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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 74-78

Impact of stress, anxiety, and depression on cognition and quality of life in stroke patients: Influence of cognitive behavioral therapy

1 Department of Physiotherapy, Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India
2 Department of Physiotherapy, Yatharth Super Speciality Hospital, Noida, Uttar Pradesh, India

Date of Submission21-Feb-2022
Date of Decision12-May-2022
Date of Acceptance27-Jun-2022
Date of Web Publication30-Jul-2022

Correspondence Address:
Dr. Pooja Sharma
Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_20_22

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Context: The pandemic has resulted in rapid spread of disease-causing fear in adults, children and unhealthy people. The enactment of national policies resulted in reduced outpatient visits in hospitals and perceived stress, anxiety and depression have become very common in neurological ill patients impacting their cognition and affecting their quality of life (QOL). Cognitive behavioral therapy (CBT) is a sort of neuropsychiatric treatment which helps patients to cope up with stress, anxiety, and depression and it needs further research.
Aim: The present study focuses on the understanding the effect of anxiety, stress, and depression on the cognition and QOL of neurological ill patents and the influence of CBT in improving the cognitive ability of stroke patients.
Settings and Design: This experimental study was conducted on neurologically ill patients
Materials and Methods Thirteen subjects diagnosed with stroke were given 3-week protocol for CBT. Pre- and postassessment was done to evaluate depression, stress, anxiety, cognition and QOL on the basis of outcome measures including Depression Anxiety Stress Scale-21 and Montreal Cognitive Assessment Test for cognition and Neuro-QOL Brief for QOL.
Statistical Analysis Used: Correlation between DASS-21 and MoCA was done using Pearson's correlation coefficient test.
Results: 40% of the patients suffered from depression, stress, and anxiety. The results of paired t-test for pre- and poststress, depression, and anxiety showed a significant result. There was a significant difference in the scores of precognition and postcognition.
Conclusion: CBT is effective in reducing perceived stress, depression, and anxiety and thereby improving cognition and QOL of stroke patients.

Keywords: Anxiety, Cognition, Cognitive behavioral therapy, Depression, Quality of life, Stress

How to cite this article:
Sharma P, Varshney N. Impact of stress, anxiety, and depression on cognition and quality of life in stroke patients: Influence of cognitive behavioral therapy. Indian J Phys Ther Res 2022;4:74-8

How to cite this URL:
Sharma P, Varshney N. Impact of stress, anxiety, and depression on cognition and quality of life in stroke patients: Influence of cognitive behavioral therapy. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Feb 5];4:74-8. Available from: https://www.ijptr.org/text.asp?2022/4/1/74/353016

  Introduction Top

The rapid spread of coronavirus has been a cause for fear in all individuals, but especially in those who already have co-morbidities. The enactment of national policies resulted in restrictions related to social gatherings and high-risk areas travelling.[1] It also restricted the visits to outpatient clinics and hospitals. As per available research perceived, disorders such as anxiety, depression, and stress are very common in neurologically impaired patients such as stroke, traumatic brain injury, Parkinson's disease, and multiple sclerosis.[2] These perceived neuropsychological impairments also cause a subsequent impact on their quality of life (QOL). Clinical anxiety, acute stress, and depression caused by the major life events have well documented detrimental effects on cognition process, like working memory.[3] Depression is known to impair one's attention, memory, and information processing and advancing skills. It can also lower the cognitive flexibility and executing functioning. As per the 2015 update of Canadian Stroke Society, the module of cognition, fatigue, and mood reinforces the growing and changing body of research evidence available to guide screening, assessment, and management of those conditions following stroke. It has been noted that Depression and anxiety frequently coexist in stroke patients.[4]

Psychological stress could affect the cognitive function either short-term or long-term causing the deteriorating effects on cognition by diminishing the attention or processing, which hampers the QOL of patient.[5] Giulia Perini 2019 stated very little or almost no attention has been paid toward the cognitive impairment in relation to depression. These cognitive impairments remarkably impact the functioning of patients and declining their QOL.[6],[7] There are many approaches which helps reduce neuropsychological disorders. Cognitive behavioral therapy (CBT) is one of them which focuses on changing the automated negative thoughts contributing to emotional difficulties, depression, and anxiety. These unconstrained negative thoughts have a detrimental influence on mood. With the help of CBT, these thoughts can be recognized, challenged, and replaced with more objective, realistic thoughts.[8] CBT includes many techniques such as cognitive restructuring and reframing, guided discovery, desensitization technique, relaxation exercises, meditation, imagery, behavioral experiments, relaxation, and stress reduction techniques. Available literature shows that the CBT helps the neurological ill patient to conquer their stress, depression, and fear and thereby it helps upgrade their overall QOL. There is limited literature to focus on the efficacy of CBT in stroke patients including the home program regime. The present study focuses on the understanding the effect of anxiety, stress, and depression on the cognition and QOL of neurological ill patents and the influence of CBT in improving the cognitive ability of stroke patients.

  Subjects and Methods Top

Sample consisted of the neurologically ill patients poststroke with the age of 40 years and above suffering from chronic conditions for at least 6 months or more belonging to both the gender. A total of 30 patients were screened and 13 patients poststroke constituted the study sample. The patients included were those with Depression Anxiety Stress Scale (DASS-21) score 78 and above and Montreal Cognitive Assessment (MoCA) score 22 and less. Those who were already suffering from any diagnosed psychological conditions such as schizophrenia, delirium, taking any psychiatric medicine or on psychiatric treatment, and suffering from any other acute neurological condition were excluded. The potential volunteered candidates were explained about the research and the purpose of the study and all the eligible participants filled the consent form. The participants descriptive data were recorded following which the preassessment was done using DASS-21 for depression, anxiety, and stress, MoCA for cognition, and Neuro-QOL short form to evaluate the QOL. Subjects suffering from stress, anxiety, and depression and score range with mild cognitive impairment were included for the interventional treatment of CBT. Postassessment was done after CBT intervention using DASS-21, MOCA, and Neuro-QOL to check the influence of CBT treatment on these patients. A 3 weeks protocol of CBT, 5 times in a week with the total of 15 sessions was administered. The CBT protocol included outpatient department based formal relaxation exercises: breathing exercises, progressive muscle relaxation (once daily 3 set of each with 10 repetition each), and a home protocol that included breathing exercise (slow paced diaphragmatic breathing 10 repetition, 3 sets daily), meditation for 10 min, pleasure, and mastery for 15 min daily. The program was well explained and monitored by the physical therapist at regular intervals.

  Results Top

A total of 13 patients poststroke constituted the study sample. The results were analyzed for thirteen patients by DASS-21, MOCA, and Neuro QOL short form. Correlation between DASS-21 and MoCA was done using Pearson's correlation coefficient test. Pre- and postassessment scores of each DASS-21, MoCA, and Neuro-QOL short form were compared using paired t-test to know the efficacy of CBT.

A significant difference in the mean and standard deviation (SD) value of the anxiety, stress, and depression was found pre- and posttest. The correlation between the depression, anxiety, stress, and MOCA was done. It was found that depression, anxiety, and stress effected the cognition [Table 1] and [Figure 1].
Figure 1: Paired t-test of pre- and postdepression, anxiety, stress, and cognition

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Table 1: Correlation of depression, anxiety, stress, and Montreal Cognitive Assessment Test

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Paired t-test was applied for pre- and postdepression, anxiety, and stress values. There was a significant difference in the scores of predepression (mean = 13.15, SD = 2.60) and postdepression (mean = 9.07, SD = 1.70) results; t(13) = 7.59, P = 0.005, scores of prestress (mean = 14.69, SD = 2.52) and poststress (mean = 7.92, SD = 2.25) results; t(12) = 7.90, P = 0.005, scores of preanxiety (mean = 10.61, SD = 2.60) and postanxiety (mean = 7.84, SD = 1.99) results; t(12) = 5.08, P = 0.005 [Table 2].
Table 2: Paired t-test of pre- and postdepression, stress, anxiety, and cognition

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Pre- and post-domain-wise mean and SD of QOL of neurological patients after CBT treatment showed a significant improvement. The most affected domain was emotional and behavioral dyscontrol, fatigue positive affect and well-being, satisfaction with social role, and cognition function. There was a significant difference in the scores of precognition (mean = 18.0, SD = 2.16) and postcognition (mean = 18.84, SD = 2.57) results; t(12) = 2.51, P = 0.005 [Table 3].
Table 3: Domain-wise pre- and post-mean and standard deviation of Neuro-Quality of Life Brief

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  Discussion Top

Evidence shows that clinical anxiety and stress cause the detrimental effect on cognitive process and is associated with the changes in working accomplishment.[9] Although there are many research papers supporting the effect of CBT on neuropsychological aspects, there is limited literature available on stroke patients. Nguyen et al., 2019 related stress as one of the major factors which can result in depression and can affect one's cognitive ability by declining the learning and the cognitive memory.[10] Depression is known to affect one's ability to think and impair the attention, memory as well as the person's lifestyle.[11]

CBT is a neuropsychological approach which is used to treat the psychological illness of patients.[12],[13] Four weeks intervention of cognitive behavioral training is found to be effective for poststroke depression symptoms and resulted in enhancing the QOL of poststroke patients.[14],[15] Three to four sessions of physical therapy in combination with psychological therapy is helpful in attaining reduction in depression in patients having stroke.

The study further confirmed that stress, anxiety, and depression have a significant effect on the cognitive ability of the person impacting the QOL of patients. Three weeks of CBT including the relaxation therapy, leisure activity, meditation, and breathing exercises was significantly beneficial in improving the symptoms related to stress, anxiety, and depression in stroke patients. CBT comprises activity planning, challenging one's own thoughts, resolving practical issues, mental imagery, and engaging in enjoyable activities. These activities are beneficial for treating anxiety and depression.[16],[17],[18]

QOL and activities of daily living have shown improvement after the CBT protocol in all the affected domains.[19] Counseling, physical therapy, and behavioral therapy help in the significant improvement in anger management and emotions and enhancement in the ADLs of stroke patients.[20] The limitation of the study was a smaller sample size due to time-bound study; hence, further studies may evaluate the outcomes of CBT on different set of neurologically ill patients with variable treatment duration and protocol to see its efficacy.

  Conclusion Top

Depression, stress, and anxiety are very common in postneurological conditions and these psychological factors deteriorate patient's QOL. CBT is effective in reducing depression, stress, and anxiety and helps in enhancing the overall QOL for the patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

COVID-19 Significantly Impacts Health Ser vices for Non-Communicable Diseases, World Health Organizations; [Internet] June 2020. Available from: https://www.who.int/news/item/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-disease. [Last accessed on 2020 Nov 15].  Back to cited text no. 1
Lyketsos C, Kozauer N, Rabins PV. Psychiatric manifestations of neurologic disease: Where are we headed? Dialogues Clin Neurosci 2007;9:111.  Back to cited text no. 2
Lukasik KM, Waris O, Soveri A, Lehtonen M, Laine M, et al. The relationship of anxiety and stress with working memory performance in a large non-depressed sample. Front Psychol 2019;10:4.  Back to cited text no. 3
Eskes GA, Lanctôt KL, Herrmann N, Lindsay P, Bayley M, Bouvier L, et al. Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Following Stroke practice guidelines, update 2015. Int J Stroke 2015;10:1130-40.  Back to cited text no. 4
Scott SB, Graham-Engeland JE, Engeland CG, Smyth JM, Almeida DM, Katz MJ, et al. The effects of stress on cognitive aging, physiology and emotion (ESCAPE) project. BMC Psychiatry 2015;15:146.  Back to cited text no. 5
Perini G, Cotta Ramusino M, Sinforiani E, Bernini S, Petrachi R, Costa A. Cognitive impairment in depression: Recent advances and novel treatments. Neuropsychiatr Dis Treat 2019;15:1249-58.  Back to cited text no. 6
Stites SD, Harkins K, Rubright JD, Karlawish J. Relationships between cognitive complaints and quality of life in older adults with mild cognitive impairment, mild Alzheimer's disease dementia, and normal cognition. Alzheimer Dis Assoc Disord 2018;32:276.  Back to cited text no. 7
Timothy J. Legg Written by Crystal Raypole, How Cognitive Behavioural Therapy can Review your Thoughts, Healthline.Com; June, 26, 2019.  Back to cited text no. 8
James C. More than Sad: Depression Affects your Ability to Think. United States: Havard Health Publishing; 2016.  Back to cited text no. 9
Sandi C. Stress and cognition. Wiley Interdiscip Rev Cogn Sci 2013;4:245-61.  Back to cited text no. 10
Liu TW, Ng GY, Ng SS. Effectiveness of a combination of cognitive behavioral therapy and task-oriented balance training in reducing the fear of falling in patients with chronic stroke: Study protocol for a randomized controlled trial. Trials 2018;19:168.  Back to cited text no. 11
Rasquin SM, Van De Sande P, Praamstra AJ, Van Heugten CM. Cognitive-behavioural intervention for depression after stroke: Five single case studies on effects and feasibility. Neuropsychol Rehabil 2009;19:208-22.  Back to cited text no. 12
Yang Z, Oathes DJ, Linn KA, Bruce SE, Satterthwaite TD, Cook PA, et al. Cognitive behavioral therapy is associated with enhanced cognitive control network activity in major depression and posttraumatic stress disorder. Biol Psychiatry Cogn Neurosci Neuroimaging 2018;3:311-9.  Back to cited text no. 13
Bourbeau K, Moriarty T, Ayanniyi A, Zuhl M. The combined effect of exercise and behavioral therapy for depression and anxiety: Systematic review and meta-analysis. Behav Sci (Basel) 2020;10:116.  Back to cited text no. 14
Kootker JA, Rasquin SM, Smits P, Geurts AC, van Heugten CM, Fasotti L. An augmented cognitive behavioural therapy for treating post-stroke depression: description of a treatment protocol. Clin Rehabil 2015;29:833-43.  Back to cited text no. 15
Kneebone II, Jeffries FW. Treating anxiety after stroke using cognitive-behaviour therapy: Two cases. Neuropsychol Rehabil 2013;23:798-810.  Back to cited text no. 16
Waldron B, Casserly LM, O'Sullivan C. Cognitive behavioural therapy for depression and anxiety in adults with acquired brain injury: what works for whom? Neuropsychol Rehabil 2013;23:64-101.  Back to cited text no. 17
Ward SK, Turner A, Hambridge JA, Halpin SA, Valentine ME, Sweetapple AL, et al. Group cognitive behavioural therapy for stroke survivors with depression and their careers. Top Stroke Rehabil 2016;23:358-65.  Back to cited text no. 18
Chang K, Zhang H, Xia Y, Chen C. Testing the effectiveness of knowledge and behavior therapy in patients of hemiplegic stroke. Top Stroke Rehabil 2011;18:525-35.  Back to cited text no. 19
Nguyen S, Wong D, McKay A, Rajaratnam SM, Spitz G, Williams G, et al. Cognitive behavioural therapy for post-stroke fatigue and sleep disturbance: A pilot randomised controlled trial with blind assessment. Neuropsychol Rehabil 2019;29:723-38.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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