|
Psychosocial
Aspects of Recovery from Stroke |
|
Scott
B. Patten, MD, PhD
Associate Professor,
Departments of Community Health Sciences and Psychiatry,
University of Calgary, Population Health Investigator,
The Alberta Heritage Foundation for Medical Research,
Calgary, AB.
|
|
| ----Stroke
has the potential to disrupt several facets of a person's life including
communication, emot- |
| ional regulation,
cognitive function and coping skills.1 Furthermore, stroke does not
just impact on the |
| individual
but also on his or her family members and other social networks of
which he or she is a part |
| Stroke
has been regarded as form of "double-jeopardy"1 in the sense
that the condition creates many |
| new problems
and challenges for those afflicted, and simultaneously detracts from
the afflicted perso- |
| ns' capacity
to cope with those challenges. It can also lead to disruptions in
those same social conne- |
| ctions
that would normally support adaptation to loss. |
| ----Understanding
the role of psychosocial factors in recovery from stroke requires
adopting a conc- |
| eptual
viewpoint that transcends the traditional biomedical perspective.
A suitable framework is prov- |
| ided by
the World Health Organization's International Classification of Impairments,
Disabilities and Ha- |
| ndicaps
(WHO-ICIDH). The WHO system differentiates among impairment, disability
and handicap. Acc- |
| ording
to the WHO, impairment is defined as any loss or abnormality of structure
or function. In essen- |
| ce, impairment
refers to the impact of stroke at a neurological level, which can
be evaluated by clincic- |
| al means.
However, of itself, impairment has very little specific social or
personal significance. |
| ----The
WHO defines disability as a restriction or lack of ability to perform
an activity or task in a man-
|
| ner considered
normal. This concept helps us understand the impact of a stroke from
the point of view |
| of the
person who has had a stroke--for instance, what tasks is this person
able or unable to perform? |
| An assessment
of disability can range from an evaluation of activities of daily
living (ADL) to an occup- |
| ational
assessment. |
| ----Finally,
the WHO's concept of handicap refers to a social dimension--can the
person fulfill a role |
| that
is normal for that person? The term handicap thus reflects an interaction
between individuals and |
| their
social environment. |
| ----Inherent
in the WHO Classification is a great degree of optimism. First, the
brain is probably much |
| more plastic
than was previously believed,2 and rehabilitative efforts may affect
fundamental aspects |
| of neural
recovery. Second, even in the presence of neurological deficits, disabilities
can often be |
| overcome
and handicaps can be effectively addressed. If impairment leads to
difficulty in completing a |
| task, household
modifications and various aids to daily living can be used, in order
to maximize functi- |
| ioning.
By a process of psychosocial adaptation, persons who have had a stroke
can learn to adapt to |
| the new
reality in their life--albeit one that may include some impairments.
They can adopt new roles |
| and develop
new interests. As such, it should not be considered inevitable that
neurological impairme- |
| nts must
translate into a poor quality of life. The Framingham study confirmed
that extent of impairme- |
| nt was
related to outcome (the dependent variable in this study was institutionalization),
but also iden- |
| tified
an important role for psychosocial factors. In men, marital status
was more strongly related to |
| institutionalization
than was extent of impairment; however, this was not true for women. |
| ----In
the acute stages of a stroke, the emphasis tends to be on medical
treatment and assessment. |
| Once
the condition has stabilized, a decision is made on whether to proceed
with rehabilitation. Often, |
| the
initial goal of rehabilitation is regaining physical function with
psychosocial factors becoming more |
| important
over time. However, this delay in psychosocial intervention may affect
outcome; those trials |
| of
psychosocial interventions that have been implemented many months
post-stroke have generally |
| reported
disappointing results, whereas support provided in the first six months
has been strongly |
| associated
with favourable outcomes. Therefore, an assessment of important psychosocial
variables |
| should
be performed during the early stages of rehabilitation.
|
| ----Psychosocial
assessment should be individualized, but must include certain elements.
The asse- |
| sment
should allow a differentiation between the self-limited distress associated
with psychological |
|
adaptation (as occurs in adjustment disorders) and the signs and symptoms
of psychiatric disorders |
|
that require treatment. In order to make such distinctions, a clinical
interview focusing on the severity |
|
and persistence of symptoms is essential, but should be supplemented
by information provided by |
|
significant others and observations by members of the health care
team. The risk of suicide is elevat- |
| ed
post-stroke, and inquiries should be made regarding suicidal ideation.
More broadly-based assess- |
| ment
of the psychosocial and physical environment of the afflicted individual
is also essential. These a- |
| re
areas where family meetings, home visits and occupational therapy
assessment can be very help- |
| ful.
Neuropsychological assessment can contribute to the assessment by
identifying deficits, and can |
| also
uncover cognitive deficits that might otherwise act as subtle sources
of frustration and poor co- |
| mmunication.
Psychosocial assessment need not entirely be oriented towards identifying
deficits: |
| the
pursuit of happiness is a universal human objective, and one that
can be facilitated by recreational |
| and
social opportunities. |
| ----Certainly,
professionals should recognize that their way of interacting with
stroke survivors helps |
| to
lay the foundation for improved outcomes. In addressing such considerations,
it is useful to consider |
| the
psychological concept of self-efficacy. Self-efficacy refers to the
belief in one's capabilities to cope |
| with
specific situations and is related to quality of life after a stroke
(and inversely to depressive symp- |
| tom
levels). Rehabilitation nurses, physicians and therapists can promote
self-efficacy by negotiating |
|
with patients about setting goals and by providing feedback during
the treatment and rehabilitation pr- |
| ocess.
Interactions using a collaborative style and language are likely to
assist with the patient's pre- |
| servation
of dignity, autonomy and sense of control.1 Professionals must also
recognize that the nor- |
| mal
process of adaptation to loss is characterized by a plurality of emotions
and not just sadness. Gr- |
| ieving
the losses associated with stroke (loss of independence, mobility,
social roles,etc.) can involve |
| expressions
of frustration or anger and these should generally be regarded as
normal rather than ca- |
| using
defensive anger. Another important need, related to the concept of
self-efficacy,is the need of in- |
| formation.
Knowledge about stroke can offer a sense of greater control and autonomy
to the stroke s- |
| urvivor. |
| ----Particularly
important during the post-stroke period is surveillance for depressive
disorders. For |
| example,
it has been shown that remission of post-stroke major depression is
associated with impro- |
| ved
recovery of ADL.7 Depressive disorders impair quality of life in psychological
and social domains, |
|
and perhaps even in the domains of physical function. Depression,
always a destructive entity in its |
|
clinical forms, is especially destructive after a stroke when optimism,
enthusiasm and motivation are |
| so
valuable for rehabilitation and psychological adaptation. When depression
is severe, the most min- |
| or
of life's challenges can seem insurmountable. Even persons without
any neurological limitations m- |
| ay
struggle with the day to day demands of functioning (hygiene, housekeeping
etc.) when they are se- |
| verely
depressed, making it easy to understand the ways in which depression
can undermine a perso- |
| n's
capacity to face the many challenges of the post-stroke period. The
literature concerned with |
| lesion
location and depression has been inconsistent. However, recent advances
in brain imaging |
| techniques
may lead to better recognition of those lesions most likely to cause
depression. |
| ----In
diagnosing post-stroke depression, DSM-IV recommends that symptoms
directly attributable to |
| the
stroke not be counted towards the diagnosis, reflecting concern that
inclusion of physical |
| symptoms
may render the diagnostic criteria non-specific. However, these issues
may have been |
| over-emphasized
in the past. It has been shown that the psychological and physical
symptoms that
|
| characterize
post-stroke depressive disorders are typical of those seen in major
depression.These |
| symptoms
include depressed mood, loss of interest, psychomotor changes (agitation
or retardation), |
| sleep
and appetite disturbance, fatigue, problems with memory and concentration,
a negative thinking |
| style
(e.g. low self esteem, pessimism, guilt), and thoughts of suicide
or death. Because the patient |
| may
experience aphasia, communicating symptoms may present a problem even
greater than that of |
| discerning
the origin of symptoms. |
| ----Recently,
a randomized placebo-controlled clinical trial of nortriptyline versus
fluoxetine found a |
| higher
rate of remission (over 12 weeks of treatment) with nortriptyline.
However, in this specific |
| study,
neither drug impacted upon recovery of cognitive or social functioning,
and the response to |
| fluoxetine
did not differ from placebo. In another randomized-controlled trial,
one SSRI antidepressant, |
| citalopram,
was shown to be more effective than placebo. The trial reported a
high rate of spont- |
| aneous
remission (and no superiority for the antidepressant over placebo
in this group) for patients |
|
who experienced onset of depressive symptoms within seven weeks of
the stroke. However, in su- |
| jects
whose depression had its onset seven or more weeks post-stroke, the
rate of spontaneous |
| remission
was low and the impact of the medication was significant. Observational
studies have |
| generally
confirmed the effectiveness of antidepressant treatment in the "real
world" setting. |
| ----Unfortunately,
the results of randomized-controlled trials (RCTs) of non-pharmacological
intervent- |
| ions
for psychosocial problems have been disappointing. A variety of interventions
have been evaluat- |
| ed,
with most of these focusing on the mobilization of community resources,
family and social suppo- |
| rt
and education. A recent review of such RCTs was conducted by Knapp
et al.;13 the results were |
| largely
negative. At best, weak effects have been reported. These sentiments
were echoed by Glass et |
| al.,who
have also designed a family-based intervention that is currently under
evaluation in the |
| clinical
trial called the Families in Recovery from Stroke Trial (FIRST). |
| ----While
RCTs of psychosocial interventions have so far been disappointing,
this does not alter the |
| fact
that human beings are psychological and social beings as well as biological
ones. After a stroke, |
| cherished
social roles may no longer exist for a disabled person. This most
obviously applies to |
| occupational
functioning, but more subtly defined social roles may be cherished
to the same extent as |
| careers--for
example, family and recreational roles. Direct intervention is often
needed to help families |
| and
individuals adapt to the new reality of their situation. Continued
progress within the public policy |
| sphere
is also needed in order to ensure that post-stroke impairments do
not lead to undue isolation |
| and
immobility for stroke victims. Social support is important for at
least two reasons--because the |
| stroke
survivor may direct physical assistance with specific tasks and because
of the need for |
| emotional
support that tends to occur at times of stress and loss. When family
support is unavailable |
| or
families are dysfunctional, additional social support may be mobilized
through programs that |
| encourage
socialization (e.g. recreational programs for seniors), through supportive
individual |
| counseling
and/or peer support groups.
|
| ----Inherent
in these many clinical challenges are tremendous opportunities to
improve the lives of |
| stroke
victims. Clinicians can make a tremendous impact when they approach
psychosocial problems |
| with
interest, enthusiasm and optimism. |
|
References |
| 1.Glass
TA, Dym B, Greenberg S, et al. Psychosocial intervention in stroke:
Families in recovery from stroke trial (FIRST). Am J Orthopsychiat
2000; 70:169-81. |
| 2.Robertson
IH. Compensations for brain deficits. Br J Psychiatry 2001; 176:412-3.
|
3.Kelly-Hayes M, Wolf PA, Kannel WB, et al. Factors influencing survival
following stroke: the Framingham study. Arch Phys Med Rehabil 1988;
69:415-18. |
4.Kelly-Hayes
M, Paige C. Assessment and psychologic factors in stroke rehabilitation.
Neurology 1995; 45(Suppl 1):s29-s32.
|
5.Glass
TA, Matchar DB, Belyea M, Feussner JR. Impact of social support on
outcome in first stroke. Stroke 1993; 24:64-70.
|
6.Robinson-Smith
G, Johnston MV, Allen J. Self-care self-efficacy, quality of life,
and depression after stroke. Stroke 2000; 81:460-4.
|
7.Chemerinski
E, Robinson RG, Kosier JT. Improved recovery in activities of daily
living associated with remission of poststroke depression. Stroke
2001; 32:113-7.
|
8.Kathol
RG, Noyes R, Williams J, Mutgi A, Carrol B, Perry P. Diagnosing depression
in patients with medical illness. Psychosomatics 1990; 436:434-40.
|
9.Paradiso
S, Ohkubo T, Robinson RG. Vegetative and psychological symptoms associated
with depressed mood over the first two years after stroke. Int J Psychiatry
Med 1997; 27(2):137-57.
|
10.Robinson
RG, Schultz SK, Castillo C, et al. Nortriptyline versus fluoxetine
in the treatment of depression and in short-term recovery after stroke:
a placebo-controlled, double-blind study. Am J Psychiatry 2000; 157:351-9.
|
11.Andersen
G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression
with the selective serotonin reuptake inhibitor citalopram. Stroke
1994; 25:1099-104.
|
12.Finklestein
SP, Weintraub RJ, Karmouz C, et al. Antidepressant drug treatment
for poststroke depression: retrospective study. Arch Phys Med Rehabil
1987; 68:772-6.
|
| 13.Knapp
P, Young J, Forster A. Non-drug strategies to resolve psychosocial
difficulties after stroke. Age Aging 2000; 29:23-30. |
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