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)
• 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, more common with left frontal lobe and basal ganglia strokes
• 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: music therapy, mindfulness, motivational interviewing, problem solving therapy
• Physical exercise
• Lifestyle medication interventions: yoga, tai chi, pilates, Feldenkrais method, qigong, acupuncture
• 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)
• 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

MDT Role in Assessment

MDT Member	Scope of practice	Role in mental health care
Case Management
Medical Doctor
Neuropsychology
Nursing
Occupational Therapy
Physiotherapy
Social Work
Speech Language Pathology

Formal Assessment Tools/Scales

Vocational Assessments

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

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

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

Also, there are specialised skills to check for general intellectual functioning, language, visual neglect, or inattention, visual-spatial and visual-perceptual functioning, attention, and memory. All of these details are present in the Physiopedia pages. Kindly refer, the list of scales will be provided.

Motor Function Assessment

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

So assessment scales for depression are

• Montogometry-Asberg's Depression Rating Scale,
• Hamilton Depression Rating Scale,
• Hospital Anxiety and Depression Rating Scale, and
• Becks Depression Inventory. It is very much important that if you suspect the patient is going towards PSD, it is mandatory to have an objective assessment using these scales.

Scales for anxiety include

• Hamilton Anxiety Scale,
• Hospital Anxiety and Depression Scale, the anxiety version. Or the subscale.

For PTSD,

• clinician-administered PTSD scale,
• Impact of Event Scale, the revised one, the revised version.
• Post-Traumatic Stress Diagnostic Scale, and
• Acute Stress Disorder Scale.

Management

When to refer

So, now if we talk about the intervention for depression, Cognitive Behavioural Therapy, then there is Interpersonal Therapy, Behavioural Activation Therapy, couples therapy, counselling, short-term psychomotor or psychodynamic therapy, antidepressants, combined interventions, and collaborative care, self-help groups. Now, it is very important that these therapies are given by experts, professionals. So the aim here is to make you aware that these therapies are available and when your patients show these clinical symptoms, they're in need of these clinical therapies. So you need to refer the patient to these specialists for particular interventions.

MDT Role in Management

MDT Member	Scope of practice	Role in mental health care
Case Management
Medical Doctor
Neuropsychology
Nursing
Occupational Therapy
Physiotherapy
Social Work
Speech Language Pathology

Stepped Care Model

INSERT IMAGE OF PYRAMID HERE

https://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf

https://www.mhm.org.uk/pages/faqs/category/stepped-care

Cognitive Behavioral Therapy

So now, when we talk about generalised anxiety disorders. So generalised anxiety disorders, the patient will receive Cognitive Behavioural Therapy with ERP, that is Exposure and Response Prevention Therapy, which is a specialised form of CBT, followed by case management. Case management is particularly developed where there is a plan of how the patient is going to receive these interventions. Combined therapy of any combination of these. Self-help groups and any form of support from the self-help groups is encouraged here. The next is PTSD. That is, when we are talking about PTSD, what happens is that the Cognitive Behavioural Therapy has a particular trauma-focused type, so that is being used for patients with PTSD. What happens is that EMDR, that is eye movement desensitisation, so it has been found that when the person is anxious or when the person is having any of these responses to stress, the eye movements are very particular. So this therapy is based on that, which is done by specialists, psychologists, or psychiatrists. And drug treatment, as and when required.

Now we are talking about step two. Step two is depression, where the persistent depression is there, but at a sub-threshold level, or it is mild to moderate. Generalised anxiety disorders or panic disorders are mild to moderate. PTSD is mild to moderate. So, for depression, individualised self-help, right. Computerised CBT can work. Structured physical activity has been found to be helpful. Peer support groups, self-help programmes, non-directive counselling, which can be given at home, antidepressants if required. For generalised anxiety disorders and panic disorders, individualised, non-facilitated or facilitated groups, psychosocial education, psychological education, and self-help groups. For other conditions OCD and PTSD, now CBT or EDMR typically provided within three steps, which is done by experts. The details can be found on the Physiopedia pages. For all of these, you need to refer the patient to peer groups, right, employment services, referral for further assessment and interventions.

So step one, known and suspected presentation of all the mental health disorders, right? So, this step particularly focuses on identification and assessment of the psychological disorders, this is particularly psychological screening, right, and refer, as and when required.

Now you can see a pyramid which has three levels. So at level one, the problems are very sub-threshold and which is common to majority of the patients. So there is a generalised difficulty in coping. Then there is, as the patient has a change in lifestyle, right? So the patient faces difficulty in coping up to the new set of challenges, mild to moderate, or mild to transitory symptoms associated with cognitive disorders, such as a fatalistic attitude that okay, something is going to go wrong, and the worst outcome the patient thinks of, right? And here, the treatment is, the support can be encouraged by peer-support groups and a stroke specialist.

At level two, as you can see on your screen, that there is mild to moderate symptoms of impaired mood and cognition which can interfere with the rehabilitation. This can be assessed by a non-specialised staff that not much of specialisation is required, right? But, it has to be supervised by a clinical psychologist, right. Which is, preference is given to the psychologist who are specialised with stroke or neuropsychologists. Level three. As you can see, there are severe and persistent disorders of mood and of the cognition that are diagnosable and they require specialist interventions, pharmacological interventions. They require a suicide risk assessment because a tendency of self-harm and suicidal thoughts becomes very much prevalent in this stage. Right? And here, neuropsychiatrists are preferred.

Now, we are going to look for some details in the psychological care, stepwise. So level one is basically for all the patients, right. They have mental health issues, or they do not have, level one is given to all of the patients. So patient at this level, they face some coping difficulties with a new set of challenges they are facing here. So the interventions here comes from a multidisciplinary team, which includes active listening to the patient, understanding their problems, and not dismissing the patient, normalising what they're facing, providing adjustment advice, strategies for adjustment, goal setting, and make the patient aware that the outcomes are not always fatalistic, these are the achievable goals, right? Problem-solving is recommended. A regular review of mood and signposting these moods, right, for an informal support. And any, if required, any professional help is indicated. Now, specific interventions at this level particularly come from an activity-based support group, right? And these activity-based support groups are very much, they provide a very much supportive environment, a very much informal environment, right? So what happens is here the patient is not being judged by their disability, and the activities are not targeted to the stroke. So what happens is the patient becomes confident, okay, I can do this, I can do that. So, confidence builds up when the patient is in these particular groups. In UK there are about 700 support groups which are available. And here the major aim is to develop confidence for the patient, and followed by this also, there are groups which are specialised in relaxation. So relaxation groups are common, leisure activity groups which include leisure education and recreation, music therapy, art therapy, where stroke is not being targeted, but it helps in improvement of the mood for these patients. Following stroke it is very important to engage the patient in a peer-support group because what happens is that even the patient and the caregivers, the stroke survivor and the caregivers, face new set of challenges. So also for the caregivers their role shifts, there's an increase in burden. They also face isolation from their social networks, so it also affects their mental health. So it is important to engage the patient as well as the caregiver into social support groups, right? And these support groups, they have similar kind of population around, they see that, okay, I'm not the only one who is facing these problems, there are other people, there are other people who are facing it. They are coping up so they can learn a few coping strategies from these peers, right? So they get some social and emotional support, and some positive attitude they will develop in this. So also they provide, also, they get information about services. Also, they get information about some other emotional support, activities. So this is how they learn from each other with same type of circumstances, the patient sees people around who face the same circumstances. So this is quite good for their emotional and psychological health. So the easiest way to find a support group is the American Stroke Association website. They have access according to your PIN code, you just have to enter your PIN code and you'll get the nearest support groups. So at level one, it is more about motivating the patient through motivational interventions, motivational interviews, problem-solving approach, which comes from a multidisciplinary team.

Now what happens is at level one itself, it is very important to refer the patient to a speech-language therapist if they face aphasia, because patients with aphasia will have more difficulties because they have difficulty in conveying what they feel. So, speech therapists are experts, professionals, who help the patient in developing and enhancing communication by developing a stroke story along with activities to promote positivity and provide them with some social support. At level one, rehabilitation should be assessed because we need to refer the patient ahead by a Neurorehabilitation Experience Questionnaire. At level two, the multidisciplinary team with specialised skills, physical therapist, occupational therapist, speech and language therapist, psychologist, psychiatrist, pharmacological interventions all come together here. They provide psychological interventions, along with advice with respect to goal setting and problem-solving, medication if and when required, under guidance. At this level, the patient is going to encounter mild to moderate mood impairments, which tend to interfere with the rehabilitation outcomes. So, brief psychological interventions, advice, information for adjustment, goal setting, problem solving, consideration of antidepressant if required, is indicated at this level. So, behavioural activities at this level includes a systematic analysis of all the activities that the patient is performing, which is followed by planning such activities, which are very much motivating, very much pleasurable for the patient and they reduce psychological impact. Relaxation training is very important, which is given by a multidisciplinary team at various levels for handling psychological issues. Here, one-to-one patient counselling is very much important. One-to-one therapy becomes important here for cognitive rehabilitation and also with the patients with communication deficits. So along with CBT, motivational interviewing and problem-solving is indicated here. At level three, as the severity increases the mood disorders become very much persistent. So it is very important to consider a stroke specialist in all the disciplines here, right? So clinical psychologist who specialises in stroke are roped in. Antidepressant medications if and when required. At level three, it is very important to assess for suicide risk and prevent it through a team of psychologists, clinical psychologists, specialising in stroke. Here the patient tends to develop tendency of self-harm and suicide, so one-to-one CBT is important. Now, it is very important that a clinical psychologist, along with a team, of improving access to psychological therapy. So if you see on the website itself, so there are various types of facilities or services which are available to improve the access for a patient to psychological therapy. One of them is digitally enabling the patient. So, you can just go on the website and check how many options are available. So clinical psychologists can help and make the patient choose the best, whatever is, whatever suits the patient at that particular level.

So these are the levels and at each and every level, we are talking about different set of problems and different set of interventions, right? So how do we determine the level? So that is very important, how we determine the level. So before that, when we just talk about step three, step four I just discussed initially. That the patient will require a lot of high-intensity interventions. Now I just want to clarify here that in my presentation somewhere you saw four steps. Somewhere you saw three steps. So these are the two widely accepted models which are presented. So, depending on what model that particular hospital or that particular geographical area follows, it can be a three-step model or a four-step model. So levels three and four, they are quite overlapping. Depending on the severity, the interventions are going to increase according to the severity. So that was just a clarification.

Now on a screen, you can again see your pyramid. So how to determine a level, right? You cannot just subjectively determine a level. You need something objective. So at level one, it is for all clients, right? Anyone with a stroke is considered at level one. Level two. The scale, that is HADS. (Hospital Anxiety and Depression Scale) D stands for depression specialisation, and A stands for anxiety specialisation. Right. So the scorings are been given that more than nine and more than six comes at level two. Now, level three, suicidal ideation, tendency of self-harm, PTSD, OCD, that is obsessive-compulsive disorder, mania and psychosis. HADS for depression more than 16, for anxiety also more than 16 will fall in level three. Level four is severe, challenging behaviour. So this is how you will develop anything more than 16 is going to be for level four.

Now, also I wish to discuss role of a few pivotal specialists, one of them is physical therapy, occupational therapy, speech. So when we talk about role of physical therapists and physical activity, it has been proven that physical therapy and physical activity improve the mental health condition of these patients. So what interventions can be given? So the exercises which are proven to be best for psychological health of the patients are any form of aerobic activity, particularly aquatic exercises because they become easy for the patients and it has been proven that they give most benefit to the patient. Then any form of resistance training, yoga, relaxation training, other allied therapies such as Tai chi, self-help mindfulness, and acupuncture are proven to provide the patients with improvement in the symptoms of psychological disorders.

The role of occupational therapists. Occupational therapists (OTs) play a major role in elevating the symptoms of psychological issues. So they are trained professionals. They identify specific individual environmental changes which are necessary to achieve the goals, and they train the patients in strength-based strategies for improving functional capacities across various domains or whatever the patient's requirements are. They help the patient in improving their day-to-day living skills, activities of daily living, they make the patient functionally independent and they mitigate the impact of mental health issues. OTs (Occupational Therapists) are trained professionals who help the patient in improving and developing coping skills and helping transition from a clinical setup to their day-to-day lives. They help the patients with these mental illnesses to engage in healthy roles and routines.

The next is also very important, the role of speech-language therapist because the patient with aphasia who will not be able to convey their problems efficiently to you, so they'll not receive proper treatment. So it is very important to engage them into speech-language therapy. Now, what happens is these speech-language therapists are experts and specialists who will maximise an individual's language and communication ability. They will maximise their activity level, participation, and help with overall rehabilitation outcomes. So what they do is, they assess, diagnose, and wherever appropriate, they treat the aphasia resulting due to stroke. They help the patient in communicating a message by developing a language which can be spoken, which can be written, or non-verbal, or a combination of these with data, and they help them to incorporate this language into their day-to-day activities. And this language, which incorporates a spoken language or written verbal, non-verbal, or combination of any of this is known as functional communication, which only these experts can develop. So it is very important to refer them to these experts.

Role of nursing professional, very important. Nursing professionals and caregiver support will play a very vital role for post-stroke mental health issues. So what happens is there are types of nursing professionals, which is effective nursing. Effective nursing will help the patient to adapt to unfamiliar environments, the challenges the patient faces after stroke, and they provide the patient with emotional security. Generalised nursing, they provide a comfortable environment, they provide a comfortable environment for sleep, they can help with supplements, they can make the patient very much comfortable while doing their personal care. So this is what general nursing does. Whereas psychological nursing aims to reduce stress, develop coping skills, and promote health. So it is important to rope in nursing professionals at each and every level.

The next, which is very interesting, and towards the end of the course, that is role of spiritual care for patients with post-stroke mental illnesses and caregivers also. So it has been found that the patients who are into spiritual engagement, or you could say spiritual rehabilitation or spiritual programmes, right, these are also specialist professionals. It is important to refer them to these professionals, which helps the patient in developing a positive attitude, instils hope, and helps in better adjustment after stroke, right? So this sometimes, like not what any interventions can do, that hope can do. So it is very important to engage the patient into spiritual care, which is going to help overall which is going to help all of us in our respective treatment outcomes.

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