Developing consensus-based clinical competencies to guide stroke clinicians in the implementation of psychological care in aphasia rehabilitation.

Background People with aphasia experience depression and anxiety associated with negative outcomes across a range of time post-stroke. Stroke clinicians are well-positioned to facilitate low-intensity psychotherapeutic interventions after aphasia (e.g. mood screening, behavioural activation, problem-solving therapy, relaxation therapy); however, they self-report a lack of knowledge, skills and confidence to do so. The Theoretical Domains Framework (TDF) provides a lens through which to view and target clinician behaviours and training needs in this area of practice. The aim of this study was to develop and gain consensus on items for a rating scale of clinical competencies in facilitating individual-based, low-intensity psychotherapeutic interventions for people with aphasia. Methods An e-Delphi methodology using focus groups and survey rounds was used to gain consensus on clinical competencies considered important. Results Eight stroke clinicians (speech pathologists and psychologists), two people with aphasia and three family members participated in one of four focus groups. Four themes were derived from the data: (1) Communication support, (2) Assessment and therapy structure, (3) Interpersonal skills, and (4) Needs of the significant other (family or friend). Themes informed an initial list of 23 self-rated and observer-rated competency items. Following two rounds of e-Delphi surveys, 11 stroke clinicians (six speech pathologists and five psychologists) reached consensus (80-100%) for 19 competencies. Conclusions The Psychological Care in Aphasia Rehabilitation Competency scale offers a preliminary list of items to guide and train clinicians to implement low-intensity psychotherapeutic interventions for people with aphasia.

Aphasia Depression and Psychological Therapy (ADaPT): Perspectives of People with Post-Stroke Aphasia on Participating in a Modified Cognitive Behavioral Therapy.

Aphasia, a communication disability commonly caused by stroke, can profoundly affect a person's mood and identity. We explored the experiences of stroke survivors with aphasia and depression who received a modified cognitive behavioral therapy (CBT)-based psychological intervention. The therapy is manualized with a flexible treatment protocol, including 10 individually based therapy sessions (+2 booster sessions) either via telehealth or in person. Six participants with chronic aphasia (60% of the total sample) participated in in-depth interviews that were analyzed using reflexive thematic analysis. Two core themes were derived from the data: the first theme, helpful elements of therapy-doing enjoyable activities, new ways of thinking, problem solving, working with the experienced therapist, and using telehealth; and the second theme, making progress-mood, communication, acceptance of the 'new me', and improving relationships. All participants found the therapy to be helpful in managing mood problems with various elements being beneficial depending on the individual, highlighting the importance of tailoring the intervention. Therefore, delivering modified CBT to individuals with aphasia is likely to be acceptable both in person and through telehealth. Further evaluation of the intervention and its impact on mood would be beneficial.

Aphasia, depression, and psychological therapy (ADaPT): A single case design evaluation of a modified cognitive behavioural therapy to treat depressive symptoms in stroke survivors with aphasia.

Cognitive behavioural therapy (CBT) can effectively treat depression in the general population, but there is a lack of studies evaluating CBT tailored to specific cognitive and communication needs of individuals with post-stroke aphasia. We aimed to evaluate the feasibility and preliminary efficacy of a modified CBT intervention to ameliorate depressive symptoms. An ABA withdrawal/reversal single case design with concurrent multiple baselines (2.5, 4.5, or 6.5 weeks) was repeated across 10 participants (six male, four female) with post-stroke aphasia and self-reported depression. Participants completed 10 individual intervention sessions with a clinical neuropsychologist and a 4-week follow-up. The primary outcome was self-rated depression, and secondary outcomes included observer-rated symptoms of depression and anxiety. Data were analysed visually and statistically controlling for baseline trend. Feasibility was addressed by analysing recruitment and retention rates, treatment adaptations, and fidelity ratings. Three participants self-reported decreased depression levels during the intervention phase, which was sustained for two participants. Four additional participants improved during the follow-up phase. Close others reported sustained improvements in depressive symptoms (six participants) and anxiety symptoms (seven participants). Modified CBT appears feasible and potentially efficacious in reducing depressive symptoms in post-stroke aphasia. A randomized controlled trial is warranted, and should consider additional treatment sessions.

Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques - A prospective observational study.

OBJECTIVES: To compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge. DESIGN: A prospective observational study. SETTING: Adult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022. MAIN OUTCOME MEASURES: Incidence and anatomical distribution of PIs during ICU stay for "Face Down" and "Swimmers Position" as well as on ICU and hospital discharge. RESULTS: We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed. CONCLUSION: Swimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge. IMPLICATIONS FOR CLINICAL PRACTICE: There are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.

Inclusion of People With Aphasia in Stroke Trials: A Systematic Search and Review.

BACKGROUND: Although people with aphasia (PwA) represent 30% of stroke survivors, they are frequently excluded from stroke research, or their inclusion is unclear. Such practice significantly limits the generalizability of stroke research, increases the need to duplicate research in aphasia-specific populations, and raises important ethical and human rights issues. OBJECTIVE: To detail the extent and nature of inclusion of PwA in contemporary stroke randomized controlled trials (RCTs). METHODS: We conducted a systematic search to identify completed stroke RCTs and RCT protocols published in 2019. Web of Science was searched using terms "stroke" and "randomized controlled trial". These articles were reviewed by extracting rates of PwA inclusion/exclusion, whether "aphasia" or related terms were referred to in the article or supplemental files, eligibility criteria, consent procedures, adaptations made to support the inclusion of PwA, and attrition rates of PwA. Data were summarized, and descriptive statistics applied when appropriate. RESULTS: 271 studies comprising 215 completed RCTs and 56 protocols were included. 36.2% of included studies referred to aphasia/dysphasia. Of completed RCTs, only 6.5% explicitly included PwA, 4.7% explicitly excluded PwA, and inclusion was unclear in the remaining 88.8%. Among RCT protocols, 28.6% of studies intended inclusion, 10.7% intended excluding PwA, and in 60.7%, inclusion was unclear. In 45.8% of included studies, sub-groups of PwA were excluded, either explicitly (ie, particular types/severities of aphasia, eg, global aphasia) or implicitly, by way of ambiguous eligibility criteria which could potentially relate to a sub-group of PwA. Little rationale for exclusion was provided. 71.2% of completed RCTs did not report any adaptations that could support the inclusion of PwA, and minimal information was provided about consent procedures. Where it could be determined, attrition of PwA averaged 10% (range 0%-20%). CONCLUSION: This paper details the extent of inclusion of PwA in stroke research and highlights opportunities for improvement.

Co-designing a digital mental health platform, "Momentum", with young people aged 7-17: A qualitative study.

Introduction: Digital mental health interventions (DMHIs) offer a promising alternative or adjunct treatment method to face-to-face treatment, overcoming barriers associated with stigma, access, and cost. This project is embedded in user experience and co-design to enhance the potential acceptability, usability and integration of digital platforms into youth mental health services. Objective: To co-design a digital mental health platform that provides self-directed, tailored, and modularised treatment for young people aged 7-17 years experiencing anxiety, depression and other related problems. Methods: Sixty-eight participants, aged 7-17 years, engaged in one of 20 co-design workshops. Eight workshops involved children (n = 26, m = 9.42 years, sd = 1.27) and 12 involved adolescents (n = 42, m = 14.57 years, sd = 1.89). Participants engaged in a variety of co-design activities (e.g., designing a website home page and rating self-report assessment features). Workshop transcripts and artefacts (e.g., participants' drawings) were thematically analysed using Gale et al.'s Framework Method in NVivo. Results: Six themes were identified: Interactive; Relatable; Customisable; Intuitive; Inclusive; and Personalised, transparent and trustworthy content. The analysis revealed differences between children's and adolescents' designs and ideas, supporting the need for two different versions of the platform, with age-appropriate activities, features, terminology, and content. Conclusions: This research showcased co-design as a powerful tool to facilitate collaboration with young people in designing DMHIs. Two sets of recommendations were produced: 1) recommendations for the design, functionality, and content of youth DMHIs, supported by child- and adolescent-designed strategies; and 2) recommendations for clinicians and researchers planning to conduct co-design and intervention development research with children and adolescents.

Preventing depression in aphasia: A cluster randomized control trial of the Aphasia Action Success Knowledge (ASK) program.

BACKGROUND: Stroke patients with aphasia and their caregivers have higher incidence of depression than those without aphasia. AIMS: The objective of the study is to determine whether a tailored intervention program (Action Success Knowledge; ASK) led to better mood and quality of life (QoL) outcomes than an attention control with a 12-month end point at cluster and individual participant level. METHODS: A multi-site, pragmatic, two-level single-blind cluster randomized controlled trial compared ASK to an attention control (secondary stroke prevention program). Ten metropolitan and 10 non-metropolitan health regions were randomized. People with aphasia and their family members were recruited within 6 months post-stroke who scored ⩽12 on the Stroke Aphasic Depression Questionnaire Hospital Version-10 at screening. Each arm received manualized intervention over 6-8 weeks followed by monthly telephone calls. Blinded assessments of QoL and depression were taken at 12 months post-onset. RESULTS: Twenty clusters (health regions) were randomized. Trained speech pathologists screened 1744 people with aphasia and 373 participants consented to intervention (n = 231 people with aphasia and 142 family members). The attrition rate after consent was 26% with 86 and 85 participants with aphasia in the ASK arm and attention control arm, respectively, receiving intervention. Of those 171 who did receive treatment, only 41 met the prescribed minimum dose. Multilevel mixed effects modeling under the intention-to-treat protocol showed a significant difference on the Stroke and Aphasia Depression Questionnaire-21 (SADQ-21, N = 122, 17 clusters) in favor of the attention control (ß = -2.74, 95% confidence interval (CI) = -4.76 to -0.73, p = 0.008). Individual data analysis using a minimal detectable change score for the SADQ-21 showed the difference was not meaningful. CONCLUSION: ASK showed no benefit over attention control in improving mood and preventing depression in people with aphasia or their family members.

Prognostication in post-stroke aphasia: Perspectives of people with aphasia on receiving information about recovery.

Many people with aphasia (language impairment post-stroke) want to know their prognosis for recovery, yet current understanding of their experience of receiving prognoses is limited. Such insight is necessary to inform clinical practice in formulating and delivering aphasia prognoses, especially given the psycho-emotional distress and secondary adverse effects on recovery associated with conversations about prognosis. We sought an in-depth understanding of the perspectives of people with aphasia in relation to receiving prognoses post-stroke, with the aim of informing an evidence-based approach to aphasia prognostication in clinical practice. Semi-structured interviews, facilitated by communication support strategies, were conducted one-to-one with eight people with aphasia (ranging from mild to very severe) 3-12 months post-stroke. Reflexive thematic analysis was used to analyse the qualitative data, yielding two over-arching themes: (1) How would you know without knowing me?; (2) I need to know, but I don't want to know. Our findings illustrate issues of mistrust within the patient-clinician relationship, and complex emotions relating to hope and post-stroke adjustment. The present insight into the lived experience of receiving aphasia prognoses highlights the need for focused consideration of personal definitions of normalcy, measures for fostering trust, and the role of prognostic uncertainty.

Development of the "Kalmer" relaxation intervention: co-design with stroke survivors with aphasia.

PURPOSE: Anxiety is common after stroke and more prevalent in survivors with aphasia. Relaxation is an effective first-line therapy. The current study aimed to obtain the perspectives of stroke survivors with aphasia to inform the development of an accessible, technology-based, relaxation intervention. MATERIALS AND METHODS: Qualitative co-design methods were used with twelve people with aphasia after stroke. The "Kalmer" Relaxation treatment package materials were iteratively based on participants' experiences and preferences; barriers and facilitators to treatment compliance were explored. Participants were also asked to consider how the intervention might be evaluated in a research trial. RESULTS: A thematic analysis highlighted the importance and need for the development of an appropriate and inclusive relaxation product, to be implemented by health professionals early post-stroke. Several behavioural strategies to improve treatment adherence were recommended. Participants had varying perspectives on clinically meaningful treatment outcomes. CONCLUSIONS: Overall, a co-designed accessible relaxation product was viewed as a necessary component of usual stroke care. Acceptability and feasibility and preliminary efficacy of the "Kalmer" intervention should be trialled in future studies. IMPLICATIONS FOR REHABILITATIONCo-designing psychological interventions for people with aphasia after stroke is needed to meet the needs of this at-risk population.Technology-based relaxation interventions to manage anxiety after stroke are viewed positively by people with aphasia and deemed acceptable and feasible.Clinical trials of these co-designed relaxation interventions are required before recommending integration into routine practice.

A survey of speech pathologists' opinions about the prospective acceptability of an online implementation platform for aphasia services.

BACKGROUND: Online knowledge translation (KT) approaches are becoming increasingly prevalent within healthcare due to their accessibility and facilitation of international support networks. Online platforms enable timely and far-reaching dissemination of current evidence and best-practice recommendations. Although there is potential to improve the uptake of rehabilitation guidelines, it is essential to consider the acceptability of online approaches to healthcare professionals to ensure their successful integration within everyday clinical settings. AIMS: To establish the prospective acceptability of a theoretically informed online intervention for speech pathologists, Aphasia Nexus: Connecting Evidence to Practice, that aims to facilitate the implementation of aphasia best practice. METHODS & PROCEDURES: A mixed-methods multinational electronic survey based on the Theoretical Framework of Acceptability (TFA) completed by aphasia researchers and clinicians. OUTCOMES & RESULTS: A total of 43 participants completed the survey with 91% (n = 39) indicating that they would use Aphasia Nexus. Understanding the intervention and how it works (intervention coherence as per the TFA) was the key factor influencing the likelihood of integration within everyday clinical practice. Participants identified potential areas where the intervention could influence service change and also recommended further design and content changes to improve the intervention. CONCLUSIONS & IMPLICATIONS: Aphasia Nexus is an acceptable platform for further feasibility testing in the form of a pilot trial within an Australian-based health service. The study progresses the theory of TFA as it was a valuable framework facilitating the identification of prominent factors influencing acceptability. The study also informs further intervention refinements in preparation for the next stage of research. WHAT THIS PAPER ADDS: What is already known on the subject Online strategies have the potential to enhance KT and promote the uptake of rehabilitation guidelines. An online intervention, however, can only be effective if implemented well. For this reason, it is essential to establish the acceptability of online interventions to the intended recipients and therefore increase the likelihood of successful implementation. What this paper adds to existing knowledge This study used a theoretically based framework to establish the acceptability of an online implementation intervention, Aphasia Nexus, to multinational aphasia clinicians and researchers. It demonstrated the value in identifying the prominent factors influencing acceptability to inform further intervention refinements and warrant continuing research. What are the potential or actual clinical implications of this work? Speech pathologists should use online platforms to drive the implementation of best practice on an international scale. It is important for clinicians to have an in-depth understanding of online interventions and how they work to enhance their successful uptake into routine clinical practice. Aphasia Nexus is an acceptable online platform for implementing best practice in aphasia.

Evaluating the feasibility and acceptability of the Mood Assessment Post-Stroke (MAPS) mood screening training.

Mood problems are common after stroke, and screening is recommended. Training may support staff knowledge and implementation of screening, but the feasibility of training programmes in the Australian healthcare system has not been formally established. This study aimed to assess the feasibility of a mood screening training for a multidisciplinary team (MDT) of stroke clinicians working in a post-acute inpatient rehabilitation service.Twelve staff from a rehabilitation service at a major hospital in Sydney, Australia participated in a 3-h interactive training session. The feasibility of running the course, assessment of knowledge gained via a consolidation exercise and quiz and acceptability of the training were assessed via focus groups.The in-person modality of the training hindered recruitment and assessment of participants' knowledge, though the actual measures themselves appeared appropriate. Nine participants provided feedback in two focus groups. Thematic analysis identified positive reactions to the training. However, low self-efficacy persisted and organisational/socio-cultural barriers to implementation emerged. Following training, the medical officers of the MDT had successfully implemented routine screening.Overall, the training appeared acceptable and to foster knowledge in staff. However, limitations to recruitment and administering evaluations were identified. The development of flexible online training may improve future evaluations of screening training programmes/pathways.

Pilot trial of the online implementation intervention Aphasia Nexus: Connecting Evidence to Practice.

PURPOSE: Aphasia Nexus: Connecting Evidence to Practice is a theoretically-based online implementation intervention designed to overcome the barriers related to the implementation of intensive and comprehensive aphasia services. The objective was to establish the feasibility of incorporating Aphasia Nexus within routine clinical practice through an evaluation of: (1) its potential to positively influence the intensity and/or comprehensiveness of aphasia services; (2) the ability of selected outcome measures to capture changes to factors influencing implementation; and (3) the acceptability of the website to on-site speech-language pathologists (SLPs). METHOD: A single arm pre-post pilot trial was conducted within an Australian health service. The design collected qualitative and quantitative pre-post data in the form of therapy logs, behaviour change questionnaires, and a post-intervention focus group. Data were collected one week prior to, and one week following, a 12 week implementation period where participating SLPs (n = 5) were provided access to the Aphasia Nexus website. RESULT: Quantitative data revealed improvements in the median time per patient with aphasia from 65 to 115 minutes per week (intensity/dose), an additional 50 minutes per week. SLPs trialled at least one new therapy approach (Attentive Reading and Constrained Summarisation) and service delivery model (group therapy) representing an increase in the comprehensiveness of their services to patients. SLPs perceived a reduction in the barriers associated with the promotion of new aphasia services. Qualitative analysis of focus group discussion revealed that participants considered Aphasia Nexus in the overarching theme of practice efficiency (obtaining the best outcome from the least amount of effort) and the sub-themes of accessible therapy resources and the prioritisation of time. CONCLUSION: Overall, Aphasia Nexus was considered a useful clinical tool with the potential to positively influence clinical aphasia practice. These results will inform further implementation intervention refinements and will inform the methodology of future research.

Towards the Consistent Inclusion of People With Aphasia in Stroke Research Irrespective of Discipline.

People with aphasia have been systematically excluded from stroke research or included without the necessary modifications, threatening external study validity. In this paper, we propose that 1) the inclusion of people with aphasia should be considered as standard in stroke research irrespective of discipline and that 2) modifications should be made to stroke research procedures to support people with aphasia to achieve meaningful and valid inclusion. We argue that outright exclusion of this heterogenous population from stroke research based purely on a diagnosis of aphasia is rarely required and present a rationale for deliberate inclusion of people with aphasia in stroke research. The purpose of this paper is fourfold: 1) to highlight the issue and implications of excluding people with aphasia from stroke research; 2) to acknowledge the current barriers to including people with aphasia in stroke research; 3) to provide stroke researchers with methods to enable inclusion, including recommendations, resources, and guidance; and 4) to consider research needed to develop aphasia inclusive practices in stroke research.

Prognostication in Poststroke Aphasia: Perspectives of Significant Others of People With Aphasia on Receiving Information About Recovery.

PURPOSE: Knowing what to expect poststroke is important for many significant others of people with aphasia, yet an understanding of their perceptions and preferences in receiving prognostic information is limited. This knowledge is needed to inform the formulation and delivery of aphasia prognoses as conversations about prognosis can be harmful or helpful depending on their alignment with key stakeholder perspectives. Our preliminary study sought insight into the perspectives of significant others of people with aphasia on receiving prognostic information, with an aim toward informing evidence-based practice in aphasia prognostication. METHOD: We interviewed seven significant others of people with aphasia, 3-12 months poststroke. The interviews were semistructured, conducted one-to-one, and analyzed qualitatively using reflexive thematic analysis. RESULTS: Five themes were drawn from the interviews: (a) You don't know what you don't know. (b) Having them alive is the best you can ask for. (c) Recovery in the eye of the beholder. (d) Outcomes don't matter unless they help me help them. (e) It's my prognosis too if I'm living with aphasia. CONCLUSIONS: A significant other's prognosis-related perceptions and preferences are products of their poststroke reality and may inadvertently shape that of the person with aphasia. In order to facilitate recovery, prognostication practices need to consider the needs of significant others both as providers of care and as requiring care themselves for their first-hand experiences of third-party disability.

A systematic review of non-drug interventions to prevent and treat anxiety in people with aphasia after stroke.

PURPOSE: To investigate the effectiveness of non-drug interventions for people with aphasia in the prevention and/or treatment of anxiety post-stroke as either a primary or secondary outcome. MATERIALS AND METHODS: A systematic search of Medline, CINAHL, PsycINFO and Cochrane Library up to March 2021 was carried out. Studies of stroke populations were included if people with aphasia represented 25% or more of the enrolled participants. Quality of the evidence was assessed. A narrative synthesis of results is presented. The PROSPERO record ID for this study is 106451. RESULTS: Ten studies were included: five randomised controlled trials (RCTs), a single case experimental design, and four pre-post studies. The quality of the RCT trials was at least adequate but none demonstrated a benefit to anxiety outcomes. Those studies that reported benefit were of lower-level evidence with respect to National Health and Medical Research Classifications. No studies were found that evaluated the prevention of anxiety after stroke for people with aphasia. CONCLUSION: Definitive conclusions about the effectiveness of non-drug interventions for the prevention and/or treatment of anxiety in people with aphasia post-stroke cannot be made. Interventions that may show promise for those with aphasia and symptoms of anxiety include mindfulness meditation, modified cognitive behaviour therapy, unilateral nostril breathing, and the "Enhance Psychological Coping after Stroke" programme. Further high-quality research with better reporting of the inclusion of participants with aphasia and their specific sub-group results are required.Implications for RehabilitationIt is important for rehabilitation professionals to consider prevention of anxiety post-stroke as well as treatment.Mindfulness meditation, modified cognitive behavioural therapy, unilateral nostril breathing, and the and the "Enhance Psychological Coping after Stroke" programme may be of benefit to people with aphasia post-stroke.Adapting intervention protocols to be more communicatively accessible and training health professionals in supported communication may help people with aphasia engage in psychological therapies.

Development of an online implementation intervention for aphasia clinicians to increase the intensity and comprehensiveness of their service.

PURPOSE: To describe the process and outcome of a user and theory informed online intervention for speech pathologists targeting the implementation of intensive and comprehensive aphasia services. METHODS: The design process followed the eight steps outlined by the Behaviour Change Wheel and incorporated the principles of Integrated Knowledge Translation (IKT). Eight speech pathology researchers and clinicians from four countries (Australia, Canada, the United Kingdom and Ireland) contributed to three focus groups via videoconference. RESULTS: The online platform, Aphasia Nexus: Connecting Evidence to Practice, provides resources, guidance and support for speech pathologists seeking to improve the intensity and comprehensiveness of their aphasia service. A collaborative and iterative design process facilitated the creation of an intervention envisioned by participants. CONCLUSIONS: The website contains both interactive elements and resource links which have been arranged under the three headings of resources, action and support. The inclusion of multi-national researchers and clinicians benefitted a design process to make implementation more likely.IMPLICATIONS FOR REHABILITATIONTheoretically informed implementation interventions aim to change the everyday clinical practice of health workers.An online platform has been developed to support speech pathologists' implementation of intensive and comprehensive aphasia services.A collaborative design process can be beneficial in creating an intervention that is relevant to research-users and is more likely to be implemented.

Prognostication in post-stroke aphasia: speech pathologists' clinical insights on formulating and delivering information about recovery.

PURPOSE: For people with post-stroke aphasia, "Will I get better?" is a question often asked, but one that is intellectually and emotionally demanding for speech pathologists to answer. Speech pathologists' formulation and delivery of aphasia prognoses is varied and there is limited evidence for optimising practice. We aimed to understand speech pathologists' clinical experiences, reasoning, and support needs in aphasia prognostication. MATERIALS AND METHODS: Twenty-five Australian speech pathologists working with people with aphasia participated in individual, semi-structured interviews. Their age, level of experience, work setting, and location were maximally varied. Interview responses were analysed qualitatively using thematic analysis. RESULTS: Five themes were drawn from the interviews: (1) prognostic challenges are shared but not voiced; (2) truth is there's no quick fix; (3) recovery is more than words; (4) the power of words; and, (5) prognostic competence is implicit. CONCLUSIONS: Speech pathologists use implicit competencies to formulate and deliver aphasia prognoses. A patient-centred, holistic contextualisation of aphasia recovery may enable realistic, optimistic, and constructive conversations about prognosis. These conversations may have therapeutic potential if prognostic uncertainty, emotional adjustment, and conditional outcomes are carefully addressed. Future research should seek to understand the perceptions and preferences of people with aphasia and their significant others.Implications for RehabilitationAphasia prognostication in clinical practice is complex and nuanced, thus increased clinical and research focus is warranted to ensure key stakeholder needs are met.Conversations about prognosis may be more meaningful to people with aphasia if recovery is conceptualised as encompassing impairment, activity, and participation outcomes.Given the implicit competencies required for prognostication, a structured approach to reflective practice and experience-based training may be beneficial.Conversations about prognosis may have therapeutic value, but further research is needed to explore this potential.

Stroke health professionals' management of depression after post-stroke aphasia: a qualitative study.

Background: People with post-stroke aphasia commonly experience mental health conditions, with depression having a high prevalence. An understanding of current practice may inform ways to improve psychological care for people with aphasia.Aim: To explore current practice for managing depression after post-stroke aphasia from the perspective of stroke health professionals.Method: Five semi-structured focus groups were conducted with 39 stroke health professionals across the care continuum. Focus groups were transcribed verbatim and analyzed using the method of Interpretive Description.Results: Analysis of verbatim transcripts revealed four core themes: (1) concomitant aphasia and depression after stroke is a challenging area of rehabilitation, (2) mood difficulties and depression are not always a high stroke rehabilitation priority, (3) approaches to identification and management are ad hoc, and (4) stroke health professionals are trying to bridge the gap between clients' psychological care needs and limited services. Sub-themes were also identified.Conclusion: This study demonstrates that health professionals are challenged by and limited in managing depression after post-stroke aphasia. Health professionals have the opportunity to improve services through the translation of evidence-based interventions. The integration of mental health care into stroke rehabilitation may be achieved through policy development, leadership and specialist training.Implications for rehabilitationPeople with aphasia need routine mood screening using aphasia-specific clinical tools and communication support.Stroke health professionals report a need for communication partner training to facilitate mental healthcare for people with aphasia.Family members need to be involved in aphasia rehabilitation to gain psychological care for themselves and the person with aphasia.

Barriers and facilitators to implementing stepped psychological care for people with aphasia: Perspectives of stroke health professionals.

Background Concomitant aphasia and depression after stroke is highly prevalent, but there is a lack of psychological care in stroke rehabilitation for people with aphasia and family members. Evidence-based frameworks such as stepped psychological care may be viable, but the barriers and facilitators to translating this framework into aphasia rehabilitation practice are unknown.Aim The aim of this study was to identify, from the perspective of stroke health professionals, the barriers and facilitators to implementing stepped psychological care for depression after post-stroke aphasia.Method Five semi-structured focus groups of stroke health professionals were conducted (n = 39) across the stroke care continuum. Verbatim transcripts were analyzed using Interpretive Description.Results Barriers and facilitators were identified within three core themes: knowledge, skills, and attitudes have the most impact on implementing stepped psychological care; the physical environment impacts on managing depression and communication disability for people with aphasia; and the support and leadership of the health organization influence change in any implementation of a stepped psychological care approach. Barriers included: no experience with stepped psychological care; limited understanding of aphasia and communication support; lack of adequate physical space and resources; lack of psychologists. Facilitators included: specialist training; enhancement of physical spaces; communication tools; leadership; funding; specialized staff.Conclusion Addressing the identified barriers and facilitators to stepped psychological care will improve the viability of implementing this evidence-based framework after post-stroke aphasia. Change may be driven through specialist training for health professionals in communication support; mood assessment and treatments; modification of physical space; and accessible resources.

How Do Audiologists Respond to Emotional and Psychological Concerns Raised in the Audiology Setting? Three Case Vignettes.

OBJECTIVES: Emotional and psychological well-being are essential to overall health, but there is little research showing how to approach emotional and psychological concerns in the audiological setting. This study investigated audiologists' self-reported clinical behaviors in response to emotional and psychological concerns and/or symptoms raised by audiology clients. DESIGN: A sample of 83 Australia-based audiologists completed a survey including vignettes presenting older adults with hearing loss and experiencing symptoms consistent with either depression or grief. Content analysis was used to explore: (1) audiologists' self-reported usual response when clients present with emotional and psychological concerns and/or symptoms in the audiological setting; (2) audiologists' ability to identify and describe psychological symptoms; and (3) audiologists' self-reported clinical behaviors relating to client referral for psychological support. RESULTS: When asked to describe their usual clinical course of action in response to the vignettes, over one half the audiologists described actions that address the clients concerns related to psychological well-being. Where audiologists described how they would provide psychological support, they described modifications to the audiological rehabilitation program including involving significant others in the rehabilitation process, recommending additional support outside of the audiology setting (such as General Practitioner or psychologists), and providing emotional support and counseling. When prompted, the majority of participants recognized the two cases with depression as having a mental health condition; however, 48% of participants indicated the control case as also having a mental health condition. When asked directly, the majority of audiologists indicated that they would refer the three vignettes for specialist support; however, less than one third described referral to a General Practitioner and less than 5% described referral to a mental health professional as their normal course of action in the open response item. Twenty-five different professions/people were reported as potential sources for referral. CONCLUSION: These findings support the need for further training and/or resources for audiologists to enable them to appropriately detect, describe and refer for emotional and psychological concerns and/or symptoms raised by clients' in the audiology setting.