Exploring Associations Between a Biological Marker of Chronic Stress and Reported Depression and Anxiety in People With Aphasia

Safety-Seeking Behaviors and Anxiety Maintenance in People With Aphasia: A Viewpoint

PURPOSE

People with aphasia (PWA) often experience higher levels of anxiety and social isolation than people without aphasia. Although the presence of anxiety is appreciated in PWA, literature examining the etiology and persistent nature of anxiety in PWA is underdeveloped. Safety-seeking behaviors, or maladaptive acts used by individuals to decrease anxiety from a feared outcome, have been reported as key facilitators of long-term anxiety toward feared situations across a variety of clinical populations. The purpose of this viewpoint is to explore the concept of safety-seeking behaviors and discuss their potential relevance to the maintenance of anxiety in PWA. We further discuss the distinction between maladaptive (i.e., safety seeking) and adaptive (i.e., coping) behaviors and how this knowledge may improve the quality of clinical services for PWA.

CONCLUSIONS

The present review advocates for further exploration of the safety-seeking behaviors that are used by PWA. Until critical attention is given to this subject, clinicians may remain ill-equipped to identify and depict whether a self-management strategy is facilitative or inhibitive to PWA's communicative participation goals. Critically, a behavior that may be "maladaptive" for one individual may be "adaptive" for another. Future research should seek to identify common behavioral and cognitive strategies that PWA implement to reduce acute perceptions of anxiety. This knowledge may help facilitate holistic aphasia rehabilitation by allowing clinicians to foster conversations around behaviors that inhibit or promote successful communicative participation.

Perspectives of U.S. speech-language pathologists on supporting the psychosocial health of individuals with aphasia

INTRODUCTION

Individuals living with aphasia (IWA) are more likely than stroke survivors without aphasia to experience depression, anxiety, stress, and social isolation due to communication difficulties, social and life barriers, and neurobiological changes (Hilari, 2011). Researchers in the U.K., Australia, and elsewhere have surveyed speech-language pathologists (SLPs) to ascertain their training and confidence in addressing the psychosocial well-being of IWA (Northcott et al., 2017; Sekhon et al., 2015). To date, no similar survey has been performed in the U.S. The aim of this study was to survey the perspectives of U.S. SLPs on addressing the psychosocial well-being of IWA.

METHODS

The survey questions were drawn from Northcott et al. (2017), with adjustments for a U.S. audience and additional questions. We conducted a Qualtrics survey which remained open from November 2021 through May 2022 and collected 101 responses. Responses to the closed questions were analyzed using descriptive statistics and open-ended responses were analyzed with qualitative content analysis.

RESULTS

Some of the most significant findings of this survey include the low levels of confidence in addressing psychological health, lack of training among SLPs, and rarity of successful collaboration with mental health professionals. In comparison to surveys conducted in other countries, many overarching themes were similar, but there was some variation in specific responses and patterns. Categories emerging from the open-ended responses included the need for more trained mental health professionals, improved collaboration, and emphasis on the importance of the topic.

CONCLUSIONS

This research highlights the necessity of increased training, as well as improved interprofessional collaboration between SLPs and mental health professionals. Limitations of the study include the potential bias of respondents, as well as the number and scope of the questions and responses. Future studies can employ interviews, trial models for collaboration, and partner with IWA to explore their experiences with psychosocial health support and services.

A Scoping Review on the Effects of Emotional Stimuli on Language Processing in People With Aphasia

PURPOSE

Emotional stimuli have been shown to influence language processing (both language comprehension and production) in people with aphasia (PWA); however, this finding is not universally reported. Effects of emotional stimuli on language performance in PWA could have clinical and theoretical implications, yet the sparsity of studies and variability among them make it difficult to appraise the significance of this effect. The purpose of this scoping review was to (a) determine the extent and range of research examining the effect of emotional stimuli on language processing in PWA, (b) summarize and evaluate research findings, and (c) identify gaps in the literature that may warrant future study.

METHOD

PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases were systematically searched for articles that compared performance in response to emotional and nonemotional stimuli on at least one language measure in one or more adults with aphasia. Data related to methods and results were extracted from each article and charted in Excel.

RESULTS

Five hundred forty unique articles were found, and 18 articles, consisting of 19 studies, met inclusion/exclusion criteria for this review. Of the 19 studies included, 11 studies reported enhanced performance on a language task for emotional compared to nonemotional stimuli, seven reported no difference, and one reported worse performance for emotional compared to nonemotional stimuli. Possible modulating variables such as task type, measurement, stimulus characteristics, and sample characteristics are discussed along with gaps in the literature.

CONCLUSION

The extent of research in this area is sparse; however, there does appear to be some early evidence for better performance in response to emotional over nonemotional stimuli in PWA for some, but not all, language processes investigated.

Associations among depression, demographic variables, and language impairments in chronic post-stroke aphasia

INTRODUCTION

Depression may influence treatment participation and outcomes of people with post-stroke aphasia, yet its prevalence and associated characteristics in aphasia are poorly understood. Using retrospective data from an overarching experimental study, we examined depressive symptoms and their relationship to demographic and language characteristics in people with chronic aphasia. As a secondary objective, we compared prevalence of depressive symptoms among the overarching study's included and excluded participants.

METHODS

We examined retrospective data from 121 individuals with chronic aphasia including depression scale scores, demographic information (sex, age, time post onset of stroke, education, race/ethnicity, and Veteran status), and scores on assessments of general and modality-specific language impairments.

RESULTS

Approximately 50% of participants reported symptoms indicative of depressive disorders: 23% indicative of major depression and 27% indicative of mild depression. Sex (males) and comparatively younger age emerged as statistically significant variables associated with depressive symptoms; naming ability was minimally associated with depressive symptoms. Time post onset of stroke, education level, race/ethnicity, Veteran status, and aphasia severity were not significantly associated with depressive symptoms. Depression-scale scores were significantly higher for individuals excluded from the overarching study compared to those who were included.

CONCLUSIONS

The rate of depressive disorders in this sample was higher than rates of depression reported in the general stroke literature. Participant sex, age, and naming ability emerged as factors associated with depressive symptoms, though these links appear complex, especially given variable reports from prior research. Importantly, depressive symptoms do not appear to diminish over time for individuals with chronic aphasia. Given these results and the relatively limited documentation of depression in aphasia literature, depression remains a pressing concern for aphasia research and routine clinical care.

Chronic Stress Is Associated with Reduced Mindful Acceptance Skills but Not with Mindful Attention Monitoring: A Cross-Sectional Study

Mindfulness-based interventions (MBIs) are effective in reducing chronic stress, but their therapeutic mechanisms are unclear. One possibility is that MBIs act by re-training attention monitoring and acceptance skills that have been impaired by chronic stress exposure. However, little research has investigated the association between chronic stress, monitoring, and acceptance. In this cross-sectional study we hypothesised observing correlations between stress, and (impaired) monitoring and acceptance. Moreover, we exploratively compared the magnitude of the correlations between chronic stress and four acceptance measures. Finally, we explored whether the association between stress and monitoring is moderated by acceptance. Eighty-five adults participated in the study and completed self-reported chronic stress and acceptance questionnaires and a mindful attention behavioural task. The results revealed that chronic stress was associated with reduced acceptance (all ps < 0.01) but not with monitoring. Exploratory analyses revealed no differences in the magnitude of the correlations between stress and each acceptance measure, except for the combined facets of mindfulness acceptance subscales and nonreactivity subscale (p = 0.023). Further analyses revealed a significant negative association between stress and the interaction between acceptance and the target detection component of monitoring (p = 0.044). Surprisingly, these results show that stress is associated with reduced monitoring at higher levels of acceptance. Theory-driven intervention studies are warranted to complement our results.

Spectrum of neuropsychiatric symptoms in chronic post-stroke aphasia

BACKGROUND

Neuropsychiatric symptoms (NPS) have been insufficiently examined in persons with aphasia (PWA) because most previous studies exclude participants with language and communication disorders.

AIM

To report a two-part study consisting of a literature review and an observational study on NPS in post-stroke aphasia.

METHODS

Study 1 reviewed articles obtained from PubMed, PsycINFO, Google Scholar and Cochrane databases after cross-referencing key words of post-stroke aphasia to NPS and disorders. Study 2 examined language deficits and activities of daily living in 20 PWA (median age: 58, range: 28-65 years; 13 men) with the Western Aphasia Battery-Revised and the Barthel Index, respectively. Informants of these 20 PWA were proxy-evaluated with the Neuropsychiatric Inventory and domain-specific scales, including the Stroke Aphasia Depression Questionnaire-10 item version and the Starkstein Apathy Scale. In addition, an adapted version of the Hospital Anxiety and Depression Scale was directly administered to the PWA themselves. This observational study is based on the baseline assessment of an intervention clinical trial (EudraCT: 2017-002858-36; ClinicalTrials.gov identifier: NCT04134416).

RESULTS

The literature review revealed a broad spectrum of NPS in PWA, including depression, anxiety, apathy, agitation/aggression, eating and sleep disorders, psychosis, and hypomania/mania. These findings alert to the need for improving assessment and treatment approaches of NPS taking into consideration their frequent occurrence in PWA. Study 2 showed that the 20 participants had mild- to-moderate aphasia severity and were functionally independent. A wide range of comorbid NPS was found in the post-stroke aphasic population (median number of NPS: 5, range: 1-8). The majority of PWA (75%) had depressive symptoms, followed by agitation/aggression (70%), irritability (70%), anxiety (65%) and appetite/eating symptoms (65%). Half of them also presented symptoms of apathy, whereas euphoria and psychotic symptoms were rare (5%). Domain-specific scales revealed that 45% of participants had apathy and 30% were diagnosed with depression and anxiety.

CONCLUSION

Concurrent NPS are frequent in the chronic period of post-stroke aphasia. Therefore, further research on reliable and valid assessment tools and treatment for this aphasic population is strongly warranted.

Demystifying the complexity of aphasia treatment: Application of the Rehabilitation Treatment Specification System (RTSS)

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate papers in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia.

Does COVID-19 Impact Less on Post-stroke Aphasia? This Is Not the Case

Background

The coronavirus disease 2019 (COVID-19) pandemic has greatly affected people’s mental health resulting in severe psychological consequences. One of the leading causes of long-term disability worldwide is aphasia. The language changes experienced by a person with aphasia (PWA) often have a sudden and long-lasting negative impact on social interaction, quality of life, and emotional wellbeing. The main aim of this study was to investigate the impact of COVID-19 on the different psychosocial dimensions which affect PWA.

Methods

This retrospective study included 73 PWA and 81 elderly matched controls. All patients were in the chronic phase. They were all discharged from rehabilitation services, which left them with different degrees of language deficits (i.e., severe vs. mild vs. moderate). All participants were administered the hospital anxiety and depression scale (HADS) through an online survey. PWA also took part in the stroke and aphasia quality of life scale questionnaire (SAQOL-39).

Results

Although the comparison between two different time points [one month before (T0) and one month after the lockdown (T1)] led to a significant increase in depression and anxiety symptoms in both groups (PWA vs. control), lower rates of depression and anxiety were found in PWA compared to the healthy group. Significant deterioration was also present in PWA in the communication and psychosocial scales of the SAQOL-39 test, which correlated with the observed changes in the psychological domains. Interestingly, the results were not significantly influenced by the degree of aphasia severity. Similarly, in both groups, none of the demographic variables (gender, age, and educational level) significantly affected the scores in the different subscales.

Conclusions

This evidence which, at first glance, seems to suggest that PWA have been partially spared from the impact of COVID-19, actually masks a dramatic situation that has always characterized this population. Indeed, given that PWA already live in a state of social isolation and emotional instability, these conditions might have, paradoxically, limited the effects of the coronavirus. However, as our results showed a deterioration in the emotional state and communication skills of our patients, possible solutions are discussed in order to prevent further decline of their cognitive abilities.