psychological impact of stroke - university of...
TRANSCRIPT
PsychologicalImpact of
Stroke
Dr Shirley Thomas
Associate Professor inRehabilitation Psychology
Overview
Day 1: Outline
• Sharing your experiences
• Feeling overwhelmed
• What does the evidence tell us about• Post stroke depression• Post stroke anxiety
• Working with people with aphasia/dysphasia
• Examples of assessments and approaches
Overview
Psychological impact
Overview
Day 1: Outline
Stroke Association survey of over2,700 people affected by stroke
• 67% had experienced anxiety• 59% felt depressed• Almost three-quarters of stroke
survivors said they felt lessconfident after their stroke
• Nearly half said theirrelationships or contact withfriends and families had been putunder strain
Overview
Day 1: OutlineAcute care Inpatient rehabilitation Discharge home
Stroke crisis trajectory (adapted from Lutz et al, 2011)
Phase 1Stroke crisis
Phase 2Expectations forrecovery
Phase 3Crisis ofdischarge
Overview
Day 1: Outline
• About one third of stroke survivors depressed at anyone time (Hackett & Pickles, 2014)
• Negative impact on rehabilitation, QoL and carers (e.g.Ayerbe et al, 2013)
• Consistent predictors: physical disability, strokeseverity, history of depression and cognitiveimpairment (Towfighi et al, 2016)
• Depression also common in people with aphasia(Kauhanen et al, 2000)
Post stroke depression
Overview
Day 1: Outline
• Anxiety prevalence reported between 18%-25%(Campbell Burton et al, 2013)
• Prevalence increased to 44% in people with aphasia(Morris et al, 2017)
• Impact on quality of life, social contact and functionalability (Astrom, 1996)
• Post stroke depression associated with post strokeanxiety (Wright et al, 2017). Other predictors currentlyunclear.
Post stroke anxiety
Overview
Day 1: Outline
Asking about emotions
Conversations
Recognising symptoms
Formal questionnaires
Overlapping symptoms
Need to consider peoplewith communicationdifficulties
Overview
Day 1: Outline
Self-report Visual analogue/ picture based
Observationaltools
• Patient HealthQuestionnaire (PHQ-9)• Hospital Anxiety andDepression Scale (HADS)• Beck Depression Inventory(BDI-II)• Beck Anxiety Inventory (BAI)• Beck Depression InventoryFastScreen• Geriatric Depression Scale(GDS)• Brief Assessment ScheduleDepression Cards (BASDEC)•Generalised Anxiety DisorderAssessment (GAD-7)
• Visual Analog MoodScales (VAMS)
• Visual Analogue Self-Esteem Scale(VASES)
• Depression IntensityScale Circles (DISCS)
• DistressThermometer
• Stroke AphasicDepressionQuestionnaire(SADQ)
• Signs ofDepression Scale(SODS)
• BehaviouralOutcomes ofAnxiety Scale(BOA)
Overview
Day 1: Outline
B: People with or at risk of depression or anxiety after stroke shouldbe offered brief psychological interventions such as motivationalinterviewing or problem-solving therapy (adapted if necessary for usewith people with aphasia or cognitive problems) before consideringantidepressant medication.
C: People with mild or moderate symptoms of psychological distress,depression or anxiety after stroke should be given information,support and advice and considered for one or more of the followinginterventions: increased social interaction; increased exercise; otherpsychosocial interventions such as psychosocial education groups.
D: People with aphasia and low mood after stroke should beconsidered for individual behavioural therapy e.g. from an assistantpsychologist.
National Clinical Guidelines for Stroke(RCP, 2016) p.77
Overview
Day 1: Outline
• Insufficient evidence for preventing depression(Hackett et al, 2008a, Tsai et al, 2011)
• Drug treatments alone (Hackett et al, 2008b, Mead etal, 2012) or in combination with psychologicalinterventions (Mitchell et al, 2009) may be helpful intreating depression
• Cochrane review of SSRIs for stroke recovery foundSSRIs reduced depression but no one SSI wassuperior to others (Mead et al, 2012)
Drug treatments for post-strokedepression
Overview
Day 1: Outline
• Brief psychological interventions may help prevent andtreat depression (Hackett et al, 2008a) e.g.
• Problem-solving therapy
• Motivational interviewing (Watkins et al, 2011)
• Behavioural therapy may be helpful for treating lowmood in people with aphasia (Thomas et al, 2013)
• Newer therapies being explored in stroke –Acceptance and Commitment Therapy (ACT) (Ivey-Williams & Morris) and mindfulness (e.g. Lawrence etal, 2013)
Psychological interventions for post-stroke depression
Overview
Day 1: Outline
Cochrane Review (Knapp et al, 2017) of three studies
• Pilot trial relaxation CD v waiting list (n=21)
• Paroxeting v paroxetine + psychotherapy v standardcare (n=81)
• Buspirone hydrochloride v standard care (n=94)
• Quality of evidence low
Interventions for post-stroke anxiety
“Evidence is insufficient toguide the treatment of anxietyafter stroke” (p.2)
Overview
Day 1: Outline
• Augmented, individualised CBT (Broomfield et al., 2011,Kneebone, 2016)
• Behavioural activation (BA) effective in non strokepopulations including older adults and people withdementia
• BA can be adapted for aphasia and cognitive difficultiesand delivered by non specialists
Behavioural activation
Communication and cognitivedifficulties
- BTCBT
[Adapted fromKneebone, 2016]
+
Overview
Day 1: Outline
Overview
Day 1: Outline
ThoughtsI’ll mess up
No pointtrying
BehaviourDo nothingStay in bed
FeelingsDownFed upGuilty
Overview
Day 1: Outline
BehaviouralActivation
approaches
Activityand moodmonitoring
Gradedtasks
Activityscheduling
Setting andagreeing
goals
Problemsolving
Identifyingenjoyableactivities
Overview
Day 1: Outline
Overview
Day 1: Outline
• Psychological impacts are common and affect
rehabilitation
• Depression has received the most attention but quality of
evidence limited
• More research needed into interventions for anxiety
• Need assessments and interventions accessible for
people with aphasia
Summary
Overview
Day 1: OutlineNational Clinical Guidelines for Stroke (RCP, 2016)https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
Hackett, M.L., Yang, M., Anderson, C.S., Horrocks, J.A., & House,A.O.(2008). Interventions for treating depression after stroke.Cochrane Database of Systematic Reviews (4) CD003437.
Hackett, M.L., Anderson, C.S., House, A., & Halteh, C. (2008).Interventions for preventing depression after stroke. CochraneDatabase of Systematic Reviews (3), CD003689.
Knapp, P. et al. (2017). Interventions for treating anxiety afterstroke. Cochrane Database of Systematic Reviews (5),CD008860.
Kneebone, I. (2016). A framework to support cognitive behaviourtherapy for emotional disorder after stroke. Cognitive andBehavioral Practice, 23, 99-109.
Key references
Overview
Day 1: Outline
Lincoln, N.B., Kneebone, I.I., Macniven, J.A.B., & Morris, R.C.
(2012). Psychological management of stroke. Wiley-Blackwell.
Thomas, S.A., Walker, M.F., Macniven, J.A., Haworth, H., &
Lincoln, N.B. (2013). Communication and Low Mood (CALM): a
randomized controlled trial of behavioural therapy for stroke
patients with aphasia. Clinical Rehabilitation, 27, 398-408.
Towfighi, A. et al. (2016). Post stroke depression. A scientific
statement for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke, 48, e30-e43.
Watkins, C.L. et al. (2011). The 12-month effects of earlymotivational interviewing after acute stroke: a randomizedcontrolled trial. Stroke, 45, 1956-1961.
Key references
Overview
Day 1: Outline
