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TOPIC. This secondary analysis study examined patients comments at 1 and 6 months poststroke when they had scores of 16 on the Center for Epidemiologic StudiesDepression Scale. Stroke survivors depressive comments were matched with items of two well-established depression instruments. METHODS. A qualitative study using content analysis to analyze the data (N = 7). FINDINGS. Verbal indicators of depression were evident in patients comments, and depressive themes were identified. Depression instrument items were congruent with minor themes, except for spirituality. CONCLUSIONS. The analysis provides guidance for assessment of stroke survivor depression. It provides direction for designing interventions to decrease depression after stroke. Search terms: Depression, stroke, qualitative study Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 61 Gale Robinson-Smith, PhD, RN, CS, is Assistant Professor, Villanova University College of Nursing, Villanova, PA. Stroke is a major cause of long-term disability in the United States (American Heart Association, 2000). De- pression is readily understood to be a common experi- ence after stroke, and is partially related to coping with poststroke sequelae such as hemiplegia, poor balance, vi- sual difficulties, and aphasia. Estimates of poststroke de- pression range from 20% to 50% (Robinson, 2002). Depression affects the motivation that is needed for improving functional independence after stroke. Investi- gators have reported strong relationships between symptoms of depression and functional outcome in pa- tients from 3 months to 2 years after stroke (Herman, Black, Lawrence, Szekely, & Szalai, 1998; Parikh et al., 1990). These studies highlight the need to screen all stroke survivors for depression, as lower independent functioning is associated with depression symptoms. Within the context of limited healthcare resources, the ability to identify a subgroup of poststroke survivors who are vulnerable to ongoing or serious depression is critical. Information about major clinical depression in the post- stroke population can alert the psychiatric nursing com- munity to those who are at risk for psychosocial morbid- ity. With increased knowledge about stroke-survivor depression, clinical nurses can intervene more effectively to reduce the severity of depression and improve func- tional ability with their patients. Therefore, the purpose of this secondary analysis study was to examine comments made by stroke survivors while interpreting their conver- sational elements as indicators of depression. Additionally, the study compared comments made by stroke survivors that pointed to depression with items of two well-established depression instruments. The research questions were: (a) What were the depres- sive themes evident in the comments made by post- stroke survivors, who were depressed at 1 and 6 months poststroke and who scored 16 on the Center for Epi- demiologic Studies Depression Scale (CES-D) (Radloff, 1977)? and (b) Do comments made by depressed stroke Verbal Indicators of Depression in Conversations With Stroke Survivors Gale Robinson-Smith, PhD, RN, CS

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Page 1: Verbal Indicators of Depression in Conversations With Stroke Survivors

TOPIC. This secondary analysis study examined

patients� comments at 1 and 6 months poststroke

when they had scores of ≥ 16 on the Center for

Epidemiologic Studies�Depression Scale. Stroke

survivors� depressive comments were matched

with items of two well-established depression

instruments.

METHODS. A qualitative study using content

analysis to analyze the data (N = 7).

FINDINGS. Verbal indicators of depression were

evident in patients� comments, and depressive

themes were identified. Depression instrument

items were congruent with minor themes, except

for spirituality.

CONCLUSIONS. The analysis provides guidance

for assessment of stroke survivor depression. It

provides direction for designing interventions to

decrease depression after stroke.

Search terms: Depression, stroke, qualitative

study

Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 61

Gale Robinson-Smith, PhD, RN, CS, is Assistant Professor,Villanova University College of Nursing, Villanova, PA.

Stroke is a major cause of long-term disability in theUnited States (American Heart Association, 2000). De-pression is readily understood to be a common experi-ence after stroke, and is partially related to coping withpoststroke sequelae such as hemiplegia, poor balance, vi-sual difficulties, and aphasia. Estimates of poststroke de-pression range from 20% to 50% (Robinson, 2002).

Depression affects the motivation that is needed forimproving functional independence after stroke. Investi-gators have reported strong relationships betweensymptoms of depression and functional outcome in pa-tients from 3 months to 2 years after stroke (Herman,Black, Lawrence, Szekely, & Szalai, 1998; Parikh et al.,1990). These studies highlight the need to screen allstroke survivors for depression, as lower independentfunctioning is associated with depression symptoms.

Within the context of limited healthcare resources, theability to identify a subgroup of poststroke survivors whoare vulnerable to ongoing or serious depression is critical.Information about major clinical depression in the post-stroke population can alert the psychiatric nursing com-munity to those who are at risk for psychosocial morbid-ity. With increased knowledge about stroke-survivordepression, clinical nurses can intervene more effectivelyto reduce the severity of depression and improve func-tional ability with their patients. Therefore, the purpose ofthis secondary analysis study was to examine commentsmade by stroke survivors while interpreting their conver-sational elements as indicators of depression.

Additionally, the study compared comments madeby stroke survivors that pointed to depression withitems of two well-established depression instruments.The research questions were: (a) What were the depres-sive themes evident in the comments made by post-stroke survivors, who were depressed at 1 and 6 monthspoststroke and who scored ≥16 on the Center for Epi-demiologic Studies Depression Scale (CES-D) (Radloff,1977)? and (b) Do comments made by depressed stroke

Verbal Indicators of Depression in ConversationsWith Stroke Survivors

Gale Robinson-Smith, PhD, RN, CS

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survivors correspond with items on two depression in-struments, CES-D and Geriatric Depression Scale (GDS)(Brink et al., 1982)?

Depression indicators emerged in patients� conversa-tions with a nurse investigator during a larger study(Robinson-Smith, Johnson, & Allen, 2000). Identifyingcomments that suggest depression may help othernurses identify stroke survivors at risk for severe or sus-tained depression.

Background

Poststroke Depression

The first year after stroke is considered a crucial timefor recovery from depression. Astrom, Adolfsson, andAsplund (1993) examined depression, functional ability,and social network over a period of 3 years after stroke.Factors that contributed to serious depression in the firstyear poststroke included left anterior brain stroke, dys-phasia, living alone, and dependence in activities of dailyliving. At follow-up in the second and third year post-stroke, chronic depression was most likely to occur inthose stroke survivors who had not recovered from de-pression at 1 year following the stroke diagnosis. Thefindings suggested that psychosocial adjustment factorswere related to depression after stroke, since depressionincreased over time in some patients.

In another study (Morris, Robinson, Andrezejewski,Samuels, & Price, 1993), depression was related to in-creased mortality 10 years after stroke in a sample of 91patients. Either minor or major depression was signifi-cantly associated with mortality, when other variables,such as age, sex, social class, type of stroke, lesion loca-tion, and physical and social functioning were controlledfor. Additionally, the investigators reported that fewersocial ties and increased co-morbid conditions con-tributed to poststroke mortality in this group of strokesurvivors.

Gainotti, Antonucci, Marra, and Paolucci (2001) inves-tigated the recovery of 49 poststroke patients who hadsimilar levels of impairment and depression during their

62 Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004

rehabilitation. Depressed stroke survivors were placed inone of two groups based on whether or not they re-ceived antidepressant medication during rehabilitation.Patients in the group who had not received antidepres-sants regained less functional independence when theywere compared to stroke survivors who received treat-ment for depression.

In contrast, Robinson-Smith et al. (2000) examined therelationship among self-care self-efficacy, quality of life,and depression in poststroke patients (N = 63). Self-careself-efficacy is the confidence a person has in his or herability to perform relevant self-care activities (Lev &Owen, 1996). Depression was present in 25% (n = 17) ofsubjects who attained a score of ≥16 on the CES-D at 1month poststroke. Self-care self-efficacy and depressionwere strongly correlated in the study, and self-care self-efficacy accounted for more than 50% of the variance indepression. King, Shade-Zeldow, Carlson, Feldman, andPhilip (2002) followed 53 stroke survivors from inpatientrehabilitation to 2 years poststroke. They comparedchanges in depression over time and identified variablesthat would predict depression after stroke. Patients whohad poorer perception of their physical health, lowerfamily functioning, and less satisfaction with social sup-port had higher depression scores on the CES-D. Addi-tionally, older age and the use of coping strategies, suchas avoidance and less frequent use of finding meaningafter stroke, were predictive of higher depression beforedischarge from inpatient rehabilitation.

Communication

Communication theories often include description ofmanifest and latent levels of verbal messages. Penman(1980), for example, discussed the more apparent or ob-vious meanings of manifest communication and the sub-tle complexity of latent communication. The basis forPenman�s description of two levels of communicationderived from theory developed by Ruesch and Bateson(1968) about report and command aspects of language.The command aspect provides explicit informationabout a topic, so it is similar to manifest communication.

Verbal Indicators of Depression in Conversations With Stroke Survivors

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The report aspect of a communication exchange refers tothe implicit or latent message. Metacommunication wasdescribed by the theoreticians to encompass the entiretyof communication with its overt and more subtle aspectsof establishing communication between human beings(Ruesch & Bateson). Additionally, Watzlawick, Bavelas,and Jackson (1967) developed a communication theorythat further delineated content and relationship aspectsof communication. The content aspect is similar to the re-port dimension, the relationship aspect to the commanddimension of communication. The relationship aspect ofan interaction is complex, described as �a communica-tion about a communication� (Watzlawick et al., p. 53).

These theories emphasized acknowledging the impor-tance of paying attention to the obvious content of a con-versation and, at the same time, the salience of the rela-tionship aspect of communication. When measuringdepression in stroke survivors with research instru-ments, therefore, the fullness of the depression experi-ence can be better understood when patient commentsare analyzed for the meaning conveyed.

Methods

Design

This secondary analysis study (Szabo & Strang, 1997)employed a qualitative approach to describe the conver-sational elements indicating depression in poststroke

Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 63

survivors and the depressive themes interpreted fromthe comments. The study also compared these com-ments to two instruments that measure depression. Con-tent analysis (Polit & Hungler, 1999) was used to analyzethe meaning of the comments as they represented de-pression and to compare items on the CES-D and GDS tothose comments. The subgroup for the analysis was se-lected from a longitudinal, correlational design investiga-tion (N = 63) focusing on self-care self efficacy and qual-ity of life (Robinson-Smith et al., 2000). Depression alsowas studied, because it was considered to be importantto understanding the primary relationship between self-care self-efficacy and quality of life.

Sample and Setting

Seven patients constituted the sample (Table 1). Theunique attribute (Kennedy, 1979) of the seven specialcases was that subjects scored ≥16 on the CES-D at 1 and6 months poststroke. All initial interviews were con-ducted at a rehabilitation institution; 6 months after thestroke, interviews took place at home. All seven patientshad experienced an ischemic stroke. Cognitive status wasadequate for participation in the study and was evalu-ated by means of the Mini Mental Status Examination(MMSE) (Folstein, Anthony, & McHugh, 1975). Patientshad no previous psychiatric history. Only three strokesurvivors were taking antidepressants 6 months post-stroke (one of these patients was receiving additional

Table 1. Demographic Characteristics of Subjects

Subject# Gender Age Race Marital Status Side of Stroke Co-Morbid Condition

1 Female 62 White Divorced Right Headaches2 Male 71 White Widowed Right Heart disease3 Male 45 Black Married Undetermined Sarcoidosis, heart disease4 Male 72 White Married Left Degenerative arthritis5 Male 58 White Married Left Heart disease, alcohol

dependence6 Male 83 White Widowed Left and right Prostate cancer7 Male 77 White Married Right Heart disease

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psychotherapy), even though the entire sample was seri-ously depressed at 1 and 6 months after stroke.

Ethical Considerations

Patients signed consent forms for the primary study,and confidentiality and anonymity were maintained. Insti-tutional review board permission was obtained at a majorrehabilitation hospital in the northeastern United States.

Instrumentation

In the primary study, depression was measured bythe Center for Epidemiologic Studies Depression Scale.The CES-D Scale is a widely used 20-item self-report de-signed to evaluate symptoms of depression in the gen-eral population. It is considered a reliable and valid toolfor evaluating stroke patients (Shinar et al., 1986). TheGeriatric Depression Scale is a self-report instrument de-signed to evaluate depression in older medical patients.It is considered to be a valid and reliable tool (Hyer &Blount, 1984). CES-D and GDS items were compared tosubjects� comments.

Data Collection

The investigator recorded comments made by post-stroke survivors (N = 63) directly on the CES-D when sheconducted the primary study. Later, she typed the com-ments on a patient data form. Next, the researcher identi-fied seven subjects who most likely suffered from a majorclinical depression as evidenced by scores of 16 or aboveon the CES-D Scale. The recorded comments of the sevencases were culled for indicators that pointed to depres-sion and were embedded in conversation. Those conver-sational elements were organized into a separate data setthat specified subjects using identification numbers.

Data Analysis

Content analysis was performed on comments madeby clinically depressed subjects. The comments are

64 Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004

�speech messages� (Silverstein, 1976, p.13) that indicatemeaning and purpose in communication. The investiga-tor read and reread the transcribed comments as indica-tors of depression. She coded the depressive indicatorsand identified depressive themes. As the minor themessignifying depression were clustered, major themes wereidentified. Minor depressive themes in comments ofstroke survivors were compared to items on the CES-Dand GDS.

Rigor or Scientific Adequacy

The investigator attempted to establish the study�strustworthiness (Lincoln & Guba, 1985). For the credibil-ity criterion to be accomplished, she engaged in readingand reflecting on the material of the study, includingtranscribed comments. She attempted to achieve triangu-lation by matching CES-D and GDS instrument items tocomments of subjects (Streubert & Carpenter, 1995). Atrusted, qualitative investigator reviewed transcribedcomments, and the minor and major themes. She agreedwith the analysis.

To establish dependability, the audit trail was avail-able for review by the peer reviewer. The audit trail in-cluded transcribed comments, depressive indicators, andmajor and minor themes.

The investigator, a psychiatric nurse, was aware ofherself in relation to the participants, the data, and herrole in the study (Lipson, 1989). She also was aware ofher interpretation of the material and her sensitivity tothe meanings of the comments.

Findings

Findings in this study describe the verbal indicators ofstroke survivors who were depressed. Table 1 containsdemographic information about the sample of strokesurvivors. Major and minor depressive themes wereidentified. The five major depressive themes (Table 2)emerged during the analysis of transcribed commentsthat suggested depression: Turning to negative emo-tions, having nighttime symptoms, feeling down about

Verbal Indicators of Depression in Conversations With Stroke Survivors

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Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 65

ally, compliance in self-care may be assisted through reg-ulation of physical and emotional symptoms. Nursesmight teach stress management using mind-body tech-niques such as imagery, relaxation exercises, and journalwriting so that patients will take a more active role intheir own care.

This study emphasizes the importance of listening topatients to assess verbal indicators of depression duringinterviews. The findings point to the need for psychiatric

self, asking for spiritual help, and feeling changes in bod-ily sensations.

Minor themes were compared to items from establisheddepression instruments. The instruments did not includeitems that address spirituality. Ellison and Levin (1998),who reviewed research studies that examined the effects ofreligion on physical and mental health, suggested that bet-ter instruments are needed to measure the relationship be-tween religion and health outcomes, such as depression.

Table 3 contains a comparison of CES-D and GDSitems and stroke survivor minor depressive themes.

Discussion

Clinical Implications: Advanced Practice Nursing

When a patient has been identified as depressed,nurse practitioners or other advanced practice nurses canexplain the depression�s causes, symptoms, and treat-ment options. Some patients may not know they are de-pressed because they have focused primarily on thestroke�s physical effects and recovery. Nurse practition-ers must help patients describe emotions that indicatedepression. Since most people experience stroke as emo-tionally upsetting, nurses can be supportive of patientverbalizations about depression and stroke.

Wheeler (2000) discussed strategies that assist patientswith regulating physical and subjective symptoms. Sherecommended that nurses help patients link physicaland emotional states. For example, stroke survivors oftenbecome self-critical and pessimistic if they are unable toperform a valued task, such as cooking for family or re-turning to full-time work. When nurses explore the dis-tress associated with specific instances of activities thatcannot be performed at a prestroke level, they become abridge for patient understanding of a physical symptom,such as hemiplegia and its connection to feelings, such assadness and loss.

Nurse practitioners might encourage patients to iden-tify the link between physical activities and emotionalsymptoms that are persistent, such as sadness, irritabil-ity, or pessimism, that may lead to depression. Addition-

Table 2. Major and Minor Depressive Themes in Comments of Poststroke Subjects (N = 7)

Major Themes Minor Themes

■ Turning to negative emotions ■ Pessimistic■ Anger■ Instability■ Self-criticism■ Irritability

■ Having nightly symptoms ■ In pain■ Felt self-pity ■ Worried

■ Feeling changes in bodily ■ Found common tasks sensations very challenging

■ Lacked energy■ Movement affected■ Had physical discomfort■ Had balance problems

■ Feeling down about self ■ Cried■ Frustrated■ Negative self-concept ■ Resigned to situation■ Self-centered■ Devaluation of self

■ Asking for spiritual help ■ Relied on God ■ Prayed■ Visited spouse�s grave

daily■ Expressed ambivalence

about stroke

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nurses to assess depression after stroke with open-endedquestions and to respond with supportive, focused tech-niques to decrease the discomfort of depression. Nursesmust assess the presence of risk factors for depressionafter stroke, including personal or family history of de-pressive disorders, history of alcohol abuse/dependence,and recurring stroke. Assessment of social support andstressful life events contributing to poststroke depressionis essential. Nurses must explore the meaning and senseof loss encountered with decreased independence andbodily changes associated with stroke.

66 Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004

If antidepressants are prescribed, nurses must monitorpatients carefully for dose, side effects, and drug interac-tions, because many stroke survivors are elderly and takemultiple medications. Additionally, compliance may be af-fected by the decreased energy and motivation accompa-nying depression. Anxiety complicates the clinical pictureof poststroke depression; therefore, care must be taken toassess anxiety. For example, patients may report more se-vere somatic symptoms and may experience difficultywith medication compliance (Lenze et al., 2000) when theyexperience both anxiety and depression poststroke.

Verbal Indicators of Depression in Conversations With Stroke Survivors

Table 3. Comparison of Items from the Center for Epidemiologic Studies�Depression Scale (CES-D), Geriatric Depression Scale (GDS), and Minor Depressive Themes

CES-D Item Number GDS Item Number Minor Themes

#1. I was bothered by things that usually #6. Are you bothered by thoughts you ■ Worrieddon�t bother me. can�t get out of your head? ■ Irritability

■ Instability■ In pain■ Having physical discomfort

#2. I felt that I could not shake off the #16. Do you often feel downhearted and ■ Pessimisticblues even with help from my family and blue? ■ Self-centeredfriends. ■ Felt self-pity

■ Resigned to the situation

#6. I felt depressed. #7. Are you in good spirits most of the ■ Devaluation of selftime? ■ Anger

■ Cried■ Self-concept affected■ Self-criticism

#7. I felt that everything I did was an #21. Do you feel full of energy? ■ Found common tasks challenging effort. ■ Movement affected

■ Had balance problems■ Lacked energy

#11. My sleep was restless. #27. Do you enjoy getting up in the ■ In painmorning? ■ Had physical discomfort

#17. I had crying spells. #25. Do you frequently feel like crying? ■ Cried ■ Frustrated

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Lev and Owen (2000) conducted studies that usedself-care counseling interventions with patients who hadbreast cancer, based on Bandura�s theory of self-efficacy(Bandura, 1997). The interventions included self-behav-iors, such as attention refocusing, imagery, dissociation,reframing, and self-encouragement. With the self-care in-terventions, patients were more likely to experience lesssymptom distress and mood changes, as well as betterquality of life. Similarly, stroke survivors may benefitfrom self-care techniques that could increase self-efficacyand decrease depressive symptoms.

Research Implications

Findings in this study emerged from an analysis ofstroke survivors� comments (see vignettes) as they re-sponded to a depression instrument. Phenomenologicstudies are recommended that address poststroke clinicaldepression. Since this study included six male and one fe-male stroke survivor, future studies that compare com-ments of male and female stroke survivors would behelpful to identify possible gender differences related topoststroke depression.

Lenze et al. (2001) reported on the risk factors for anxi-ety as a co-morbid condition accompanying depression toinclude grief, physical illness, disability, and cognitive diffi-culties, and their work supports the findings of this study.They recommended that more psychiatric studies areneeded in home care and medical settings to determinewhen anxiety and depression coexist to prevent their nega-tive impact on stroke recovery and other physical illnesses.

A study limitation was that the researcher could notask patients to discuss each standardized instrument itemin more detail. For example, for the item, �I was botheredby things that usually don�t bother me,� most stroke sur-vivors did not report specifically what was troublesomeor disturbing. Additionally, each study patient answeredaffirmatively to the item, �My sleep was restless.� The re-searcher, however, was not able to assess sleep problems.Thematic saturation was not obtained in this study; a lim-itation of secondary analysis is that more subjects couldnot be recruited until saturation was completed.

Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 67

Vignette 1A 62-year-old woman experienced a right temporal

and basal ganglia infarction. Effects from the stroke in-cluded left hemiparesis, left-sided neglect, anddysarthria. This patient lived alone on the first floor ofa rental home. She worked as a supervisor of schoolteachers and was placed on sabbatical poststroke. Achief concern for this patient was whether she wouldbe able to go back to work. The patient had a history ofmigraine headaches. She was divorced and had threegrown children, none of whom lived close. Onedaughter kept in touch with the patient on a weeklybasis. While in the hospital, the patient took Buspar foranxiety, however, she did not continue taking it athome.

After discharge, the patient took Zoloft 100 mgdaily and saw a psychotherapist for depression.Transportation was difficult for the patient. She couldnot drive, and taking public transportation, in terms ofwalking to the bus stop and getting to her destination,took more energy than she had. The patient described�being angry at being a senior now.� The patient ex-pressed hope she would find ways to decrease heranxiety. She tried to practice stress-reduction tech-niques, such as prayer and exercise, which involvedwalking, even when she was not feeling well. The pa-tient stated that she was �by nature a pessimist,� andshe thought that the �passage of time� might give hermore confidence to deal with the frustration associ-ated with the stroke. She described feeling �more un-stable now,� and was often bothered by worries aboutthe stroke. Additionally, the patient felt depressed,sad, and lonely. Her sleep pattern was restless, andshe felt she could not �get going,� with everythingtaking more effort. Additionally, the patient had trou-ble concentrating and described having trouble doingthings for herself. Prior to the stroke, the patient datedsomeone regularly. However, after the stroke this rela-tionship ended. She described having friends but didnot feel useful to others. The patient also expressedless satisfaction with the amount of control over herlife.

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Vignette 2A 71-year-old male had experienced a right basal gan-

glia infarction with left hemiparesis. He had a myocardialinfarction and coronary artery bypass surgery about 8 yearsbefore the stroke. This patient also had non-insulin-dependent diabetes and an enlarged prostate,which had been surgically corrected. His wife had diedabout 3 years before the stroke. The patient visited hergrave every day. Previously employed as a cook, he was re-tired and lived alone, although three children lived nearby.

This patient had experienced several life events over aperiod of several years. He had experienced cardiacproblems; his wife and mother died within 2 years ofeach other, and a sister had died from breast cancer fol-lowing the patient�s stroke. He described being lonelyand crying more poststroke. He said he was depressedand talked less frequently most days of the week. Thepatient slept restlessly, felt sad, and said he �could notget going.� He felt �self-pity� and said he consideredhimself �too important.� The patient wanted to see hisgrandchildren grow up. He described having nice neigh-bors and being active in his church, and having a priestas a friend. This stroke survivor was taking several car-diac medications and an antidiabetic agent. He had nottaken an antidepressant.

Conclusion

These data expand what is known about poststrokedepression, especially in patients who are at risk formajor clinical depression. Nurses who have busy worklives can tune in to conversations with patients to discernwhat is below the surface that would identify clinical sig-nificant indicators of depression.

Psychiatric liaison nurses can guide nursing practicein home care, outpatient settings, extended and long-term care facilities, and primary care practices for pa-tients with poststroke depression, providing leadershipand guidance for other nurses. Furthermore, these find-ings can sensitize nurse practitioners and other ad-vanced practice nurses, so they can be attentive to thehidden, latent meanings of stroke survivors� comments.

68 Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004

Acknowledgment. I wish to acknowledge the assistanceof Yasser al-Khatib, MS, RN, and Sada al-Barwani, MS,RN, who were graduate students at Villanova Universitywhen they typed my field notes.

Author contact: [email protected], with acopy to the Editor: [email protected]

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