The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke

Original Editor - Stacy Schiurring based on the course by Srishti Banerjee
Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson and Matt Huey

Introduction

Rehabilitation professionals are well educated on stroke impairments such as sensory and motor deficits, impaired balance, gait dysfunction, decreased independence with activities of daily living (ADLs), and changes in language ability and cognition. Mental health disorders are also common following stroke. Recent evidence has shown that mental health disorders following stroke are associated with decreased functional outcomes and lowered quality of life. However, they continue to be under-diagnosed and under-treated. With the exception of poststroke depression, other mental health disorders lack reliable and high-quality evidence for clinical practice. Further research is needed to develop protocols or guidelines for the diagnosis, treatment, or prevention of mental health disorders following stroke.

This article outlines the risk factors of mental health disorders following stroke, discusses assessment steps and tools for mental health disorders, and gives a basic overview of interventions from a multidisciplinary team perspective.

To learn more about specific mental health diagnoses commonly associated with stroke, please read Mental Health Disorders Following Stroke.

Risk Factors of Mental Health Disorders Following Stroke

Mental health conditions following stroke are increasingly recognised by the medical community. Currently, most of the research has focused on specific concerns such as (1) depression, (2) dementia, (3) anxiety, and (4) suicide. Other mental health conditions, such as substance abuse disorders, have less evidence-based support.

Due to the time-intensive nature of rehabilitation assessments, treatments, and interventions, rehabilitation professionals are well-placed to aid in screening and preventive education of stroke survivors.

Common risk factors for mental health disorders following stroke include:

• Female biological sex
• Age: <70 years for poststroke depression (PSD), younger populations for poststroke anxiety (PSA) and post-traumatic stress disorder (PTSD)
• Previous history of mental health issues
• Family history of mental illness
• Neuroticism ("broad personality trait dimension representing the degree to which a person experiences the world as distressing, threatening, and unsafe")
• Severity of stroke
• Location of the stroke
  • PSD is more common with left frontal lobe and basal ganglia strokes
  • PSA is more common with right hemispheric lesions
• The resulting level of disability following stroke
• Level of independence following stroke
• Previous history of smoking
• Lower socioeconomic status
• Decreased social support
• Decreased level of education

A 2017 meta-analysis by Shi et al. found that having a predisposing illness, such as hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and myocardial infarction, was not associated with a diagnosis of PSD.

Screening

The American Stroke Association's 2019 Guidelines for the Early Management of Patients With Acute Ischemic Stroke recommend screening for PSD in the acute phase of stroke recovery, starting two weeks post-stroke. Further research is needed to determine the optimal timing, setting, and follow-up for screening. While PSD is a major focus of recent research, this statement can be generalised to include other, less studied mental health disorders which are known to occur after stroke.

Please see below for more information on recommended screening tools.

Prevention

An important component of prevention is to identify those patients at greatest risk and any potential modifiable risk factors. Rehabilitation professionals should use their clinical assessment skills and referral network to identify, diagnose, and appropriately manage mental health symptoms.

Interventions to improve mental health following stroke include:

• Psychosocial interventions: art therapy, music therapy, mindfulness, motivational interviewing, problem solving therapy
• Physical exercise
• Lifestyle medication interventions: yoga, tai chi, pilates, Feldenkrais method, qigong, acupuncture, nutritional care
• Pharmacological interventions

Stroke can also lead some to suicide ideation, attempts, and completion. A 2021 meta-analysis found the risk of suicide in stroke survivors to be nearly twice that of the general population. It is important for rehabilitation professionals to be aware of the risk factors for suicide, refer patients for the treatment of mood disorders, and provide education on limiting access to the means of self-harm as able.

Risk factors for suicide ideation following stroke include:

• Severe acute disability post-stroke
• Longer hospital stay post-stroke
• Ischaemic stroke survivors
• History of depression
• History of hypertension

Special Topic: Stroke Rehabilitation in Low- and Middle-Income Countries

Approximately 70 percent of strokes occur in low- or middle-income countries (LMICs). These countries also have a greater disease burden than high-income countries, with most of the stroke speciality resources centralised in urban areas. A 2019 scoping review found that most LMIC are "acute care oriented, urban located, and ill prepared to provide even essential stroke care with access to rehabilitation."

Researchers are attempting to find solutions to known barriers to stroke care services (e.g. lack of human resources, infrastructure, financial support, clinical guidelines, and national policy to support provisions). Many proposals point to the use of digital health strategies, such as telemedicine, tablet-based risk assessment tools, mobile-phone apps for physicians, and text messaging interventions, to fill in the gaps of services stemming from geographic access and provider availability.

Consider this information as you continue reading. How could telemedicine be used to address the mental health care needs of patients following stroke in LMICs?

Assessment

Below is a list of assessment components which can easily be added to a rehabilitation evaluation or assessment to capture information regarding a patient's risk of mental health disorders.

History of present illness:

• Screen for possible psychological symptoms in the acute phase post-stroke
• History of onset of symptoms
  • psychological symptoms
  • somatic symptoms (anxiety)
• Detailed history of stroke

Past medical history:

• Age
• Sex
• Previous episodes of stroke or transient ischaemic attack (TIA)
• Previous history of any psychological disorder (e.g. depression, anxiety, etc)
• Medication and treatment outcomes of past medical conditions
• Family history of mental health disorders

Social and vocational history:

• Personal and social support
• Family income/insurance

Formal Assessment Tools/Scales

Clinical Assessment Tools by Topic

Behavioural Assessments

• Worker Role Interview (WRI)
• Work Environment Impact Scale (WEIS)
• Bay Area Functional Performance Evaluation (BaFPE)
• Assessment of Occupational Functioning (AOF)
• Kawa Model

The following optional 4-minute video provides a general overview of the Kawa Model from an occupational therapy perspective.

Motor Function Assessment

• National Institute of Health (NIH) Stroke Scale (app version) (PDF version)
• Barthel Index (BI) (app version, modified Barthel Index) (PDF version)
• Modified Rankin Scale (mRS) (app version) (PDF version)

Orientation and Alertness Assessment

• Wechsler Memory Scale-III (WMS-III)

Pre-morbid Intellectual Functioning Assessment

• National Adult Reading Test (NART)
• Wechsler Test for Adult Reading (WTAR)
• Spot-the-Word test

Rehabilitation Experience

• Neurorehabilitation Experience Questionnaire

Vocational Assessments

• Performance Assessment of Self-Care (PASS)
• Community Adaptive Planning Assessment (CAPA)

Assessment Tools for Specific Mental Health Diagnoses

Assessment Scales for Depression

• Montogometry-Asberg's Depression Rating Scale (MADRS)
• Hamilton Depression Rating Scale (HAM-D)
• Hospital Anxiety and Depression Scale (HADS)
• Becks Depression Inventory (BDI-II)

Assessment Scales for Anxiety

• Hamilton Anxiety Scale (HAM-A)
• Hospital Anxiety and Depression Scale (HADS)

Assessment Scales for Post Traumatic Stress Disorder (PTSD)

• Clinician Administered PTSD Scale (CAPS-5)
• Impact of Event Scale - revised (IES-R)
• Post-Traumatic Diagnostic Scale (PDS-5)
• Acute Stress Disorder Scale (ASDS)

Management and Interventions

Managing mental health issues following stroke involves a diverse team of rehabilitation professionals. All team members need to have strong and reliable referral networks to quickly assess and properly treat a patient with mental health care needs.

MDT Role in Management

MDT Member	Scope of practice	Role in mental health care
Case Management	Facilitates communication and care coordination among the MDT Protects the patient’s right to self-determination Goals of Case Management include the "achievement of optimal health, access to services, and appropriate utilisation of resources"	Coordinates care and communication among the MDT Coordinates how the patient will receive services and interventions per the MDT care plan
Clinical Psychologist and/or Neuropsychology	A psychological speciality that provides "continuing and comprehensive mental and behavioural health care" The scope of clinical psychology "encompasses all ages, multiple diversities, and varied systems"	Speciality in stroke management is preferred One-to-one therapy for cognitive rehabilitation, which includes cognitive behavioural therapy (CBT), motivational interviewing and problem-solving therapy Specialist interventions, brief psychological interventions, goal setting Pharmacological interventions such as antidepressant medications Assesses for suicide risk Improves access to psychological therapy using telemedicine
Nursing	Within the scope of practice as a nurse, mental health nursing: has a holistic approach, considering the whole person provides education on how to manage mental health and improve overall health emphasises health education, wellness promotion, and prevention of disease may have prescriptive ability depending on education and licensing	According to the American Psychiatric Nurses Association, nurses: "Partner with individuals to achieve their recovery goals Provide health promotion and maintenance Conduct intake screening, evaluation, and triage Provide Case management Teach self-care activities Administer and monitor psychobiological treatment regimens Practice crisis intervention and stabilisation Engage in psychiatric rehabilitation and intervention Educate patients, families, and communities Coordinate care"
Occupational Therapy	Therapeutic use of everyday life occupations Skilled care provided to promote and preserve the occupational identity of patients at risk of developing "an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction."	Plays a major role in elevating the symptoms of psychological issues due to training in assessing cognition and functional ability Identifies specific individual environmental changes needed to achieve patient goals Trains patients in strength-based strategies to improve functional abilities Improves an individual's ability to complete activities of daily living (ADLs) with greater independence to mitigate the impact of mental health issues Develops and improves coping skills and transition strategies from a clinical setting to the patient's discharge environment Engages the patient in healthy roles and routines
Physiotherapy	Physiotherapists help "diagnose and manage movement dysfunction as it relates to the restoration, maintenance, and promotion of optimal physical function and the health and well-being" They maximise a patient's ability to "engage with and respond to their environment, emphasizing movement-related interventions to optimize functional capabilities and performance."	Uses physical activity to improve the mental health condition, including: (1) aerobic activity, (2) aquatic exercises, (3) resistance training, (4) yoga, (5) relaxation training, and (6) other allied therapies such as Tai chi, mindfulness
Speech Language Pathology/Therapy	Engages in "professional practice in the areas of communication and swallowing across the life span" Communication includes speech production and fluency, language, cognition, voice, resonance, and hearing Swallowing includes all aspects of swallowing, including related feeding behaviors"	Develops and enhances communication ability and strategies, verbal or nonverbal Develops a stroke story with activities to promote positivity and social support Maximises an individual's language and communication ability Maximises their activity level and participation, and help with overall rehabilitation outcomes
Spiritual Care	Involved in making "spiritual care more accessible to clients, families and staff" Aware of and "has a working knowledge of relevant healthcare policies ... and understands why this is important for chaplaincy"	Helps the patient develop a positive attitude, instils hope, and helps in better adjustment post-stroke Engages the patient in spiritual care

Stepped Care Model

"Stepped care aims to offer patients psychological care in a hierarchical approach, offering simpler interventions first and progressing on to more complex interventions if required. However, not all patients will progress through the system in a sequential manner. Over the course of their recovery, patients may move in and out of this system several times and at different levels. This approach makes best use of skills of the multi disciplinary team and utilises more specialist staff for the patients with complex problems that require this level of help." -NHS Improvement | Stroke

• Initiates care with less intensive treatments (e.g. telemedicine, bibliotherapy, group therapy), then progresses to more intensive treatments involving specialised individual therapy and pharmacological treatment
• As a healthcare delivery method, Stepped Care has two defining core features, least restrictive and self-correcting
  • “Least restrictive refers to a low-intensity, cost effective, and least time consuming feature of this method and is used as the first-line treatment."
  • “Self-correcting refers to the 'stepping-up' criteria that are utilized in possible preparation of more intensive and expensive treatment, and this is necessary based on treatment outcome."
• Patients are continuously monitored and reassessed. If they are not responding to treatments at their current step, they are referred to the next step of more intensive therapy options
• Case management or nursing can be assigned to coordinate the treatment programme, monitor for progress, and assist with care planning
• An advantage of the stepped care model is that it maximises treatment effectiveness and efficiency while optimising resource utilisation
• The stepped care model has been evaluated and implemented in the treatment of (1) eating disorders, (2) depression, (3) anxiety, (4) obsessive-compulsive disorder (OCD), (5) PTSD, (6) chronic fatigue syndrome, (7) nicotine dependence, and (8) alcohol use disorders

Interventions

Cognitive Behavioural Therapy (CBT)

CBT is a form of psychological treatment which places an emphasis on helping patients learn to "be their own therapist" by developing coping strategies and changing their frame of thinking. According to the American Psychological Association, CBT involves the following core principles:

1. "Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
2. Psychological problems are based, in part, on learned patterns of unhelpful behavior.
3. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives."

Trained psychologists and the patient work together to gain an understanding of the patient's current frame of thinking and collaboratively develop treatment strategies.

If you want to learn more about how CBT can be adapted for patients following stroke, please read this article.

Exposure and Response Prevention Therapy (ERP)

ERP is a type of CBT specially designed for the treatment of OCD. According to the International OCD Foundation, "The exposure component of ERP refers to practicing confronting the thoughts, images, objects, and situations that make you anxious and/or provoke your obsessions. The response prevention part of ERP refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been 'triggered'."

Like traditional CBT, a specially trained psychologist works with the patient to gain insight into their triggers and collaboratively create a treatment plan.

Interpersonal Psychotherapy (IPT)

According to the International Society of Interpersonal Psychotherapy, IPT is a "time-limited, diagnosis-targeted, well studied, manualized treatment for major depression and other psychiatric disorders".

This treatment approach involves specially trained therapists working with patients to understand that their emotions are "social signals" and how to use this knowledge to improve interpersonal situations and empower social supports.

Behavioural Activation Therapy

Behavioural Activation Therapy encourages the patient to engage in meaningful activities. The goal is to change the way the patient interacts with their environment to improve their outlook and develop a positive mental state. The therapist assists the patient by scheduling activities and monitoring the patient's behaviours. Behavioral Activation Therapy is a flexible form of therapy that can be undertaken in-person, over the phone, or online, and usually over multiple sessions.

Psychomotor or Psychodynamic Therapy

The main goal of Psychomotor Therapy is to demonstrate how goal-directed movement situations can bring about a "positive psychological effect, not only physical skills but also cognitive, perceptual, affective and behaviour." The physical moving of the patient's body is the cornerstone of the psychomotor approach.

For optional additional reading, please see Psychomotor Physical Therapy.

Other forms of psychological interventions include: couples therapy, counselling services, group therapy, and medications or pharmacological interventions such as antidepressants. Treatment interventions can also be a collaboration or combination of any of the above interventions.

Resources

Clinical Resources

• Psychological Care After Stroke (National Health Services)

Optional Additional Reading

• Frank D, Gruenbaum BF, Zlotnik A, Semyonov M, Frenkel A, Boyko M. Pathophysiology and current drug treatments for post-stroke depression: A review. International Journal of Molecular Sciences. 2022 Dec 1;23(23):15114.
• Mughal S, Salmon A, Churchill A, Tee K, Jaouich A, Shah J. Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture. Community Mental Health Journal. 2023 Apr 1:1-8.
• Tjokrowijoto P, Stolwyk RJ, Ung D, Kneebone I, Kilkenny MF, Kim J, Olaiya MT, Dalli LL, Cadilhac DA, Nelson MR, Lannin NA. Receipt of Mental Health Treatment in People Living With Stroke: Associated Factors and Long-Term Outcomes. Stroke. 2023 Jun;54(6):1519-27.