'Feeling sad and useless': an investigation into personal acceptance of disability and its association with depression following stroke.

OBJECTIVES: To study the association of acceptance of disability with depression following stroke and its ability to predict depression at follow-up. DESIGN: A prospective cohort mixed (quantitative and qualitative) design was used. SETTING AND SUBJECTS: Patients admitted to a stroke unit were consecutively recruited. Eighty-nine participated at one month and 81 were followed up nine months post stroke. MAIN MEASURES: Depressive disorder was assessed using a structured clinical interview. Disability and acceptance of disability were measured using self-report scales. At one month post stroke, 60 consecutive participants also participated in open-ended interviews exploring their individual concerns about having had a stroke and their responses were analysed qualitatively. RESULTS: One-third of participants were found to have depression (29/89; 33% at one month and 24/81; 30% at nine months). Non-acceptance of disability remained associated with depression after controlling for age, gender, original stroke severity and current disability at one month (odds ratio (OR) = 1.27, 95% confidence interval (CI) 1.09-1.47) and nine months (OR = 1.46, 95% CI 1.22-1.75). Also, non-acceptance of disability measured at one month independently predicted depression measured at nine months (OR = 1.19, 95% CI 1.05-1.35). The qualitative findings illustrated a self-reproachful element to non-acceptance of disability. Patients with depression often said that they 'should still' be capable and sometimes referred to themselves as 'useless'; whereas patients who were not depressed commonly reported having accepted stroke-related disability. CONCLUSIONS: These finding suggest that personal beliefs about accepting disability are associated with and predict emotional adaptation following stroke.

A systematic evaluation of the adaptation of depression diagnostic methods for stroke survivors who have aphasia.

BACKGROUND AND PURPOSE: One in 3 stroke survivors has aphasia (impaired language comprehension and expressive abilities). Conventionally, depression diagnosis uses language-based methods. We aimed to systematically review methods that have been used to diagnose depression and adaptations to these methods intended for people with aphasia. METHODS: We systematically reviewed stroke studies (to January 2006) that included a depression diagnosis and individuals with aphasia. We extracted data related to depression diagnostic methods used for individuals with/without aphasia. We sought clarification from authors when required. RESULTS: A total of 60 studies included people with aphasia. Almost half the studies (29/60; 48%) adapted their main depression diagnostic method (most typically a clinical interview and published criteria) for individuals with aphasia. Adaptive methods included: using informants (relatives or staff), clinical observation, modifying questions and visual analogue scales. Evidence of the validity or reliability of these adaptations was rarely reported. However, use of informants or clinical observation did achieve the inclusion of most people with aphasia in the diagnosis of depression. Remaining studies, that did not report adaptive methods, suggested that conventional language-based methods are suitable for individuals with only 'mild' aphasia. CONCLUSIONS: People with aphasia can be and have been included in depression diagnostic assessments. However, we suggest that depression and language experts collaborate to develop a more valid method of depression diagnosis for patients with aphasia that has good reliability.

Exclusion and inclusion criteria for people with aphasia in studies of depression after stroke: a systematic review and future recommendations.

BACKGROUND/AIMS: A third of individuals are depressed following stroke. A similar proportion have aphasia. The extent of their inclusion in depression following stroke studies affects the generalizability of findings. METHODS: We systematically reviewed published studies (to December 2005) that diagnosed depression following stroke. We identified aphasia screening methods, aphasia exclusion and inclusion criteria and respective numbers of individuals with aphasia. RESULTS: Of 129 studies (n = 19,183), aphasia screening methods were only reported by 57 (31 described a published aphasia-specific tool). No mention of aphasia was made in 13 studies. Most studies (92, 71%) reported some exclusion of people with aphasia (49 reported how many: n = 3,082, range = 2-554). Almost half of the studies (60, 47%) actually reported participants with aphasia (37 specified numbers: n = 829, range = 5-60). Aphasia exclusion or inclusion was not associated with sample source (community, acute hospital, other) or study purpose (observation, intervention, screening). Studies that reported screening for aphasia were more likely to describe aphasia exclusion and inclusion criteria and include participants with aphasia. CONCLUSION: Aphasia screening, exclusion and inclusion criteria reporting across studies of depression following stroke has been highly inconsistent. This impairs the interpretation of generalizability. Improved aphasia screening and reporting of exclusion and inclusion criteria are urgently recommended.

Fear of recurrence and beliefs about preventing recurrence in persons who have suffered a stroke.

OBJECTIVES: The aim of this study was to investigate fear of recurrent stroke and beliefs about its causes and prevention. METHODS: Eighty-nine patients participated 1 month following stroke and 81 were followed up at 9 months. Interviews addressed fears and beliefs about stroke, causes, recurrence and prevention by using closed and open-ended questions. Responses were subject to quantitative and qualitative analysis, respectively. RESULTS: Fear of recurrence was common. Profound disability was a particularly feared outcome. Participants were knowledgeable about causes. However, causal controllability ratings were low. Some reported concern about preventative strategies (e.g., difficulty stopping smoking). Many reported idiosyncratic beliefs (e.g., avoiding overexertion) or fatalistic ideas about strokes (e.g., 'nothing' can prevent them). Similar quantitative results were obtained at follow-up. CONCLUSIONS: Many patients fear stroke recurrence. They lack a sense of control over causes and have fears associated with idiosyncratic and fatalistic beliefs. There is a need to elicit and address individuals' own fears and beliefs about stroke before providing evidence-based secondary prevention recommendations.