Translating stepped psychological care to aphasia rehabilitation

Abstract

Stroke rehabilitation needs more psychological services to address mood changes and depression after aphasia. An evidence-practice gap exists that can be minimised through implementation of stepped psychological care -  an evidence-based framework offering multidisciplinary intervention after stroke. However, stepped psychological care has not been adapted for the communication disability associated with aphasia. Further, there is a lack of research exploring the perspectives of key stakeholders in managing depression after post-stroke aphasia. The overarching aim of this research was to describe the evidence-practice gap in managing mood changes and depression after post-stroke aphasia.Chapter one of this thesis comprises: an introduction, including a review of the literature, the aims of the thesis, and an overview of the methodology and the thesis structure. The thesis then reports on three research studies investigating the management of mood changes and depression after post-stroke aphasia: 1) a systematic review of rehabilitation interventions to prevent and treat depression after post-stroke aphasia; 2) a description, from the perspective of stroke health professionals, of: a) current practice; and b) the identification of barriers and facilitators to implementing stepped psychological care to clinical practice; and 3) a description, from the perspective of people with aphasia, of: a) experiences of mood changes, depression and current practice; and b) preferences within a stepped psychological care approach.   Study 1 systematically reviewed the research evidence for rehabilitation interventions to prevent and treat depression after post-stroke aphasia. It followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 45 studies were eligible for inclusion. It is not clear which interventions may prevent depression. A range of interventions that may enhance mood or treat mild depression after post-stroke aphasia were identified and described within the stepped psychological care framework.Study 2 described, from the perspectives of stroke health professionals: a) current practice for the management of depression after post-stroke aphasia; and b) the barriers and facilitators to implementing stepped psychological care for depression after post-stroke aphasia. Thirty-nine stroke health professionals participated in qualitative focus groups. Five focus groups within acute, rehabilitation and community settings were divided into two parts: 1) a discussion about current practice; and 2) information provision about the stepped psychological care framework, followed by a discussion of the barriers and facilitators to implementing this framework to clinical practice. Four core components of current practice were derived from an interpretive description analysis: 1) concomitant aphasia and depression after stroke is a challenging area of rehabilitation; 2) mood difficulties and depression are not always a high stroke rehabilitation priority; 3) approaches to assessment and treatment are ad hoc; and 4) stroke health professionals are trying to bridge the gap between clients’ psychological care and limited services. Barriers included: no experience with stepped psychological care; limited understanding of aphasia and communication support; lack of adequate physical space and resources; and a lack of psychologists. Facilitators included: specialist training in psychological care, aphasia and communication support; specialist staff (e.g., psychologists); enhancement of physical spaces; communication tools; leadership; and funding.Study 3 described, from the perspective of people with aphasia: a) the experiences of mood changes, depression and current practice after post-stroke aphasia; and b) preferences within a stepped psychological care approach. Ten people with aphasia participated in qualitative interviews. Participants varied in severity of language impairment, depressive symptoms and transition phase of care. Each participant had two interviews: the first explored their experiences of mood changes, depression and current practice after stroke and aphasia; the second included aphasia-friendly information about stepped psychological care and participants were asked about their preferences within the context of that approach. Video-data were transcribed for speech and non-speech communication. Three core themes were derived from an interpretive description analysis: 1) the onset of stroke and aphasia is a traumatic event resulting in mood difficulties and depression; 2) people with aphasia are trying to work through communication and mood difficulties with limited psychological support and services in stroke rehabilitation; and 3) positivity, supported communication and access to individually tailored therapy through stepped psychological care are essential to people with aphasia. The results of studies 1–3 were compared and integrated to describe a significant evidence-practice gap in managing mood changes and depression after post-stroke aphasia. Stepped psychological care may be a viable solution to minimising this gap, however a range of needs and supports are required to implement the framework to aphasia rehabilitation. This program of research identified recommendations for clinical practice in stroke rehabilitation and policy development. It also developed a future research agenda that may focus on training stroke health professionals; investigating psychological therapies for people with aphasia; and exploring the perspectives of significant others. The effective implementation of stepped psychological care is a key priority to improve stroke and aphasia outcomes.