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Effectiveness of Interventions for Adults With

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Stroke: An...

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 Effectiveness of Interventions for Adults With
Psychological or Emotional Impairment After Stroke:
An Evidence-Based Review

Mary W. Hildebrand

MeSH TERMS This evidence-based review was conducted to evaluate the effectiveness of occupational therapy interventions
 affective symptoms to prevent or mitigate the effects of psychological or emotional impairments after stroke. Thirty-nine journal
articles met the inclusion criteria. Six types of interventions were identified that addressed depression, anx-
 anxiety
iety, or mental healthrelated quality of life: exercise or movement based, behavioral therapy and stroke
 depression education, behavioral therapy only, stroke education only, care support and coordination, and community-
 evaluation studies as topic based interventions that included occupational therapy. Evidence from well-conducted research supports
 occupational therapy using problem-solving or motivational interviewing behavioral techniques to address depression. The
 stroke evidence is inconclusive for using multicomponent exercise programs to combat depression after stroke
and for the use of stroke education and care support and coordination interventions to address poststroke
anxiety. One study provided support for an intensive multidisciplinary home program in improving de-
pression, anxiety, and health-related quality of life. The implications of the findings for practice, research,
and education are discussed.

Hildebrand, M. W. (2015). Effectiveness of interventions for adults with psychological or emotional impairment after stroke:
An evidence-based review. American Journal of Occupational Therapy, 69, 6901180050. http://dx.doi.org/10.5014/
ajot.2015.012054

Mary W. Hildebrand, OTD, OTR/L, is Associate

Professor, Occupational Therapy, MGH Institute of Health
Professions, Boston, MA; mhildebrand@mghihp.edu
T he purpose of this evidence-based review was to search the literature and
critically appraise and synthesize the applicable evidence to address the fo-
cused question, What is the evidence for the effectiveness of interventions to
improve occupational performance for those with psychological and/or emo-
tional impairment after stroke?

Background Literature and Statement of Problem

As many as 50% of stroke survivors may experience a stroke-related psychological
or emotional disorder. Carota and Bogousslavsky (2009) placed these disorders
in the following categories: (1) affective and mood disorders such as depression,
poststroke emotionalism, and generalized anxiety disorders; (2) behavioral and
personality changes such as anger, irritability, apathy, sexual changes, and ob-
sessivecompulsive disorder; (3) cognitive and behavioral disintegration such as
acute confusional state and delirium; and (4) perceptionidentity disorders of
the self or of other people and places.
Between 35% and 50% of stroke survivors develop depression, the most
common psychological sequela of stroke (Barker-Collo, 2007; Go et al., 2013).
Risk factors for development of poststroke depression are hypothesized to be
either biological, a result of neurological damage, or psychosocial, a result of
coping with a life-threatening event. However, the origin of poststroke depression
is widely accepted as multifactorial (Whyte & Mulsant, 2002). The highest
prevalence of depression occurs from 3 to 6 mo after stroke, but it remains high

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 even as long as 3 yr later (Barker-Collo, 2007; Whyte &
Mulsant, 2002). Poststroke depression impedes rehabi-
litation, impairs physical and cognitive function, increases
stress on caregivers, increases the stroke survivors risk of
death and suicide, increases use of drugs and alcohol, in-
creases use of health resources, and predicts poor compliance
with treatment of comorbidities (Hackett, Anderson, House,
& Halteh, 2008; Lenze et al., 2004; Whyte, Mulsant,
Rovner, & Reynolds, 2006). In spite of its devastating
effects, depression is often underdiagnosed and under-
treated (Miller et al., 2010). Prevention and treatment of
poststroke depression typically consists of administration
of antidepressant medications and psychotherapy. Yet,
there is mixed evidence for the efficacy of both types of
intervention and concern about the side effects of these
medications for older adults (Miller et al., 2010).
The prevalence of poststroke anxiety has been esti-
mated to range from 20% to 36%, with length of time after
stroke leading to findings of different prevalence levels
(Bergersen, Frslie, Stibrant Sunnerhagen, & Schanke,
2010; Burton et al., 2011). Comparable to depression after
stroke, anxiety often goes undertreated. It reduces partic-
ipation in activities of daily living (ADLs), results in poorer
physical and social outcomes, increases caregiver burden,
and increases health care costs (Bergersen et al., 2010;
Gurr & Muelenz, 2011). When a person is diagnosed with
anxiety, pharmaceutical therapy and psychotherapy are the
first treatment options (Burton et al., 2011).
Other stroke-related psychological impairments such
as irritability, aggressiveness, apathy, poststroke emo-
tionalism, and sexual dysfunction are reported to occur in
20%50% of stroke survivors, but these conditions are
often difficult to distinguish from symptoms of depression
or anxiety (Carota & Bogousslavsky, 2009). Perception
identity disorders of the self are typically associated with
unilateral spatial neglect and, for the purposes of this
review, are considered cognitive disorders. Carota and
Bogousslavsky (2009) stated that other psychological im-
pairments (e.g., obsessivecompulsive disorder, confusional
state) occur after stroke but are rare.
Intervention with stroke survivors is an important area
of practice for occupational therapists in many settings. In
contrast to other health care professionals, occupational
therapists have training in assessing and treating both
psychological and physical impairments to improve oc-
cupational performance, thus making their role in stroke
rehabilitation vital. With the increasing number of people
who have had a stroke and may develop psychological
impairments as a consequence, identifying evidence-based
interventions within the scope of occupational therapy
practice is imperative.
6901180050p2
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Method for Conducting the
Evidence-Based Review
This evidence-based review was completed in collabora-
tion with the American Occupational Therapy Association
(AOTA) as part of an evidence-based review project on
interventions for adults with stroke. The focused question
addressed here was, What is the evidence for the effec-
tiveness of interventions to improve occupational per-
formance for those with psychological and/or emotional
impairment after stroke? Arbesman, Lieberman, and
Berlanstein (2015) provide a detailed description of the
methodology used in the evidence-based reviews, which
can be found in their article Method for the Evidence-
Based Reviews on Occupational Therapy and Stroke in
this issue. Supplemental Table 1 summarizes selected
articles on interventions that address psychological and
emotional impairments after stroke (available online at
http://otjournal.net; navigate to this article, and click on
Supplemental). Complete evidence tables are available
in Occupational Therapy Practice Guidelines for Adults
With Stroke (Wolf & Nilsen, 2015).
Results
Abstracts of 2,261 articles were retrieved from Medline,
PsycINFO, CINAHL, OTseeker, Ageline, the Cochrane
Database of Systematic Reviews, DARE, and databases
and abstracts found through hand searches of journals and
bibliographies. Of those, 39 articles describing 38 studies
were included in this review. (Two articles reported results
of 1 study at different times postintervention: Ellis,
Rodger, McAlpine, & Langhorne, 2005, and McManus,
Craig, McAlpine, Langhorne, & Ellis, 2009.) Evidence
provided by the studies was Level I (n 5 37), Level II (n 5
1), and Level III (n 5 1). I then abstracted articles using
the evidence table format and summarized them in a
Critically Appraised Topic format (Hildebrand, 2014).
They were divided into six themes according to type of
intervention: (1) exercise or movement based, (2) behav-
ioral therapy and stroke education, (3) behavioral therapy
only, (4) stroke education only, (5) care support and co-
ordination, and (6) community-based interventions that
included occupational therapy. A summary of each theme
is presented here.
Exercise- or Movement-Based Interventions
Fifteen original research articles were analyzed that in-
cluded exercise or movement interventions and outcomes
measures for depression, anxiety, or mental healthrelated
quality of life (HRQOL). Thirteen articles provided
January/February 2015, Volume 69, Number 1
 Level I evidence; 1, Level II evidence; and 1, Level III
evidence. The articles were further divided into two sub-
groups: single-component exercise or movement programs
and multicomponent exercise programs, including a com-
bination of strengthening, endurance, balance, or range-of-
motion exercises. I use the term exercise here to describe
these interventions.
Single-Component Exercise Programs. Eight Level I
studies included interventions using one type of exercise
only. They included very early mobilization, passive range
of motion (PROM), bilateral upper-extremity tasks, ergo-
metry, progressive resistive exercises, tai chi, and treadmill
walking (Cumming, Collier, Thrift, & Bernhardt, 2008;
Lennon, Carey, Gaffney, Stephenson, & Blake, 2008; Morris
et al., 2008; Ouellette et al., 2004; Sims et al., 2009;
Smith & Thompson, 2008; Taylor-Piliae & Coull, 2012;
Tseng, Chen, Wu, & Lin, 2007). Two single-component
exercise interventions, very early mobilization in acute
care and a PROM intervention in long-term care fa-
cilities, were found to reduce incidence of depression or
anxiety in the intervention group (IG) compared with the
control group (CG; Cumming et al., 2008; Tseng et al.,
2007). However, the reduction in depression and anxiety
was not maintained after the interventions ended. The
results of the PROM intervention may be questioned be-
cause of the small sample size and lack of additional at-
tention to the control group.
The six single-component exercise studies using pro-
tocols of bilateral upper-extremity tasks, ergometry, pro-
gressive resistance training, tai chi, or treadmill walking
found no significant differences between groups on mental
HRQOL, anxiety, or depression (Lennon et al., 2008;
Morris et al., 2008; Ouellette et al., 2004; Sims et al., 2009;
Smith & Thompson, 2008; Taylor-Piliae & Coull, 2012).
They also reported sample sizes that were too small to
determine significant differences between groups. There-
fore, from the results of the 8 studies considered here, the
evidence is insufficient to support or refute the efficacy of
providing single-component exercise interventions to im-
prove depression, anxiety, or mental HRQOL after stroke.
Multicomponent Exercise Programs. Seven studies
combining strengthening, balance, range of motion, or en-
durance exercises in outpatient, in-home, or community
settings measured the effects on mental HRQOL, depression,
and anxiety (Level IHolmgren, Gosman-Hedstrom,
Lindstrom, & Wester, 2010; Lai et al., 2006; Langhammer,
Stanghelle, & Lindmark, 2008; Mead et al., 2007; Olney
et al., 2006; Level IIStuart et al., 2009; Level IIIRand,
Eng, Liu-Ambrose, & Tawashy, 2010). Two Level I out-
patient multicomponent exercise interventions demonstrated
significant differences in depression scores and mental
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HRQOL in favor of the IG 3 mo after the intervention
(Lai et al., 2006; Olney et al., 2006). However, signifi-
cant differences were not maintained at follow-up as-
sessments between 6 and 12 mo after the interventions
were completed. Three Level I studies found no signifi-
cant differences between the IG and CG after intensive
exercise programs involving strength, endurance, and bal-
ance training (Holmgren et al., 2010; Langhammer et al.,
2008; Mead et al., 2007).
A Level II study of a community-based exercise group
found that a small subgroup of those who had depressive
symptoms at study onset improved significantly on a de-
pression measure compared with those in the CG group
who also had depressive symptoms at study onset (Stuart
et al., 2009). Conversely, a Level III pilot study found no
significant changes for a community-based exercise group
in pre- and posttest depression scores (Rand et al., 2010).
Although 3 multicomponent exercise interventions dem-
onstrated efficacy in decreasing depression or increasing
mental HRQOL (Lai et al., 2006; Olney et al., 2006; Stuart
et al., 2009), an important limitation may include the ad-
ditional attention and social interaction the IG received.
In addition, Stuart et al. (2009) reported depression
changes in small participant subgroups, but not for all
participants. Four studies in the multicomponent exercise
intervention subcategory found no significant differences
between groups (Holmgren et al., 2010; Langhammer
et al., 2008; Mead et al., 2007; Rand et al., 2010).
Therefore, the efficacy of multicomponent exercise pro-
grams is inconsistent across studies. An important result
of exercise interventions to note is that even if scores
improved, the differences between the IG and CG were
not maintained after the exercise intervention had ended.
Behavioral Therapy and Stroke Education
Five Level I studies described in 6 articles were included in
the category of interventions with both behavioral therapies
and stroke education (Chang, Zhang, Xia, & Chen, 2011;
Clark, Rubenach, & Winsor, 2003; Ellis et al., 2005;
Johnston et al., 2007; Kendall et al., 2007; McManus
et al., 2009). Four studies, described in 5 articles, imple-
mented behavior modification or behavior change coun-
seling and stroke-specific education on discharge and
shortly after discharge from the hospital (Clark et al.,
2003; Ellis et al., 2005; Johnston et al., 2007; Kendall
et al., 2007; McManus et al., 2009). No significant dif-
ferences were found between groups on depression,
anxiety, or mental HRQOL measures. In an inpatient
rehabilitation facility, Chang et al. (2011) implemented
behavioral therapy and stroke education and found that
6901180050p3
 the IG had statistically significant improvements in an-
xiety, depression, and mental HRQOL compared with
the CG. From the results of the 5 studies considered here,
the evidence is insufficient to support or refute the efficacy
of providing these types of behavioral therapies in com-
bination with stroke education to treat depression or
anxiety or improve mental HRQOL in people after stroke.
Behavioral Therapy Only
Five Level I studies implemented behavioral therapyonly
interventions (Davis, 2004; Lincoln & Flannaghan,
2003; Mitchell et al., 2009; Robinson et al., 2008;
Watkins et al., 2007). Problem-solving therapy was used
in 2 well-conducted randomized controlled trials (RCTs)
with statistically significant improvement in depression
scores for the IG (Mitchell et al., 2009; Robinson et al.,
2008). In another well-conducted RCT, motivational
interviewing was found to be effective in improving de-
pression and mental HRQOL (Watkins et al., 2007).
Cognitivebehavioral therapy was not found to provide
significant improvement on depression measures when
compared with an attention placebo group and a group
with no intervention (Lincoln & Flannaghan, 2003).
Finally, in a very small pilot study of life review therapy,
Davis (2004) reported significant differences between the
IG and the CG on a depression measure. However, be-
cause the study was inadequately powered, life review
therapy requires further research to determine its effect
with this population (Davis, 2004). These results provide
some support for problem-solving therapy and motiva-
tional interviewing to treat depression after stroke.
Stroke Education Only
Two Level I studies implemented stroke education only with
people poststroke in inpatient rehabilitation (Hoffmann,
McKenna, Worrall, & Read, 2007; Smith, Forster, &
Young, 2004) and found conflicting evidence. Smith et al.
(2004) found that the IG had significantly better anxiety
scores, but Hoffman et al. (2007) reported that the CG had
significantly less anxiety than the IG. These authors found
no difference between groups on depression scores. On the
basis of these 2 studies, the evidence for stroke education in
the treatment of anxiety is mixed and is not sufficient to
support or refute its use in treatment of depression.
Care Support and Coordination
Six Level I studies used care support and coordination
beginning just before or immediately on discharge from
the hospital and consisting of a combination of face-to-
face meetings, home visits, and telephone contacts (Boter,
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2004; Burton & Gibbon, 2005; Claiborne, 2006; Lincoln,
Francis, Lilley, Sharma, & Summerfield, 2003; Mayo
et al., 2008; Tilling, Coshall, McKevitt, Daneski, &
Wolfe, 2005). Three studies found a significant difference
between groups on anxiety scores (Boter, 2004), emotional
distress (Burton & Gibbon, 2005), and mental HRQOL
and depression (Claiborne, 2006). However, Lincoln et al.
(2003), Tilling et al. (2005), and Mayo et al. (2008) found
no significant differences between groups in improving
anxiety, depression, or mental HRQOL. Thus, the evi-
dence for care support and coordination is inconsistent.
Community-Based Interventions That Included
Occupational Therapy
Five Level I studies included occupational therapy as the
primary discipline delivering a community-based in-
tervention, as a part of a multidisciplinary team in home
health, or as researchers evaluating a day program (Corr,
Phillips, & Walker, 2004; Desrosiers et al., 2007; Egan,
Kessler, Laporte, Metcalfe, & Carter, 2007; Logan et al.,
2004; Ryan, Enderby, & Rigby, 2006). An intensive
multidisciplinary intervention (defined as six or more
home health visits) showed significant differences for the
IG in mental HRQOL, depression, and anxiety (Ryan
et al., 2006). An occupational therapydirected program
with intervention by an occupational therapist and a rec-
reation therapist addressing leisure activities in the com-
munity was found to improve depression but not mental
HRQOL scores (Desrosiers et al., 2007).
The other 3 studies1 on an occupational therapist
led community occupation-based treatment approach
(Egan et al., 2007), 1 on a community mobility in-
tervention (Logan et al., 2004), and 1 on a day service
pilot program for younger adults (Corr et al., 2004)did
not show significant differences in mental HRQOL,
anxiety, or depression between groups. Therefore, there is
some support for implementation of more intensive
home health that includes occupational therapy (Ryan
et al., 2006) and for a community occupational therapy
led leisure activity program (Desrosiers et al., 2007).
However, there is not enough evidence to support or
refute the efficacy of the other community-based inter-
ventions that included occupational therapy.
Discussion and Implications for Practice,
Education, and Research
The purpose of this evidence-based review was to examine
the evidence for the effectiveness of interventions within
the scope of occupational therapy practice to improve
occupational performance of those with psychological or
January/February 2015, Volume 69, Number 1
 emotional impairment after stroke. Although most of the
studies reviewed were not implemented by occupational
therapists, the intervention themes fall within occupa-
tional therapys scope of practice as outlined by the
Occupational Therapy Practice Framework: Domain and
Process (3rd ed.; AOTA, 2014).
This evidence-based review yielded 39 articles de-
scribing 38 interventions for depression, anxiety, and
mental HRQOL poststroke. No Level I, II, or III studies
were found for treatment of other psychological sequelae
of stroke. Although literature exists for treatment of these
conditions, it did not meet the inclusion criteria for this
review. The evidence from the studies was wide ranging
and diverse, but it provides guidance to occupational
therapists in implementing best practices for clients with
depression, anxiety, or decreased mental HRQOL poststroke.
Implications for Practice
In practice, mental health may be a specialty area for some
occupational therapists working in settings that primarily
address psychological factors. However, occupational
therapists in all rehabilitation settings in which clients with
stroke will be served must be prepared to assess and treat
mental health impairments so that stroke survivors may
fully participate in and receive the maximum benefit of
rehabilitation. This must be fundamental to occupational
therapists services to stroke survivors.
The largest number of studies in this evidence-based
review analyzed treatment effects of exercise on depression,
anxiety, or mental HRQOL. The Framework (AOTA,
2014) states that occupational therapists use exercise to
prepare for or in conjunction with occupations and ac-
tivities. However, the studies cited here examined the
effects of exercise-only interventions. Although single-
component exercise programs may provide other benefits
to people after stroke, little evidence was found for their
efficacy in treating psychological impairments. Multicom-
ponent exercise interventions showed more promise in that
3 studies demonstrated efficacy in improving depression or
mental HRQOL (Lai et al., 2006; Olney et al., 2006;
Stuart et al., 2009). Although exercise has been shown to be
an effective intervention in management of depression
(Rimer et al., 2012), one may not automatically assume
that exercise will be effective for preventing or treating
depression after stroke. Additionally, these studies did not
examine the effect of exercise as a preparatory method
within an occupation-based intervention approach.
Support for the effectiveness of treatment of depression
was found for problem-solving techniques and motivational
interviewing (Mitchell et al., 2009; Robinson et al., 2008;
Watkins et al., 2007). Both behavioral therapy techniques
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are emerging in occupational therapy educational literature,
but todays practitioners may not have been introduced
to them (Brown & Stoffel, 2011). Further training in
these techniques is recommended when working with this
population.
Anxiety was reduced after one stroke education
program and two care support and coordination inter-
ventions (Boter, 2004; Burton & Gibbon, 2005; Smith
et al., 2004). Occupational therapists are well suited to
provide education in all aspects of stroke and are an es-
sential part of the multidisciplinary team in follow-up
services postdischarge. Preparing clients for function in
the home and community is fundamental to occupational
therapy practice.
Finally, because evidence has shown that more home
health visits to people with stroke may improve their
mental HRQOL, depression, and anxiety, occupational
therapists should recommend more visits and advocate for
them (Ryan et al., 2006). Occupational therapists in
home health and community practice should address not
only basic ADLs but also leisure activities for improving
depression among stroke survivors (Desrosiers et al.,
2007).
Implications for Education
It is essential that educational programs recognize that
rehabilitation with people poststroke includes psycho-
logical interventions, not just interventions addressing
physical impairments. The Accreditation Council for
Occupational Therapy Education has recognized the
importance of psychological factors for occupational
therapy clients in its requirements; that is, all programs
will include course work that will enable practitioners to
understand human behavior and support quality of life in
promotion of both physical and mental health (AOTA,
2012). This requirement necessitates that students study
psychology, and many complete fieldwork in settings that
address psychological factors. These courses should include
problem-solving therapy and motivational interviewing
techniques with case examples of people who have expe-
rienced stroke or other disabling health conditions.
Implications for Research
Occupational therapy interventions are complex and
multifaceted. This is particularly apparent in treatment of
psychological impairments resulting from stroke. Thus, in
future development of evidence-based interventions, oc-
cupational therapy protocols must be clearly defined, and
treatment fidelity must be measured. A clearly defined in-
tervention protocol will allow comparison and replication
of studies, and measurement of intervention therapists
6901180050p5
 treatment fidelity will ensure that the results are attribut-
able to the intervention and not to confounding factors or
therapists skill (Hildebrand et al., 2012). Additionally,
future research must take into consideration study partic-
ipants heterogeneity when developing inclusion criteria
(e.g., age, length of time since stroke, treatment setting,
stroke severity). Interventions that are successful in one
group or setting may not be translatable to all others. It is
also crucial that researchers include people with aphasia or
cognitive deficits because they are at high risk for experi-
encing anxiety and depression after stroke.
Occupational therapists are uniquely qualified health
professionals who can address both the physical and the
psychological impairments caused by stroke. However,
many of the studies in this evidence-based review did not
include occupational therapists. Future research must
examine occupational therapy interventions for psycho-
logical impairments after stroke that are within occupa-
tional therapys scope of practice and focused on
occupation. Finally, the interventions found through this
evidence-based review should be systematically reviewed
to further determine whether they are efficacious in the
prevention or treatment of depression, anxiety, or de-
creased mental HRQOL after stroke.
Limitations
The results of this evidence-based review must be inter-
preted cautiously because of several limitations of the
studies. A majority of studies, 25, had too few participants
and were not powered enough to determine significant
differences between IGs and CGs. Thirty-one studies did
not provide equivalent attention to the CG participants,
which is an essential component when measuring depression,
anxiety, or mental HRQOL. Only 3 of 10 studies using
behavioral therapy and education or behavioral therapy
reported on the training, supervision, and treatment fidelity
of their interventionists. Reporting on these areas is critical in
the psychotherapy fields for interventions to be considered
evidence based (Hildebrand et al., 2012). Finally, many of
the studies were not dedicated to preventing or alleviating
depression or anxiety, particularly the exercise interventions,
but researchers measured these as secondary outcomes.
Conclusion
This evidence-based review provides some guidance, but
more research is required to ascertain what interventions are
effective for people with psychological impairments after stroke.
The prevalence of these impairments compels us to focus on the
importance of mental health assessment and treatment in
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occupational therapy education, practice, and research and
provides an important opportunity to demonstrate our unique
skills for assessing and treating both the physical and the
psychological impairments resulting from stroke. s
Acknowledgments
I gratefully acknowledge the contribution of Sarah Timmons,
who completed many Critically Appraised Paper reviews
and drafts of evidence tables while an occupational therapy
masters degree student at East Carolina University. I
gratefully acknowledge the guidance and support received
from Deborah Lieberman and Marion Arbesman during
the article selection, review, and evidence table and Critically
Appraised Topic development process.
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