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PSYCHOLOGICAL ADJUSTMENT AFTER STROKE
EPIDEMIOLOGY, IMPACT, ASSESSMENT, AND TREATMENT EVALUATION
Reg Morris 2017
PLAN
• EPIDEMIOLOGY OF PSYCHOLOGICAL CONDITIONS AFTER STROKE
• THE NATURE, FREQUENCY AND EFFECTS OF CONDITIONS.
• ASSESSMENT AND SCREENING FOR PSYCHOLOGICAL CONDITIONS
• INTERVENTIONS FOR PSYCHOLOGICAL CONDITIONS
• DRUG TREATMENTS
• PSYCHOLOGICAL INTERVENTIONS
• EVALUATING INTERVENTIONS: ARE WE GETTING IT RIGHT?
• CLINICAL TRIALS (RCTS)
• OTHER FORMS OF TREATMENT EVALUATION
PSYCHOLOGICAL ISSUES AFTER STROKEARE COMMON
• DEPRESSION PREVALENCE AFTER STROKE IS 33% WITH A CUMULATIVE INCIDENCE OF 55%
OVER 10 YEARS (AYERBE, AYIS, WOLFE, & RUDD, 2013; HACKETT, YAPA, PARAG, & ANDERSON,
2005).
• ANXIETY PREVALENCE AVERAGES ABOUT 25% (CAMPBELL BURTON ET AL., 2013). 10 YEAR
CUMULATIVE INCIDENCE IS 57% (AYERBE, AYIS, CRICHTON, WOLFE, & RUDD, 2014).
• MODERATE AND SEVERE FATIGUE AFFECTS 57% (LERDAL ET AL., 2011).
• EMOTIONALISM AFFECTS ABOUT 16% (HOUSE ET AL. 1989).
SUB-CLINICAL PSYCHOLOGICAL DISTRESS IS EVEN MORE COMMON AFTER STROKE
• ‘LOSS’ OF IDENTITY/SENSE OF SELF IS COMMON (ELLIS-HILL & HORN, 2000;
PALLESEN, 2014).
• SELF-ESTEEM IS OFTEN REDUCED (VICKERY ET AL,. 2008.; KEPPEL & CROWE,
2000).
• 73% OF STROKE SURVIVORS LACK CONFIDENCE,
• 56% FEEL PEOPLE TREAT THEM DIFFERENTLY
• 55% FEEL UNABLE TO CARE FOR THEIR FAMILIES AS BEFORE.
(THE STROKE ASSOCIATION, 2016)
MANY STROKE SURVIVORS HAVE MORE THAN ONE PSYCHOLOGICAL ISSUE
40% OF STROKE SURVIVORS AT ANY GIVEN TIME ARE AFFECTED BY ONE OR
MORE OF:
• DEPRESSION, ANXIETY, COGNITIVE IMPAIRMENT, SEXUAL PROBLEMS,
ATTITUDES TO RECOVERY, IDENTITY CHANGE AND ISOLATION (MCKEVITT ET
AL., 2010)
60% OF STROKE SURVIVORS SAY THEY FEEL DEPRESSED AND 67% SAY THEY
FEEL ANXIOUS. (THE STROKE ASSOCIATION, 2013)
RESEARCH INTO EPIDEMIOLOGY
THE EFFECTS OF PSYCHOLOGICAL CONDITIONS ARE SERIOUS AND UTILISE SCARCE RESOURCES
PSYCHOLOGICAL CONDITIONS THAT OCCUR AFTER STROKE ARE
ASSOCIATED WITH:
• REDUCED QUALITY OF LIFE (BAYS, 2001; GODWIN, OSTWALD, CRON, & WASSERMAN,
2013; STURM ET AL., 2004)
• POORER SOCIAL FUNCTIONING. (D’ALISA S ET AL. 2005)
• IMPAIRED FUNCTIONAL RECOVERY (HUANG ET AL, 2017; GILLEN, ET AL. , 2001).
• POORER FUNCTIONAL ABILITY. (SHIMODA ET AL., 1998)
• INCREASED MORTALITY (AYERBE ET AL., 2013).
• INCREASED HEALTHCARE UTILISATION (APPLEBY, THOMPSON, & GALEA, 2012; GHOSE,
WILLIAMS, & SWINDLE, 2005; VAN EEDEN ET AL., 2016)
• INCREASED COST TO HEALTHCARE (NAYLOR ET AL, 2012)
RESEARCH INTO EFFECTS/OUTCOMES
VALIDATED ASSESSMENTS AND SCREENS FOR PSYCHOLOGICAL CONDITIONS IN STROKE
MOOD
• HOSPITAL ANXIETY AND DEPRESSION SCALE (HADS)
• PATIENT HEALTH QUESTIONNAIRE -9 (PHQ-9)
• GENERAL ANXIETY DISORDER-7 (GAD-7)
• BECK DEPRESSION INVENTORY (BDI) & HAMILTON DEPRESSION
RATING SCALE (HDRS)
• BRIEF ASSESSMENT SCHEDULE DEPRESSION CARDS (BASDEC)
• SIGNS OF DEPRESSION SCALE (SODS)
• STROKE APHASIC DEPRESSION QUESTIONNAIRE (SADQ)
• BEHAVIOURAL OUTCOMES OF ANXIETY SCALE (BOA)
• GENERAL HEALTH QUESTIONNAIRE (GHQ- 28)
COGNITION
• CAMBRIDGE COGNITION EXAMINATION (CAMCOG)
• MONTREAL COGNITIVE ASSESSMENT (MOCA)
• TRAIL MAKING TEST (TMT)
• EXECUTIVE FUNCTION PERFORMANCE TEST (EFPT)
• CLOCK DRAWING TEST (CDC)
QUALITY OF LIFE
• Stroke Specific Quality of Life Scale (SS-QOL)
RESEARCH INTO SCREENING
Measures of several facets of psychological distress are not yet
validated for stroke. (e.g. Self-esteem, trauma, identity change)
PSYCHOLOGY RESEARCH DONE GOOD
BUT WHAT ABOUT TREATMENTS FOR PSYCHOLOGICAL CONDITIONS?
DRUG TREATMENTS: (ISWP GUIDELINES, 2016)
FATIGUE
• SOME PHARMACOLOGICAL INTERVENTIONS (ANTIDEPRESSANTS OR STIMULANTS), PSYCHOLOGICAL
INTERVENTIONS AND PHYSICAL TRAINING ARE POTENTIAL TREATMENTS BUT ….THERE IS
INSUFFICIENT EVIDENCE TO RECOMMEND ANY SPECIFIC INTERVENTION (WU ET AL, 2015).
ANXIETY
• DRUG TREATMENTS APPEAR USEFUL (CAMPBELL BURTON ET AL, 2011; MEAD ET AL, 2012). SSRI’S
REDUCE ANXIETY (MEAD ET AL, 2012).
DEPRESSION
• DRUG TREATMENTS ALONE (HACKETT ET AL, 2008B, MEAD ET AL, 2012) OR IN COMBINATION WITH
PSYCHOLOGICAL INTERVENTIONS (MITCHELL ET AL, 2009) MAY BE HELPFUL.
(ALL REVIEWS MENTION ADVERSE EFFECTS IN SOME INDIVIDUALS)
DRUG TREATMENTS: LESSONS FROM MENTAL HEALTH
SIMPLE SEROTONIN THEORY UNDERPINNING SSRI ACTION IS NOT CONSISTENT WITH NEW
RESEARCH (ANDREWS ET AL, 2015)
• SOME FORMS OF DEPRESSION ARE ASSOCIATED WITH INCREASED SEROTONIN LEVELS
• SSRI THERAPEUTIC LAG IS NOT PREDICTED.
DRUG TREATMENTS: LESSONS FROM MENTAL HEALTH
PUBLICATION BIAS HAS RESULTED IN SUPPRESSION OF NEGATIVE TRAILS OF SSRI’S
(Thanks to Steve Hollon, 2017; Vanderbilt University)
DRUG TREATMENTS: LESSONS FROM MENTAL HEALTH
HRSD= Hamilton Rating
Scale for DepressionThanks to Steve Hollon, 2017: Vanderbilt University
DRUG TREATMENTS: LESSONS FROM MENTAL HEALTH
Anti-depressant medications are associated with
higher relapse rates than placebo.
Psychological treatments alone have lower risk of
relapse than when combined with imipramine.
Elevated Relapse Rates: Rebound Effect
PSYCHOLOGICAL TREATMENTS AFTER STROKE: WHERE ARE WE AFTER THREE DECADES OF RESEARCH?
PSYCHOLOGICAL TREATMENT WITH EVIDENCE (ISWP GUIDELINES, 2016)
• MOTIVATIONAL INTERVIEWING (MI), PREVENTION OF DEPRESSION
• PROBLEM-SOLVING THERAPY, PREVENTION OF DEPRESSION
• RELAXATION, (TWO SMALL STUDIES, TENTATIVE), ANXIETY TREATMENT
• BEHAVIOURAL THERAPY, TREATMENT OF DEPRESSION IN APHASIA
(BUT EVIDENCE IS TENUOUS COMPARED WITH MENTAL HEALTH)
SYSTEMATIC REVIEWS HAVE CONCLUDED LIMITED EVIDENCE FOR THE EFFICACY OF
PSYCHOSOCIAL THERAPIES
• CAMPBELL-BURTON ET AL, 2011: 2 TRIALS, 175 PARTICIPANTS
• LOETSCHER T & LINCOLN NB, 2013; 6 TRIALS, 223 PARTICIPANTS
• HACKETT, ANDERSON, HOUSE, & HALTEH, 2008A: 14 TRIALS, 1515 PARTICIPANTS
• HACKETT, ANDERSON, HOUSE, & XIA, 2008B: 16 TRIALS, 1655 PARTICIPANTS
• SUGAVANAM, MEAD, BULLEY, DONAGHY, & VAN WIJCK, 2013; 17 TRIALS, 614 PARTICIPANTS
(SURVIVORS)
• GILLESPIE ET AL, 2014: 44 TRAILS, >1500 PARTICIPANTS
• KNAPP ET AL, 2017: 3 STUDIES, 196 PARTICIPANTS
• CHUNG ET AL. 2013: 19 STUDIES, 907 PARTICIPANTS
TOTAL = 121 TRIALS : 6,785 PARTICIPANTS
Lack of robust evidence for (condition-specific) psychological
treatments after two decades and much research.
CONCLUSIONS OF SYSTEMATIC REVIEWS
• HACKETT ET AL 2008A: A SMALL BUT SIGNIFICANT EFFECT OF PSYCHOTHERAPY ON IMPROVING MOOD AND
PREVENTING DEPRESSION WAS IDENTIFIED. MORE EVIDENCE IS REQUIRED BEFORE RECOMMENDATIONS CAN BE MADE
ABOUT THE ROUTINE USE OF SUCH TREATMENTS AFTER STROKE.
• KNAPP ET AL 2017: EVIDENCE IS INSUFFICIENT TO GUIDE THE TREATMENT OF ANXIETY AFTER STROKE. FURTHER WELL-
CONDUCTED RANDOMISED CONTROLLED TRIALS (USING PLACEBO OR ATTENTION CONTROLS) ARE REQUIRED….
• WU ET AL 2015: THERE WAS INSUFFICIENT EVIDENCE ON THE EFFICACY OF ANY INTERVENTION TO TREAT OR PREVENT
FATIGUE AFTER STROKE.
• CHUNG ET AL. 2013 WE IDENTIfiED INSUFfiCIENT HIGH-QUALITY EVIDENCE TO REACH ANY GENERALISED
CONCLUSIONS ABOUT THE EFFECT OF COGNITIVE REHABILITATION ON EXECUTIVE FUNCTION,..
• CAMPBELL BURTON ET AL 2011: THERE IS INSUFFICIENT EVIDENCE TO GUIDE THE TREATMENT OF ANXIETY AFTER
STROKE.
LACK OF CONCLUSIVE EVIDENCE FOR PSYCHOLOGICAL TREATMENTS AFTER TWO DECADES
• SUGAVANAM, ET AL 2013; DUE TO THE HETEROGENEITY AND QUALITY OF INCLUDED STUDIES, NO FIRM
CONCLUSIONS COULD BE MADE ON THE EFFECTIVENESS, FEASIBILITY AND ACCEPTABILITY OF GOAL SETTING IN
STROKE REHABILITATION.
• LOETSCHER T & LINCOLN NB, 2013; THE EFFECTIVENESS OF COGNITIVE REHABILITATION REMAINS UNCONFIRMED. THE
RESULTS SUGGEST THERE MAY BE A SHORT-TERM EFFECT ON ATTENTIONAL ABILITIES, BUT FUTURE STUDIES NEED TO
ASSESS THE PERSISTING EFFECTS
GILLESPIE ET AL 2016: DESPITE RESEARCH INVOLVING OVER 1500 PATIENTS IN 44 RANDOMIZED STUDIES, THERE IS
VERY LITTLE STRONG EVIDENCE FOR THE EFFECTIVENESS OF REHABILITATION FOR COGNITIVE DEFICITS FOUND
AFTER STROKE, AND VERY FEW DIRECT CLINICAL RECOMMENDATIONS CAN BE MADE.
The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects
RESEARCH INTO PSYCHOLOGICAL INTERVENTIONS AFTER STROKE
TREATMENT: NOT QUITE THERE YET!
IS OUR FOCUS ON CONDITION-SPECIFIC TREATMENTS RIGHT?
OR SHOULD WE FOCUS ON TRANSDIAGNOSTIC TREATMENTS?
Let’s take a risk and think!
ARE CONDITION-SPECIFIC OR TRANSDIAGNOSTICTREATMENTS RIGHT FOR STROKE?
• MANY STROKE SURVIVORS (40%+) HAVE MULTIPLE PSYCHOLOGICAL ISSUES. TREATING ONE
CONDITION MAY SIMPLY INCREASE ATTENTION TO THE OTHERS. (SYMPTOM SUBSTITUTION).
• MANY PSYCHOLOGICAL ADJUSTMENT ISSUES ARE NOT CAPTURED BY DIAGNOSIS (E.G. PAIN,
FATIGUE, LOW SELF-ESTEEM).
• CORE PROCESSES COMMON TO GROUPS OF CONDITIONS ARE GOOD TARGETS FOR
TRANSDIAGNOSTIC TREATMENT. (SEE NEXT SLIDE)
• PEARL & NORTON (2017). META-ANALYSIS OF 67 STUDIES COMPARING CONDITION-SPECIFIC TO
TRANSDIAGNOSTIC. TRANSDIAGNOSTIC THERAPIES WERE STATISTICALLY SUPERIOR.
• EVEN IF EFFICACIOUS, DELIVERING AN ARMOURY OF CONDITION-SPECIFIC THERAPIES MAY BE
IMPRACTICAL IN THE STROKE CONTEXT.
TRANSDIAGNOSTIC PSYCHOLOGICAL TREATMENTS
Core Process Psychological Condition Associated Therapy
Perceptual control
(Powers, 1973)
anxiety, depression, stress,
distress
‘Take Control Course’ (Morris et
al 2016)
Method of Levels (Carey &
Mullan, 2008)
Intolerance of uncertainty
(Dugas et al. 2004)
anxiety in all its forms Unified Protocol for the
Transdiagnostic Treatment of
Emotional Disorders (Barlow et
al., 2011)
Psychological flexibility (Barlow
et al., 2011)
psychological distress in general Acceptance and Commitment
Therapy (Hayes, et al 2006)
IS OUR OBSESSION WITH THE RCT THE RIGHT TREATMENT EVALUATION APPROACH FOR
PSYCHOLOGICAL INTERVENTIONS?
Let’s take another risk and think!
CLINICAL TRIALS (RCTS) AND PSYCHOLOGICAL TREATMENTS ARE A DIFFICULT MATCH
• 1) TAKES DECADES TO COMPLETE THE DEVELOPMENT AND EVALUATION OF A PSYCHOLOGICAL TREATMENT BY
RCT. BUT EFFICACY OF PSYCHOLOGICAL TREATMENTS HAS LIMITED LIFE.
• E.G. CBT EFFICACYIN TRIALS DECLINED OVER 5 DECADES 1977-2014: JOHNSON & FRIBORG, 2015.
• (THIS IS NOT UNIQUE TO PSYCHOLOGY C.F. IMMUNISATION AND ANTIBIOTIC TREATMENTS).
• 2) PSYCHOLOGICAL INTERVENTIONS, LIKE SURGERY, DON’T LEND THEMSELVES EASILY TO EVALUATION BY RCT.
• VARIABILITY TO SUIT INDIVIDUAL NEEDS IS A FEATURE OF PSYCHOLOGICAL TREATMENTS.
• GRADUAL EVOLUTION OF PSYCHOTHERAPIES IS NOT CAPTURED BY RCTS.
• TECHNICAL NATURE OF TRAILS LEADS TO THE TRIALIST---PRACTICE GAP.
• BLINDING DURING TREATMENT DELIVERY IS NOT POSSIBLE.
• BLINDING DURING ASSESSMENT IS OFTEN COMPROMISED.
• COST-EFFECTIVE GROUP AND SELF-MANAGEMENT TREATMENTS ENTAIL MAJOR STATISTICAL AND DESIGN CHALLENGES.
ALTERNATIVE QUASI-EXPERIMENTAL APPROACHES TO THE RCT EXIST, BUT ARE LITTLE USED IN PSYCHOLOGICAL STROKE RESEARCH AND
WHEN THEY ARE USED THEY ARE BASED ON FEW CASES.
(MUCH MORE USED IN PHYSIO- AND OCCUPATIONAL THERAPY RESEARCH)
WHITALL J. STROKE REHABILITATION RESEARCH: TIME TO ANSWER MORE SPECIFIC QUESTIONS? NEUROREHABIL NEURAL REPAIR 2004;18:3–8.
PRACTICE-DERIVED EVIDENCE
• INVOLVES CLINICIANS IN DATA COLLECTION (SEEMS TO HAVE DECLINED IN
RECENT YEARS)
• SELECTS CASES FOR TREATMENT ACCORDING TO CLEAR INCLUSION AND
EXCLUSION CRITERIA
• AT THE VERY LEAST RECORDS PRE- AND POST-TREATMENT SCORES.
• NOT A BAD INDEX OF EFFICACY IN THE ABSENCE OF UNDERLYING TRENDS. (E.G. TRAUMA
DEBRIEF!)
• BUILDS CASES INTO CASE SERIES
• IDEALLY USES SINGLE-CASE, SMALL-N AND QUASI-EXPERIMENTAL DESIGNS
TO PROVIDE ROBUST EVIDENCE OF EFFICACY QUICKLY.
RESOURCES
Graham JE, Karmarkar AM and Ottenbacher KJ. Small sample research designs for evidence-based
rehabilitation: issues and methods. Arch Phys Med Rehabil 2012; 93(8 Suppl.): S111–S116.
Forthcoming
SINGLE CASE EXPERIMENTAL DESIGNS: REPEATED MEASURES WITH PHASE SHIFTS
MULTIPLE BASELINE DESIGN
REGRESSION DISCONTINUITY DESIGN
CHANGING CRITERION DESIGN
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