Stroke is considered to be one of the most devastating vascular events (Beekman et al 1998) which can cause death. The patients who survive are developing physical impairment. This impairment can make the patients disable or dependent. As a result of loss of functional activity and normal life style, the stroke survivors may also develop psychosocial disorders. The most common disorders among stroke survivors are depression, anxiety, impatience, impulsivity, insensitivity toward others, poor social perception, memory disabilities, apathy, irritability, and eating disturbance (Barker-Collo 2007, Barskova et al 2006, Bour et al 2009). In my research, I will focus more on the prevalence of post stroke depression in the Arab world. I will also investigate the QOL among the Arabic stroke survivors and the factors that influence their mental health and their QOL.
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Stroke, which also called cerebrovascular accident (CVA), is a neurological disorder that results from blood vessels disease (Carr et al, 242). It is caused by a sudden block of blood from flowing to brain leading to irreversible tissue damage result from thrombotic, embolic, or hemorrhagic events (Robinson et al 2010). There are two types of stroke: occlusive and hemorrhage. Occlusive stroke results from closure of a blood vessel while the hemorrhage is due to bleeding from a vessel. It is considered to be a third killer in the world after coronary heart disease and cancer and it is the most cause of disability among people who living in their own homes (Carr et al, 243). In the united state, Europe, and Australia, approximately 400 person per 100,000 populations over age 45 have a stroke (Bruce et al 2005). About 20% of stroke patients die within the first month of onset (Carr et al, 244). However, the reminding 80% of stroke patients can survive with medical management and rehabilitation. The medical management depends on the type of lesion (Carr et al, 245). Surgery is recommended for patients with subarachnoid hemorrhage, well-defined carotid disease, and good surgical risks (Carr et al, 246??). To reduce the muscle spasm, pain, and posture that interfere with patient’s functions, the patients are injected with botulinum toxin into the muscles (Bruce et al. 2005). After the patients are stable medically, they commence active rehabilitation to prevent secondary physical, emotional, and intellectual deterioration (Carr et al 247). The rehabilitation team of stroke survivors usually consists of the followings: physician, nurse, physical therapy, occupational therapy, speech therapy, social worker, and psychologist.
The clinical picture of the stroke patient is complex and varied between physical and psychological disorder. To insure the patient acceptance to different levels of care, it is important for all health care providers to communicate with information about patient’s moods, general symptoms, and worries and concerns about their own health as well as their neurological handicaps, treatments, and co-morbidity (Skaner et al, 2007). The psychiatric complications of stroke include a higher frequency of depressed mood, anxiety, memory disabilities, apathy, irritability, impatience, impulsivity, poor social perception and insensitivity toward others, and eating disturbance(Bour et al 2009 , Barskova et al 2006). Fatigue and sadness are the most common symptoms and 39% of patients always felt tired that is associated with feeling of depression(Skaner et al 2007).
Depression is affective disorder characterized by intense feelings of sadness, hopelessness, despair and the inability to experience pleasure in usual activities(Rang et al 2007).It is more common with left anterior hemisphere injury (Robinson et al 2010). It is considered to be significant risk factors for increase death within 7 years from date of onset (Robinson et al 2010). Every year there is 5000,000 new strokes in United State. Approximate 150,000 of them develop depression in the first year of post stroke (Elis et al 2010). The depressed patients complain from loss of interest, impaired ADL, psychomotor impairment, and gastro-intestinal complaints (Bour et al 2009).
Management of Depression:
The treatment of these symptoms can be established by pharmacotherapy and
Non-pharmacotherapy. The pharmacotherapy may include the followings: imipramine, phenelzine, and fluoxetine which have some side effects on patients. It can cause nausea, anxiety, insomnia, weight loss tremor, drowsiness, and orthostatic hypotension (Rang et al 2007). The non-pharmacotherapy can include aerobic exercises and stretching (Foley et al 2008).
Despite of previous symptoms, the diagnosis of depression in stroke patients is difficult because of overlap of somatic and neurocognitive symptoms directly related to the cerebral damage of stroke and the symptoms of a depressive episode (coster et al 2005). However, the examiner can observe some behavior or use some instrument to judge if the patient is depressed or not (Robinsion et al 2010). The behaviors include: difficulty falling asleep, waking up early in the morning, not eating, losing weight, frequent tearfulness, social withdrawal, or acts as self-harm(Robinsion et al 2010). Whereas, the instruments include Montgomery Asberg depression rating scale (Farner et al 2009), Mooddepression questionnaire, and Beck’s depression scale (Cohen 2007).
Montgomery Asberg Depression Scale is an assessment tool that measure psychological symptoms of depression as symptoms that can affect physical function. Snaith et al defined four degree of depression severity and recognize the patient as a depressed if the score more than 6 in this scale (Sagen et al 2009). Because it is valid and reliable, it can be used in assess treatment outcome and can also used in research (Zimmerman et al 2004).
Another scale is Beck’s depression scale which was designed by Beck, Rush, Shaw, and Emery (Cohen 2007). The scale, which is a questionnaire, consists of 21groups of statements. The patient selects the most statement that best describes hisher feeling past 2 weeks (Questionnaire form). The patient is considered as a minimal depressed if the scale range between 0-13, mild depressed if range between 14-19, moderate depressed if range between 20-28, and sever depressed if range between 29-63(Barker-Collo 2007). It is valid and reliable measurement and (Beck et al 2002) it translated to Arabic to use in assessment and research (Abdel-Khalek et al 1998).
Manchester Short Assessment of Quality of life (MANSA), which is the LQLP modified and brief version, is another assessment tool (Priebe et al 1999). It is used to measure quality of life of people with mental illness and physical disability (Eklund et al 2006). It is administered as a structured interview and consists of three sections (Priebe et al 1999). First section is about personal details: date of birth, gender, ethnic origin, and diagnosis. Section 2 contains details that can be varying over time: education, employment status, monthly income, state benefits, and living situation (Priebe et al 1999). The last section covers 16 quality of life domains which are work, finances, social relations, leisure, living situation, safety, family relations, sexual relations, and health. Fourteen domains have one item and the reminders two have two domains. These domains are health which assessed as physical health and psychological health and living situation: satisfaction with housing and living with someone or alone. Satisfaction scale are rated on 7-point rating scales started with couldn’t be worse and ended with couldn’t be better. This tool is reliable and valid and has good internal consistency (Eklund et al 2006).
One further measure instrument is Patient Competency Rating Scale (PCRS) which is self rating tool. This instrument is used to assess emotional competencies such as: empathy, social initiative, and communication of one’s own emotional states through 30 items. Its items are divided in four domains which are activities of daily living, emotional, interpersonal, and cognition. It is designed to measure patient’s mental and physical status after traumatic brain injury. Later on, it is used with stroke patients also. It is valid and reliable tool that can be used with stroke (Barskova et al 2006).
Stroke is the third cause of death in the world (Carr et al, 243). It is lead to disability and restricts activity of daily living. As a result of these physical problems, the patients can develop many psychological issues. Depression is considered to be one of these problems. Many studies show that 19.3% among hospitalized patients can develop post stroke depression and 23.3% among outpatients (Robinson 2003) .Here I mention some of studies that were done on post stroke depression.
Townsend and his colleges (2010) did a study to evaluate the relationship between the acceptance of disabilities and depression following stroke. Ninety eight patients who were diagnosed with a stroke before one month and had no cognitive impairment or aphasia participated in this study. Twenty two of them had had a prior stroke. However, only 81 of participants were followed up nine months post stroke. The researchers used a prospective cohort mixed design with them. All participants participated in structured interview which yielded quantitative data one month after stroke. It included diagnostic type interview for depression and self report scale to measure disability and personal beliefs about accepting disability. Depression symptoms were assessed using the Structured Clinical Interview of the Diagnostic and Statistical Manual of the American Psychiatric Association. In addition, they used National Institute for Health Stroke Severity Scale to measure stroke severity, Barthel Index to measured personal activities of daily living, reverse scored Nottingham Extended Activities of Daily Living Scale to measure disability in extended activities of daily living, and adapted version of eight-item Acceptance of Illness Questionnaire to measure non-acceptance of disability.
This structured interview was repeated after nine months of onset. In addition, there was semi-structure interview done in the first month of onset and only sixty participants participated in this interview. It included open-ended questions about patients concerns and it was used to extract thoughts and feeling about their condition. The researchers found that for every three stroke patient one of them complained from depression. In their sample, 29 of 89 (33%) patient developed depression one month after stroke, while 24 of 81 (30%) developed depression after nine months. They also found that there is no relationship between disability and depression or no physiological relationship. The non acceptance of disability, or psychological issue, has been the cause of post stroke depression. The depressed participant described themselves as useless and inadequate.
Skaner and his collages (2007) aimed to investigate the self rated health after stroke and the prevalence of symptoms of depression and general symptoms three and twelve months of onset. Their study included 145 patients (69 were men and 76 were women) with a first -ever stroke and their mean age was 73.3 years. The participants were classified according to Katz ADL Index into seven groups, A-G, to assess the patient’s functional level. The ‘A’ refer to patients that had no need of help, and patients in ‘G’ are dependant and the help is necessary for them. They received questionnaires from the researchers to assess their self -rated health, symptoms of depression, and general symptoms. Self-rating of health was assessed by Goteborg Quality of life Instrument (GQLI). The same instrument was used to assess the prevalence of general symptoms which covered six different symptoms: mental, gastro-intestinal/urinary, musculoskeletal, metabolic, cardio-pulmonary and head/miscellaneous. The prevalence of depression symptoms were evaluated by Montgomery Depression Rating Scale which includes nine items: mood, feeling of unease, sleep, appetite, ability to concentrate, initiative, emotional involvement, pessimism, and zest for life.
In this study the researchers compared the patient’s situation three and twelve months after stroke and they found that more than half of patients suffered from symptoms of depression with no significant change frequency between 3 and 12 months. The most common general symptoms after 3 months were reported by patients were fatigue 69%, sadness 58%, pain in legs 52%, dizziness 48%, and irritability 46%. While the most common symptoms after 12 months were fatigue 58%, impaired hearing 49%, pain the joints 49%, sadness 46%, and pain in the legs 45%.
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Barker-Collo (2007) examined the prevalence of depression and anxiety after stroke. He also investigated the relationship between depression and anxiety with age, gender, hemisphere of lesion, functional independence, and cognitive functioning. He included 73 patients who were diagnoses of stroke three months before. Of the participants, 40 were males and 33 were females with a mean age of 51.7 years. Their CT scans showed that 31 of them had left hemisphere damage and 33 were right hemisphere damage. The researcher used many measurement tools to get the results. He used Beck Depression Inventory-II (BDI-II) to measure depression. BDI-II is contain 21 four-choice statements and its total score ranges from 0 to 63. Participants selected the better choice that descripts their emotional and vegetative symptoms in the past two weeks. According to this scale, result between 0-13 is considered to be minimal depression, 14-19 is mild, 20-28 is moderate, and 29-63 is severe.
The researcher also used Beck Anxiety Inventory to examine the anxiety symptoms and California Verbal Learning Test-II to measure recall memory. Visual Paired Associates test was used to examine visual learning and memory, and Digit and spatial spans test was used to test memory working. Additionally, Functional Index Measure which includes 13 motor and 5 cognitive items was also used to assess outcomes of rehabilitation. The motor items include self care, sphincter control, mobility, locomotion, and social cognition. While the five cognitive items cover independence in comprehension of communication, expressive communication, social interactions, problem solving, and memory. Furthermore, the researcher included Integrated Visual Auditory Continuous Performance Test and Victoria Stroop. The mood assessments and neuropsychological took about 120 min to be completed according to standardized procedures.
The researcher found from his measurements that the prevalence of depression and anxiety three months post stroke was 22.8 and 21.1% respectively with one in five patients have either moderate or severe depression or anxiety. According to the site of injury, he found the patients with left hemisphere injury were more likely to get depression or anxiety. Because of the left hemisphere is the part which is responsible about language skills, the lesion in it can cause communication deficits which then can lead patients to feel depressed. Suffering of post stroke depression or anxiety can affect the physical therapy sessions. Depressed patient may lack the motivation to complete the session while the anxious patient can suffer from fearful of falling to attempt to walk without device.
Appelros and Viitanen (2004) also measured the prevalence of post stroke depression in a Swedish Population during 1999-2000. They included 377 patients, 129 were females and 124 were males, with first ever cases of brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, and stroke of undetermined pathological type and with mean age 74.5 years old. One hundred and nine patients complain of right hemisphere damage while 138 patients were left hemisphere damage. The researchers used Swedish version of the Geriatric Depression Scale (GDS) which include 20 items, and cutoff is >5. The items cover anxiety, panic, insomnia, hypochondria, and pain. Patients in all cases answered the questions which were read aloud for them. Further evaluation was subjected to patients who crossed cutoff on the GDS. One year follow up, Modified Rankin Scale was used to assess dependency. Cognitive impairment was measured by using Mini Mental State Examination which define the cognitive impairment at a score of <24. Also, at one year follow up the patients were asked to describe their satisfaction with life by choice one of four choices: very satisfied, satisfied, dissatisfied, or very dissatisfied. At the end of this study, the researchers conclude that according to GDS the prevalence rate was 27%. The best predictor of depression after one year is functional outcome. However, functional outcome can be improved by active rehabilitation which then influences depression positively. They also conclude that the depression after stroke is strongest predictor for a low life satisfaction.
Purpose of Study
The purpose of this study is to investigate the prevalence of depression among Arabic stroke survivors. The QOL of the Arabic stroke survivors will also be further investigated. The researcher will use Barthel Index to measure level of function of the participants. Additionally, the researcher will investigate the factors influencing the mental health and the QOL of the Arabic stroke survivors in terms of: onset date of injury, site lesion, type of brain injury (infarct, intracerebral hemorrhage, or subarachnoid hemorrhage), functional level, gender, educational level, employment, and productivity level.
In this study, 200 Arabic patients with first-ever stroke will be included. Inclusion criteria: stroke at least 6 months or above, right and left hemisphere types of stroke, both male and female participants will be recruited from all government hospitals in Kuwait. However, patients with aphasia, cognitive impairments, dementia, and current psychotic episode, and non Arabic patients will be excluded from the study. Patients who will participate in this study will receive a written informed consent.
Data Collection Procedure
After obtaining approval from the Committee for the Protection of Human Subjects in Research at Kuwait University Health Sciences Center, the researchers will initiate the proposed project. This study will be run by two researchers and one research assistance. The research will select all the names of Arabic participants with stroke from the registry from the 5 general hospitals in Kuwait. The hospital include: AL-Adan, AL- Jahra, PMR, and AL-Amiri hospital. Then, the research assistant will randomly select names. Each participant will be asked to voluntarily participate in this study. Upon approval, each participant will sign a consent form indicating his/her willingness to participate in this study.
The Beck Depression Inventory (BDI), which was translated to Arabic form, will be used to measure depression among the 200 stroke patients in Kuwait Hospitals. BDI-II contains 21 four-choice statements and its total score ranges from 0 to 63. The participants will select the most accurately statement which describe their feelings in relation to emotional, behavior, and vegetative symptoms over the past two week. According to this scale, result between 0-13 is considered to be minimal depression, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. The participants will have one hour to complete the test (Cohen 2007).
Another tool that which will be used is the Arabic version of MANSA. This tool is used to measure the quality of life of people with mental illness and physical disability (Eklund et al 2006).
To assess functional ability and ADL of stroke survivors, the researchers will use the Barthel Index. It has 10 items of ADL which can collect via direct conversation, questionnaire, or phone interview. These items are feeding, bathing, grooming, dressing, bowel and bladder control, toileting, ambulation, transfers, and stairs climbing. The final score is ranged between 0, fully dependant, and 20, independent. It is valid and reliable to be used as outcome measurement for clinical and research purpose (Yang J et al 2008).
Data Analysis: All data will be analyzed by using SPSS (19) for analysis.
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