Cognitive Rehabilitation Therapy: these are the remedial processes of helping people especially stroke patients with neuropsychological problems in this case post-stroke depression to enhance their level of cognitive functioning and independence or help the patient to better understand the nature of these difficulties while teaching him or her methods of compensation. This includes interventions to lessen impairments, or disabling impact of those impairments. This rehabilitation allows the stroke survivors to accomplish important life activities and fully participate in society. These modules are developed and tailored to meet each client specific needs in a nine session format.
Psycho-education therapy: This refers to the giving of information, leaflets and answering questions about stroke generally. This treatment is ―information gathering based‖ and it involves being knowledgeable about causes, course, prognosis and mortality of illness. The module of this group lasts for nine sessions weekly for about 45-60 minutes of individual therapy.
Control/waiting list: This refers to respondents who are not exposed to any of the psychological treatment procedures; however, continue the usual care of the facility.
Stroke: a rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain, caused by a blocked or burst blood vessel, as diagnosed by a medical physician with classification of ischemic, hemorrhagic or mixed.
Location of brain lesion: this is the identification of the specific area where there had been the traumatic injury to the brain which might either be right or left hemisphere and this will be determined by the result of a Computed Tomography (CT scan) assessed and diagnosed by a physician neurologist with a classification of left or right hemispheric brain lesion.
Physical disabilities: these are physical impairments that can make performing an everyday task more difficult, which has either direct or interactive effect on the patient‘s health status, such as activities of daily living for patients recovering from stroke and these are broad range of activities associated with everyday living. Such as preparing main meals, washing up, washing clothes, light housework etc. This was measured with the Mahoney and Barthel, (1965) which had 10 items on a continuum of classification of fully dependent to independent i.e. 100-0.
Perceived social support: this is the perceived availability of people whom the stroke patient trusts and who make the patient feel cared for and valued as a person, also the perception of the stroke patients towards the help they can or receive from people they regard as close to them. This was measured with the 12 item multidimensional scale of perceived social support by Zimmet et al., (1988) with classification of high perceived social support or low perceived social support.
Health locus of control: these are the attributions people make after getting sick that are critical in determining what effects that illness episode will have on them either
of control scale by Wallston ,(2005) with classification of internal, chance, powerful others.
Post-stroke depression: This is the mood disorder or changes in emotional experience and behaviour of a client who had undergone stroke. As defined by the DSM-IV-TR it is the depressive disorder due to a general medical condition (i.e.
stroke). This will be measured using the Becks depressive Inventory, the long form (21 items) with classification or mild, moderate or severe.
Prior Illness: This is the physical illness the stroke survivor treats before the stroke attack which is a risk factor for the development of stroke.
Concordance: This is the limb or part of the body being used by the survivor which is also the affected part of the body after the stroke attack with classification of concordance or non-concordance.
CHAPTER THREE
3.0 METHOD
3.1 (a) Phase one
The first phase (cross-sectional survey using ex-post facto design) is the assessment of the variables of interest on post-stroke depression i.e. ascertains the impact of location of brain lesion, physical disability, number of cerebrovascular accidents, perceived social support and health related locus of control as determinants of post-stroke depression. This is an intervention study and multi- staged as with clinical research which encompasses assessment preceding the experimental/intervention research. The independent variables are brain lesion, physical disability, concordance, prior illness, gender, religion, perceived social support and health related locus of control while the dependent variable is post-stroke depression.
(b) Phase two
The second phase of this study, which is an (experimental research design) utilizing a pre-post randomized control design. This phase assessed the therapeutic efficacy of the treatment modality of cognitive rehabilitation therapy on post-stroke depression as against psycho educational training and waiting list control which was in three homogenous groups namely homogenous except treatment modality. A baseline score was obtained at entry, then the interventions was introduced to group A (CRT) and B (PET) of the three groups i.e. group A (cognitive rehabilitation therapy), group B (Psycho-education) and group C (Usual care).
All groups had the following variables held constant – level of Physical disability, negative life events, usual medical/Para-medical care, and lesion location
The assessments were done at first contact, then at the third session, the sixth session and at the end of the ninth session (while the interventions were usually held weekly all over a period of 3 and half months).
The experimental groups received a pre-test, the intervention and post-test on the dependent variable (post-stroke depression) using the independent variable.
On other hand the control group received only pre-test and post test only (though the control also received weekly text messages over the phone on general greetings and quotable quotes). Finally the follow up was collected on both the experimental and control group using the dependent variable a week after the intervention was done, pre assessment and post assessment.
The design can be represented in a tabular form as follows
Quasi-Experimental Groups (QEG )
Pre-Test Assessment
(PreTA)
Treatment Types Post-Test Assessment
QEG1 PreTA1 CRT PostTA1
QEG2 PreTA2 PET PostTA2
QEG3 PreTA3 Control(Usual care) PostTA3
CRT- Cognitive Rehabilitation treatment PET –Psycho-education treatment
Control- Usual treatment without psychological based intervention
Those who score ≥11 on the Beck Depression Inventory are offered the opportunity to consent for the intervention study, with diagnosis of depression validated by diagnostic interview using DSM IV criteria. Because of the short length of stay for ischemic stroke, all subsequent contacts with study participants occur in out-patient setting at clinic follow-up in a pre - arranged rehabilitation facility for psychotherapy facilities at the Family medicine department beside the office of the clinical psychologist at the University College Hospital. While a score of less than 10 at the end of the intervention is considered of therapeutic significance in reduction of post-stroke depression.
No patient had the intervention in hospital bed/ on admission and all the sessions were individualized psychotherapy sessions.
* The intervention was done by integrating the psychotherapy sessions into the body of care of the consenting participants of the study to ensure follow-up, also because patients with stroke deal more with caregivers, the carers were the first to consent and short motivational interviewing was done conducted with them.
At the start of each recruitment process, the patients were carefully told the study purpose, right to consent or wi thdraw, benefits of the study and the likelihood of falling into any of the three groups. Patients who score less than 11 in the becks depression inventory were excluded from the intervention parts of the study. For the intervention stage the patients were randomly assigned into the three groups of intervention with cognitive rehabilitation therapy / Psycho-education and those with no treatment as the third group, the randomization was done using the table of random numbers