A systematic review of non-drug interventions to prevent and treat anxiety in people with aphasia after stroke

Knowledge, Beliefs, and Experiences With Mental Health Services and Help-Seeking in People With Aphasia and Care Partners

PURPOSE

Supporting psychological well-being in persons with aphasia (PWA) can improve social and health outcomes; however, PWA and their care partners (CPs) are often not receiving mental health support. Previous research explores this from the perspective of health care professionals.

AIMS

The aim of this study was to examine knowledge, beliefs, and experiences related to mental health services directly from PWA and CPs.

METHOD

The study included 11 PWA and 11 CPs. Participants completed a guided survey (virtual) with opportunities for elaboration related to the knowledge, beliefs, and experiences of mental health.

RESULTS

There was variability in personal preferences for referrals, types of coping strategies, and confidants for general thoughts and feelings and those specific to aphasia. PWA identified health care professionals as people to share thoughts and feelings, whereas CPs chose family and friends more often. Both CPs and PWA reported communication difficulty and finding a counselor as "sometimes" preventing access to services but cited fear and trust as "always" preventing access.

CONCLUSIONS

Knowledge, beliefs, and experience with help-seeking and mental health services are personal and variable. Assessing barriers unique to living with aphasia, such as communication challenges and locating a suitable counselor, must also be considered within more complex and personal barriers of fear and trust that are consistently reported in the general public. Health professionals across the continuum of aphasia care need to understand the communication challenges of living with aphasia in tandem with understanding individual differences to personalize approaches to mental health services and help-seeking.

Aphasia Depression and Psychological Therapy (ADaPT): Perspectives of People with Post-Stroke Aphasia on Participating in a Modified Cognitive Behavioral Therapy

Aphasia, a communication disability commonly caused by stroke, can profoundly affect a person's mood and identity. We explored the experiences of stroke survivors with aphasia and depression who received a modified cognitive behavioral therapy (CBT)-based psychological intervention. The therapy is manualized with a flexible treatment protocol, including 10 individually based therapy sessions (+2 booster sessions) either via telehealth or in person. Six participants with chronic aphasia (60% of the total sample) participated in in-depth interviews that were analyzed using reflexive thematic analysis. Two core themes were derived from the data: the first theme, helpful elements of therapy-doing enjoyable activities, new ways of thinking, problem solving, working with the experienced therapist, and using telehealth; and the second theme, making progress-mood, communication, acceptance of the 'new me', and improving relationships. All participants found the therapy to be helpful in managing mood problems with various elements being beneficial depending on the individual, highlighting the importance of tailoring the intervention. Therefore, delivering modified CBT to individuals with aphasia is likely to be acceptable both in person and through telehealth. Further evaluation of the intervention and its impact on mood would be beneficial.

Inclusion of People With Aphasia in Stroke Trials: A Systematic Search and Review

BACKGROUND

Although people with aphasia (PwA) represent 30% of stroke survivors, they are frequently excluded from stroke research, or their inclusion is unclear. Such practice significantly limits the generalizability of stroke research, increases the need to duplicate research in aphasia-specific populations, and raises important ethical and human rights issues.

OBJECTIVE

To detail the extent and nature of inclusion of PwA in contemporary stroke randomized controlled trials (RCTs).

METHODS

We conducted a systematic search to identify completed stroke RCTs and RCT protocols published in 2019. Web of Science was searched using terms "stroke" and "randomized controlled trial". These articles were reviewed by extracting rates of PwA inclusion/exclusion, whether "aphasia" or related terms were referred to in the article or supplemental files, eligibility criteria, consent procedures, adaptations made to support the inclusion of PwA, and attrition rates of PwA. Data were summarized, and descriptive statistics applied when appropriate.

RESULTS

271 studies comprising 215 completed RCTs and 56 protocols were included. 36.2% of included studies referred to aphasia/dysphasia. Of completed RCTs, only 6.5% explicitly included PwA, 4.7% explicitly excluded PwA, and inclusion was unclear in the remaining 88.8%. Among RCT protocols, 28.6% of studies intended inclusion, 10.7% intended excluding PwA, and in 60.7%, inclusion was unclear. In 45.8% of included studies, sub-groups of PwA were excluded, either explicitly (ie, particular types/severities of aphasia, eg, global aphasia) or implicitly, by way of ambiguous eligibility criteria which could potentially relate to a sub-group of PwA. Little rationale for exclusion was provided. 71.2% of completed RCTs did not report any adaptations that could support the inclusion of PwA, and minimal information was provided about consent procedures. Where it could be determined, attrition of PwA averaged 10% (range 0%-20%).

CONCLUSION

This paper details the extent of inclusion of PwA in stroke research and highlights opportunities for improvement.

How do speech and language therapists enact aphasia psychosocial support in Ireland? A cross-sectional online survey informed by normalization process theory

BACKGROUND

Supporting psychosocial well-being in aphasia is necessarily person-centred, interdisciplinary and coordinated. Shortcomings in such support are described in Ireland and elsewhere. Speech and language therapists (SLTs) are integral; and describing current practice and barriers they experience is important for enhancing service delivery.

AIMS

To understand how SLTs enact, and are supported to enact, aphasia psychosocial care in Ireland.

METHODS & PROCEDURES

This is a cross-sectional, online, self-administered clinician survey targeting SLTs working minimally 1 year post-qualification with persons with aphasia of any aetiology in Ireland. The survey questions were charted against key constructs of the implementation science framework, normalization process theory (NPT), and descriptive statistics were applied.

OUTCOMES & RESULTS

A total of 54 eligible datasets were included. SLTs believed psychosocial support to be part of their role, but perceived multiple barriers in enacting it. These included a lack of training, clinical supervision, management support, role recognition, and access to and joint working with mental health professionals and services.

CONCLUSIONS & IMPLICATIONS

SLTs in Ireland face a range of individual and structural barriers, including care coordination and resourcing. There is a clear need not only for training, upskilling and mentorship, but also for wider changes around access to mental health professionals and clarity around the processes of referral, coordination and integration of aphasia care across settings. These findings comprise preliminary insights into current practices. Further research is needed as well as clarity on best-practice pathways for different aetiologies of aphasia. Articulating current practices using NPT may have utility for developing empirically informed and principled interventions to improve service delivery.

WHAT THIS PAPER ADDS

What is already known on this subject People with aphasia of all aetiologies are at risk of psychosocial problems. Shortcomings in access and the availability of appropriate support have been documented both internationally and in Ireland. To address this issue, an important first step is to understand how SLTs in Ireland currently enact and are supported to enact aphasia psychosocial care. What this study adds to the existing knowledge The findings describe the potential levers and barriers to progressing aphasia psychosocial care in Ireland. A range of individual, team and structural factors were identified. These were locally contextualized but similar issues are reported in other countries. Linking attitudes with NPT constructs provides a first step for further principled implementation projects. What are the practical and clinical implications of this study? Addressing psychosocial problems is perceived as a legitimate part of the speech and language therapy role. SLTs in Ireland enact a range of therapeutic approaches but may need opportunities for formal training and supervision, and for better coordination and integration with other mental health services and disciplines. Understanding differences in care pathways across the range of aphasia aetiologies is additionally important given the emphasis on post-stroke aphasia in the literature.

A literature review and meta-analysis of the optimal factors study of repetitive transcranial magnetic stimulation in post-infarction aphasia

BACKGROUND

The existing literature indicates that repetitive transcranial magnetic stimulation (rTMS) can potentially enhance the prognosis of poststroke aphasia (PSA). Nevertheless, these investigations did not identify the most effective parameters or settings for achieving optimal treatment outcomes. This study involved a meta-analysis aimed to identify the optimal variables for rTMS in treating post-infarction aphasia to guide the use of rTMS in rehabilitating PSA.

METHODS

PubMed, Embase, and Cochrane Library databases were searched from inception to May 2023, and articles were reviewed manually using subject words and free words and supplemented with references from the included literature to obtain additional relevant literature. The search terms included "poststroke aphasia" and "repetitive transcranial magnetic stimulation (rTMS)" repetitive transcranial magnetic stimulation. Additionally, a review of the reference lists of previously published systematic reviews identified through the Cochrane Database of Systematic Reviews (search terms: poststroke aphasia, rTMS; restrictions: none) and PubMed (search terms: poststroke aphasia, rTMSs; restrictions: systematic review or meta-analysis) was performed. Information from studies involving different doses of rTMS in PSA was independently screened and extracted by 2 researchers.

RESULTS

This meta-analysis included 387 participants with PSA across 18 randomized controlled trials. The results showed that the total pulse had a trend toward a significant correlation with the treatment effect (P = 0.088), while all other variables did not correlate significantly. When rTMS was not grouped by stimulus parameter and location, our nonlinear results showed that when the total pulses were 40,000 (standardized mean difference (SMD):1.86, 95% credible interval (CrI) 0.50 to 3.33), the pulse/session was 1000 (SMD:1.05, 95% CrI 0.55-1.57), and an RMT of 80% (SMD:1.08, 95% CrI 0.60-1.57) had the best treatment effect. When rTMS was grouped by stimulus parameters and location, our nonlinear results showed that when the total low-frequency (LF)-rTMS-right inferior frontal gyrus (RIFG) pulse was 40,000 (SMD:1.76, 95% CrI:0.36-3.29), the pulse/session was 1000 (SMD:1.06, 95% CrI:0.54-1.59). Optimal results were obtained with an RMT of 80% (SMD:1.14, 95% CrI 0.54 - 1.76).

CONCLUSIONS

The optimal treatment effects of rTMS for PSA may be obtained with a total pulse of 40,000, a pulse/session of 1000, and an RMT of 80%. Further rigorous randomized controlled studies are required to substantiate the validity of these results.

The Efficacy of Integrated Rehabilitation for Post-Stroke Anxiety: Study Protocol for a Prospective, Multicenter, Randomized Controlled Trial

Background

Methods

Conclusion

Trial Registration

Post-stroke Anxiety Among Patients in Jordan: A Multihospital Study

This study aimed to assess the prevalence, correlates, and significant associated factors of anxiety among patients with stroke. A cross-sectional, correlation design was utilized. The Hospital Anxiety and Depression scale was used to detect and assess the severity of anxiety and depression among mentally well patients at general hospital settings. Among the 226 patients with stroke, 45.6% had clinically significant levels of anxiety to be considered as a definite case. Having a short duration since the stroke onset, being a definite case of depression, being unable to perform self-care activities, having an insufficient monthly income, and having visual problems due to stroke were the significantly associated factors. The high prevalence of anxiety among patients with stroke highlights the need for interventions of early detection and management to enhance recovery. Patients who have any of the significant traits predicted post-stroke anxiety required special attention.

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.

How Do You Do Talk Therapy With Someone Who Can't Talk? Perspectives From Mental Health Providers on Delivering Services to Individuals With Aphasia

Purpose Aphasia is correlated with depression and anxiety, and it has a negative impact on quality of life. Aphasia is also frequently misunderstood among mental health care providers. The aim of this study was to explore the experiences of mental health providers who provide services to people living with aphasia. Method Interpretative phenomenological analysis was used to analyze interviews of six mental health providers who had some experience in providing services to people with aphasia. Results Three main themes among mental health care providers' experiences providing services to people with aphasia were identified: barriers, interprofessional collaboration, and therapy looks different. Subthemes associated with barriers included insufficient training and knowledge of aphasia, the stigma of receiving mental health services, and accessibility to services. Subthemes related to interdisciplinary collaboration included referrals, knowledge and awareness, and strategies and tools. Subthemes supporting therapy looks different included a new approach to therapy and challenges. Conclusions Mental health providers' experiences reveal the need for an action-oriented approach to overcome barriers, a nontraditional approach to talk therapy for people with aphasia, and increased collaboration with speech-language pathologists (SLPs). Future research should explore expanding the collaboration between SLPs and mental health providers to increase shared knowledge and skills in issues related to reducing depression and anxiety to support the well-being of people with aphasia.