Stroke Caregiver Depression: Qualitative Comparison of Treatment Responders and Nonresponders at 1 Year.

BACKGROUND: Mixed-method studies can shed light on the mechanisms through which interventions effectively reduce caregiver depression. OBJECTIVE: The objective of this qualitative study was to understand factors contributing to reduced depressive symptoms in stroke caregiver treatment responders compared with nonresponders. METHODS: A mixed-methods explanatory sequential design was used to assess cognitive behavioral coping use and helpfulness in reducing depression among experimental study treatment responders and nonresponders. Using purposive sampling at 1-year of caregiving, we selected responders who were not depressed or demonstrated reduction to probable depression and nonresponders whose scores indicated worsened or new depression. Participants responded to semistructured interviews on life changes and the use and helpfulness of intervention coping strategies. Thematic analysis identified codes and themes. RESULTS: Twelve of 25 participants were responders. We identified 2 overarching outcome themes: "It was about me, changing to make life better" (responders) and "Lamenting our changed lives" (nonresponders). Five subthemes related to coping were identified. Whereas responders coped actively and were less dependent on the counseling relationship, nonresponders were passive in coping and more dependent on the initial counseling relationship. Anger or previous psychologic treatment was found in more than a quarter of nonresponders and in no responders. Negative life change was found in 9 of 13 nonresponders compared with 1 responder. CONCLUSION: Findings support the helpfulness of cognitive behavioral coping. For many caregivers, engagement interviews and a more intense, longer intervention, such as stepped care and anger management, are indicated to mitigate treatment resistance and depressive symptoms, respectively.

Survey of survivors' perspective on return to work after stroke.

PURPOSE: To describe the development and results of a detailed survey on return to work (RTW) after stroke completed by survivors at various stages of recovery. METHOD: This study used a multi-method qualitative and quantitative research strategy to design and implement a 39-item survey for stroke survivors. Individual interviews, focus groups, and working committees were used to conceptualize the issues and translate them into a survey format. Surveys were distributed in regular and electronic mail. Groups of rehabilitation professionals, employers, and stroke survivors were assembled to review findings and obtain feedback to aide in interpretation. RESULTS: Overall 715 surveys were completed. The respondents were on average 54 years of age, mostly white, well-educated, urban dwelling, and in skilled occupations. Results are described in seven areas: financial, stroke impairments, organizational, work and psychological issues, interpersonal support, and therapy. Several salient findings are described including the role of fatigue, under utilization of vocational rehabilitation (VR) services, and motivational factors related to finances, self-esteem, work, and workplace relationships. CONCLUSION: Although earning an income is a strong motivation to RTW, salary decreases in importance when compared with other psychological benefits. Fatigue was rated as the second highest impairment barrier to RTW and persisted as a relevant impediment over time. Attitudes of co-workers and flexibility in work schedule were viewed as most helpful to the RTW process, whereas work stress was viewed as the greatest impediment to return. Only 24% of the sample received VR counseling with more respondents receiving counseling if they returned 6 months or longer after their stroke. Other trends and clinical and research implications are discussed.

The stroke caregiver unmet resource needs scale: development and psychometric testing.

The purposes of this study were to develop and validate a measure of unmet resource needs of the caregivers of survivors of stroke and to describe the caregivers' unmet needs during 1 year. A longitudinal, descriptive design was used to test the reliability and validity of the Unmet Resource Needs (URN) measure. Item development was based on literature review and preliminary study findings. A stress and coping conceptual model framed the hypotheses. Psychometric testing was based on 6-month postdischarge data (n = 166). Content and structural construct validity, internal consistency reliability through 1 year, and concurrent validity were tested. Change in URN over time was examined. Content validity was supported by floor and ceiling effects less than 5%. Principal axis factoring yielded a 12-item, two-factor solution reflecting general and technology unmet needs. Internal consistency reliability was satisfactory for the total scale and subscales at all times, excepting the baseline three-item technology scale (α = .56). Concurrent validity was supported by significant correlations with model constructs (threat, positive problem solving, depression, preparedness; p < .01) in the expected direction. Functional status and resource use were not associated with the URN. Repeated measures analysis of variance (n = 123) indicated a significant decrease in unmet needs from baseline to 3, 6, and 12 months postdischarge (p < .001). Nevertheless, 42% reported one or more unmet needs at year 1. Assessment and counseling on unmet needs is indicated throughout the caregiving trajectory to reduce negative outcomes.

A problem-solving early intervention for stroke caregivers: one year follow-up.

PURPOSE: The study purposes were to assess the efficacy of a caregiver problem-solving intervention (CPSI) on stroke caregiver physical and psychosocial adaptation compared with a wait-list control (WLC) treatment, and to assess the mediation effects of coping on outcomes. METHODS: A stress and coping model guided the study design. Outcomes were depression, anxiety, preparedness, life changes, and family functioning. CPSI started during acute rehabilitation and continued 3 months postdischarge. Data were collected at baseline (T1), postintervention (T2), and 6 (T3) and 12 months postdischarge (T4). RESULTS: Of 255 caregivers, 75% were depressed at baseline. Repeated measures ANOVA of study completers (n = 121) indicated improved T2 depression, life change, and health (ps < .04) favoring the CPSI group. Improvements faded by 6 months. Although no group differences in outcomes were found in the intention-to-treat analysis, growth curve modeling indicated a difference in depression rate of change, favoring the CPSI (p = .04). Perceived health, threat appraisal and rational problem-solving were significant mediators (ps < .05). CONCLUSIONS: Findings provide direction for future interventions to promote and sustain healthy caregiver adaptation.

Critical factors related to return to work after stroke: a qualitative study.

Return to work (RTW) after stroke is often perceived as a critical marker of recovery and contributes to overall well-being and life satisfaction of survivors. Quantitative studies have yielded conflicting results in identifying specific predictors of successful RTW, and qualitative studies have been very limited. The current study conducted in-depth interviews with 12 stroke survivors selected by job type and extent of RTW. Seven themes were identified in an analysis of interview transcripts: financial, impairments as barriers, interpersonal support, therapy supporting RTW, organizational influences, work/job specific issues, and psychological issues. These themes confirm and expand on existing qualitative data that focus on survivors' perceptions of their work potential and efforts by emphasizing the need to focus beyond the survivors and their work to include other people and organizations to facilitate the RTW process. Implications for intervention at the individual, work, and community levels are discussed.

Patterns of relationships between background characteristics, coping, and stroke caregiver outcomes.

PURPOSE: Little is known about mediators of stroke caregiver outcomes or patterns of relationships of outcome predictors. We examined relationships between the variable sets of caregiver and stroke survivor characteristics, coping (proposed mediators), and caregiver outcomes. METHODS: We assessed 253 dyads prior to discharge from acute rehabilitation. Outcomes were depression, anxiety, preparedness, life change, and family functioning. Coping included problem solving, caregiver appraisal, and unmet resource needs. Multivariate canonical correlation analyses were computed between the sets of variables to identify unique patterns of relationships. RESULTS: Six patterns of significant relationships were found (R =.30 to .84, Ps <.01 to .02). The strongest relationship was that between greater threat appraisal and negative life change, greater anxiety, and lower caregiving preparedness (P < .01). Caregiver characteristics (nonwhite, spousal caregivers) were related significantly to several outcomes (positive life change, lower anxiety, and less healthy family functioning) (R = .43, P <.01) and remained significant after controlling for the effect of mediators (R = .32, P < .02). CONCLUSION: Findings suggest various patterns of relationships that provide guidance for individualizing early caregiver intervention. Clinicians can build on caregivers' strengths while identifying threats to adaptation to tailor interventions that promote healthy outcomes.

Stroke caregivers: pressing problems reported during the first months of caregiving.

The major purpose of this study was to identify the types and frequency of caregiving problems and associated stress and coping effectiveness. Secondary purposes were (a) to examine changes in problem frequency, stress, and coping effectiveness over time and (b) to identify relationships between problem stress and personal, illness, coping, and well-being variables. A stress and coping model guided the study. Fifty-eight caregivers participated during the first 4 months of caregiving. Caregiver and stroke survivor demographic and well-being data were collected during acute rehabilitation. Three problem-related themes emerged: interpersonal disruptions, sustaining the self and the family, and stroke survivor functioning. Although problems sustaining the self and the family were most frequent, interpersonal disruption problems were rated most stressful and lowest in coping effectiveness. A component of emotional distress, either anxiety or depression, was related significantly (p < .05) to the stress level of each problem theme. Counseling on problem-solving strategies may improve caregiver well-being.

Problem-solving early intervention: a pilot study of stroke caregivers.

Caregivers (CGs) of stroke survivors assume their role suddenly and with little preparation. Negative emotions are common, persist over time, and are related to other negative outcomes. This pilot study, guided by a coping model, examined the efficacy and durability of a caregiver problem-solving intervention (CPSI) on CG and stroke survivor outcomes. Additional aims included assessment of feasibility issues and reliability and sensitivity of the study measures. The nonrandom sample of 15 stroke CGs was matched on depression and demographics with a comparison group. The CPSI started during acute rehabilitation and continued through 2 months after discharge. Parametric and nonparametric tests were used to assess achievement of the aims. CG depression, anxiety, preparedness, and survivor motor function improved significantly in the intervention group over time. Burden, life changes, and taking care of CG's own needs did not change significantly. CPSI group CG depression significantly improved compared with the matched group. The improvement in outcomes for the CPSI group supports further testing of the intervention with a large sample.

The use of writing groups to facilitate adaptation after stroke.

PURPOSE: This is a report on a pilot study of small writing groups to assist in long-term adaptation after stroke onset. METHOD: 26 stroke survivors participated in a small group experience to write a short essay to be published about their recovery. The sample consisted of middle-aged, well-educated participants who were several years post stroke and were self-selected by interest and experience in writing. The sample was evenly divided between men and women, and minority racial groups were adequately represented. Essays were published on a website and clustered in themes about coping with recovery and personal growth/changes in self-concept. RESULTS: The group experience was well received by participants. Objective measures showed a trend toward improvement in positive identity and no significant change in depression or well-being. Significant differences found between subgroups (improved vs. declined; aphasia vs. no aphasia) are discussed. Anecdotal observations of the group process and implications for practice and further research are provided.

Telephone group intervention for older stroke caregivers.

PURPOSE: This study evaluated the effectiveness of telephone groups for older, spousal caregivers of stroke survivors. METHOD: The 88 caregivers were mostly white females who were 70 years old on average and who had been providing care for an average of 3 years. Participants were randomized to treatment or control conditions, followed for 6 months, and assessed for depression, burden, loneliness, stress, and competence. Treatment participants engaged in an eight-session psychoeducational telephone group. RESULTS: Treatment participants showed decreased stress over time but were not significantly different from control participants in the amount of change in stress. Control participants showed a significant increase in burden during the study; treatment participants showed a significant increase in competence.

Analysis of problem types and difficulty among older stroke caregivers.

Stroke onset causes disruption of family roles as caregiving tasks are assumed. The current study presents a qualitative and quantitative analysis of the problems of 123 older, spousal stroke caregivers. Problems were coded into 14 categories; frequencies of occurrence and difficulty were also analyzed. Differences in problem difficulties were examined by race, gender, years caregiving, and care receiver's functional level, depression, burden, and loneliness. Noncompliance was the least frequent but most difficult problem type. Lack of social involvement was the most frequent problem type and the most difficult for the more depressed, burdened, and lonely caregivers. This increase in problem specificity and detail of analysis has provided direction for clinical application in counseling the spouses of stroke survivors on how to manage the stress of their new life role.

Assessment of the needs of the young stroke survivor.

As part of program planning efforts by the RIC Stroke Team, convenience samples of 100 young (<60 years old) stroke survivors and 65 referring physicians were surveyed to determine the unique needs ofthis patient group. The correlation between survivors' and physicians' rankings of programs/activities value was not significant. Survivors ranked exercise/fitness, education/information, individual counseling, stress management, and recreation/social programs as the five most valuable programs. Physicians ranked education/ information, individual counseling, sexual, vocational, and family adjustment programs as the five most valuable. Other comparisons and program planning implications are analyzed and discussed.