The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke

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Introduction

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

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.

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

• Age: <70 years for PSD , younger populations for poststroke anxiety (PSA) and 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 more common with left frontal lobe and basal ganglia strokes, PSA more common with right hemispheric lesions
• Resulting level of handicap following stroke
• Level of independence following stroke
• previous history of smoking
• lower socioeconomic status
• decreased social support
• decreased level of education

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).

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 2-weeks post-stroke. Further research is needed to 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 common 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 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.

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

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. 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.Risk factors for suicide ideation following stroke:

• 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

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

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.

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

• 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

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

• 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

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	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"	Coordinate care and communication among the MDT Coordinate how patient will receive services and interventions per the MDT care plan
Clinical Psychologistand/or Neuropsychology	a psychological specialty 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 in preferred One-to-one therapy for cognitive rehabilitation whtch io include cognitive behavioural therapy (CBT), motivational interviewi,ng and problem-solving thera Specialist interventions, brief psychological interventions, goal setting Pharmacological interventions such as antidepressant medications Assess for suicide risk Improve access to psychological therapy using telemedicine
Nursing	Within the scope of practice as a nurse, mental health nursing: treats the patient as a holistic individual educates on how to manage mental health and improve overall health. emphasize health education, wellness promotion, and prevention of disease may have prescriptive ability depending on education and licensing	According to the American Psychiatric Nurses Association: "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 for developing "an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction."	Play a major role in elevating the symptoms of psychological issues due to training in assessing cognition and functional ability Identify specific individual environmental changes needed to achieve patient goals Train the patients in strength-based strategies to improve functional abilities Improve the ability to complete activities of daily living (ADLs) with greater independence to mitigate the impact of mental health issues Develop and improve coping skills and transition strategies from a clinical setting to the patient's discharge environment Engage the patient in healthy roles and routines
Physiotherapy	"diagnose and manage movement dysfunction as it relates to the restoration, maintenance, and promotion of optimal physical function and the health and well-being" miximise an patient's ability to "engage with and respond to their environment, emphasizing movement-related interventions to optimize functional capabilities and performance."	Use of physical activity to improve the mental health condition to include: (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	"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"	Develop and enhance communication ability and strategies, verbal or nonverbal Develop a stroke story with activities to promote positivity and social support Maximise an individual's language and communication ability Maximise their activity level and participation, and help with overall rehabilitation outcomes
Spiritual Care	"make 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, instills hope, and helps in better adjustment post-stroke Engage 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 change 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 behaviour.
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.

To learn more about how CBT can be adapted for patients following stroke, please read this optional 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 the 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

Psychomotor Therapy main goal 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 the patient's body is the cornerstone of the psychomotor approach.

Optional additional reading on a related topic, psychomotor Physical Therapy.

Other forms of psychological interventions include: couples therapy, counseling services, group therapy, and medications or pharmacological interventions such as antidepressant. 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.