Working with the community neurorehab teams in Cambridgeshire, PhD student Sara Simblett identified a way of making computerised Cognitive Behavioural Therapy (cCBT) accessible to stroke patients. Gathering small groups of patients and using local library or community village hall facilities, or providing cheap laptops for use in the patient's home, she implemented a trial of the approach. Positive results, and learning from some adverse reactions build on the NICE guidelines for cCBT.
Aims and objectives
The aim was to find ways to provide psychological interventions for people living with the consequences of stroke. In particular, to help people overcome anxiety and depression after stroke. The main objective was to test the acceptability and effectiveness of the approach in this patient group. A secondary objective concerned the interactions of mood problems with cognitive consequences of stroke. As this was part of a PhD thesis these topics were contained within further detailed hypotheses and objectives that were investigated, but are beyond the scope of this short report.
Reasons for implementing your project
Although there is a National Stroke Strategy target for all stroke patients to have access to Clinical Psychology, in Cambridgeshire there was no such service available to the Community Rehabilitation teams and their patients.
We knew that the distressing emotional consequences of stroke deserved supportive intervention but did not know what approach to take to make this available to at least some of our patients.
As neuro-rehabilitation manager I was able to make it possible for a research student to spend time embedded within the community stroke team to observe the types of issues and consequences of this. Based on this collaboration, the student devised a study that included collecting a baseline assessment of 130 stroke patients' responses to standard anxiety and depression questionnaires. This helped determine the scale of the problem (patients reporting at least mild problems with depression 47% and anxiety 42%).
The key benefit to implementing the use of the cCBT was that some of the patients were able to report great improvement. For example, a number of people commented that cCBT helped to improve their level of confidence; feel more positive about the future; and less frustrated. One participant commented:
"I do feel as if I have strategies for coping now. I just have to keep reminding myself to use them. The program did help me a lot and I believe it has helped me cope with a lot of the inner beliefs about myself that were not quite accurate". Another participant, who particularly benefited from cCBT, said: "It has helped me come out of my comfort zone and face things", and "it helps you to understand yourself because you feel different" (previously, this participant had described experiencing a stroke as "it is like an alien creeping in one side of you" and "you feel as though you have been hit by a bus").
These narratives illustrate why it is imperative for services to grasp the issue of how to provide long term support for people living with this condition. In our locality Psychology services (such as IAPT) are not geared toward being able to accept people with neurological conditions. This work has shown that it is possible to build psychological interventions into the work of community rehabilitation teams.
How did you implement the project
Access to computers in this patient group was anticipated to be a problem. One innovative solution was to purchase low cost refurbished laptops (cost less than £200) that could be loaned to patients for the purposes of the project. Another was to provide support to access the software through being available to guide the patients in the use of it. Arranging to meet in a group of 2 or 3 patients in various community settings (libraries and village halls) with remote access internet dongles meant some people could take part in the project.
At the scientific end of the project were problems with measurement of depression and anxiety after stroke because standard tools to measure these conditions include physical symptoms that also follow stroke. This can be confusing and over-inflate depression or anxiety scores. For example asking people if you feel wobbly or unsteady - almost inevitable consequences of stroke - in this context is not necessarily a symptom of depression. This meant that some careful psychometric research was needed to reconsider the measurement tools.
The project costs were met by the NIHR Collaborations for Leadership in Applied Health and Care for Cambridgeshire and Peterborough (NIHR CLAHRC-CP). This funded the salary of the PhD student who devised and implemented the study. A clinically focused PhD like this was very attractive to the student, but also being highly applied to the needs of community therapists and their patients demonstrated a very valuable approach to collaboration between the NHS and the University.
It is suggested that this project showed that "behavioural activation", thought to be a key active ingredient of CBT for depression, was found to be helpful in reduction of depression. Furthermore patients learned to reframe their experiences in a more positive way and this helped with reduction of worry.
Although the project was organised in the form of research trial, a more general positive outcome was that patients identified by the Occupational Therapists and Physiotherapists were able to benefit from psychological interventions not otherwise available to them. For the duration of the study this added no costs to the delivery of community rehabilitation. Encouraging participation in research studies is another element of the national Stroke Strategy - this project also underlines the need for further projects that address issues that arise in community settings.
Evaluation of outcomes was carefully monitored using self-report questionnaires. The results broadly met with expectations, but also yielded important findings that guide both further research and clinical implementation.
Key learning points
This research study recently completed by a PhD student who worked as part of a community rehabilitation service, has shown that cCBT has the potential to reduce symptoms of depression and some symptoms of anxiety disorders following stroke. Although some modifications to the treatment protocol are required, there is a role for this type of support in neurorehabilitation services. The recommendation to collaborate with local health research groups to tackle specific clinical service problems is a fairly obvious point.
I recommend avoiding use of 'off the shelf' questionnaires to assess complex psychological presentations in neurological rehabilitation settings without the support of people experienced in analysing and interpreting the results. It is important to be able to recognise the shortcomings of assessment tools designed for use in one population - for example designed to assess people with anxiety and depression without neurological conditions - and to be able to appropriately adapt the scoring. A fundamental scientific step in this work is to make sure that "total scores" are not recorded in clinical databases, but rather item-by-item responses should collated so that more detailed analyses can be completed later.
It is important to recognise that psychological interventions need to be provided within a context of other services and with support. A computer programme is again fairly obviously not going to be sufficient for some people. Adverse reactions are to be expected - worsening of anxiety or depression through use of the cCBT software was also observed in this project - and mechanisms need to be in place to meet these needs.