Psychological Care in Stroke:
What is important and whose
responsibility is it?
Dr Jane Barton
Consultant Clinical Psychologist
Overview
• What is psychological care?
• What is the scale of the problem?
• Why are we focussing on this now?
• The context & current drivers
• What can we do about it?
Emotional experience of stroke
“We’re not just legs and arms and a mouth…we are human beings
with a mixture of emotions. All these feelings…self esteem, self
worth, confidence, identity …they’re all under attack after a
stroke…you can feel vulnerable, frightened and you can lose
yourself. Psychological support puts you back together again especially psychological support from someone who’s been down
that road before. The timing can’t be predicted…sometimes it’s
when you come out into your real world after hospital or it may be
two - or more – years later when you discover that you will not make
a ‘full’ recovery…it’s about reinvention and finding direction”
Harry Clarke , Counsellor at Connect who has aphasia
(Taken from Psychological Care after Stroke, NHS Improvement, 2011)
Psychological care in physical
health settings – what is it?
• Essentially about integrating a psychological
content within the overall physical care.
• It is not something that stands alone and is
separate from physical care.
• Should be organised, systematic and practical.
• Everybody’s business!
Psychological Care
(Nichols 2003)
• Level 1
• Awareness of psychological issues
• Patient centred listening & communication
• Awareness of patient’s psychological state
• Level 2
• Monitoring psychological state; keeping records
• Information & education
• Counselling & support
• Level 3
• Psychological therapy & interventions
What is the scale of the
problem?
Psychological & mental health
consequences of stroke
Scale of the problem 1
• Cognitive impairment
Problems with memory, concentration, planning,
sequencing, decision making, insight
• Approx 75% experience cognitive impairment
• Approx 35% have significant impairment long term
• Significant proportion go on to develop dementia
Scale of the problem 2
• Depression
• Most common psychological presentation
• Approx 25-50%
• Independent of disability
• Fluctuating course
Scale of the problem 3
• Anxiety
• Between 30-49% up to 12 years post stroke
• Phobias, generalised anxiety, panic
• Trauma response - PTSD
• 20% show trauma response
• Flashbacks, avoidance, hyperarousal
The Impact
• Untreated psychological mood disorders
are associated with higher rates of :
•
•
•
•
•
Mortality
Suicide
Long term disability & institutionalisation
Hospital readmission
Higher utilisation of outpatient services
Mental Illness Associated with
Stroke
• Depressive disorders increase risk of cardiovascular
disease by 1.5x the general population, equivalent to
risk from smoking or diabetes
• People with severe mental illness have a 2.5x greater
mortality from stroke
• Those receiving highest doses of antipsychotic
medication are at greatest risk of death from both
CHD and stroke
• Psychological stress associated with an 11%
increased risk of stroke
Why are we focussing on this
now?
Recent audits
National drivers
Audits & Reviews
National reviews of stroke services demonstrate
the need for improvement
• CQC in 2011 found psychological support for
patients and carers was less than readily available
• NAO reported that psychological support for
patients and carers was lacking
Policy & Guidance
• National Stroke Strategy (2007)
• RCP Guidelines for stroke (2004; 2008)
• And…
“No health without mental health”
(DH, 2011)
“There is a clear link between mental and
physical health and an urgent need to
strengthen the provision of mental health
care to people with physical illness and the
quality of physical health care to people
with mental health problems in general
hospitals and in primary care”
What can we do about it?
• NAO report led to NHS commitment to
improve 9 domains through Accelerating
Stroke Improvement
• Psychological support – ASI 6
• Targets set
• Guidance on developing services
Psychological Care After Stroke
(NHS Improvement, 2011)
• Guidance on developing services
• Addressing psychological need after
stroke should be accepted as an essential
part of the culture of stroke services and
equivalent to the management of physical
need.
• Stepped care model
Stepped Care approach
to psychological care
• A hierarchical approach.
• Offers simpler interventions first,
progressing onto more complex
interventions if required.
• Not necessarily a linear process.
• Makes best use of skills of MDT & utilises
more specialist staff for more complex
problems.
Stepped Care Model for
psychological interventions after stroke
(NHS Improvement 2011)
• Level 3: Severe and persistent
disorders of mood and/or
cognition – requiring specialist
intervention from clinical
psychology / Mental Health
• Level 2: Mild/moderate
symptoms of impaired mood
and / or cognition that interfere
with rehab – requiring
specialist stroke staff with
psychol / MH expertise.
• Level 1: Sub-threshold
problems – requiring
awareness and screening by
stroke specialist staff
Level 1
Screening & sub threshold problems
•
Task
•
By whom?
•
Awareness of psychological
issues & patient’s psychological
state
•
The whole of the MDT – everyone!
•
Providing low level psychological
care: e.g. patient centred listening
& communication
•
Alerting others & signposting on
•
Ensuring discussion & review at
MDT
•
Mood and Cognitive screening
•
Sub group with training
Psychological Screening
Formal, standardised measures (RCP, 2008)
• Mood & distress
PHQ-9; GAD-7
DISCS – aphasia
SADQ – severe aphasia / cognition
• Cognition
ACE-R
MOCA
Level 2
Mild – Moderate problems
• Task
• By whom?
• Further assessment &
monitoring
• Brief psychological
interventions (including
psychotherapeutic
groups)
• Onward referral &
signposting – to clinical
psychology
• MDT staff with additional
competence in
psychological / mental
health
Level 3
Severe or persistent mood / cognitive
problems
• Task
• By Whom?
• Specialist assessment with
complex mood & cognitive
presentations
• Clinical Psychologists…….with
training in neuropsychology
• Suicide risk assessment and
management
• Psychological interventions &
therapy
• Liaison & onward referral to
specialist MH services
• Specialist mental health
practitioners
Summary
• Understand the importance of physical
and mental health
• Raise awareness within the services
• Know your role and level of expertise
• This is everybody’s business!!