The most recent studies reveal that between 16% and 85% of stroke survivors face at least one psychosocial issue, such as depression, anxiety, stress, fatigue, and/or a reduced quality of life. Essential nursing practices—like consistent mental health screenings, patient education, symptom management, and ongoing care—are crucial for mitigating the adverse impacts on a patient’s mental health following a stroke. However, only a small percentage of patients actually receive necessary treatment.
Nurses are pivotal in assisting patients to cope with emotional and social health difficulties, known as psychosocial health, after experiencing a stroke. Enhanced screening and evaluation of psychosocial needs are vital for delivering high-quality patient care. These insights are presented in a new statement released by the American Stroke Association, a branch of the American Heart Association, titled “Nursing’s Role in Psychosocial Health Management After a Stroke Event,” which has just been published in the Association’s esteemed scientific journal, Stroke.
Despite significant advancements in stroke prevention and treatment, strokes continue to rank as the second leading global cause of death and a primary source of disability. Current findings show that between 16% and 85% of individuals recovering from a stroke suffer from psychosocial symptoms like depression, anxiety, stress, fatigue, and/or a diminished quality of life.
“There is often a stigma around discussions regarding psychosocial health. It is essential for nurses and all healthcare providers to cultivate a safe and therapeutic atmosphere for patients, offering hope and thorough education on these issues,” stated Patricia A. Zrelak, Ph.D., R.N., FAHA, chair of the scientific statement’s writing group and a regional stroke program quality nurse consultant for Kaiser Permanente Northern California, who is also a member of the American Heart Association’s Council on Cardiovascular and Stroke Nursing.
The scientific statement encompasses an extensive review of the most current research from 2018 to 2023 concerning the psychological health of stroke patients. It discusses the outcomes, root causes, screening, diagnosis, and treatment of five key psychosocial factors: depression, stress, anxiety, fatigue, and quality of life. The aim is to provide a framework for nursing care throughout a patient’s recovery journey after a stroke, from preventing negative psychosocial health issues to identifying and managing symptoms.
“Changes in emotional, cognitive, behavioral, and/or personality traits may arise following a stroke,” Zrelak noted. “These changes can manifest immediately after the event or have a delayed onset, sometimes surfacing more than a year later, and they can vary in severity over time. Additionally, psychosocial symptoms are interconnected; patients facing one issue are at an increased risk of developing other mental health problems. Consistent and effective screening is crucial for timely detection and intervention.”
Depression
Approximately 30% of stroke survivors experience depression, especially during the first three months of recovery. Symptoms can include ongoing sadness, anxiety or feelings of emptiness, restlessness, irritability, loss of interest in activities, difficulty concentrating, changes in sleep patterns, appetite fluctuations, and weight changes. Post-stroke depression can impair cognitive and functional recovery, heightening risks of mortality or another stroke.
The AHA/ASA Guidelines for Early Management of Patients With Acute Ischemic Stroke advocate for routine screenings for depression in all post-stroke patients. Nurses can provide education to stroke survivors and their families regarding symptom identification, prevention strategies, and treatment options, which may include medications and/or cognitive behavioral therapy.
Stress
A 2022 study revealed that around one in six stroke survivors (approximately 16.5%) experience post-stroke stress and post-traumatic stress disorder (PTSD). These conditions can lead to further health complications, such as anxiety and poor adherence to medication. Screening for stress and PTSD in stroke patients should take place during hospitalization and continue through rehabilitation and outpatient care after discharge.
Nursing interventions that may alleviate patients’ distress include providing education about stroke and self-management strategies like mindfulness and meditation. Additionally, nurses should consider the coping strategies of stroke survivors; individuals with high-anxiety coping methods are significantly more likely to develop PTSD post-stroke compared to those with low-anxiety coping styles.
Anxiety
The occurrence of anxiety ranges from 20% to 25% during the initial months following a stroke, escalating to 32% within a year and reaching 34% over five years. Variables such as being younger at the time of the stroke, lower income, unemployment, social isolation, pre-existing mental health issues, and stroke severity all contribute to increased anxiety risk. Anxiety is also associated with a higher likelihood and severity of depression.
Regular screening for anxiety and prompt identification can lead to early treatment, enhanced patient participation, and better recovery outcomes for stroke survivors. While established guidelines exist for the treatment of general anxiety, further research is required to explore anxiety interventions following various types of strokes.
Fatigue
Fatigue after a stroke can arise at any time, but it is most prevalent during the first six months of recovery. Symptoms may include diminished physical and mental energy, which can hinder daily activities, plus difficulties with self-control, emotions, and memory. Women, and individuals dealing with depression, sleep disturbances, anxiety, or multiple health issues are at an increased risk for post-stroke fatigue.
More research is necessary to determine effective management strategies for post-stroke fatigue, as no validated treatments currently exist. However, strategies aimed at enhancing overall physical fitness may help prevent, lessen, or treat fatigue and other aspects of psychosocial health.
Quality of Life
Achieving a similar quality of life post-stroke is challenging, particularly after a severe event. Factors such as physical strength, speech recovery, incidences of depression and anxiety, along with the ability to resume employment and social activities, significantly impact a stroke survivor’s quality of life. Conversely, conditions like chronic pain can adversely affect recovery and the return to independent living.
Physical activities that promote social interaction, such as yoga and tai chi, have proven beneficial for enhancing patients’ quality of life. Nurses can assist stroke survivors in improving their quality of life by connecting them with local social services, including post-stroke support groups and community organizations.
“Minding mental and emotional health is vital for recovery, and nurses are integral in providing support to patients after a stroke,” Zrelak emphasized. “Engaging stroke survivors and their caregivers is crucial for raising awareness about these psychosocial challenges and how they can contribute. Early identification of symptoms and timely treatment can significantly enhance recovery outcomes post-stroke.”
The statement further underscores research indicating that stroke outcomes can differ markedly among individuals from various racial and ethnic backgrounds. Social determinants, including structural racism, socioeconomic status, inadequate housing, and limited access to healthcare services—including mental health support—can greatly affect a stroke survivor’s recovery process.
Zrelak concluded, “The stroke care team plays a crucial role in tackling these health disparities by employing targeted interventions and tailored treatments to enhance mental health support and ensure comprehensive care for those most vulnerable. Additional research is necessary to better understand how to support psychosocial health for stroke survivors, enabling them to return to their daily routines and improve their overall quality of life.”
This scientific statement was drafted by a volunteer writing group representing the American Heart Association’s Council on Cardiovascular and Stroke Nursing and the Council on Lifestyle and Cardiometabolic Health. The American Heart Association’s scientific statements intend to increase awareness regarding cardiovascular diseases and issues related to stroke, aiding in informed healthcare decisions. These statements summarize current knowledge on specific topics and identify areas needing further investigation. Although they inform the guideline development process, they do not make treatment recommendations. The official clinical practice guidelines from the American Heart Association provide distinct recommendations.
Additional contributors and members of the writing group include Vice Chair Karen B. Seagraves, Ph.D., M.P.H., FAHA; Samir Belagaje, M.D.; Wendy Dusenbury, Ph.D., D.N.P., FAHA; James J. García, M.S., Ph.D.; Niloufar Hadidi, Ph.D., FAHA; Kiffon M. Keigher, D.N.P., M.S.N., FAHA; Mary Love, Ph.D., M.S.N., R.N.; Gianluca Pucciarelli, Ph.D., FAHA; Erica Schorr, Ph.D., R.N., FAHA; and Cesar Velasco, B.S.N., R.N.
