Impact case study database

Across the world, 20 million people including 100,000 in the UK, will experience a stroke annually, of whom two-thirds will survive. One in three stroke survivors experience depression, particularly within the first year, and this increases cardiovascular-related morbidity and mortality, whilst also contributing to further NHS costs. Emotional difficulties directly and indirectly reduce quality-of-life for the patient by hindering post-stroke activities like taking medication, engaging in rehabilitation, maintaining social networks, and returning to work. Improving psychological care after stroke enhances patients’ health and quality-of-life and reduces burden on NHS services.

Impact on practice

The Stroke Team validated two screening tools, SODS and Yale-Brown Obsessive-Compulsive Scale, to reliably detect depression in patients following stroke. This validation has led to greater screening for depression amongst stroke survivors. These screening tools have now been implemented in clinical stroke pathways by numerous NHS stroke services including Cornwall, Dartford, Manchester, Lancashire, London and Glasgow. They are also used in the Netherlands and in Germany [D].

The Royal College of Physicians National Clinical Guideline for Stroke now recommend that “People with or at risk of depression or anxiety after stroke should be offered brief psychological interventions such as motivational interviewing…before considering antidepressant medication” [A] The Australian Clinical Guidelines for Stroke Management, which is also used in New Zealand, similarly recommend that “…psychological strategies (e.g. problem solving, motivational interviewing) may be used to prevent depression.” [B]

The Stroke Team’s research, as one of the only sources of evidence on motivational interviewing managing depression after stroke, is increasingly being used in practice and in guidelines. Motivational interviewing training and principles are now being widely implemented by and for stroke staff. NHS stroke services in Hereford, Cornwall, Manchester, Liverpool and Glasgow have implemented the training. Internationally it is found in online training by the Stroke Foundation in Australia, by stroke nurses in the Netherlands and in professional stroke education in the Heart and Stroke Foundation in Canada [D].

By adapting motivational interviewing from its original use in behaviour change to adjustment, the clinical impact was extended beyond stroke. For example, the Stroke Team were approached by HIV nurses in Atlanta, USA to provide training in motivational interviewing and guidance into incorporating motivational interviewing within their consultations. They have appreciated Stroke Team’s contribution, stating: “We and our study participants have truly benefitted from your expertise and input into our motivational adjustment intervention.” [J]

The ADOPTS trial has improved care through staff training and the organisation of services. An evidence-based pathway was developed that enhanced access to psychological support following stroke. The implementation of this pathway resulted in fostering collaborative working between multidisciplinary staff in stroke and generic mental health services, such as Improving Access to Psychological Therapies (IAPT), who were previously seen and felt to be working in silos. Working alongside these services to support the adoption of best practice the research resulted in an increased awareness, better networking and peer-support between the services which previously had minimal collaboration. These new collaborations stimulated the creation of innovative solutions for the provision of psychological support post-stroke. As one IAPT psychological therapist reported “I bumped into someone from the stroke team who I met through ADOPTS and we agreed to meet up and try to help each other.” [I] A stroke occupational therapist said: “I asked [IAPT] if they could come and talk about mental health, and obviously stroke-related, and how we could help patients.” [I] This innovative model has now been widely employed across north-west England, resulting in increased awareness and collaboration resulting in ADOPTS becoming a shortlisted finalist for the North West Coast Research and Innovation Awards.

Impact on practitioners

Training developed and implemented as part of the ADOPTS research, underpinned by the screening and interventions research, has increased the knowledge and skills among stroke and IAPT teams in identifying and managing psychological problems after stroke. The training improved stroke teams’ psychological awareness, IAPT teams’ stroke awareness and facilitated better psychological support for stroke survivors. Training was initially delivered to 152 staff across six NHS Trusts (Countess of Chester Hospital NHS Foundation Trust, East Lancashire Hospitals NHS Trust, Wirral University Teaching Hospital NHS Foundation Trust, Lancashire Teaching Hospitals NHS Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust). The training was well received by participants with one IAPT practitioner stating: “In the training, thinking about the way we communicate… I found [it] really useful… to adapt our therapies.” Some stroke services and psychological services have cascaded the training, extending its reach beyond the staff trained within ADOPTS. A stroke senior occupational therapist said, “I’ve incorporated it into in-service training for therapy staff, because things around psychological impact weren’t really there, and the feedback’s been really positive.” The training has since been endorsed by the UK Stroke Forum for Education and Training which ensures high quality and relevant training for stroke practitioners and is accessible across the UK. Following ADOPTS, we have been invited to teach on the IAPT course around long-term stroke recovery conditions. Training has also been delivered in areas beyond those included in the study in Cheshire and Wirral Partnership NHS Foundation Trust and North West Boroughs Healthcare NHS Foundation Trust, increasing the knowledge and skills of IAPT staff across the North West region.

Impact on patients

There have been national and international implementations of the work on mood screening, motivational interviewing therapy and antidepressants. This has resulted in substantial impacts on patient care and survival after stroke. Patients who received motivational interviewing in the Stroke Team’s research said they found it beneficial: “It helps me get things clearer in my mind… stops me sitting and worrying on things,” While another patient stated “It’s been worthwhile talking to someone… it’s been great just talking through things because you can talk with family but they don’t understand certain things.” [I]

Stroke and IAPT staff felt that stroke survivors, over 1500 per year across the services in which ADOPTS was implemented, benefited from the model. One stroke occupational therapist stated that “The training brought their [patients] psychological wellbeing to the forefront … they’re hopefully getting more holistic care.” This is corroborated by a stroke survivor who took part in the study and who benefited from an IAPT referral resulting in improved coping methods and an increase in confidence: “I ended up being referred to Mindsmatter, then attending several group sessions…I know the sessions were a benefit to me. They have helped me in developing my coping methods… I now have more confidence and acceptance of what I can achieve since my stroke.” [I]

Reducing the use of fluoxetine

The FOCUS study showed a 1.4% absolute excess risk of bone fractures with the prescription of fluoxetine. This has led to the antidepressant, which was commonly used to manage post stroke depression, being prescribed less. The study has been cited in American and Canadian clinical guidelines for stroke management to guide practitioners on the use of antidepressants after stroke [F, G]. The guidelines state that the antidepressant fluoxetine does not have an effect on functional recovery. The use of the antidepressant fluoxetine is now increasingly avoided due to evidence from the Stroke Team’s research showing its use increases the risk of adverse effects and alternative antidepressants are now considered in the first instance [H].