Examination of Poststroke Occupational Therapy Mental Health Care in Inpatient Rehabilitation

Stroke survivors with poststroke depressive and anxiety symptoms (PSDAS) have increased mortality and decreased functional independence. Occupational therapy (OT) providers offer valuable insight to the treatment of PSDAS, as OT providers are uniquely qualified to address physical and mental sequelae of stroke. However, only approximately half of OT providers report feeling satisfied with the mental health care they provide to stroke survivors. Rehabilitation after a stroke often begins in inpatient rehabilitation (IPR) and therefore investigation of OT mental health care provided in this setting is warranted. This dissertation encompasses a mixed methodological examination of OT mental health care delivery to stroke survivors in an academic medical center IPR setting. Chapters 2 and 3 present the results of retrospective electronic health record (EHR) analyses of OT provider PSDAS documentation. Descriptive quantitative and directed content EHR analyses were performed to characterize practice for OT providers addressing PSDAS in IPR. Ninety of 213 (42%) stroke survivors admitted to the IPR facility during the 2019 review period were included in the EHR analyses. The results of the descriptive quantitative analysis determined that OT providers (N=23) did not perform any objective PSDAS screens, nor were any goals written to target reduced PSDAS. There were two instances of provider referral; one provider referred to rehabilitation psychology only and another provider referred to both rehabilitation psychology and the attending physiatrist. For the directed content EHR analyses, treatment strategies documented by OT providers were mapped to interventions in an evidence-based review published in the American Journal of Occupational Therapy for addressing emotional challenges after stroke. OT providers documented PSDAS interventions among 60 stroke survivors with PSDAS, 67% of included patients. Supportive techniques, including empathetic listening and therapeutic use of self were most documented in 46 patients (77%). Stroke education only being the most common PSDAS intervention utilized by OT providers in 18 patients (30%). Chapter 4 presents the results of online semi-structured interviews conducted with OT providers in IPR to determine their perspectives of PSDAS practice, barriers and facilitators to implementing PSDAS care, and the utility and acceptability of OT’s role in addressing PSDAS. OT providers reported a high degree of clinical utility for addressing PSDAS, however, multi-level barriers including lack of time, prioritization of physical over mental health, and lack of OT- and setting-specific resources to guide clinical decision making were perceived to negatively impact PSDAS care implementation. OT providers reported a desire for additional training and PSDAS practice guidance resources. Participants felt additional resources could increase acceptability and self-efficacy for PSDAS care delivery. OT providers specifically mentioned a desire for resources for PSDAS outcome measures, mental health goal writing, implementing mental health interventions, and documentation to support PSDAS care provision in IPR. Overall, these results indicate that OT provider PSDAS care provision in IPR has room for improvement, as therapists documented limited evidence-based care and did not follow established guidelines, particularly for PSDAS screening and intervention selection. This research identifies practice gaps in how OT providers are addressing PSDAS to begin the implementation of evidence-based care into routine practice. Resource allocation to support clinical skill development in evidence-based strategies for addressing PSDAS is also needed. Subsequent efforts including perspectives of all qualified personnel, including OT providers, can facilitate functional recovery and augment mental health care among stroke survivors in the IPR setting.