Feasibility and Effectiveness of an Integrated Cognitive Behavioral Treatment to Address Psychological Distress in a Stroke Self-Management Program

Abstract

This is a case-study of a Hispanic man who had an ischemic stroke and was participating in a stroke self-management (SSM) program. He was identified as having comorbid symptoms of anxiety and depression that were not addressed by the SSM program and was subsequently enrolled in the Enhance Psychological Coping after Stroke (EPiC) program. EPiC is a telephone-based cognitive-behavioral treatment integrating mental and stroke-related behavioral health principles that is delivered concurrent to the SSM program. Over the course of six sessions, the participant learned psychological symptom and behavioral monitoring, thought stopping, cognitive restructuring, deep breathing, calming thoughts, social support, and problem-solving skills aimed at overcoming barriers to engagement in behaviors taught in the SSM program. Client-centered psychological distress and behavioral health treatment goals were integrated into each session. The client demonstrated reduced anxiety symptoms and improved stroke SSM behaviors at 6, 12, and 18 weeks after the initiation of treatment. He also improved in disability, social role limitations, quality of life, and stroke self-efficacy at 18 weeks following the initiation of treatment. This case study demonstrates that incorporating an integrated cognitive behavioral treatment to an SSM program can be beneficial for decreasing psychological symptom barriers to SSM, which may reduce the risk of stroke recurrence.

Keywords

depression anxiety stroke self-management behavioral

1 Theoretical and Research Basis for Treatment

Psychological distress, characterized as depression and anxiety, is a common co-occurring problem in stroke patients that complicates recovery and increases risk of stroke recurrence. Approximately 30% of stroke survivors are affected by depression (Benjamin et al., 2017; Campbell Burton et al., 2013; Hackett & Pickles, 2014; Nichols, 2017) and 18% to 29% are affected by anxiety disorders (Hackett & Pickles, 2014). Co-occurring stroke and psychological distress are associated with greater difficulties in physical functioning than stroke alone. Psychological symptoms of decreased energy, poorer sleep, and increased pain (Morris, van Wijck, Joice, & Donaghy, 2013) contribute to decreased participation in physical activity and physical rehabilitation treatment. Inadequate participation in these activities and treatments is associated with decreased physical functioning and increased disability following a stroke (Billinger et al., 2014). Co-occurring stroke and psychological distress are also associated with greater social isolation, which could impede abilities in both work and social interactions (Morris et al., 2013; Shimoda & Robinson, 1998). Psychological symptoms of decreased motivation and fear are associated with reduced engagement in community activities and interactions with family and friends (Mayo, Wood-Dauphinee, Côté, Durcan, & Carlton, 2002). Inadequately treated psychological distress is predictive of declines in physical mobility, social engagement, and quality of life (Dossa, Glickman, & Berlowitz, 2011; Morris et al., 2013; Shimoda & Robinson, 1998; van Mierlo et al., 2014).

Stroke self-management (SSM) programs commonly support patients in behavior change to reduce risk of recurrent stroke and should incorporate behavioral strategies to help patients overcome the emotional consequences of surviving a stroke. However, SSM programs and the extent to which behavioral treatment for comorbid psychological distress is incorporated into SSM is not well described in the literature. Self-management terminology is not routinely used in the context of stroke; when applied, the focus is primarily on preventing stroke through lifestyle behavior changes in nutrition, exercise, medication adherence, and smoking cessation (Parke et al., 2015). SSM programs are patient centered and use a collaborative process between the clinician and patient to support development of self-management skills. Behavior change is achieved via goal setting and patient engagement in action planning, problem-solving, decision-making, resource utilization, and self-tailoring skills. Effective practice of self-management skills can lead to behavior changes and improvements in chronic diseases such as hypertension and diabetes that contribute to overall stroke risk (Wagner et al., 2001).

It is well established that lifestyle behavior change can be attained and sustained through SSM programs. Moreover, SSM programs are associated with improvements in physical function and the chronic conditions that contribute to stroke risk (Billinger et al., 2014). Participants of SSM programs who have comorbid psychological distress, compared with stroke survivors without comorbid psychological distress, have lower self-efficacy and engagement in stroke risk-reduction behaviors, limited social interactions, and poor quality of life (Chau, Thompson, Twinn, Chang, & Woo, 2009; Choi, DiNitto, & Marti, 2016; Dossa et al., 2011; Jones & Riazi, 2011; Sinyor et al., 1986). Current SSM programs focus on reducing the risk of recurring stroke and recovery of physical functioning prior to the stroke levels of motor ability and independence (Sugavanam, Mead, Bulley, Donaghy, & van Wijck, 2013; Tennant, 2007). Despite improvements in this critical area, patients with stroke and co-occurring psychological distress do not demonstrate improvements in depression or anxiety symptom severity, social integration, and quality of life. Although SSM programs may address the emotional consequences of stroke survival generically, there is no evidence that current SSM programs incorporate brief tailored behavioral treatments to specifically address poststroke depression or anxiety. In fact, only 6% of stroke trials address psychological distress (Kapoor et al., 2017). Failing to adequately address the comorbid psychological distress limits the effectiveness of current SSM treatments (Parke et al., 2015).

We sought to establish the feasibility of incorporating brief, tailored treatment for psychological distress by merging two established telehealth SSM programs—the Video-teleconference Self-management TO Prevent Stroke (V-STOP-II) and Enhance Psychological Coping after Stroke (EPiC) programs. Both programs have been previously adapted for video-teleconference (VT) and telephone delivery (Evans-Hudnall et al., 2017). As part of a current open pilot trial within the Lone Star Stroke Network, we implemented V-STOP-II with EPiC as adjunctive support in patients who demonstrated psychological distress (mild to moderate depression or anxiety symptoms). A hub/spoke delivery model was applied, by which trained health care professionals at larger academic hub-sites delivered V-STOP-II to the affiliate spoke-sites via VT and EPiC as adjunctive support via telephone. The V-STOP-II program provides education and skills that support patients in self-management of stroke risk factors to prevent a second stroke and other vascular events. The program is delivered from a central hub to participants at their local health care facility and/or in their home using VT. The V-STOP-II intervention consists of three individual visits and three sessions of self-management group classes over 6 weeks.

In a previous study using the V-STOP protocol, the program received very high approval from participants and providers. Attendance was 87% using VT delivery, which was almost twice as high as in-person delivery of the program (Anderson, Godwin, Petersen, Willson, & Kent, 2013). Participants who completed the program significantly improved stroke-risk knowledge, cognitive symptoms management, communication with health care providers, and goal attainment and decreased risk of recurring stroke. However, similar to other SSM programs, the program did not provide tailored and brief treatment for psychological distress, leaving a significant gap in treatment needs for participants with depression and anxiety. Thus, in the current open trial within the Lone Star Stroke Network, we sought to incorporate EPiC as adjunctive treatment to address this critical treatment gap.

The EPiC program was modified from an evidence-based cognitive behavioral therapy (CBT) targeting psychological distress and weight management (Renn et al., 2017). The EPiC program uses brief CBT (BCBT) for depression and anxiety treatment, tailored to patient-specific needs, to improve coping skills and decrease symptoms of psychological distress (Bond & Dryden, 2002). BCBT has strong empirical backing for treating mood and anxiety disorders and is efficacious among medically ill populations (Kunik et al., 2008). These treatments for patients with co-occurring medical illness address disease-specific self-management behaviors and psychological distress. BCBT is evidence based with positive physical, emotional, and quality of life outcomes in patients with neurological conditions similar to stroke (Calleo et al., 2015). Other psychological treatments, such as acceptance and commitment therapy, have been found to be useful in treatment psychological distress post stroke (Graham, Gillanders, Stuart, & Gouick, 2014). The length of sessions and lack of emphasis on disease management create limitations for use with an SSM program. Thus, incorporating BCBT to address psychological distress may prove to be an essential component for the V-STOP-II program.

The following case study is an example of how BCBT strategies, developed in the EPiC program, were applied as adjunctive therapy in the V-STOP-II program to address mental health barriers and improve SSM outcomes. Our current project tested the efficacy and feasibility of providing EPIC in conjunction with V-STOP-II.

2 Case Introduction

The identifying information has been changed to protect the patient’s privacy. Mr. “Benitos” is a 54-year-old Hispanic man who resides in a predominately low-income community in South Texas. He suffered an ischemic stroke and received inpatient services from a local state-funded hospital that treats predominately Hispanic and indigent patients. Mr. Benitos was approached by a member of the V-STOP-II study staff on the last day of hospital discharge and provided information regarding the SSM program. He expressed interest in participating in V-STOP-II and was screened for its inclusion criteria, which consisted of (a) being >18 years old; (b) having a history of stroke and/or transient ischemic attack (TIA) within 6 months of intake; (c) having two or more uncontrolled stroke risk factors (i.e., blood pressure > 140/90; hemoglobin A1c > 7, low density lipoprotein-cholesterol > 100, being a current smoker, body mass index of 30 kg/m² or higher); (d) reading and speaking English or Spanish; (e) having access to a telephone; (f) being willing to participate in VT group education; and (g) having no current presentation of poorly controlled or severe psychiatric illness, as evidenced by a score in the severe range for psychiatric assessments. After meeting the inclusion criteria and signing the informed consent, Mr. Benitos was enrolled in the study and administered the baseline health behavior, psychological symptom, disability, self-efficacy, social role limitations, and quality of life assessments for V-STOP-II by a research coordinator with a master’s degree in public health. After scoring in the moderate to severe range on the psychological distress assessments, he was then invited to participate in EPiC. He expressed interest in participating, and we enrolled him in the program. He completed V-STOP-II and EPiC simultaneously over a period of 6 weeks.

3 Presenting Complaints

Mr. Benitos demonstrated significant physical and cognitive limitations as a result of the stroke, including decreased physical strength, problems with balance and mobility and limited use of his right hand. His physical limitations caused him to use a wheel chair. He also demonstrated cognitive difficulties, such as slurred and slowed speech, mild aphasia, and word-finding difficulties. He was provided physical rehabilitation exercise to complete at home to improve his physical functioning. However, potentially due to his demonstrated comorbid psychological symptoms, he was noncompliant with his prescribed physical rehabilitation and other SSM behaviors upon discharging from the hospital.

Mr. Benitos presented to EPiC with anxiety symptoms, including feelings of excessive worry, racing thoughts, poor initiation and maintenance of sleep, and restlessness. He described feeling overwhelmed by the change in functioning and doctor’s appointments. He also expressed significant stress as a result of his health care; he did not have insurance and relied on social welfare programs in the area to continue receiving health care and paying his family’s bills. He also described feeling tired and frequently napping during the day because of his difficulty falling and staying asleep at night. He attributed his racing thoughts to his sleep difficulties. Feeling tired during the day and having to take frequent naps caused him to have decreased energy and motivation to engage in his physical rehabilitation exercises needed to improve his physical functioning. Mr. Benitos denied having any history of depression and anxiety symptoms prior to his stroke.

Mr. Benitos expressed interest in the EPiC program to decrease his psychological barriers to practicing physical rehabilitation and other healthy SSM habits. Specifically, he hoped to overcome his sleep, worry, and motivation-related barriers to practicing his physical rehabilitation activities. He ultimately wanted to improve his balance and mobility, to be less reliant on his wheel chair, and to increase his overall functional recovery to the point of returning to work.

4 History

Mr. Benitos was born in Mexico but immigrated to the United States with his parents as a young child. He is married and has two children (a 20-year-old daughter and a 15-year-old son). Both children live in his home. He obtained a high school degree and reported an annual income of under $25,000. He primarily worked jobs requiring physical labor (e.g., home construction and remodeling, pulling and laying new carpet and tile, etc.). Prior to his stroke, he worked for a contractor who assigned him to a construction site where he was helping to build homes. At the onset of treatment, Mr. Benitos reported that he had been working up until he had his stroke but had not worked since.

His family did not have health insurance when he had his stroke. He worked with a health educator to complete the paperwork to receive medical insurance provided by the county for indigent individuals. He was waiting to receive an answer regarding being accepted on the county insurance and, thus, did not have access to physical, occupational, cognitive, or mental health treatment. As a result, he worried about his and his family’s health. He also worried about his ability to obtain additional medical care for stroke rehabilitation post stroke. Mr. Benitos denied receiving regular medical care prior to his stroke but stated he did not have any knowledge of having any chronic illnesses. Notably, he waited 3 days after experiencing stroke-like symptoms before getting medical attention because of a fear of cost due to his lack of medical insurance.

Mr. Benitos denied having a history of psychological disorders or treatment. He also endorsed a history of substance use, though he was minimally forthcoming about this history. Mr. Benitos tested positive for cocaine after admittance to the hospital for his stroke. He reported infrequent use but would not discuss that frequency at length. He agreed to remain sober during his participation in V-STOP-II and EPiC. He had completed urine analysis during follow-up outpatient appointments following his stroke and had not tested positive for cocaine. Mr. Benitos was fully engaged in both the V-STOP-II and EPiC treatments. He presented with his wife, who drove him to all his appointments, to each session, was on time, engaged, and he completed his homework assignments.

5 Assessment

Mr. Benitos was administered psychological, health behavior, stroke recovery and quality of life assessments by an independent evaluator at baseline, post treatment (after the last V-STOP-II and EPiC sessions), and at 12- and 18-week follow-ups; see Table 1 for scores.

Table 1.

Psychological and Rehabilitation Data for Baseline, 6 Weeks, 12 Weeks, and 18 Weeks.

	Baseline	6 weeks	12 weeks	18 weeks
PHQ-8	0	5	4	4
GAD-7	18	6	11	2
Exercise Behaviors	240	X	540	360
Self-Efficacy	3.67	X	8.30	10
Social/Role Limitations	2.25	X	2.25	0
HAQ Disability	1.38	X	1.25	0
CIQ	15	12	11	11

Note. X = data not due at 6 weeks. PHQ-8 = Patient Health Questionnaire−8 (Kroenke et al., 2009); GAD-7 = Generalized Anxiety Disorder−7 (Spitzer, Kroenke, Williams, & Löwe, 2006); Exercise Behaviors (Lorig, 1996);Self-Efficacy = Self-Efficacy for Managing Chronic Disease−6 (Lorig, 1996); Social/Role Limitations (Lorig, 1996); HAQ Disability = Stanford Health Assessment Questionnaire Eight-Item Disability Scale (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001); CIQ = Community Integration Questionnaire (Wilier, Ottenbacher, & Coad, 1994).

Patient Health Questionnaire Depression Scale

The eight-item Patient Health Questionnaire (PHQ-8; Kroenke et al., 2009) is an eight-item measure of depressive symptoms experienced in the past 2 weeks, derived from the nine-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001). Each item is rated on a 4-point Likert-type scale, with responses ranging from 0 = not at all to 3 = nearly every day. The PHQ-8 excludes the suicide item from the PHQ-9 and was as reliable and valid as the PHQ-9 in a large study of military personnel, with high correlation (r = 1.00) between the two measures (Kroenke, Spitzer, Williams, & Löwe, 2010).

Generalized Anxiety Disorder−7

The seven-item Generalized Anxiety Disorder scale (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006) is a seven-item measure that assesses to what degree patients have been experiencing symptoms of GAD during the past 2 weeks. Each item is assessed on a 4-point Likert-type scale with 0 = not at all and 3 = nearly every day. The GAD-7 scale has demonstrated reliability and validity for detecting generalized anxiety, panic, social anxiety, and posttraumatic stress disorders in primary care (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007).

Self-Efficacy for Managing Chronic Disease

The Self-efficacy for Managing Chronic Disease (SeMCD-6) is a six-item scale that measures participants’ self-efficacy across several domains common in many chronic diseases, including symptom control, role function, emotional functioning, and communicating with physicians. Patients respond to each item using a 10-point level of confidence response option set anchored by not at all confident and totally confident. Higher item and total scale scores indicate greater levels of patient confidence in self-managing their chronic conditions. Internal consistency reliability has been reported on scale use with patients with chronic disease and ranged from .77 to .92; test–retest reliability has also been reported on scale use with chronic disease patients and ranged from .72 to .89 (Lorig, 1996).

Exercise Behaviors Scale

The Exercise Behavior Scale comprises six items and contains two subscales: (a) Stretching/Strengthening Exercise (one-item subscale) and (b) Aerobic Exercise (five-item subscale). Participants respond to each item using a 5-point length of time response option set that ranges from none to less than 30 min/week, 30-60 min/week, one-three hours/week, and up to more than three hours/week. Participants’ responses are then converted to set minute values per response category as follows: none = 0 min; less than 30 min/week = 15 min; 30-60 min/week = 45 min; one-three hours/week = 120 min; and, finally, more than three hours/week = 180 min per subscale. Higher item, subscale, and total scale scores indicate greater amounts of patient time spent performing exercise activities. The total scale score from both subscales were calculated. Subscale test–retest reliability is .56 and .72, respectively, for the two subscales (Lorig, 1996).

Stanford Health Assessment Questionnaire Eight-Item Disability Scale

The Stanford Health Assessment Questionnaire Eight-Item Disability Scale is an eight-item scale that rates patients’ perceived level of disability. Patients respond to each of the eight using a 4-point level of difficulty response option set that ranges from without any difficulty to with some difficulty, with much difficulty, and finally to unable to do. Higher item and total scale scores indicate greater levels of patient disability in performing specified activities. Item and total scores can range from 0 to 3, with total score being the mean of the scores of items one through eight. Patient response time frame is the present (i.e., the patient’s present level of disability in regularly performing specified daily activities). Internal consistency reliability has been reported on scale with a normative group of individuals with a variety of chronic disease as .85 (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001).

Social/Role Activities Limitations Scale

The Social/Role Activities Limitations Scale is a four-item assessment of limitations on which patients respond to each item using a 5-point level of interference response option set that ranges from not at all to slightly, to moderately, to quite a bit, and up to almost totally. Higher item and total scale scores indicate greater levels of health interference and limitations in patient social, recreational, household, and shopping activities. Item and total scores can range from 0 to 4, with total score being the mean of the four item scores. Patient response time frame is the past four weeks (i.e., the patient’s perceived level of health-related interference in social, recreational, and maintenance activities over the last approximate 1-month period). Internal consistency reliability has been reported on scale use with chronic disease patients as .91; test–retest reliability has also been reported on scale use with chronic disease patients as .68 (Lorig, 1996).

The SF-12 Health Survey

The 12-item Health Survey is a subset of the 36-item Short Form Health Survey that measures the same eight domains of health (physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health). The 12-item Health Survey is a brief, reliable measure of overall health-related quality of life. The test–retest reliability of the Physical Components Summary was 0.890. Coefficients of 0.760 were observed for the Mental Components Summary (Salyers, Bosworth, Swanson, Lamb-Pagone, & Osher, 2000).

Community Integration Questionnaire

The Community Integration Questionnaire (CIQ; Wilier, Ottenbacher, & Coad, 1994) is a 15-item self-report scale that measures functional ability across multiple domains. Scores on individual items range from 0 to 7, with higher scores indicating greater involvement in their community. The CIQ comprises three subscales, measuring functioning in three settings: Home (e.g., meal preparation, housework, and child care), Social, and Productive (e.g., work). The CIQ has demonstrated good reliability and validity (Sander et al., 2018; Wilier et al., 1994) in a normative population of individuals with a variety of chronic diseases.

6 Case Conceptualization

A cognitive behavioral theory was applied to the present case. At the onset of the EPiC treatment, Mr. Benitos endorsed multiple symptoms of anxiety after having a stroke. He was having significant difficulty sleeping, experiencing interfering worry about his future and his finances, and feeling overwhelmed by his change in quality of life, health, and ability to provide for his family. His anxiety symptoms created barriers to engaging in physical rehabilitation and other SSM tasks daily. Mr. Benitos indicated that his constant feeling of being overwhelmed and that his sleeping difficulties combined with his physical limitations caused him to experience mild depressive symptoms after being discharged home. He described his depressive symptoms as low mood, crying almost daily, anhedonia, difficulty concentrating, and difficulty sleeping. He noted his symptoms of depression as occurring after 1 to 2 weeks of being at home and having difficulty completing tasks. Mr. Benitos’s co-occurring symptoms of anxiety and depression caused him to participate less in his rehabilitation efforts. As a result, he showed slow physical progress, which in turn caused more worries about his physical functioning and mobility in the future. Thus, Mr. Benitos’s cycle of anxiety and depression not only served to maintain his negative emotional symptoms but also delayed his stroke recovery as well.

At the start of EPiC, Mr. Benitos’s efforts at managing his stroke symptoms were minimal and he reported experiencing significant anxiety and depression that interfered with his ability to engage in SSM behaviors. He most readily identified his anxiety symptoms as barriers to his health management, indicating that he was not sleeping and therefore was too tired to manage his health or too anxious and overwhelmed to begin his recovery. Mr. Benitos acknowledged the interfering role that anxiety and depression played in his symptoms and recovery. He did not think his substance use may have contributed to his stoke and or that it might also interfere with his recovery, though he indicated he would not use cocaine in the future.

7 Course of Treatment and Assessment of Progress

Course of Treatment

The treatment presented here was offered in the context of a clinical research project investigating EPiC as an adjunctive intervention for the V-STOP-II program being implemented across six medical facilities in the Southwestern United States. Before participation, Mr. Benitos provided informed consent and a waiver of authorization to release protected health information. The study was approved by Baylor College of Medicine’s Institutional Review Board.

Mr. Benito enrolled in the V-STOP-II program during his first outpatient visit for follow-up care 2 weeks after being discharged from the hospital. The structure and format of V-STOP-II was 6 weekly sessions (three individual and three group) facilitated by a nurse. All V-STOP-II sessions were conducted using a Health Insurance Portability and Accountability Act compliant VT application loaded to the participant’s mobile device. Group sessions also could be attended in person at local outpatient clinics (cf. via smartphone using VT conferencing), where group members used VT to meet with group leaders. Mrs. Benitos was present for all V-STOP-II individual and group sessions. Mr. Benitos’s son was present for two sessions. Each V-STOP-II group session has been designed to help study participants recognize and understand their personal risk for stroke and to coach them in developing self-management skills for stroke risk factor reduction. The three group sessions provided lifestyle SSM education and health behavior goal planning to reduce stroke risk. Group Session 1 provided education regarding what causes a stroke and TIAs, recognition of signs and symptoms of stroke, description of the development of psychological distress after stroke, identification of personal stroke risk factors, making a personal action plan to manage a stroke risk factor, and use of health-related problem-solving skills. Group Session 2 focused on explaining how dietary changes to control stroke risk factors relate to the Dietary Approaches to Stop Hypertension (DASH) diet (a federally supported diet focusing on flexible and balanced eating to promote overall and heart-health; Sacks et al., 2001), portion control, reading food labels and reviewing progress with action plans. Group Session 3 concentrated on teaching cognitive symptom management techniques; adoption of an exercise for strength, flexibility, and endurance; medication compliance; and review of progress with action plans. The phone calls occurred on a weekly basis and lasted 25 to 45 min. They were used to inquire about goal attainment and problem-solving for any potential barriers. The first phone session focused on a review of the medical history, medications, lifestyle practice, and lifestyle stressors and assessment of readiness to change. Patients developed action plans to work on their individual stroke risk factors (e.g., smoking, unhealthy diet, poor medication adherence). Following individual sessions continued to focus on attaining goals identified in the individual action plans.

Given his endorsement of anxiety symptoms during the V-STOP-II baseline assessment, Mr. Benitos was subsequently enrolled in EPiC. EPiC consisted of six individual sessions delivered by a master’s level therapist with training in psychology and health education. The EPiC sessions were provided simultaneous to V-STOP-II. Treatment targeted depression and anxiety symptoms that served as barriers to practicing SSM health behaviors. Evidence-based behavior change techniques (Abraham & Michie, 2008) were used throughout treatment to improve physical health, including goal-setting, self-monitoring, and problem-solving. Sessions were delivered via VT to increase access to care, reduce attrition, and improve acceptability and feasibility. The clinician collaborated with Mr. and Mrs. Benitos, and their son during the two sessions he attended, at the end of each session to review strategies to overcome depression and anxiety-related barriers to practicing his physical functioning exercises and physical activity goals he established in V-STOP-II. Mr. and Mrs. Benitos were provided with a participant workbook, which included health and psychoeducation, review of module skills, and worksheets for practice and self-monitoring.

Session 1: Mental and physical health behaviors

This session focused on health behaviors related to recovery after stroke (i.e., sleep hygiene, physical rehabilitation, medication adherence). Psychoeducation about comorbid stroke, anxiety, and depression was reviewed with Mr. Benitos and his wife, with specific attention to Mr. Benitos’s symptoms of anxiety as interfering with his stroke recovery. Most notable were Mr. Benitos’s complaints of feeling “overwhelmed” and “worried” and having poor sleep causing him to be tired and take naps during the day. As a result, he was not engaging in his physical rehabilitation. Subsequently, he described having depressive symptoms of irritability and decreased motivation. Mr. Benitos indicated that he took his medication consistently. The clinician collaborated with him to identify strategies to address health interfering behaviors when he was feeling anxious and depressed. For example, Mr. Benitos and the clinician discussed appropriate sleep hygiene techniques and set up a daily schedule by which, upon awaking each morning, he would take his medication, engage in his physical rehabilitation exercises, spend 15 min in physical activity (i.e., gardening), shower, and make a list of no more than three things he needed to do that day to reduce his feeling of being “overwhelmed.” Mrs. Benitos offered support by helping create a schedule that fit with their daily activities and writing the schedule for Mr. Benitos, who was unable to write with his dominant hand because of muscle weakness after the stroke. His son offered to support Mr. Benitos by helping to remind him of his scheduled tasks.

Session 2: Deep breathing and thought stopping

The clinician reviewed Mr. Benitos’s progress toward his physical activity goal established in V-STOP-II and improving his sleep hygiene discussed in the prior EPiC session. He denied practicing the sleep hygiene techniques or meeting his goal of engaging in 15 min of physical activity per day (i.e., gardening). The clinician reviewed perceived barriers to achieving this goal. Mr. Benitos noted spending a great deal of time feeling anxious and “drained” and having a hard time falling and staying asleep. Because of expending a great deal of energy feeling anxious and his poor sleep pattern, he did not have energy to engage in physical activity.

This session introduced deep breathing, as a relaxation technique, and thought stopping, as a distress tolerance technique, to target Mr. Benitos’s anxiety. Mr. Benitos readily engaged in deep breathing exercises. He noted feeling less physically anxious and having more clarity with his thoughts after completing them. The “CBT triangle” and bidirectional influences of thoughts, physical feelings, and behaviors on anxiety were discussed. Afterward, Mr. Benitos practiced a thought stopping technique to stop ruminative cycles. He reported that he believed the technique would be helpful, particularly at night when he was “too anxious” to sleep. Mr. Benitos was asked to practice both skills daily at home for homework.

Session 3: Calming thoughts and cognitive restructuring

Mr. Benitos reported using his skills taught in Session 2 and completing his homework assignments. As a result, he engaged in his physical rehabilitation exercises 3 to 4 times a week since the last session, an improvement from completing the exercises 1 to 2 times per week before entering the program. He also reported having a more consistent daily schedule, getting more sleep, engaging in 5 to 10 min of physical activity daily (i.e., gardening) and experiencing improvements in mobility. He took notes himself during session for the first time, after having his wife take notes in previous weeks.

The focus of this session was on learning calming thoughts to counter negative self-statements and identifying and replacing cognitive distortions with more realistic thoughts. Mr. Benitos learned to identify negative statements about his mood and/or physical functioning, such as, “I will never be able to walk again,” and “I cannot spend meaningful time with my children.” The clinician provided psychoeducation about the link between thoughts, feelings, and behaviors; and Mr. Benitos noted how these types of cognitions contributed to increased anxiety, lower mood, and reduced SSM behaviors. He then collaborated with the clinician to identify two calming statements in response to these thoughts (e.g., “I am improving and can keep improving”). Next, Mr. Benitos learned to identify basic cognitive distortions associated with his stroke and associated functioning difficulties and to replace them with more realistic thoughts. For example, he often evidenced all-or-nothing thinking, such that if he did not do his exercises in the morning there was no need to watch his diet the rest of the day or try his exercises later. He was taught to recognize how this cognitive distortion resulted in reduced SSM activities (e.g., laying on the couch rather than exercising), which further exacerbated his symptoms of anxiety and depression. He then developed a more realistic thought (“I have many more opportunities to improve today”). Throughout the session, Mrs. Benitos provided support by assisting her husband in identifying patterns and generating alternative thoughts. She also endorsed her own cognitive distortions related to the family’s financial situation and indicated that both she and Mr. Benitos could benefit from the realistic thoughts identified in session. Mr. Benitos’s son provided support by encouraging his father to focus on what the family had rather than what they did not have. Self-monitoring of cognitive distortions during the upcoming week was encouraged via tracking forms in the participant workbook.

Session 4: Problem-solving

Mr. Benitos reported using his previously thought self-monitoring of cognitive distortions tools to manage his negative thoughts regarding not being physically able to return to work or earn an income. He was able to use calming statements to interrupt his cycle of worry, rumination, and racing thoughts that usually impact his motivation for compliance to his rehabilitation and physical activity self-management exercise. For example, he noted using calming and more balanced statements, such as, “Even doing simple exercises will help my mobility,” when he did not feel like engaging in physical activity; as a result, he went out in the front yard and performed some gardening work.

The focus of the session was on problem-solving, using the SOLVED technique (Select a specific problem, Open your mind to all possible solutions, List the pros and cons of each potential solution, Verify the best solution, Enact the plan, and Decide if the plan worked). Although this technique was applied during the session to one specific problem, Mr. Benitos was taught to use this strategy for a variety of problems, to generalize effects of treatment. Mr. Benitos’s identified problem was poor social support from his sister and teenage son. He noted his son would frequently return home from school and stay in his room, having limited interaction with him and using only basic or single-word responses when he tried to engage him in conversation. Mr. Benitos noted feeling worried and mildly stressed that his son was avoiding and disconnecting from him since he had his stroke. He expressed wanting his son to be involved with his stroke recovery process. First, he listed potential solutions and identified asking his son to spend at least 30 min sitting and talking with him before retiring to his room after school as the best solution to his problem. He anticipated possible barriers (e.g., his son having little interest in his father’s conversation and low energy during the time of day he returns home from school) and provided possible solutions, including skills previously learned in this intervention (e.g., cognitive restructuring). He noted that he was highly motivated and very confident that he could attain this goal. He noted his son had been an inconsistent encourager of his engagement in appropriate SSM habits in general (e.g., healthy eating, appropriate sleep hygiene, and adequate engagement in rehabilitation exercises). Thus, he noted perceived benefits of having the conversation with his son as an even greater involvement in his SSM care and building a closer relationship.

Session 5: Social support for symptom management

Mr. Benitos reported that he was successful with his goal of talking with his son regarding wanting to spend additional time with him each day after school during the previous week. He used his cognitive restructuring skills and his calming statements to overcome anxiety about how his son might receive his request. He also noted feeling unsupported by his sister and described how she would frequently complain about him not helping her with home repairs and make negative statements about him not focusing on her needs rather than asking about his recovery. He felt supported only by his wife. This statement led him to realize that he might benefit from social support for engaging in physical activity and other SSM behaviors (i.e., practicing healthy eating habits during times of worry or stress) from other family members and friends.

The focus of the fifth session was on social support, which dovetailed with problem-solving skills from prior sessions. Mr. Benitos acknowledged receiving positive support and encouragement for improving his SSM skills, particularly healthy eating habits, from Mrs. Benitos but wanted to also solicit such support from his son and sister. He noted how socially isolated he had become since his stroke. Most of his social contact was with fellow coworkers, and he has not been able to return to work. Some coworkers occasionally called to check on him and his recovery. Psychoeducation about assertive communication and eliciting social support for positive SSM care was provided by the clinician. Mr. Benitos learned communication strategies to facilitate approaching his son and sister for support, as well as how to ask his sister to decrease her nagging. He was coached regarding how to discuss his need for additional support and provide specific examples as to how he would like to receive support, especially for managing his symptoms of worry and engaging in his physical mobility and a physical activity regimen. Mr. Benitos also role-played asking for support with the clinician. He found the communication strategies helpful in communicating his needs to his family.

Session 6: Maintenance and relapse prevention

During the final treatment session, the clinician collaborated with Mr. Benitos to create a relapse prevention plan, including identifying triggers for physical inactivity and worry and creating a strategy to overcome these lapses in progress. Notably, Mr. Benitos acknowledged his chronic struggle with the cycle of allowing his anxiety symptoms to deter his engagement in appropriate SSM strategies (especially those regarding physical functioning and physical activity). This represented a balanced self-appraisal and reinforced Mr. Benitos’s confidence and motivation to practice his skills in light of episodes of heightened anxiety. He noted that the most beneficial strategy acquired during the EPiC intervention was the deep breathing exercise. He also noted that practicing this skill helped calm his racing thoughts and physiological response to anxiety and improve his ability to fall asleep. He also noted benefiting from cognitive skills, such as using calming statements and creating realistic thoughts. He was provided with additional resources for mood management, as well as crisis support, to use when needed. He planned to attempt to seek additional SSM resources provided by his county-based insurance and to continue asking for accountability and social support for engagement in positive SSM behaviors. His primary SSM goal was to “walk again and not have to use my wheel chair.” He also planned to pursue seeing a psychotherapist in the community for ongoing mood management.

Assessment of Progress

Table 1 lists assessment scores from baseline, 6 weeks (immediately following the final EPiC treatment session), and 12 and 18 weeks after the final EPiC treatment session. At baseline, Mr. Benitos scored in the moderate severity range for anxiety and the minimal symptom severity range for depression. His scores also indicated that he spent an average of 240 min per week engaged in rehabilitation (aerobic) exercises and general anaerobic physical activity. He scored in the low range of self-efficacy for ability to engage in SSM behaviors (have positive medication adherence, seek medical attention when needed, eat healthy stroke risk reducing foods, etc.). He endorsed a moderate level of integration into his community (e.g., attending community based activities). He participated in health-oriented, community-based activities in an effort to obtain access to health care. However, he endorsed having a moderate amount of limitations that impair performing more intimate social and family-based activities (e.g., going to the movies or to community events). However, he continued to speak and interact with his son on a regular basis. Similarly, he also scored in the moderate range of physical impairment for performing basic daily activities (e.g., cleaning the home) and social, household, and recreational activities. He endorsed a moderate level of impairment in both general physical and mental health–related quality of life.

Immediately post treatment, Mr. Benitos endorsed a clinically significant reduction in anxiety symptoms of 12 points and a mild increase in depression symptoms. The reduction of anxiety symptoms helped better manage psychological barriers to SSM engagement. This increase is likely associated with his greater awareness of symptoms of depression provided by EPiC and his difficulty in returning to his premorbid level of physical functioning after returning home from the hospital. This increase in depression symptoms was not clinically significant and remained in the mild range. He also demonstrated a small decrease in use of community resources.

8 Complicating Factors

Mr. Benitos’s guardedness surrounding discussion of his history of substance abuse complicated treatment. He tested positive for cocaine use during his admission and acknowledged to the medical staff and EPiC interventionists that he used cocaine before his stroke. However, he adamantly noted that he did not want this information revealed to his family. Mr. Benitos’s son was present for some of the sessions, and his wife was present for all EPiC sessions. In respecting Mr. Benitos’s wishes and to maintain rapport with Mr. Benitos, the EPiC interventionist decided to not discuss his drug use behaviors (frequency and possibility of polysubstance use), which may have contributed to his stroke. The EPiC interventionist was also unable to discuss how poorly managed psychological symptoms may have impacted his substance abuse. Instead, the interventionist was able only to provide general psychoeducation regarding the relationship between substance abuse and stroke risk. Being able to talk freely about his substance abuse/use history would have expanded the benefit of the EPiC treatment for Mr. Benitos. The EPiC intervention could have further enhanced and personalized this area of treatment by helping him identify the psychological triggers for his drug use. The interventionist could have then worked collaboratively to develop a treatment plan to manage the symptoms more effectively and use healthy coping skills during times of psychological distress. This additional treatment would have been an important skill to further aid in stroke risk reduction. Despite the difficulty addressing substance use issues based on Mr. Benitos’s requests, the EPiC program still had beneficial effects across multiple physical and psychological functioning domains.

Mr. Benitos possessed a traditional cultural ideology regarding mental health symptoms and treatment. Despite endorsing moderate psychological symptom severity, he did not use the terms depression or anxiety during the EPiC sessions. Despite having endorsed ruminating thoughts that impaired his sleep and engagement in rehabilitation activities, he denied any current or prior history of anxiety disorder. He described himself as being “overwhelmed,” “worried,” and “a little down.” Hispanic men commonly have a stigma against endorsing mental health symptoms (Abe-Kim et al., 2007). This stigma can present complications for identifying mental health symptoms and seeking treatment (Abe-Kim et al., 2007). Mr. Benitos was comfortable and more receptive to EPiC when it was described as a tool for skills building and when his symptoms were described in terms that were not related to a mental health disorder. Thus, it was important for the EPiC interventionist to consistently use language that was comfortable for Mr. Benitos or risk his potential reduced engagement in the program. Using culturally appropriate language helps to destigmatize treatment and improve access to care (Fortney, Burgess, Bosworth, Booth, & Kaboli, 2011).

Although it was not a problem for Mr. Benitos, providing VT-based treatment compared with in-person treatment potentially presents technological and other challenges, which may complicate establishment of strong rapport. An initial in-person meeting or conducting the first session in person to facilitate rapport-building and lessen the disruptiveness of challenges encountered during teleconference treatment may be needed for other patients.

9 Access and Barriers to Care

Mr. Benitos earned a wage that was below the poverty line and could not afford physical and mental health care coverage. He had not received medical care for several years before having his stroke. Having limited access to care acts as a barrier to receiving preventive or self-management services that aid in preventing the first episode or recurrent stroke or other chronic disease (Norrving & Kissela, 2013). Not having access to medical care also acts as a barrier to potentially identifying comorbid mental health symptoms. Primary care settings have incorporated mental health screenings for psychological symptoms. This screening is often the first identification of psychological symptoms and an identified need for treatment. Patients who screen positive for psychological symptoms are likely to be offered a referral for mental health treatment. Mr. Benitos’s lack of access to medical care may have impacted his ability to seek needed physical health treatment and screening and possible referrals for mental health treatment. Providing the treatment via VT also helped overcome his mobility, travel, and financial obstacles. As a result of his participation in EPiC, Mr. Benitos was better able to identify the impact of his mental health symptoms on his physical functioning and overall SSM.

10 Follow-Up

At 12-week follow-up, he demonstrated an increase in his overall mental health–related quality of life, decrease in impairments in motivation and anhedonia, and a continued clinical significant reduction in anxiety symptoms from his baseline score of 18. This brief increase in anxiety symptoms was in the context of increased family stressors and formal termination from his job. Notably, this was still a clinically significant reduction from the initiation of treatment. He described feeling less overwhelmed and worrying less about his physical functioning and financial matters. Because he could manage his symptoms of anxiety, they did not act as barriers to engaging in SSM exercise behaviors.

Mr. Benitos increased his engagement in exercise behaviors (physical rehabilitation exercises and physical activity) by 200 min per week from baseline, despite his increase in anxiety symptoms. As a result, he could take more steps and engage in some physical activities with the use of a walker for balance and mobility. This demonstrated a significant physical milestone for Mr. Benitos, given his goal was to return to walking independently. He also reported improved sleeping habits and decreased napping during the day. He demonstrated increased confidence in his ability to engage in appropriate SSM behaviors, by 5 points from baseline. His improved anxiety management and engagement in SSM behaviors may have attributed to his increased self-confidence.

Despite his increased physically active and mobility, he did not perceive his physical health as improved because he had not returned to premorbid functioning and was unable to return to work during the time frame he expected. He also reported a decrease in his physical health–related quality of life from baseline. However, he did not experience any declines in his perceived low level of limitations in his social functioning or level of disability. He noted maintaining the same level of social interaction with his immediate family despite his lack of return to premorbid functioning. He had a small decrease in engagement in his community and family functioning. He engaged in fewer activities with his extended family (sister) and within his community but continued to spend time with his immediate family (wife and son). He noted that his decreased motivation and continued physical limitations acted as barriers to his level of engagement in community and some extended family activities.

At 18-week follow-up, 3 months after the last EPiC and V-STOP-II session, Mr. Benitos’s symptoms of depression remained constant, but he demonstrated another clinically significant reduction in anxiety symptoms. He further noted continuing to practice the deep breathing, thought stopping, and calming statement exercises he learned while participating in EPiC. His symptoms of anxiety were reduced by 9 points from the 12-week follow-up and by 16 points from baseline assessments. His symptoms decreased by greater than 50%, a meaningful difference, and were no longer in the clinical range of severity (Spitzer et al., 2006). He described primarily using his walker rather than his wheel chair for mobility. He described not feeling well due to getting over a cold in the previous week. As a result, he engaged in fewer minutes exercising than at his 12-week assessment. This was still an increase of 120 min spent engaging in exercise behavior from his baseline assessment. He perceived himself as having a high confidence level in his ability to perform SSM behaviors and no perceived disability or limitations in social role limitations. He also experienced a return to baseline functioning in mental health–related quality of life. Physical health–related quality of life increased from the 12-week assessment. Depressive symptoms remained in the same category as the 12-week assessment (mild) and demonstrated a greater awareness of mental health versus physical health symptomology.

11 Treatment Implications of the Case

EPiC is an integrated mental and behavioral health treatment within the context of an SSM program. Mr. Benitos received no prior mental health treatment but presented with clinically significant symptoms of anxiety at the start of the EPiC treatment. His difficulties initially engaging in SSM behaviors were intensified by his poorly managed mental health symptoms. Performing appropriate SSM, especially physical rehabilitation and physical activity exercises, post stroke is essential to decreasing risks for stroke recurrence and disability (Billinger et al., 2014). Mr. Benitos’s decreased motivation, debilitating worry, and ruminating thoughts initially interfered with his engagement in SSM habits. His decreased engagement in SSM behaviors is in line with studies demonstrating that individuals with stroke and comorbid psychological distress are more likely to face barriers engaging in secondary SSM behaviors than individuals with stroke without comorbid psychological distress (Jones & Riazi, 2011; Sinyor et al., 1986; Tagay, Schlegl, & Senf, 2010). It is also in line with prior V-STOP-II findings of improvements in stroke knowledge and improved attendance to doctor’s appointments but limited engagement in actual self-management behaviors (Anderson et al., 2013). There was also antidotal evidence that participants with psychological distress had less benefit from participation. Providing an adjunctive treatment to V-STOP-II that integrated mental and health behavior treatment goals helped Mr. Benitos develop skills for managing anxiety and depression symptom barriers to engaging in SSM behaviors. This aided him in practicing specific strategies to cope with anxiety and depression symptoms that were detrimental to successfully engaging in SSM behaviors taught in V-STOP-II that are necessary for improved physical functioning and reducing secondary stroke risk.

12 Recommendations to Clinicians and Students

This case study illustrates successful inclusion of a treatment that addresses psychological distress to an SSM program. Providing EPiC as an adjunctive program to V-STOP-II, illustrated here, addresses a common gap in treatment in SSM programs. The approach of providing an SSM and psychological distress treatment simultaneously demonstrated anxiety symptom reduction in addition to improved health behaviors and stroke risk reduction in Mr. Benitos. Clinicians and students should consider the benefits of addressing psychological distress in patients with stroke and related health conditions. For this population, targeting SSM and psychological distress may provide a more holistic treatment and better health behavior outcomes than participation in SSM programs or current standard psychological distress treatment alone.

Potential benefits of this treatment to participants are vast. Not only does EPiC reinforce health behavior concepts and personalized goals from V-STOP-II, but it also allows for individualized treatment of specific problems patients may face because of their comorbid psychological distress. The modular nature of EPiC also has the potential to increase participation and adherence to treatment, as the patient can choose topics relevant to them based on their needs. Mr. Benitos’s Sessions 2 to 5, which covered deep breathing/thought stopping, calming thoughts/cognitive restructuring, problem–solving, and social support, were elective modules. Using an individualized approach can improve treatment effectiveness. In addition, introduction of psychological and health based skills allows for reduction of both psychological and physiological symptoms, as these can exacerbate one another.

Next steps in this treatment would be the consolidation of V-STOP-II and EPIC into one integrated treatment for participants who have psychological distress. This would further minimize treatment burden on the patient and allow concurrent treatment of medical and psychological symptoms. The current study relies primarily on qualitative and self-report data, particularly for the stroke SSM outcomes. This may account for Mr. Benitos’s high level of baseline physical activity. Using clinical and self-report assessments will provide a broader and detailed understanding of SSM behaviors and will also be included in the next steps. This will provide a broader understanding of improvements in SSM behaviors and clinical improvements, based on secondary stroke risk reduction. Also, an examination of the efficacy of providing V-STOP-II and EPIC simultaneously is needed.

This present case highlights the need to provide both SSM and brief CBT treatment to individuals who are demonstrating psychological distress post stroke. In this case, the V-STOP-II and EPiC treatments were delivered simultaneously. The EPiC treatment helped Mr. Benitos overcome psychological barriers to engagement in rehabilitation, physical activity, and sleep hygiene–related SSM behaviors. He demonstrated improvements in physical mobility and clinically significant change in anxiety symptoms. These gains were maintained 18 weeks post treatment.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Evans-Hudnall is supported by Texas Lone Star Stroke Project. This work was partially supported with the use of resources and facilities at the Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). The sponsors played no role in study design; the collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the article for publication. The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine.

Author Biographies

Gina Evans-Hudnall is an assistant professor in Psychiatry and Behavioral Medicine at Baylor College of Medicine and a Clinical Psychologist at the Michael E Debakey VA Medical Center. She conducts research that focuses on using integrated treatments to improve health outcomes in Veteran and underserved individuals with comorbid physical and mental health symptoms.

Adrienne Johnson is a post-doctoral fellow at the Wisconsin Veteran Affairs Medical Center. She conducts research that focuses on improving tobacco cessation using novel and integrated treatments.

Barbara Kimmel is a senior project manager. She specializes in organizing and facilitating studies that focus on improving stroke self-management in underserved individuals.

Charles Brandt is a clinical psychologist. He specializes in conducting treatments for obsessive compulsive disorder in adult males and females.

Ngozi Mbue is a post-doctoral fellow at the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety. She conducts research that focuses on improving diabetes self-management in underserved individuals.

Evan Lawson is a Master’s level graduate student in the department of clinical psychology. He is a research assistant on assists with data entry, data collection and other tasks for various research projects.

Jane Anderson is the associate director in the Department of Neurology at Baylor College of Medicine and a nurse practitioner at the Michael E. Debakey VA Medical Center. She conducts research that focuses on using technology to improve stroke self-management behaviors and outcomes in Veterans and underserved individuals.

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