Psychosocial Health After Stroke: The Importance of Identification and Management

Stroke events result in significant impairments, including physical, functional, cognitive, and psychosocial impacts. Although all of these factors strongly impact an individual's recovery and quality of life (QOL) post-stroke, research has traditionally focused on examining the physical, functional, and cognitive impacts of stroke events, while neglecting the psychosocial impacts. Yet, in recent years there has been a renewed focus on the role of psychosocial factors in cardiovascular health. Promoting psychosocial health requires healthcare providers to identify individuals at risk of or experiencing symptoms indicative of poor psychosocial health as well as managing these symptoms. This scientific statement reviews the literature related to the identification and management of psychosocial health, including depression, stress and post-traumatic stress disorder (PTSD), anxiety, fatigue, and QOL and the role of nursing in promoting psychosocial health. Further, this scientific statement discusses how these psychosocial factors interact with structural inequities and the role nurses play in addressing these inequities.

Identification

Following a stroke event, rates of psychosocial factors vary significantly from 16.5% with PTSD, 29.3% with anxiety, 30% with depression, and 48% with fatigue.^1-4 Given the prevalence of these psychosocial factors post-stroke, identifying individuals experiencing these impacts is critical. Although best practices recommend clinical interviews for formal diagnoses, screeners are an important first step in identifying individuals requiring further assessment. Nurses are uniquely positioned to implement these initial screenings, which can then be used to refer individuals to appropriate resources, such as a mental health provider. This scientific statement reviews the common screening instruments, such as the Patient Health Questionnaire (PHQ), which screens for depression, the Perceived Stress Scale (PSS), the Generalized Anxiety Disorder 7-item (GAD-7), the Fatigue Severity Scale, and stroke-specific QOL tools. Critically, it is important to recognize the limitations of some of these screening measures. First, there is limited evidence for several of these screening measures in some racial and ethnic groups and also limited evidence for the use of these measures post-stroke.⁵ In addition, it is important to consider the role of functional limitations, such as communication difficulties, in how these psychosocial factors are assessed.⁶ For example, alternative measures, such as visual analog scales, may be needed to address communication difficulties. Furthermore, the time points at which assessment occurs in the continuum of stroke recovery requires additional research. Current evidence suggests the importance of an initial screening during the acute phase and then subsequent screenings in the post-acute phase. Although there is limited research examining the frequency of screenings in the post-acute phase, it is clear that additional assessment is necessary to examine how these factors may change over time during the stroke recovery phase. Given the need for repeated screenings, nurses play an important role in conducting these screenings and monitoring changes in functioning across the stroke recovery continuum, which will then enable early opportunities for management.

Management

When an individual screens positive for depression, stress or PTSD, anxiety, fatigue, or impaired QOL, nurses play a critical role in connecting the individual to appropriate services. First, as part of an interdisciplinary approach, nurses can implement effective interventions to target these psychosocial factors in conjunction with stroke recovery interventions. For example, nurses are trained to provide stroke education using effective patient-provider communication strategies. Similar strategies can be applied when providing psychoeducation about psychosocial health. Other interventions include relaxation training, exercise training, social support interventions, mind-body interventions (eg, yoga, tai-chi), and stress management interventions.^7-10 Although these interventions may be effective for managing depression or anxiety, there are no interventions to target fatigue at present. Rather, management of post-stroke fatigue typically targets comorbidities (e.g., depression, anxiety, QOL, or functional impairments).¹¹ Nurses can also identify when patients may require referral to mental health providers for pharmacological or more intensive psychological therapies, such as behavioral and cognitive therapies as well as mindfulness-based interventions. This scientific statement summarizes the nurse-led interventions that may be effective in addressing these psychosocial impacts as well as strategies for collaborating with mental health professionals.

Addressing Structural Inequities

This scientific statement also discusses the role of structural inequities in psychosocial health and how these inequities interact with psychosocial factors to impact stroke recovery. There is clear evidence of health disparities in risk factors, outcomes, and psychosocial health among underrepresented racial and ethnic groups and nurses play an important role in addressing these disparities. For example, interdisciplinary collaboration throughout the continuum of stroke care with an understanding of how structural inequities increase stroke risk can inform early identification of patients experiencing poor psychosocial health. Additionally, nurses can help to reduce stigma surrounding psychosocial health by improving patient-provider communication and thus potentially improve access to interventions.¹² Further research is needed to help improve access to interventions to promote psychosocial health and reduce these disparities.¹³

Conclusion

Despite clear evidence of the importance of identifying and managing psychosocial factors in post-stroke recovery, there are no current best practices. Best practices will need to be informed by further research. First, it is important to identify reliable and valid screening instruments for patients post-stroke across racial and ethnic groups and among individuals with functional impairments. Additionally, it is important to determine the time points across the stroke continuum at which these screening measures should be implemented. Second, additional research examining the effectiveness of interventions must include larger and more diverse samples. Finally, research is also needed to examine the disparities in access to interventions among patients from underrepresented racial and ethnic groups. Although further research is needed to develop best practices for promoting psychosocial health post-stroke, the current evidence highlights the importance of identifying and managing psychosocial health post-stroke and the role nurses play in promoting psychosocial health.