk of abuse or neglect; if they are socially isolated; and if there are any concerns about the person’s relationship.

This is supplemented through the nursing and social work screens. Their RN completes a comprehensive screening with every patient in the first week of rehabilitation. This includes asking questions about cognition, memory, mood, depression and anxiety. They ask about changes in body image, spiritual distress, feelings of grief and lost, and ask about the person’s adjustment to the impacts of stroke. In week 2 or 3, the social worker completes a phone screen for every patient. Through conversation, they explore mood changes to identify if there are any issues.

Psychosocial issues are also commonly identified through the team’s goal- setting process. The goal-setting tool, the Schedule for the Evaluation of Individual Quality of Life (SEIQOL), prompts people to identify the areas of life most important to them, and uses this to help identify specific therapy goals using Goal Attainment Scaling. Talking about what matters most in life provides an opening for people to raise issues related to their psychosocial well-being.

Southern’s community rehabilitation service, REACH

Southern’s community rehabilitation service, REACH

Southern’s community rehabilitation service, REACH, embeds psychosocial screening in their initial interdisciplinary assessment form. Rather than having specific questions to ask patients, they have areas for discussion with associated prompts. These include topics such as ‘social situation’ with prompts that staff should explore, such as family, neighbours, relationships, intimacy,

roles and pets. The form requires that they identify the person’s living situation, whether they feel socially supported or feel socially isolated or lonely, and a prompt to provide details about the person’s mood. Other areas explored include the person’s cultural and spiritual beliefs and values, their hobbies and interests, work and productivity, fatigue, support systems and transport. Whilst their initial screening is long, it can be broken over several sessions and is helpful in identifying psychosocial issues early.