The Stroke and Carer Optimal Health Program (SCOHP) for psychosocial health: A randomised controlled trial

Abstract

Background: Stroke is a leading cause of death and disability in Australia and internationally. Stroke affects not just the physical health of the survivor; it can also have a devastating impact on their psychosocial health. Likewise, the psychosocial health of carers can often be adversely affected. It is unclear if psychosocial interventions could improve the psychosocial health of stroke survivors and their carers. This thesis presents a program of research which is comprised of a systematic review and meta-analysis, a randomised controlled trial and analysis of psychosocial mediators. The primary aim of this study was to examine and contribute to the evidence regarding the efficacy of psychosocial interventions that seek to improve the psychosocial outcomes of stroke survivors and their carers, compared to usual care. The secondary aim was to identify potential psychosocial mediators that affect stroke survivors and explore these in relation to the post-stroke experience. Firstly, a systematic review (n = 31) and meta-analysis (n = 11) evaluated the effectiveness of psychosocial interventions on depressive symptoms, anxiety symptoms, QoL, self-efficacy, coping, carer strain and carer satisfaction among stroke survivors, carers and survivor-carer dyads. Thirty-one randomised controlled trials (n = 5715) were included in the systematic review. Improvements in depressive symptoms, anxiety symptoms, QOL and coping were identified. A meta-analysis (11 trials; n = 1280) addressing depressive symptoms identified seven trials of psychosocial interventions that reduced depressive symptoms in stroke survivors (SMD: -0.36, 95% CI -0.73 to 0.00; p = 0.05) with six of these reducing depressive symptoms in carers (SMD: -0.20, 95% CI -.40 to 0.00; p = 0.05). A prospective RCT (n = 173) of a psychosocial intervention for stroke survivors (n = 89) and carers (n = 84) was conducted. Stroke survivors and carers evaluated a 9-week personalised psychosocial intervention, compared to usual care. Participants completed questionnaires at baseline, and 3, 6, 12 months. Primary measures included health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE), while secondary measures included depression and anxiety (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). A mixed-effect model– repeated measures analysis between groups and across time was conducted with data from 137 participants. Finally, an analysis of psychosocial mediators was completed from the baseline data of 72 of the stroke survivors that participated in the RCT. Using Structural Equation Modeling, it was determined the 67% of the variation in quality of life was explained by this model. Illness perceptions had a significant direct influence on maladaptive coping, depression and anxiety (β = 0.37, p < 0.001, β = 0.43, p < 0.001, β = 0.43, p < 0.001, respectively). Maladaptive coping had a significant direct influence on quality of life (β = -.22, p < 0.001). The relationship between illness perceptions and QOL were found to be fully mediated by depression and anxiety, with the relationship between illness perceptions and depression and anxiety being partially mediated by maladaptive coping. A significant positive correlation between depression and anxiety (p < 0.05) was noted. Overall, this program of research contributed significant and original findings regarding the effectiveness of existing psychosocial interventions, the effectiveness of a previously untested psychosocial intervention and shed light on the role of psychosocial mediators for stroke survivors and carers.