Sameer A. Ashaie

Background:Up to 60% of individuals with aphasia have post-stroke depression, resulting in worse quality of life. However, extant measures of depression in aphasia are insufficient, and people with aphasia are often excluded from studies of depression due to a lack of valid assessment tools. Ecological momentary assessment (EMA) involves brief, repeated surveys that capture fluctuations in the real world, and may be adapted for individuals with communication impairments. We created a novel, aphasia-accessible EMA of affective depressive symptoms and evaluated its feasibility and usability in a sample of people with aphasia. Methods: 27 people with aphasia (Western Aphasia Battery-Aphasia Quotient (WAB-AQ) range: 32.9-97.4) completed a six-item EMA survey assessing positive and negative affect through the app m-Path four times per day for 14 days (up to 56 assessments). We analyzed feasibility, validity, and user experience of the app and surveys. Results: Participants completed 89.6% of the EMA surveys, indicating strong compliance and feasibility. EMA items correlated strongly with the Center for Epidemiologic Studies Depression Scale-Revised and Patient-Reported Outcomes Measure Information System (PROMIS) Depression measures, reflecting high convergent validity. Participants gave positive feedback about their experience using the app and answering the survey questions. Conclusions: These results suggest that EMA is a useful tool for identifying affective depression symptoms in people with aphasia and could be a way to address the gap in mental health care for people with aphasia. Future research should include more diverse samples as well as add passive, ecologically valid measures of depression in order to extend these findings. Keywords: aphasia, stroke, depression, mental health, ecological momentary assessment, feasibility

Purpose: Post-stroke depression is highly prevalent in aphasia, yet existing depression measures rely heavily on language and lack sufficient validity for this population. Our aim was to develop an aphasia-friendly Ecological Momentary Assessment (EMA) of depression based on the input of people with aphasia, their care partners, and speech-language pathologists (SLPs).Methods: Nine focus groups were conducted with people with aphasia (n=15), care partners (n=13), and SLPs (n=13) to identify relevant depression symptoms. Items were selected based on factors such as endorsement rates and accessibility. Participants with aphasia also took part in individual cognitive interviews to ensure comprehensibility and accessibility of the final items, corresponding pictures, and pictorial affect scale. The process of selecting items to include in the final EMA considered both endorsement ratings and qualitative feedback across stakeholder groups.Results: The final set of items to be included in the EMA consisted of three positive valence items (determined, proud, interested) and three negative valence items (sad, like a failure, angry). Cognitive interviews confirmed comprehensibility and accessibility of the items, though the picture for interested required revision. Additionally, participants found 3-4 daily assessments feasible.Conclusion: Stakeholder engagement revealed that positive valence dysregulation (e.g., reduced interest in previously rewarding activities) may be particularly salient for depression in aphasia in addition to negative valence dysregulation (e.g., increased feelings of failure and anger). The resulting six-item EMA uses multimodal supports (e.g., text, pictures, pictorial affect scale, audio recordings) to capture both valence systems.

Background:Up to 60% of individuals with aphasia have post-stroke depression, resulting in worse quality of life. However, extant measures of depression in aphasia are insufficient, and people with aphasia are often excluded from studies of depression due to a lack of valid assessment tools. Ecological momentary assessment (EMA) involves brief, repeated surveys that capture fluctuations in the real world, and may be adapted for individuals with communication impairments. We created a novel, aphasia-accessible EMA of affective depressive symptoms and evaluated its feasibility and usability in a sample of people with aphasia. Methods: 27 people with aphasia (Western Aphasia Battery-Aphasia Quotient (WAB-AQ) range: 32.9-97.4) completed a six-item EMA survey assessing positive and negative affect through the app m-Path four times per day for 14 days (up to 56 assessments). We analyzed feasibility, validity, and user experience of the app and surveys. Results: Participants completed 89.6% of the EMA surveys, indicating strong compliance and feasibility. EMA items correlated strongly with the Center for Epidemiologic Studies Depression Scale-Revised and Patient-Reported Outcomes Measure Information System (PROMIS) Depression measures, reflecting high convergent validity. Participants gave positive feedback about their experience using the app and answering the survey questions. Conclusions: These results suggest that EMA is a useful tool for identifying affective depression symptoms in people with aphasia and could be a way to address the gap in mental health care for people with aphasia. Future research should include more diverse samples as well as add passive, ecologically valid measures of depression in order to extend these findings.

Post-stroke depression negatively impacts the quality of life of people with aphasia. Speech-language pathologists (SLPs) are in a unique position to identify signs of depression in people with aphasia because of their close involvement in the language rehabilitation process. Additionally, popular diagnostic manuals (e.g., Diagnostic and Statistical Manual of Mental Disorders) define depression based on typical populations, and assessments based on these manuals may not be reliable or valid for people with aphasia. While existing literature acknowledges the high prevalence of post-stroke depression and the challenges of diagnosing it in people with aphasia, few studies have explored the barriers in identifying symptoms of depression in people with aphasia from the perspectives of SLPs. This study sought to explore the barriers SLPs face in recognizing symptoms of depression in people with aphasia using a qualitative analytical approach. We recruited 13 SLPs with a range of ages (M = 37 years, SD = 11.18) and experience working with people with aphasia (M = 13 years, SD = 11.13). Data were collected through three virtual focus group interviews, each lasting 90 to 120 minutes. We analyzed the focus group data using Dedoose software (version 9.2) to document initial codes that reflected participants’ insights. Reflexive thematic analysis was used to generate themes related to barriers that SLPs face in recognizing depression in people with aphasia. Four central themes and two subthemes were extrapolated from the data. First, it’s difficult to disentangle symptoms of depression from post-stroke behaviors, complicating the recognition of depression for SLPs. Second, existing depression assessments are problematic, and SLPs discussed the need to modify these tools and make them more accessible for people with aphasia. Third, the lack of interdisciplinary collaboration surfaced as a barrier in accurately identifying depression. Finally, the influence of family involvement in identifying mental health issues revealed duality, with family members acting as both supportive proxies and, at times, a hindrance to accurate depression assessment. Our findings identify several key barriers that SLPs face in the recognition of depression in people with aphasia. Recognizing depression in people with aphasia requires a more interdisciplinary approach that includes SLPs, mental health clinicians, patients, and their family members. Speech-language pathologists across focus groups also noted the lack of valid assessment tools to measure depression in people with aphasia, offering suggestions to improve current assessments to better accommodate this population.

Purpose: Determining the prognosis of aphasia recovery is an important task for clinicians in the rehabilitation of persons with aphasia. Although there are many variables identified as impactful to aphasia recovery, it is less clear (a) how clinicians perceive causality in aphasia rehabilitation and (b) how prognostic variables interact with each other. This study aimed to understand causal relations between prognostic variables from the clinician perspective. Method: Ratings of perceived causality were obtained from 11 clinicians serving people with aphasia. Participants were presented with 255 directed causal relations (e.g., depression → aphasia severity), representing a total of 18 demographic, diagnostic, and psychosocial variables. Participants rated the perceived causality on a Likert scale from 0 ( no causal effect ) to 10 ( strong causal effect ). We also obtained ratings about frequency of access to information about each of the 18 variables. Results: A perceived causal network showed differences among variables in their perceived causality. There were many causal relations identified, particularly between diagnostic and psychosocial variables. The variables with the strongest perceived causality were predominantly psychosocial variables, including depression, social support, and participation. However, these psychosocial variables were also the variables that clinicians had the least frequent access to information about. There were also notable differences between participants in their perceived causal networks. Conclusions: Clinicians hold valuable information about aphasia rehabilitation, including what variables are important to aphasia recovery. Understanding the complexity of interaction among prognostic variables and obtaining data from clinicians about prognostic variables and causality will advance the rehabilitation of aphasia. Supplemental Material: https://doi.org/10.23641/asha.27105865

Speech-language therapy (SLT) is the most effective technique to improve language performance in persons with aphasia. However, residual language impairments remain even after intensive SLT. Recent studies suggest that combining transcranial direct current stimulation (tDCS) with SLT may improve language performance in persons with aphasia. However, our understanding of how tDCS and SLT impact brain and behavioral relation in aphasia is poorly understood. We investigated the impact of tDCS and SLT on a behavioral measure of scripted conversation and on functional connectivity assessed with multiple methods, both resting-state functional magnetic resonance imaging (rs–fMRI) and resting-state electroencephalography (rs–EEG). An individual with aphasia received 15 sessions of 20-min cathodal tDCS to the right angular gyrus concurrent with 40 min of SLT. Performance during scripted conversation was measured three times at baseline, twice immediately post-treatment, and at 4- and 8-weeks post-treatment. rs–fMRI was measured pre-and post-3-weeks of treatment. rs–EEG was measured on treatment days 1, 5, 10, and 15. Results show that both communication performance and left hemisphere functional connectivity may improve after concurrent tDCS and SLT. Results are in line with aphasia models of language recovery that posit a beneficial role of left hemisphere perilesional areas in language recovery.

The Life Participation Approach to Aphasia (LPAA) is a general philosophy of service-delivery that centers people with aphasia and the consequences of their aphasia on their ability to participate fully in life. LPAA focuses on supporting people with aphasia to resume doing the things that they need and want to do through providing interventions that also address factors beyond the neurolinguistic impairment of language. To live up to the ideals of LPAA, research must focus on the biological, psychological, and environmental social factors that contribute to participation in people with aphasia. The authors review the literature that has been conducted to date examining factors that contribute to life participation, as well as offer a perspective on evidence still needed to support the LPAA.

Background: Post-stroke depressive symptoms are prevalent and impairing, and elucidating their course and risk factors is critical for reducing their public health burden. Previous studies have examined the course of post-stroke depression, but distinct depressive symptom dimensions (eg, somatic symptoms, negative affect [eg, sadness], anhedonia [eg, loss of interest]) may vary differently over time. Objective: The present study examined within-person and between-person associations between depressive symptom dimensions across 3 timepoints in the year following discharge from in-patient rehabilitation hospitals, as well as the impact of multiple clinical variables (eg, aphasia). Methods: Stroke survivors completed the Center for Epidemiologic Depression Scale (CES-D) at discharge from post-stroke rehabilitation (“T1”) and at 3-month (“T2”) and 12-month (“T3”) follow-ups. Scores on previously identified CES-D subscales (somatic symptoms, anhedonia, and negative affect) were calculated at each timepoint. Random intercept cross-lagged panel model analysis examined associations between symptom dimensions while disaggregating within-person and between-person effects. Results: There were reciprocal, within-person associations between somatic symptoms and anhedonia from T1 to T2 and from T2 to T3. Neither dimension was predictive of, or predicted by negative affect. Conclusions: The reciprocal associations between somatic symptoms and anhedonia may reflect a “vicious cycle,” and suggest these 2 symptom dimensions may be useful indicators of risk and/or intervention targets. Regularly assessing depression symptoms starting during inpatient rehabilitation may help identify stroke survivors at risk for depression symptoms and facilitate early intervention.

Objective: To investigate longitudinal, predictive associations between community participation, positive affect, social support, and functional independence for individuals post-stroke at 3 and 12 months post-discharge.Design: Longitudinal design.Subjects: Data from 544 participants were obtained from the Stroke Recovery in Underserved Populations (2005–06) database.Methods: A cross-lagged panel network analysis to identify the complex set of predictive relationships between community participation, positive affect, social support, and functional independence 3 months post-discharge to 12 months post-discharge.Results: Community participation, particularly religious/spiritual activities, was an early predictor of later motor (functional) independence and social support. In addition, positive affect was an early predictor of social support.Conclusion: While participation in social situations is a desired outcome post-stroke, the results of this study indicate the importance of identifying early factors that influence community participation throughout the recovery process. LAY ABSTRACTThe ability to participate in desired activities is a common outcome goal of rehabilitation for stroke survivors. However, there are many factors that influence success in achieving this goal, including support from family and friends, mental health, and functional independence. This study sought to understand how these factors influence each other and participation over time. The results indicate that early participation post-stroke is an important predictor of later motor independence and social support needs. The results indicate that, while participation is often viewed as a rehabilitation outcome, understanding participation as a predictor of other rehabilitation outcomes is also important.

Background: Studies suggest that language recovery in aphasia may be improved by pairing speech-language therapy with transcranial direct current stimulation. However, results from many studies have been inconclusive regarding the impact transcranial direct current stimulation may have on language recovery in individuals with aphasia. An important factor that may impact the efficacy of transcranial direct current stimulation is its timing relative to speech-language therapy. Namely, online transcranial direct current stimulation (paired with speech-language therapy) and offline transcranial direct current stimulation (prior to or following speech-language therapy) may have differential effects on language recovery in post-stroke aphasia. Transcranial direct current stimulation provided immediately before speech-language therapy may prime the language system whereas stimulation provided immediately after speech-language therapy may aid in memory consolidation. The main aim of this study is to investigate the differential effects of offline and online transcranial direct stimulation on language recovery (i.e., conversation) in post-stroke aphasia. Methods/design: The study is a randomized, parallel-assignment, double-blind treatment study. Participants will be randomized to one of four treatment conditions and will participate in 15 treatment sessions. All groups receive speech-language therapy in the form of computer-based script practice. Three groups will receive transcranial direct current stimulation: prior to speech-language therapy, concurrent with speech-language therapy, or following speech-language therapy. One group will receive sham stimulation (speech-language therapy only). We aim to include 12 participants per group (48 total). We will use fMRI-guided neuronavigation to determine placement of transcranial direct stimulation electrodes on participants’ left angular gyrus. Participants will be assessed blindly at baseline, immediately post-treatment, and at 4 weeks and 8 weeks following treatment. The primary outcome measure is change in the rate and accuracy of the trained conversation script from baseline to post-treatment. Discussion: Results from this study will aid in determining the optimum timing to combine transcranial direct current stimulation with speech-language therapy to facilitate better language outcomes for individuals with aphasia. In addition, effect sizes derived from this study may also inform larger clinical trials investigating the impact of transcranial direct current stimulation on functional communication in individuals with aphasia. Trial registration: ClinicalTrials.gov NCT03773406. December 12, 2018.