Kaac 002

ann. behav. med.
(2022) XX:1–20
https://doi.org/10.1093/abm/kaac002
SYSTEMATIC REVIEW
Psychological Stress Management and Stress Reduction Strategies

for Stroke Survivors: A Scoping Review
Madeleine Hinwood, PhD, MClinEpid1,2, ∙ Marina Ilicic, PhD2,3,4 ∙ Prajwal Gyawali, PhD5 ∙ Kirsten Coupland,
PhD2,3,4 ∙ Murielle G. Kluge, PhD3,6 ∙ Angela Smith, Grad Dip Lib & Info Mgt7 ∙ Sue Bowden8 ∙ Michael Nilsson MD,
Downloaded from https://academic.oup.com/abm/advance-article/doi/10.1093/abm/kaac002/6605937 by guest on 25 July 2022

PhD2,9,10,* ∙ Frederick Rohan Walker PhD2,3,4,6,9,*
Published online: 11 June 2022

© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/li-
censes/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background Stroke can be a life-changing event, with existing literature on stress management interventions
survivors frequently experiencing some level of disability, that have been trialed in stroke survivors.
reduced independence, and an abrupt lifestyle change. Methods We performed a database search for interven-
Not surprisingly, many stroke survivors report elevated tion studies conducted in stroke survivors which re-
levels of stress during the recovery process, which has ported the effects on stress, resilience, or coping outcome.
been associated with worse outcomes. Medline (OVID), Embase (OVID), CINAHL (EBSCO),
Purpose Given the multiple roles of stress in the etiology Cochrane Library, and PsycInfo (OVID) were searched
of stroke recovery outcomes, we aimed to scope the from database inception until March 11, 2019, and up-
dated on September 1, 2020.
Results Twenty-four studies met the inclusion criteria.
Madeleine Hinwood
Madeleine.Hinwood@newcastle.edu.au There was significant variation in the range of trialed
interventions, as well as the outcome measures used to
* Contributed equally to senior authorship.
assess stress. Overall, just over half (13/24) of the in-
1
cluded studies reported a benefit in terms of stress re-
School of Medicine and Public Health, The University of duction. Acceptability and feasibility were considered in
Newcastle, Callaghan, NSW, Australia
71% (17/24) and costs were considered in 17% (4/24) of
2
Hunter Medical Research Institute, New Lambton Heights, studies. The management of stress was rarely linked to
NSW, Australia
the prevention of symptoms of stress-related disorders.
3
School of Biomedical Sciences and Pharmacy, The The overall evidence base of included studies is weak.
University of Newcastle, Callaghan, NSW, Australia However, an increase in the number of studies over time
4
Priority Research Centre for Stroke and Brain Injury, The suggests a growing interest in this subject.
University of Newcastle, Callaghan, NSW, Australia
Conclusions Further research is required to identify op-
5
School of Health and Wellbeing, Faculty of Health, timum stress management interventions in stroke sur-
Engineering and Sciences, University of Southern vivors, including whether the management of stress can
Queensland, Darling Heights, QLD, Australia
ameliorate the negative impacts of stress on health.
6
Centre for Advanced Training Systems, The University of
Newcastle, Callaghan, NSW, Australia
7
HNE Health Libraries, Hunter New England Local Health Keywords: Stroke ∙ Stress ∙ Resilience ∙ Stress interven-
District, New Lambton, NSW, Australia tion ∙ Stress management ∙ Depression
8
Consumer Investigator, Moon River Turkey, Bathurst, NSW,
Australia
9
Centre for Rehab Innovations, The University of Newcastle, Introduction
Callaghan, NSW, Australia
10
LKC School of Medicine, Nanyang Technological University, Advances in the treatment of stroke, particularly the
Singapore introduction of clot-busting drugs and clot retrieval
2 ann. behav. med. (2022) XX:1–20
technologies, have significantly reduced stroke mortality heightened risk of stress-related disorders, the recovery
[1]. Improvements in diagnosis and rehabilitation have domains influenced by stress broadly contribute to
also improved stroke outcomes; however, many stroke worse QoL, reduced motivation and lower levels of self-
survivors continue to experience poor health outcomes reported wellbeing, which in turn may negatively impact
for their remaining lifespan. Stroke is one of the five participation in rehabilitation. This is likely to potentiate
leading global causes of disability-adjusted life years, a positive feedback loop between heightened stress per-
and the number of years lost as a result of poor health or ception and poor participation in rehabilitation.
disability from cardiovascular disease (CVD), including There is clear evidence that rehabilitation interven-
stroke, is greater than the number of years lost to car- tions can influence patient outcomes after stroke [15, 17].
diovascular death globally [2]. This suggests an urgent Therefore, identifying and modifying alternative prog-

need to identify new targets and interventions to improve nostic factors for recovery outcomes are of vital import-
quality of life (QoL) following stroke. ance to improve trajectories for stroke survivors. Studies
Psychosocial wellbeing after stroke has been rela- highlighting the association between stress and signifi-
tively neglected compared with motor and other phys- cant downstream effects such as emotional and cogni-
ical symptoms, which are often the primary focus of tive problems and poor functional recovery suggest that
rehabilitation efforts. One emerging prognostic factor managing stress may be beneficial to stroke survivors
determining the quality of psychological and emotional [8–10]. There is some evidence that stress management
recovery from stroke is stress [3, 4]. Stroke survivors re- interventions in populations with other chronic illnesses,
port experiencing persistently high levels of stress, with particularly cancer and CVD, can decrease symptoms of
greater levels of perceived stress poststroke associated depression, and promote resilience [18, 19]. However, it is
with poorer long-term outcomes [5–10]. Several obser- unclear which interventions to mitigate stress have been
vational studies have consistently reported significant trialed for stroke survivors.
correlations between stress and worse stroke outcomes, Psychological stress is a complex phenomenon, and nu-
including functional independence, psychological out- merous theoretical models of stress have been proposed.
comes such as depression, and cognitive function. There are also various terminologies in the literature to
Likewise, greater resilience, which is defined as the cap- describe the evaluation of state stress. Variations in ter-
acity to withstand adversity and “bounce back” after a minology connected to stress as a short- or long-term
stressful event, is associated with better QoL poststroke outcome may include stress, distress, depression, anxiety,
[7, 11]. Further, stress is among the strongest proximal coping, and QoL. The converse can also be identified; al-
risk factors for depression and anxiety disorders, and though stress exposure can have lasting negative impacts
the risk of these stress-related mental health disorders on psychological health and wellbeing, not all individuals
is significantly greater in stroke survivors compared with will go on to develop these outcomes, and resilience scores
the general population [12]. In the 2 years immediately are therefore also frequently examined [19]. In this study,
following stroke, the risk of depression for stroke sur- we conceptualized psychological stress according to the
vivors was around 25%, compared with 8% in a control stress, appraisal, and coping framework proposed by
group of people the same age [12]. Stroke survivors are Lazarus and Folkman [20], adapted for the stroke setting
also at increased risk of other stress-related disorders, in Fig. 1, where stress is a consequence of an individual’s
including post-traumatic stress disorder (PTSD) and appraisal of their environment, and their perceived
anxiety disorders [13, 14]. These psychological prob- ability to cope with a situation or incident. Therefore, de-
lems are independently associated with increased mor- pending on how it is appraised, a stressor may have dif-
bidity, mortality, and disability [15, 16]. In addition to a ferential short- and long-term effects upon an individual.
Fig. 1. Conceptual framework of stress processes after stroke, and spectrum of interventions to manage or reduce stress (adapted from
Folkman and Lazarus [20]).
ann. behav. med. (2022) XX:1–203
Interventions to manage stress may be deployed at any and O’Malley [24] and updated by Levac et al. [25], and
point along a spectrum, with primary interventions pri- the methods outlined in the Joanna Briggs Institute
marily concerned with stressor reduction, secondary with Reviewers’ Manual [26]. The scoping review process is
stress management, and tertiary with remedial support or an iterative one, and the inclusion and exclusion criteria
treatment of stress-related conditions. Here, we expected were refined during full-text review for clarity and spe-
to find most interventions at the secondary (stress man- cificity to the review’s objectives following discussion
agement) level, with outcomes primarily based on the among the research team. The PRISMA Extension for
effectiveness of the intervention in the short term (e.g., Scoping Reviews (PRISMA-ScR) checklist was refer-
reduction in perceived stress or other stress marker; im- enced to ensure systematic reporting of this scoping
provement in coping skills; or improvement in resilience), review [22].

and on the ability of the intervention to prevent other
downstream effects of stress, such as symptoms of anx- Identification of the Research Question
iety and depression. Our framework guided the design of
the research questions, literature search, identification of Overall, we were interested in mapping the existing
studies, and the collation of results. intervention literature for stress reduction or stress
Given that research into stress management strat- management in stroke survivors. As an emerging and
egies for stroke survivors is an emerging area of re- inconsistently defined field, we anticipated enormous
search, we collated the results of existing studies under heterogeneity in the way stress is defined, operational-
several broad topic areas. In addition to mapping and ized, and measured across studies, and in the way that
assessing the reported effectiveness of interventions, we stress and stress prevention studies are designed. Based
also aimed to collate information on the stress outcome on the conceptual framework presented in Fig. 1, we in-
measures used, whether long-term effects of stress were cluded any intervention studies which measured stress or
considered, and implementation outcomes (specifically a related concept as an outcome; therefore, the included
acceptability, feasibility, and economic analyses). studies encompassed both interventions specifically de-
Given the breadth of information to be accumulated, signed for stress reduction, and interventions that did not
we decided to perform a scoping rather than a system- explicitly aim to reduce stress, but which reported a re-
atic review. Scoping reviews are designed to assess the duction in a stress-related outcome, such as self-reported
coverage of a body of literature, and to identify gaps stress. The following broad aims, which attempt to cap-
and map available evidence. Systematic reviews in health ture this heterogeneity of studies under the Lazarus and
care tend to be more focused on confirming or refuting Folkman framework [20], guided this scoping review:
whether current practice is based on evidence, and to
establish the quality of that evidence [21]. Our overall
aim was to broadly map the body of literature con- 1. To map the range of interventions trialed addressing
cerning stress management interventions in stroke sur- stress management in stroke survivors and to iden-
vivors. Further, we aimed to synthesize existing results tify which interventions are potentially efficacious for
and approaches around stress interventions in stroke reducing stress, or increasing resilience and coping
survivors to guide the development and implementation skills.
of stress management in future studies, identify know- 2. To identify the average duration of study length and
ledge gaps, and clarify key concepts around the meas- follow-up. Stroke is a chronic condition with recovery
urement of stress in stroke survivors. Therefore, as we occurring for months and years after the initial event.
were mapping a heterogeneous body of literature rather Further, it would be of interest to assess the potential
than synthesizing the best available research to answer impact of interventions on longer-term outcomes that
a specific question, a scoping review methodology was may be affected by acute improvements in stress man-
considered most appropriate. agement. Ideally, stress intervention models would
match the natural history of stroke and stress-related
problems, and this would be reflected in follow-up
Methods times of adequate duration.
3. To map the multidimensional range of outcome

This scoping review was conducted in accordance with measures that have been used for stress, resilience, and
the PRISMA extension for scoping reviews [22]. coping in stroke survivors. We anticipated heteroge-
neous literature, with no broadly accepted outcome
Protocol measure for psychological stress. Acute and chronic
stress can be quantified using various approaches
A protocol was published prior to conducting this re- including self-reported, psychometric assessments, as
view [23] based upon the framework proposed by Arksey well as physiological biomarkers.
4 ann. behav. med. (2022) XX:1–20
4. To identify whether early intervention for stress trans- The strategy was further refined through reference
lates into a reduction in longer-term stress-related checking and forward and backward citation checking.
clinical outcomes as shown in Fig. 1, including de- Search strategies from reviews in relevant areas were also
pression, anxiety, and PTSD. Although we do not searched. The search strategy drew on the work of the
expect psychological stress to be the sole cause of Cochrane Stroke Group to operationalize search terms
mental disorders poststroke, most cases of depression for stroke. The search strategy was developed in Medline
and anxiety can, to some extent, be traced back to the before being optimized for Embase, resulting in the need
influence of exogenous or endogenous stressors [27]. to include some additional Emtree terms to capture add-
Therefore, although an improvement in stress man- itional relevant citations. The strategy was then trans-
agement or coping, or a reduction in perceived stress lated to PsycInfo, CINAHL, and the Cochrane Library.

will not explain all the variation in poststroke depres- All databases were searched from inception until March
sion or anxiety, we would expect a positive effect on 11, 2019, and updated on December 12, 2019. The search
mood disorders due to a preventive effect. However, was updated again prior to submission on September 1,
since stress management does not specifically treat 2020 (Supplementary File 2). Database searches were re-
mood symptoms, significant changes in mood, and stricted to subjects and English language citations only.
diagnosis with stress-related disorders, may not be Primary evidence (empirical research) only was included.
observed. An assessment of study quality is optional in scoping
5. The success of any intervention is in part dependent reviews; however, may be conducted to gain an appre-
on the successful implementation within its environ- ciation of the quality of evidence in a field. We did not
ment and context. Therefore, we collected informa- exclude articles based on quality or design; however,
tion on whether studies considered implementation we did conduct an assessment of study quality using
outcomes, including potential barriers and limita- the Cochrane Risk of Bias tool or the Mixed Methods
tions, feasibility and acceptability, and economic Appraisal Tool (MMAT), where appropriate, in order to
considerations. This is particularly relevant for stress evaluate the existing quality of evidence in the area.
management approaches, as they may be time con-
suming, expensive, and difficult to scale up to larger Identifying Relevant Studies
populations.
The search yield was imported into Covidence software
Search and Screening Methods and duplicates were removed. Title and abstract, and
full-text screening were completed separately by mem-
The search strategy was designed around the aims of bers of the research team (M.H., M.I., P.G., M.K., and
the review and included two key concepts, stroke and KC), with each article independently screened by two
stress. The search was designed to align with the stress, team members. Discrepancies during screening and re-
appraisal, and coping framework used to conceptualize viewing were resolved by a consensus among all re-
stress in this review. Broadly, interventions for stress reviewers. Inconsistencies were discussed and resolved,
duction were operationalized in the following way: any and inclusion criteria were refined to improve the appli-
intervention (pharmacological or nonpharmacological) cation of inclusion/exclusion criteria.
delivered in individual, family, or group settings, To be included, studies had to meet the following
incorporating strategies to prevent or delay the devel- criteria: (a) include an intervention; (b) involve human
opment of excessive stress, promote coping strategies or adult stroke survivors (age ≥18 years); (c) be written in
resilience, to improve optimism and wellbeing, or to im- English; and (d) include at least one outcome measure
prove or relieve stress-related outcomes, including symp- related to stress or resilience. Outcome measures were
toms of mood disturbance. We included all types of consistent with the Lazarus and Folkman [20] stress–
intervention studies (randomized controlled trials [RCTs] coping–appraisal framework, and incorporated changes
and quasi-experimental designs). The research question in direct measures including perceived stress, resiliency,
and corresponding search strategy are defined using coping skills, and problem-solving, as well as meas-
the Population, Intervention, Comparator, Outcome, ures of changes in state stress and aligned constructs,
Study design (PICOS) framework (see Supplementary including emotional distress, coping, resilience, QoL,
File 1). A complete description of the strategies for and symptoms of anxiety or depression. Although some
database searching, filtering methods, abstract identifi- of the latter measures do not measure stress directly, they
cation, and screening was provided in a previously pub- were included as outcomes in several publications con-
lished protocol [23]. The search for this scoping review sistent with the Lazarus and Folkman framework [20]
was iterative in nature. It began with a gold standard set which aimed to improve coping or problem-solving skills,
of articles that informed the selection of medical sub- were hypothesized to thereby improve QoL, and reduce
ject headings (MeSH), keywords, and keyword phrases. emotional distress in stroke survivors [28–31], and were
therefore included in this review. This reflects the substan- stress management could be determined based on the
tial impact that stress can have on physical and mental evidence synthesis included in this review.
health. Exclusion criteria included: (a) nonexperimental
(e.g., observational, case–control, cross-sectional, lon- Assessment of Study Quality
gitudinal) studies (i.e., without implementation of an
intervention); and (b) relevant reviews (systematic and Quality appraisal was used to broadly assess the quality
meta-analysis), but reference lists were hand-searched to of the literature, to determine where the field currently
identify additional eligible articles. Studies could be ran- lies in terms of evidence development. It was not in-
domized or nonrandomized (quasi-experimental). tended to stratify papers into a hierarchy of evidence,
and publications were not excluded from the review

Charting the Data based on quality. To assess the quality of the quantita-
tive studies, the Cochrane Risk of Bias 2 (RoB2) quality
Data extraction was independently completed by five reappraisal tool was used [33]. For any included qualita-
viewers (M.H., M.I., P.G., M.K., and K.C.). The data tive or mixed-method studies, the MMAT was used [34].
extraction spreadsheet was designed to capture all rele- The MMAT does not have an overall rating category,
vant details required to answer the research questions and therefore we used the following guide to assess the
and included: author, year published, country, sample overall risk of bias associated with each publication: (a)
size, and population characteristics were recorded (e.g., strong (80% or more of the quality indicators were met),
age, stroke type, and time since stroke, severity meas- (b) moderate (between 40% and 80% of the quality in-
ures, comorbidities), outcome measures associated with dicators were met), and (c) weak (less than 40% of the
stress, length of follow-up, type of intervention, duration quality indicators were met).
of intervention, control group, any measures of accept-
ability and feasibility, any measures of barriers, study
limitations, and any measures of cost or cost-effective- Results
ness. The spreadsheet was refined via an iterative process
in collaboration with all reviewers. Included and Excluded Articles
Collating, Summarizing, and Reporting the Results The study selection process is summarized in the
PRISMA flow diagram (Fig. 2) [35]. The initial search,
We tabulated key information from included studies de- which was conducted on March 11, 2019, identified
scriptively. We categorized interventions by intervention 2,653 references after deduplication. The search was up-
type, study duration, and follow-up (in line with aims 1 dated on December 12, 2019, and again prior to submis-
and 2), explored how stress and stress-related disorders sion on September 1, 2020, after which there was a total
were measured in these studies (in line with aims 3 and 4), of 3,140 studies imported to Covidence, with 3,048 avail-
and assessed effectiveness (in line with aim 1) and other able for screening following deduplication. Of these, 116
measures that may affect implementation, including bar- articles were considered potentially relevant after initial
riers, acceptability, and cost-effectiveness (in line with exclusions of titles and abstracts. A further 92 were ex-
aim 5). Records in the PsycInfo database receive a classi- cluded after a two-person review of the full text. A total
fication code, which is used to categorize the document of 24 articles were included in this review [28–31, 36–55].
according to the primary subject matter. We used these
classification codes to map interventions to higher-order Study Characteristics
keywords to categorize them. Findings were presented in
a narrative synthesis. Study characteristics, including country, study design,
participants, intervention, comparator, and length of
Deviations From the Protocol follow-up, are summarized in Supplementary File 3.
Included studies were published between 1992 and 2020,
We originally stated that we would identify potential with most (n = 17; 70%) published in the last 5 years [28,
findings which may help to inform practice and/or guide- 31, 36, 38–42, 45–48, 51–55].
lines. Some recent guidelines for CVD identify stress as There was significant variability in study design,
an important risk factor [32]; however, there are no best- including RCTs and non-RCTs, and uncontrolled be-
practice recommendations for the management or reduc- fore and after studies. The type, duration, and frequency
tion of stress in stroke survivors. The included studies of intervention used also varied across studies, with
were overwhelmingly early phase and/or feasibility trials, interventions running from five sessions over 1 week
and as such no recommendation for an approach to (aromatherapy foot bath and massage) [46], to 6 months
6 ann. behav. med. (2022) XX:1–20
subacute phase of stroke [37, 38, 42, 49, 55]. Two studies
recruited participants during the acute period, whilst
patients were hospitalized [36, 39]. We based our assess-
ments on the mean or median times poststroke reported
in the studies; therefore, a small number of studies may
have included participants across multiple phases of re-
covery, primarily subacute to chronic. Studies rarely
specified whether included participants were first or re-
current stroke survivors or details of stroke type.
Three of the included studies used a selected popu-

lation (i.e., those reporting high distress, or those with
an existing diagnosis of depression, anxiety, or fatigue
[41, 49, 52]), in order to assess the effect of an interven-
tion on these outcomes. Many studies excluded people
with a progressive neurological disorder or cognitive dys-
function, reduced life expectancy, subdural hematomas,
moderate or severe aphasia, or who partook in excessive
drinking or drug abuse [31, 38, 39]. Studies typically jus-
tified this approach by stating that collecting and reliably
interpreting data from these patients can present signifi-
cant challenges.
Study Interventions
Fig. 2. PRISMA flow diagram [35].
The types of interventions trialed for stress manage-
(antidepressant treatment with sertraline [49]; home- ment across the included studies are summarized in
based psychoeducational program [50]). Most inter- Table 1.
ventions ran weekly sessions over approximately 8–12 We used the PsycInfo database to map each interven-
weeks (n = 15) [29–31, 40–42, 44, 45, 48–52, 54, 55]. tion to its broader subject heading category and identi-
The duration of follow-up also varied significantly be- fied the theory or hypothesis associated with each that
tween studies, ranging from 0 (immediate follow-up) to would lead to an improvement in stress-related out-
12 months. Finally, as we placed no restrictions on study comes. Although there was wide variability in the types
type beyond intervention studies, three studies used of intervention trialed, most (22; 92%) utilized psycho-
qualitative thematic analyses (via survey or interview) social interventions targeted at the individual level. These
[37, 40, 48], in which stress emerged as a theme. include social support [43], cognitive processes including
Whilst the reported sample sizes varied from 8 to 166 mindfulness-based stress reduction, meditation and
participants, most of the included studies had relatively problem-solving therapy [28, 31, 44, 47], rehabilitation
small sample sizes, with 16 out of 24 studies recruiting or neuropsychological rehabilitation targeted at memory
fewer than 50 participants [28, 29, 36, 37, 39–42, 44–48, or leisure [29, 40], a behavioral proactive coping inter-
51–54]. vention [30], physical activity programs [41, 45, 51], psy-
The populations in the included studies varied in chotherapy including both positive psychotherapy [42,
terms of time poststroke, and whether a broad or selected 54] and solution-focused brief therapy [55], creative arts
population was recruited. Most studies reported time therapy [37], cognitive behavioral therapy or positive
postonset of stroke; only Nour et al. [29] and Chouliara mental training [48, 52], multicomponent interventions
and Lincoln [40] did not explicitly define time poststroke; consisting of home-based visits and mailed information,
Nour et al. [29] stated that participants had finished active based on principles of psychoeducation [38, 50, 53] and
rehabilitation. We categorized the populations according training modules based on developing skills in either
to the critical time points of stroke recovery proposed cognitive behavior therapy/cognitive reappraisal or heart
in Bernhardt et al. [56], including hyperacute (0–24 hr), rate variability biofeedback [36, 39]. The remaining two
acute (1–7 days), subacute (7 days to 6 months), and studies assessed alternative medicine (aromatherapy mas-
chronic (>6 months) phases. The majority of studies sage and foot bath [46]), and pharmacological treatment
(n = 15) [28, 30, 31, 41, 43–48, 50–54] involved par- (the selective serotonin reuptake inhibitor antidepressant
ticipants recruited in the chronic phase of recovery. sertraline [49]). There were no organizational-level inter-
Five studies involved participants recruited during the ventions in the included studies.
Table 1. Characteristics of interventions used to address stress levels in stroke survivors
Type Subtype Theory/hypothesis Studies
Psychosocial
Social support networks Social support Social support intervention would improve the sup- Friedland and
port experienced by stroke survivors, as such McColl (1992)
leading to better psychosocial outcome. [43]
Cognitive processes MBSR MBSR will reduce mental fatigue after stroke and Johansson et al.
TBI. (2012) [44]
Problem-solving therapy Problem-solving therapy will improve coping strategy, Visser et al. (2016)

QoL, and reduce emotional distress in stroke [31]
survivors. Chalmers et al.
(2019) [28]
Meditation Meditation will cultivate mindfulness to train Love et al. (2020)
ttention and awareness, to achieve a mentally clear [47]
and emotionally calm and stable state.
Rehabilitation/ Memory rehabilitation Memory rehabilitation will develop patients’ Chouliara and
neuropsychological ability to cope with or compensate for residual Lincoln (2016)
rehabilitation memory deficits, as well as promoting partici- [40]
pation.
Leisure rehabilitation Leisure education will improve QoL and depression Nour et al. (2002)
in stroke survivors. [29]
Behavioral Proactive coping intervention Stroke survivors with better proactive coping skills Tielemans et al.
will experience improved self-efficacy and QoL. (2015) [30]
Motor processes Physical activity program/ Improving and maintaining physical activity levels Jones et al. (2016)
exercise will improve the overall health, including [45]
psychological functioning, cognitive functioning, Colledge et al.
and sleep, of adults with acquired brain injury. (2017) [41]
Aquatic therapy Aquatic therapy will minimize anxiety, fatigue, and Perez-de la Cruz
depression, which tend to be barriers to stroke (2020) [51]
rehabilitation.
Psychotherapy Positive psychotherapy Positive psychotherapy will alleviate psychological Cullen et al. (2018)
distress after acquired brain injury. [42]
Terrill et al. (2018)
[54]
SFBT SFBT will reduce depression and anxiety symptoms, Wichowicz et al.
generate a constructive attitude, and increase (2017) [55]
self-efficacy in patients poststroke.
Creative arts therapy Person-centered arts program Participation in an arts program will improve the Baumann et al.
emotional and mental wellbeing of stroke (2013) [37]
survivors.
Treatment cCBT cCBT will alleviate emotional distress and mental Simblett et al.
health problems such as anxiety and depression (2017) [52]
after experiencing a stroke.
PosMT Training in positivity using the PosMT audio tool Mavaddat et al.
could be added to rehabilitation for prevention or (2017) [48]
management of poststroke psychological problems.
Multicomponent Psychoeducation (mailed and Home-based psychoeducation will improve the per- Ostwald et al.
home visit) ceived health of stroke survivors by decreasing de- (2014) [50]
pression, fatigue, and the negative impact of stroke. Stubberud et al.
(2019) [53]
Promoting psychosocial Applying a dialog-based intervention drawing on Bragstad et al.
wellbeing following stroke narrative theory, supported conversation for people (2020) [38]
with aphasia, and guided self-determination will
promote a sense of coherence in life and reduce
threats to wellbeing after stroke, such as feelings of
chaos and lack of control.
8 ann. behav. med. (2022) XX:1–20
Table 1. Continued
Type Subtype Theory/hypothesis Studies
Training Skills-based intervention in- Training in areas including cognitive restructuring/ Bannon et al.
formed by CBT, DBT, and reappraisals, adaptive thinking, mindfulness, dis- (2020) [36]
trauma-informed care tress tolerance, impact of the illness/injury, under-
standing triggers, and role and identity changes
will prevent chronic emotional distress in stroke
survivors and their caregivers.
Biofeedback training HRV biofeedback will improve autonomic dysfunc- Chang et al. (2020)

tion, cognitive impairment, and psychological [39]
distress.
Alternative medicine
Alternative medicine Aromatherapy (foot bath and Back massage and foot bath using essential oils will Lee et al. (2017)
massage) improve stress, body temperature, mood state, and [46]
fatigue levels of stroke patients.
Pharmacological
Antidepressant drugs Sertraline (50–100 mg daily) Sertraline, a SSRI, will have positive effects on both Murray et al.
depressive symptoms and other relevant poststroke (2005) [49]
domains including emotional distress and QoL.
cCBT computerized cognitive behavior therapy; DBT dialectical behavior therapy; HRV heart rate variability; MBSR mindfulness-based
stress reduction; PosMT positive mental training; QoL quality of life; SFBT solution-focused brief therapy; SSRI selective serotonin re-
uptake inhibitor; TBI traumatic brain injury.
Stress Outcome Metrics Scale (HADS) [28, 30, 36, 39, 53, 55] were the most com-
monly used measures.
Table 2 summarizes how stress or stress-relevant out- Ten studies assessed QoL and/or life satisfaction
comes were measured in the included studies. Not all [28–31, 41–43, 49, 51, 54]; some studies reported a stress
studies were designed to examine stress or resilience as measure as a subscale of this. For example, Friedland
a primary outcome, and as such the included outcomes and McColl [43] used the General Health Questionnaire
were not necessarily primary outcomes. Studies were in- (GHQ) and the Sickness Impact Profile (SIP) to measure
cluded into this scoping review only if the stress was spe- “psychosocial adjustment”. As mentioned above three
cifically discussed in the results section of the study. This qualitative thematic analysis studies [37, 40, 48] were in-
may include data from qualitative interviews or surveys, cluded which did not measure stress outcomes but which
or within a subscale of another measure (e.g., QoL). highlighted stress as an emerging theme. For example,
Several different psychometric scales were used to Baumann et al. [37], a descriptive study of an art therapy
assess stress or related constructs; however, we found program aiming to reduce distress during rehabilitation,
no studies assessing stress biomarkers. In our search did not explicitly measure stress but described individual
strategy, we included terms for coping and resilience, re- participants’ experiences of distress associated with
sulting in the inclusion of studies that measured stress, stroke.
and resilience, coping, problem-solving, stress-related
disorders (including anxiety, depression, and PTSD), Effectiveness and Implementation Outcomes
life satisfaction, and QoL measures, where stress was
reported as a subcomponent of the measure. Of the 14 For each intervention, we assessed the effectiveness in
studies which included a psychometric measurement of terms of both reduction in stress or related construct,
stress, coping, or resilience, 8 reported using a stress- and reduction in stress-related mental health disorders
specific outcome measure [41–46, 49, 50], with others (anxiety, depression, or PTSD); implementation meas-
recording stress-related constructs via a coping scale ures including barriers and limitations, feasibility and
[30, 31], problem-solving scale [28, 31], or resilience acceptability, and any cost analysis or cost-effectiveness,
scale [47, 51, 54]. were reported. Collectively, these features are likely to
Most studies measured stress-related disorders via inform the further development of an intervention for
a scale for symptoms of depression, anxiety, or mood eventual use in practice (Table 3).
(n = 16) [28–31, 36, 39, 41, 44, 46, 47, 49, 50, 52–55]. In order to address our research question “to identify
The Center for Epidemiologic Studies Depression Scale which interventions are potentially efficacious for redu-
(CES-D) [28, 31, 47], Beck Depression Inventory (BDI) cing stress or increasing resilience and coping” we com-
[29, 41, 52], and the Hospital Anxiety and Depression piled a descriptive overview of the reported effectiveness
Table 2. Characteristics of outcome measures used to assess interventions for stress measurement
Outcome type Outcome measurement scale Studies
Stress 10-item Perceived Stress Scale (PSS-10) Colledge et al. (2017) [41]
Ostwald et al. (2014) [50]
Depression Anxiety Stress Scales (DASS-21) Cullen et al. (2018) [42]
General Health Questionnaire (GHQ) Friedland and McColl (1992) [43]
Kessler Psychological Distress Scale (K10) Jones et al. (2016) [45]
Mental Fatigue Scale (MFS) Johansson et al. (2012) [44]

Social Readjustment Rating Scale (SRRS) Lee et al. (2017) [46]
Emotional Distress Scale (EDS) Murray et al. (2005) [49]
Coping Utrecht Proactive Coping Competence scale (UPCC) Tielemans et al. (2015) [30]
Coping Inventory for Stressful Situations Visser et al. (2016) [31]
Problem-solving Social Problem-Solving Inventory-Revised (SPSIR) Chalmers et al. (2019) [28]
Visser et al. (2016) [31]
Resilience 10-item Connor Davidson Resilience Scale (CD-RISC) Terrill et al. (2018) [54]
Perez-de la Cruz (2020) [51]
Brief Resilience Scale (BRS) Love et al. (2020) [47]
Depression/anxiety/ Center for Epidemiologic Studies Depression Scale (CES-D) Chalmers et al. (2019) [28]
mood Visser et al. (2016) [31]
Love et al. (2020) [47]
Beck Depression Inventory (BDI) Colledge et al. (2017) [41]
Nour et al. (2002) [29]
Simblett et al. (2017) [52]
Beck Anxiety Inventory(BAI) Simblett et al. (2017) [52]
Hospital Anxiety and Depression Scale (HADS) Chalmers et al. (2019) [28]
Stubberud et al. (2019) [53]
Tielemans et al. (2015) [30]
Wichowicz et al. (2017) [55]
Comprehensive Psychopathological Rating Scale (CPRS) Johansson et al. (2012) [44]
Multiple Affective Adjective Checklist (MAACL) Lee et al. (2017) [46]
Montgomery–Åsberg Depression Rating Scale (MADRS) Murray et al. (2005) [49]
Presence of emotionalism (increased tearfulness and patho- Murray et al. (2005) [49]
logic crying was recorded as a dichotomous variable)
Geriatric Depression Scale (GDS) Ostwald et al. (2014) [50]
PROMIS-Depression Short Form 8b Terrill et al. (2018) [54]
State-Trait Anxiety Inventory (STAI-Y) Love et al. (2020) [47]
Quality of life Stroke Specific Quality of Life Scale (SS-QOL) Chalmers et al. (2019) [28]
Tielemans et al. (2015) [30]
Visser et al. (2016) [31]
Global subjective rating of change in quality of life (QoL) Murray et al. (2005) [49]
was measured according to a validated visual analog scale
Sickness Impact Profile Nour et al. (2002) [29]
Friedland and McColl (1992) [43]
Older People’s Quality of Life Questionnaire (OPQOL) Terrill et al. (2018) [54]
Short From 36 Health Survey (SF-36) Perez-de la Cruz (2020) [51]
EuroQol EQ-5D-5L Visser et al. (2016) [31]
Life satisfaction Satisfaction with Life Scale (SWLS) Colledge et al. (2017) [41]
Authentic Happiness Inventory (AHI) Cullen et al. (2018) [42]
Leisure Satisfaction Scale Nour et al. (2002) [29]
Likert scales: current life satisfaction, and the difference Cullen et al. (2018) [42]
from prestroke life satisfaction
Qualitative analysis Open-ended descriptive survey Chalmers et al. (2019) [28]
Semi-structured interviews Chouliara and Lincoln (2016) [40]
Mavaddat et al. (2017) [48]
Baumann et al. (2013) [37]
10 ann. behav. med. (2022) XX:1–20
of the intervention in each study. Positive effects on of the included studies referred to or measured the costs
stress, resilience, coping, or psychological QoL/life sat- of the intervention. Mavaddat et al. [48] and Ostwald
isfaction were reported in 13 of the 24 included studies et al. [50] both reported the costs of providing the inter-
[29, 31, 36, 37, 40, 42, 44–46, 48, 51, 52, 55]. Baumann vention per participant. In Terrill et al. [54] and Simblett
et al. [37] and Chouliara and Lincoln [40] reported quali- et al. [52], although costs were not explicitly measured,
tative reductions in stress associated with an inpatient both reported that the intervention was expected to be
art program and memory rehabilitation, respectively. cost-effective based on its features. The cost-effectiveness
The other studies reported a quantitative improvement of any intervention was not reported.
in stress-related outcomes associated with a number of
intervention types: skills-based training based on prin- Assessment of Study Quality

ciples of cognitive behavior therapy [36], positive psych-
ology [42, 48], mindfulness-based stress reduction [44], We used the Cochrane Risk of Bias tool to assess inter-
physical activity program [45], aromatherapy massage, vention studies, and the MMAT to assess mixed-method
and footbath [46], leisure rehabilitation [29], aquatic and qualitative studies (Supplementary File 4). The in-
therapy [51], computerized cognitive behavior therapy cluded quantitative studies (n = 21) [28–31, 36, 38, 39,
or cognitive remediation [52], problem-solving therapy 41–47, 49–55] had methodological limitations, including
[31], and solution-focused brief therapy [55]. Whilst this unclear recruitment techniques, small sample sizes,
represents many included studies (54%), most of these high attrition rates, failure to control for important
had relatively small sample sizes, ranging from 14 to confounders, use of nonvalidated measures and incon-
166, with 10/13 studies recruiting fewer than 30 stroke sistent reporting. Studies scored most strongly (low risk
survivors. Most of these were reported as exploratory, of bias) on sequence generation (12/21), allocation con-
quasi-experimental, or feasibility studies, and reported cealment (11/21), incomplete outcome data (18/21), and
other methodological concerns including lack of active selective outcome reporting (16/21). The categories where
control group and significant dropout rates. Some of studies overall were weaker (associated with a high or un-
these results were also not numerically reported or re- clear risk of bias) included blinding of participants and
ported as a qualitative perceived reduction only. personnel (16/21), blinding of outcome assessors (14/21),
The impact of the interventions on longer-term stress- and other sources of bias (20/21). Quality scoring of the
related problems, primarily symptoms of depression or qualitative or mixed-methods papers (n = 3) [37, 40, 48]
anxiety, were considered in 75% (18/24) included studies. suggested that these papers had a moderate risk of bias.
Of these, seven reported a quantitative decrease in these Studies were not excluded based on quality. The assess-
symptoms [36, 39, 42, 44, 47, 53, 55]. ment of quality for each of the included studies is pre-
In addition to effectiveness results, we also collated sented in Supplementary Appendix.
implementation outcomes reported across studies, pri-
marily acceptability and feasibility, in order to assess
whether the potential long-term sustainability of inter- Discussion
vention had been considered in the included studies.
Where studies included an explicit measure of feasibility This scoping review is the first to map the breadth of
or acceptability from participants, feedback was gener- research that has been conducted around stress inter-
ally positive [28, 29, 31, 36–39, 42, 45, 46, 48, 50–52, 54]. ventions for stroke survivors. Here, we have mapped
Several studies reported low dropout rates and high ad- the types and effectiveness of the trialed interventions,
herence to the intervention strategy (n = 8) [31, 36, 38, as well as the outcome measures used to assess stress or
45, 50, 51, 53, 54]. Broadly, this suggests a willingness related constructs. We also considered aspects of imple-
to participate in these intervention studies. However, mentation reported in the studies, including patient ac-
several studies did report problems with recruitment or ceptability, feasibility, limitations, and cost-effectiveness.
other barriers to participation, including potential re- We identified a total of 24 studies that recruited mixed
fusal to participate based on the time commitments or populations of stroke survivors in terms of susceptibility
participation burden required for some interventions to stress-related outcomes and time poststroke and iden-
(n = 8) [30, 36, 42–44, 50, 54, 55]. Further, some inter- tified a variety of primarily psychosocial interventions
ventions reported differential dropout rates for different delivered to individuals to directly address stress man-
groups of participants, particularly those with aphasia agement or promote related constructs such as resilience,
(n = 2) [30, 48]. problem-solving, or coping. Although all studies reported
We also investigated whether studies reported some the effect of the intervention on stress or stress-related
measure of cost or cost-effectiveness analysis. This is also outcome measures, a correlation to recovery outcomes
an important consideration for upscaling and eventually was not consistently addressed or investigated across
implementing a novel intervention in practice. Only four studies. We also identified significant methodological
ann. behav. med. (2022) XX:1–2011
Table 3. Measures of effectiveness, acceptability, feasibility, and cost-effectiveness
Study Stress reduction Reduction in anx- Barriers and limitations Feasibility and Cost-effectiveness
iety or mood dis- acceptability
order
Bannon et al. Increased scores on Participation in Small feasibility trial Clinical staff not NR
(2020) [36] resiliency variables, Recovering Patients discharged before invested in project
including self- Together was they could be approached Low recruitment
efficacy, mindfulness, associated with Low internal consistency on Treatment satisfaction
and perceived coping baseline to post- measures with reversed was high
in Recovering To- test decrease in scored items for patients at Adherence and

gether training dyads, symptoms of baseline acceptability of
but not control dyads depression, anx- procedures was high
from baseline to iety, and PTS in
post-test. stroke survivors
and caregivers.
Baumann Weekly art sessions NR No long-term follow-up (1 All but one patient NR
et al. (2013) during rehabilita- week after final session) indicated a wish to
[37] tion. Participants Small sample size (n = 18) continue arts activ-
reported that the ities in the future
sessions offered a
source of relax-
ation, tranquility or
calmness(qualitative
analysis).
Bragstad No between-group No statistically The intervention was de- Composite adherence NR
et al. (2020) differences in significant signed both to be de- score showed that
[38] psychosocial between-group livered uniformly and to 117 (80.1%) of the
wellbeing at difference in be individualized. The intervention
12 months depression, competing aims may have trajectories satisfied
poststroke. sense of coher- compromised session de- the criteria for
ence, or health- livery high-fidelity
related QoL at Sample may not be represen- intervention
12 months. tative; informed consent adherence
was difficult to obtain in Participants reported
the stroke unit finding the
intervention helpful
Chalmers Problem-solving Slight reduction No randomization Participants generally NR
et al. (2019) therapy did not pro- after therapy on Use of waitlist reported that each
[28] duce a significant the CES-D and control group therapy session was
change in overall no reduction on No controlling for con- helpful and
problem-solving the HADS-A. founding enjoyable
(SPISR; proxy Problems with recruitment
measure for emo- Small sample size (n = 28)
tional distress).
Chang et al. Average HR decreased HADS score sig- Small sample size 5/40 patients dropped NR
(2020) [39] compared with base- nificantly de- Short follow-up time out after
line in the HRVBF, creased in the Did not log self-practice randomization
but no significant HRVBF group at during follow-up Study reported that
difference between 1 and 3 months the intervention was
groups. but not in the feasible, but it was
control group. not clear on what
basis this was
reported
Chouliara Memory rehabilitation NR Small sample size (n = 20) NR NR
and Lin- led to perceived bene- Qualitative analysis did
coln (2016) fits in participants’ not directly assess some
[40] ability to effectively aspects
manage stress (quali- Separate results not reported
tative analysis). for stroke survivors only
12 ann. behav. med. (2022) XX:1–20
Table 3. Continued
order
Colledge No effect of exercise Descriptive reduc- Small sample size (n = 32) NR NR

et al. (2017) training on perceived tion in depressive Exploratory trial (descriptive
[41] stress. symptoms at analysis only)
follow-up. Selection bias
No nonintervention control

group
Cullen et al. Mean difference of Mean difference Small sample size (n = 37) 63% retention (15 NR
(2018) [42] −5.8 points on the of −9.6 points Exploratory trial completers)
DASS-21 Stress scale on the DASS-21 Not designed or powered for Authors considered
(intervention vs. Anxiety scale efficacy intervention feas-
controls) at week 20 (intervention vs. ible to deliver and
after positive psych- controls) at week acceptable to parti-
ology intervention. 20 after positive cipants
psychology inter-
vention.
Friedland and No differences be- NR Relatively high attrition rate NR NR
McColl tween social support Timing of intervention
(1992) [43] intervention and
control groups on
psychosocial vari-
ables including the
GHQ.
Johansson Statistically significant Significantly de- Small sample size (n = 29) NR NR
et al. (2012) reduction in reported creased scores Some participants who dis-
[44] mental fatigue, for depression continued found the pro-
including reduc- and anxiety on gram time consuming, or
tion in sensitivity to the CPRS after 8 difficult to travel to attend
stress item, following weeks of MBSR. appointments
MBSR compared
with baseline and
controls.
Jones et al. A statistically signifi- NR Small sample size (n = 24) Participants completed NR
(2016) [45] cant reduction in Contact with study partici- an average of 5.6/6
psychological distress pants occurred outside of sessions
(K10 scale) of 2.76 the intervention program Participants reported a
points immediately Mixed population (stroke high level of overall
after the myMoves and TBI) satisfaction with the
program (p = .001). program (95.7%)
The program required
little clinician con-
tact time, with an
average of 32.8 min
per participant over
8 weeks
Lee et al. Statistically significant NR Small sample size (n = 14) NR NR
(2017) [46] reduction in the so- Poor reporting of study
cial readjustment methodology and results
rating scale (means
not reported).
Love et al. Small, but NR Small sample size (n = 35) NR NR
(2020) [47] nonsignificant, No control group
postmeditation in- Selection bias
crease in resilience Sampling in single stroke
observed. clinic
Exclusion of participants lost
to follow-up
ann. behav. med. (2022) XX:1–2013
Table 3. Continued
order
Mavaddat In qualitative inter- Four stroke sur- Small sample size (n = 10) 7/10 stroke survivors £38 for access to
et al. (2017) views, stroke survivors had im- Self-selected sample reported positive the full audio
[48] vivors reported proved scores Not all participants com- benefits from lis- program (in
benefits of the posi- on PANAS; two pleted the full 12-week tening and would 2013 GBP).
tive mental training stroke survivors program recommend to

program in handling had improved others
stress, improved scores, and one Participants with
mood, and coping stroke survivor moderate aphasia
ability. had a worse found it difficult to
score on the concentrate and did
HADS. not persist with the
study
Murray et al. No statistically sig- The MADRS High discontinuation rate NR NR
(2005) [49] nificant effect of score decreased (39% in the treatment and
sertraline treatment substantially in 49% in the placebo group)
on EDS score, how- both treatment Selection of patients with
ever there was a groups, with no minor depression only
reduction from base- significant dif-
line in both groups ferences between
regardless of them at 6 and 26
treatment. Some weeks.
improvement in
QoL and
emotionalism.
Nour et al. At post-test, the ex- No statistically Small sample size Participants reported NR
(2002) [29] perimental group significant dif- Extra time (on average satisfaction with
(leisure rehabilita- ference between 20 min per session) pro- leisure activities
tion) obtained stat- groups for de- vided to intervention following the inter-
istically significantly pression (BDI). group vention
better scores for Some participants did not
total, psychological, complete the program
and physical QoL,
although effect sizes
were small.
Ostwald et al. No effect of mailed No effect of mailed Sample size not 84% of the dyads com- Number, length,
(2014) [50] or home-based or home-based large enough for subgroup pleted the study and content of
psychoeducational psychoeducational analyses 12-month follow-up. each contact
intervention on stress intervention on The sample is not representa- Dyads that did not was tracked,
as measured by the depression scores tive—included only those complete the study allowing for
PSS-10. (GDS). over 50 years of age who were older, had analysis of costs.
were being discharged higher caregiver An average
home with a spouse support scores and of two home
Analysis of multiple out- spent more days in visits a month
comes in this study pos- inpatient rehabilita- during the ini-
sibly increased the type tion than those who tial 6 months
I error rate. finished the study at home
postdischarge
from inpatient
rehabilitation
could be de-
livered at a
mean cost
of $2,500 per
dyad.
14 ann. behav. med. (2022) XX:1–20
Table 3. Continued
order
Perez-de la In the experimental NR Small sample size (n = 41) All the participants NR
Cruz (2020) group, significant Short follow-up (1 month) completed all the
[51] differences from sessions and com-
baseline were found plied with the pro-
in the resilience vari- posed program

ables (p < .001) and
these improvements
were maintained
1 month after com-
pleting the treatment
program.
Simblett et al. All groups demon- Trend toward re- Small sample size (n = 28) Feasibility and ac- Not explicitly
(2017) [52] strated a decrease in duced depression Feasibility and acceptability ceptability were the measured. How-
symptoms of distress, scores on the were the primary outcomes primary outcomes ever, the idea
measured via the BDI for compu- for this study, not efficacy for this study. Re- of small groups
BDI and BAI, and terized CBT and No blinding to intervention cruitment rate for was primarily
the NEADL across computerized of outcome assessors the intervention ran introduced as
time associated with cognitive remedi- below the expected a means of
computerized CBT ation therapy. rate improving the
and computerized Smaller trend for Broadly feasible, al- feasibility of
cognitive remediation anxiety symp- though some aspects delivery by re-
therapy. toms. required more flexi- ducing costs
bility associated
Majority suggested with providing
intervention was psychological
useful, relevant and therapy.
easy to use
Stubberud No change in self- Decrease in overall Small sample size (n = 8, of All subjects completed NR
et al. (2019) efficacy after training score on the which 5 are stroke sur- the interventions
[53] in metacogni- HADS, driven vivors)
tive strategies for by a change Results not presented separ-
improving attention, in the anx- ately for stroke and TBI
problem-solving, fa- iety subscale. survivors
tigue management, No change in Self-reported outcomes only
adaptive coping re- the depression No control group
sponses, and the use subscale.
of CBT techniques as
measured using the
GSE scale.
Terrill et al. Study not designed to Measured Small sample size; 11 stroke Participants reported Not explicitly
(2018) [54] measure effect of PROMIS- survivor/carer dyads. One satisfaction with the reported; ref-
intervention—the Depression dyad discontinued, final intervention erenced a
data collected in this Short Form 8b, 10 dyads Stroke survivors were Cochrane re-
study were used to but results not fatigued by training view stating
identify feasibility of reported. session that use of apps
a positive psychology One of the dyads to administer
app. dropped out of the self-manage-
8/10 dyads still used study ment
positive psychology Remaining dyads en- programs was
in their everyday lives gaged in a mean of cost-effective.
at follow-up. 4.08 individual and
Measured CD-RISC, 3.62 couple activities
but results not re- per week
ported.
ann. behav. med. (2022) XX:1–2015
Table 3. Continued
order
Tielemans No effect of Trend favoring the Study did not include more Of 58 patients assigned NR
et al. (2015) self-management self-management severely affected stroke to the self-manage-
[30] intervention com- intervention on survivors ment intervention,
pared with an educa- the HADS. Self-assessment used to as- 56 started the inter-
tion intervention in sess outcomes vention and 46 at-
Outcome measures too gen- tended at least three

coping skills on the
UPCC scale. eric to detect changes quarters of the inter-
Study too small to detect vention sessions
outcome differences in
partners (n = 57 partners)
Sample selected by hospital
staff
Usual care was not con-
trolled
Visser et al. Improvement in coping Depression score No active control groups The low dropout rate NR
(2016) [31] strategy as measured did not differ Intervention was investigated and positive feed-
by the Coping In- significantly be- within outpatient rehabili- back suggest that an
ventory for Stressful tween the groups tation and may not be gen- open group design is
Situations between over time (CES- eralizable to other settings feasible and effective
groups (problem- D). Sample reported a relatively in outpatient stroke
solving therapy vs. high utility score com- rehabilitation
control). pared with other stroke
populations
Wichowicz Increased self-efficacy Reduced anxiety 62 completers (100 random- Potential SFBT parti- NR
et al. (2017) and constructive at- and depression ized) cipants who refused
[55] titudes in the SFBT scores in the Participants relatively fit and to participate may
group compared SFBT group may not be representative have found the pro-
with controls (Mini- compared 35 withdrawals from study cedure of psycho-
Mental Adjustment with controls Lengthy procedure therapy too lengthy
to Cancer and Self- (HADS). Lack of complete random-
efficacy Scale). ization
BAI Beck Anxiety Inventory; BDI Beck Depression Inventory; CD-RISC 10-item Connor Davidson Resilience Scale; CES-D Center for
Epidemiologic Studies Depression Scale; CPRS Comprehensive Psychopathological Rating scale; DASS-21 Depression Anxiety Stress
Scales; EDS Emotional Distress Scale; GBP British pounds; GDS Geriatric Depression Scale; GHQ General Health Questionnaire;
GSE General Self-Efficacy; HADS Hospital Anxiety and Depression Scale; HR heart rate; HRVBF heart rate variability biofeedback;
MADRS Montgomery–Åsberg Depression Rating Scale; MBSR mindfulness-based stress reduction; NEADL Nottingham Extended
Activities of Daily Living; NR not reported; PANAS Positive and Negative Affect Schedule; PROMIS Patient-Reported Outcomes
Measurement Information System; PSS-10 Perceived Stress Scale; PTS post-traumatic stress; QoL quality of life; SFBT solution-
focused brief therapy; SPISR Social Problem-Solving Inventory-revised; TBI traumatic brain injury; UPCC Utrecht Proactive Coping
Competence.
issues associated with most studies, and a tendency for Psychological distress is commonly reported fol-
studies to be at an early or feasibility stage. Furthermore, lowing stroke and is associated with a number of signifi-
even though the majority of included studies appeared cant cognitive and psychological problems, but based
to be feasibility or exploratory trials, our search did not on this review, the evidence base for psychotherapeutic
identify any larger subsequent or follow-up studies to interventions is small and equivocal. Any recommenda-
this early work. Overall, despite the trend toward posi- tion for an intervention designed to manage excessive
tive outcomes, the limitations of the included studies stress, with the ultimate aim of preventing stress-related
made it difficult to conclusively identify the most ef- disorders and improving recovery, should be evidence
fective interventions. Despite these shortcomings, we based in order to justify the allocation of resources, and
found that the number of relevant publications increased in order to reduce harms from potentially ineffective
over time, suggesting that stress and stress management interventions. Although there is emerging evidence for
are progressively being considered important for stroke targeting stress for the prevention of some disorders
survivors. such as CVD, at present the relevance of intervening
16 ann. behav. med. (2022) XX:1–20
on stress in stroke populations remains unclear [57, 58]. memory impairment [61]. However, to date, there is very
Broadly, the population with the greatest benefit:risk little regulation of these interventions and systematic
ratio is not defined, the potential range of interven- research on the potential benefits of mHealth interven-
tions remains broad, and there is no agreement on the tions for stress management is not currently available.
best outcome measures to use for stress. The studies
included here also tended to emphasize treatment ra- Target Population
ther than prevention of emotional distress. This is in
agreement with two recent systematic reviews of dyadic The relevant population for targeting stress management
interventions for caregivers and stroke survivors, which to prevent the stress-related sequelae of stroke also re-
focused on interventions to reduce stress in caregivers. mains unclear. Prevention of stress after stroke could be

The results of these studies highlighted substantial either universal (i.e., offered to all individuals poststroke),
limitations of interventions for carers and stroke sur- or targeted to a higher risk population of stroke sur-
vivors including weighting toward treating rather than vivors identified as having elevated levels of stress prior
preventing stress, and a lack of customizable interven- to the stroke, or those most at risk of developing adverse
tions which would allow tailoring to account for the stress-related outcomes. The studies included in this re-
heterogeneity of stroke survivors’ needs [59, 60]. view were mixed; some included a broader population
of stroke survivors (21/24), whilst others included only
Stress Management Interventions and Their Delivery those at higher risk of stress and related sequelae, such
After Stroke as emotional distress or symptoms of depression (3/24).
It is also unclear at which phase of stroke recovery is best
A wide variety of interventions were trialed in the in- to intervene. Although most of the included studies were
cluded studies, which were predominantly small in scale conducted during the chronic phase of stroke recovery
and based on very localized or intensive solutions gen- (i.e., >6 months poststroke), at present it remains un-
erally run for an 8–12-week period. Often consider- known as to when might be the optimum time to manage
ations on how such an intervention might scale up to stress throughout the recovery trajectory. Whilst the rela-
the broader population were not included/made. Several tive risk of negative health outcomes due to stress may be
studies reported poor adherence and/or recruitment due small compared with other risk factors, a recent review
to the burden of participation. Stress management inter- highlighted the importance of tackling stress in people
ventions that require large amounts of time and travel with high baseline cardiovascular risk, such as stroke
may lead to adherence problems in stroke survivors and survivors, because this translates into a larger difference
should be an important consideration in the development in absolute risk [62]. In order to determine when and in
of any intervention. Unlike pharmaceuticals, funding which population stress management might be most clin-
mechanisms for integrating new psychosocial interven- ically and cost-effective, additional studies are required
tions into health systems are less clear. Further, funding which monitor stress and related sequelae over time.
for sufficiently large effectiveness trials and eventual re- Additionally, several studies excluded people with
imbursement should also be considered. These factors a progressive neurological disorder, cognitive dysfunc-
were rarely considered in the included studies. Adequate tion, or aphasia. Studies typically justified this approach
resourcing, and considering the burden of participation by stating that collecting and reliably interpreting data
for stroke survivors and health systems, are important from these patients can present significant challenges.
considerations in the design of any preventive interven- However, a high proportion of stroke patients have cogni-
tion. This is likely to be magnified for an issue such as tive or speech, and language impairments, and if studies
stress management, which will require significant adher- of interventions aiming to reduce psychological distress
ence to achieve its goals. among stroke patients fail to involve such patients, the
In order to address issues around implementation, findings may not be representative of the wider stroke
scalability, and cost-effectiveness, it may be worth con- population [37]. Therefore, a number of these studies
sidering interventions that have been trialed in other with specific inclusion/exclusion criteria may not be gen-
populations that may be likely associated with smaller eralizable to the broader population with stroke and have
participant burden, lower costs, and high effectiveness. limited external validity.
For example, mobile technologies and mHealth interven-
tions might be a low-cost, simple method of delivering Measurement of Stress
modular, customized mental health support to mitigate
stress in stroke survivors. Mobile interventions based There was a lack of consistency in measuring stress be-
on cognitive training approaches have been used suc- tween studies. Significant uncertainty in the field of stress
cessfully for stress-related cognitive problems such as research more broadly lies in the use of standardized
ann. behav. med. (2022) XX:1–2017
techniques or tools to measure the level of stress. Whilst is not affected by acute stress variables and is not subject
stress has been linked to an increased risk of secondary to diurnal variation, and finally, baseline hair samples
stroke, CVD, and psychopathology in stroke survivors, obtained within the week after stroke provides informa-
and has a negative impact on the trajectory of recovery tion about stress and cortisol level prior to the stroke in-
from stroke, the best approach to measure stress in re- cident. The relatively stable and noninvasive nature of
search and clinical settings remains unclear [63, 64]. hair cortisol as a stress biomarker may make this an ideal
Compared with other known behavioral risk factors for marker in future studies of stress poststroke.
chronic diseases, such as smoking, nutrition, and phys-
ical activity, psychosocial constructs such as stress are Does Stress Management Prevent Stress-Related
difficult to define objectively [65]. The response to stress Disorders?

can be measured using self-report, or a physiological
measurement. A number of scales have been developed Finally, it has not yet been shown that a change on a
for the measurement of stress. The Perceived Stress Scale subjective stress scale is a proxy for patient-relevant
(PSS-10) [66], Symptom Checklist 90 (SCL-90) ques- outcomes, such as prevention of anxiety or depression.
tionnaire [67], and the Depression Anxiety Stress Scales Based on the included studies, there is only limited evi-
(DASS-21) [68] tend to be the most widely used validated dence to suggest that the included interventions to
tools found in the literature for the subjective assessment manage stress and related constructs will translate into
of stress. In this review, we found considerable variation a reduction in stress-related disorders in stroke survivors.
across studies in terms of self-reported approaches for In the included studies, only 7 of the 18 that considered
measuring stress. Several studies did not use any stress symptoms of stress-related disorders reported a decrease
measurement tool, instead of reporting subscale re- in symptoms associated with the intervention. This may
sults of a QoL scale or similar to infer emotional dis- not be unexpected, since these programs were designed to
tress, qualitative results, or used an unstandardized tool, address stress management and not treat existing symp-
making it difficult to compare study results. Related con- toms of anxiety or depression. Whilst improved stress
structs such as resilience also appeared infrequently in management is likely to be an important precursor to ef-
our search, with only three studies reporting the results fective prevention of depression or anxiety, it remains un-
of an intervention on a resilience scale. clear where best to target these efforts. In future studies,
Similarly, no studies reported changes in any bio- it will be important to establish not only consistent and
markers for stress. There are numerous biological path- relevant measures of stress, but also the link between an
ways linking stress to disease outcomes, and as a result, improvement in stress management or stress levels and re-
a number of physiological stress measures or biomarkers ductions in the risk of known stress-associated disorders
are commonly used in stress research, primarily based on such as depression, anxiety, CVD, and mild cognitive im-
stress-related changes in neuroendocrine signaling [69]. pairment. Further, studies should examine longitudinally
One of the major alternatives to the psychometric assess- the impact of early compared with late stress mitigation,
ment of stress is to assess levels of stress hormones, in to examine whether stroke survivors who receive these
blood or saliva [7]. A number of studies have considered preventive measures at varying time periods in recovery
a measurement of blood cortisol levels; however, these are less likely to develop stress-related problems.
measures also suffer from serious limitations in terms of
their accuracy because stress is not the only factor that
evokes changes in the levels of these hormones [7, 63]. Limitations
Stress hormones measured within the saliva and blood
can change quickly in their concentration and fluc- There are a number of potential limitations to this re-
tuate significantly over time [70]. These issues mean that view. While we conducted a comprehensive search using
single-time point analyses using blood or saliva may be key databases and hand searching, it is possible that the
noninformative. Of course, it is possible to collect mul- review may have missed some relevant studies. We also
tiple samples across time, but the practical consider- included only papers in English and did not conduct a
ations and participant burden mean this is typically not search of the gray literature. There may be evidence of
feasible. One recent study has used an objective measure program impacts in the evaluation and other technical
of the stress level in the form of hair cortisol, to asso- reports, not available here.
ciate stroke outcome with stress [71]. The hair sample
for the determination of cortisol level instead of blood,
saliva, or urine offers several advantages in stroke–stress Conclusion
research. Firstly, its analysis can provide an accurate as-
sessment of the long-term integrated level of cortisol The successful management of chronic stress in stroke
over the course of the months. Secondly, its measurement survivors is likely to improve psychological and cognitive
18 ann. behav. med. (2022) XX:1–20
recovery outcomes and improve rehabilitation contacts. Ethical Approval This is a review of published literature, as such
However, most intervention studies we identified were ethics approval is not required.
small, primarily consisting of feasibility studies to inform
Informed Consent
larger trials. There was a trend toward a positive effect of
stress management interventions in stroke survivors, in
terms of reduction in perceived stress levels, and a smaller References
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ann. behav. med.

Psychological Stress Management and Stress Reduction Strategies

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Published online: 11 June 2022

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Type Subtype Theory/hypothesis Studies

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Table 1. Continued

Type Subtype Theory/hypothesis Studies

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Outcome type Outcome measurement scale Studies

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Table 3. Measures of effectiveness, acceptability, feasibility, and cost-effectiveness

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Table 3. Continued

Colledge No effect of exercise Descriptive reduc- Small sample size (n = 32) NR NR

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Table 3. Continued

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Table 3. Continued

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Table 3. Continued

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