The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke: Difference between revisions
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Revision as of 05:01, 19 July 2023
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Introduction[edit | edit source]
So as we know that stroke, or cerebrovascular accident, is particularly characterised by sensory and motor difficulties and which presents as hemiplegia or hemiparesis, leading to difficulty in balance, gait, activities of ADL. (Activities of Daily Living) So now what happens is that we address all of these difficulties, but the mental health aspect remains overlooked. So, as a result of which, what happens that the patient performs poorly in all of these other interventions. And it is very important to identify that this poor performance is because some psychological issues are present which are not been assessed or treated. So psychiatric disorders are very common complications following stroke and which are associated with low quality of life, worsening of treatment outcomes, also increasing the burden on the caregivers, and deterioration of the functional status of the patient.
So neuropsychiatric disorders following stroke also increase the mortality.
Always have a detailed assessment of the mental health aspect. And because this more or less affects the rehabilitation outcome, be it any rehabilitation protocol, it can be speech, it can be physiotherapy, it can be occupational therapy. So, these psychological problems following stroke should be very carefully assessed. Also by the medium of this course, that whenever you are seeing a patient, either in an inpatient or outpatient setting, with quite a lot of affection in their mental health it is important to remember that it is not that only one rehabilitation professional can deal with it. So we require a team of rehabilitation professionals from different disciplines so that we can give the patient a better clinical outcome. So, identifying the features and the disciplines which are expert in dealing with them.
This article will overview three common mental health disorders following stroke, discuss the pathophysiological changes which occur after stroke with may contribute to these mental health concerns, and outline clinical features, and give a basic overview preventative measures from a multidisciplinary team perspective.
To learn more about specific mental health diagnoses commonly associated with stroke, please read this article.
Risk Factors of Mental Health Disorders Following Stroke[edit | edit source]
The occurrence of mental health disorders following stroke is becoming more recognized by the medical community. Currently, most of the literature and research has focused on specific concerns such as (1) depression, (2) dementia, (3) anxiety, and (4) suicide. Other mental disorders, such as substance abuse disorders, have less evidence-based support[1].
Due to the time-intensive nature of rehabilitation assessments, treatments, and interventions, rehabilitation professionals are ideal members of the multidisciplinary team (MDT) to aide in screening and preventive education of stroke survivors.
Common risk factors of mental health disorders following stroke include:
- Female sex[2]
- Age: <70 years for PSD [2], younger populations for poststroke anxiety (PSA) and PTSD[3]
- Previous history of mental health issues[2]
- Family history of mental illness[2]
- Neuroticism[2] ("broad personality trait dimension representing the degree to which a person experiences the world as distressing, threatening, and unsafe"[4])
- Severity of stroke[2]
- Location of the stroke, PSD more common with left frontal lobe and basal ganglia strokes,[2] PSA more common with right hemispheric lesions[3]
- Resulting level of handicap following stroke[2]
- Level of independence following stroke[2]
- previous history of smoking[5]
- lower socioeconomic status[5]
- decreased social support[2]
- decreased level of education[2][5]
A meta-analysis performed in 2017 found that having a predisposing illness, such as hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and myocardial infarction, was not associated with diagnosis of poststroke depression (PSD)[2].
Screening[edit | edit source]
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 2-weeks post-stroke[6]. Further research is needed to to determine the optimal timing, setting, and follow-up for screening[7]. While PSD is a major focus of recent research, this statement can be generalised to include other, less studied common mental health disorders which are known to occur after stroke.
Please see below for more information on recommended screening tools.
Prevention[edit | edit source]
An important component of preventive strategies 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[8].
Interventions to improve mental health following stroke include:[8]
- 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
Stroke can also lead some to suicide ideation, attempts, and completion. A 2021 meta-analysis found a risk of suicide in stroke survivors to be nearly twice that of the general population[9]. It is important for rehabilitation professionals 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[8].Risk factors for suicide ideation following stroke:[9]
- Severe acute disability post-stroke
- Longer hospital stay post-stroke
- Ischemic stroke survivors
- History of depression
- History of hypertension
Special Topic: Stroke Rehabilitation in Low and Middle Income Countries[edit | edit source]
sources: https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.119.023565
https://bmjopen.bmj.com/content/12/8/e063181
https://www.sciencedirect.com/science/article/pii/S2405650216300119
Assessment[edit | edit source]
Below is a list of assessment components which can easily added to a rehabilitation evaluation or assessment to capture information regarding a patient's risk of mental health disorders[3].
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)
- treatment outcomes for any of the previous conditions should be assessed, if the patient was on certain medications for a longer duration of time, anything. Also, it is very important to assess for vascular risk factors such as angina pectoris, hypertension, because they're independent predictors of post-stroke depression.
- Family history of mental health disorders
Social and Vocational
- Personal and social support
- Family income/insurance
Formal Assessment Tools/Scales[edit | edit source]
Clinical Assessment Tools by Topic[edit | edit source]
Behavioural Assessments
- Worker Role Interview (WRI)
- Work Environment Impact Scale (WEIS)
- Bay Area Functional Performance Evaluation (BaFPE)
- Assessment of Occupational Functioning (AOF)
- Kawa Model
YouTube Video Kawa Model
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
Pre-morbid Intellectual Functioning Assessment
Rehabilitation Experience
Vocational Assessments
Assessment Tools for Specific Mental Health Diagnoses[edit | edit source]
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
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[edit | edit source]
The management of mental health following stroke involves a diverse team of rehabilitation professionals. It is important for any member of the team to have a strong and reliable referral network to be able 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 |
|
|
Clinical Psychologistand/or
Neuropsychology |
|
|
Nursing | Within the scope of practice as a nurse, mental health nursing:
|
According to the American Psychiatric Nurses Association:
|
Occupational Therapy |
|
|
Physiotherapy |
|
|
Speech Language Pathology |
|
|
Spiritual Care |
|
|
Stepped Care Model[edit | edit source]
Interventions[edit | edit source]
Cognitive Behavioral Therapy with Exposure and Response Prevention Therapy
Interpersonal Therapy,
Behavioural Activation Therapy,
couples therapy,
counselling,
short-term psychomotor or psychodynamic therapy,
antidepressants,
combined interventions, and
collaborative care,
self-help groups
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ Skajaa N, Adelborg K, Horváth-Puhó E, Rothman KJ, Henderson VW, Thygesen LC, Sørensen HT. Stroke and risk of mental disorders compared with matched general population and myocardial infarction comparators. Stroke. 2022 Jul;53(7):2287-98.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Shi Y, Yang D, Zeng Y, Wu W. Risk factors for post-stroke depression: a meta-analysis. Frontiers in aging neuroscience. 2017 Jul 11;9:218.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Banerjee, S. Stroke. The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke. Physioplus. 2023.
- ↑ Britannica. neuroticism. Available from: https://www.britannica.com/science/neuroticism (accessed 17/July/2023).
- ↑ 5.0 5.1 5.2 Khedr EM, Abdelrahman AA, Desoky T, Zaki AF, Gamea A. Post-stroke depression: frequency, risk factors, and impact on quality of life among 103 stroke patients—hospital-based study. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2020 Dec;56:1-8.
- ↑ American Heart Association/American Stroke Association. 4.10. Depression Screening. Available from: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000211 (accessed 17/July/2023).
- ↑ Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, Mitchell PH, Skolarus LE, Whooley MA, Williams LS. Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017 Feb;48(2):e30-43.
- ↑ 8.0 8.1 8.2 Chun HY, Ford A, Kutlubaev MA, Almeida OP, Mead GE. Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence. Stroke. 2022 Apr;53(4):1402-10.
- ↑ 9.0 9.1 Selvaraj S, Aggarwal S, de Dios C, De Figueiredo JM, Sharrief AZ, Beauchamp J, Savitz SI. Predictors of suicidal ideation among acute stroke survivors. Journal of Affective Disorders Reports. 2022 Dec 1;10:100410.
- ↑ American Case Management Association. Scope of Services. Available from: https://www.acmaweb.org/section.aspx?sID=136 (accessed 18/July/2023).
- ↑ American Psychological Association. Clinical Psychology. Available from: https://www.apa.org/ed/graduate/specialize/clinical (accessed 18/July/2023).
- ↑ 12.0 12.1 American Psychiatric Nurses Association. About PMH-APRNs. Available from: https://www.apna.org/about-psychiatric-nursing/about-pmh-aprns/?_gl=1*1tmyof4*_up*MQ..*_ga*MTY1OTIxMzcxOC4xNjg5Njk3Mzg2*_ga_79D3LBQT2E*MTY4OTY5NzM4NS4xLjEuMTY4OTY5NzYzOS4wLjAuMA..*_ga_4HD7QYR6T9*MTY4OTY5NzM4NS4xLjEuMTY4OTY5NzYzOS4wLjAuMA.. (accessed 18/July/2023).
- ↑ American Occupational Therapy Association. Occupational Therapy Scope of Practice . Available from: https://research.aota.org/ajot/article/75/Supplement_3/7513410020/23136/Occupational-Therapy-Scope-of-Practice (accessed 18/July/2023).
- ↑ APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 18/July/2023. https://guide.apta.org
- ↑ American Speech-Language-Hearing Association. Scope of Practice in Speech-Language Pathology. Available from: https://www.asha.org/policy/sp2016-00343/ (accessed 18/July/2023).
- ↑ Spiritual Care Association. Scope of Practice. Available from: https://www.spiritualcareassociation.org/docs/research/scope_of_practice_final_2016_03_16.pdf (accessed 18/July/2023).