| BackgroundThe incidence and number of stroke patients in China rank No.1 in the world.The characteristics of rapid onset and high disability rate make post-stroke psychological distress relatively common in patients and caregivers,adversely affecting disease rehabilitation and the quality of life on both sides.Studies have found that the psychological distress among patients and caregivers is highly correlated,but there is a lack of longitudinal studies that regard patients and caregivers as a whole to confirm the interactive effects and action path of psychological distress.Current dyadic health theory focuses on chronic disease management and coping,without considering the interdependence between patients and caregivers in the early stage after the occurrence of acute medical events and the impact of communication methods on their psychological health.The impact of the dyadic psychological distress of patients and caregivers caused by stroke in the early stage on the acute stage of the disease and patient rehabilitation,and the mechanism of dyadic psychological distress interaction,have not been clarified,resulting in a lack of relevant basis for targeted intervention.Therefore,based on the dyadic disruption theory propsed by professor Cornelius Talea of the cardiovascular behavioral research center at Columbia University in 2021,this study introduces the perception of social support and co-rumination,to explain the interaction and action path of dyadic psychological distress between stroke patients and caregivers,and constructs a universal non-pharmaceutical intervention based on evidence-based method,expert argumentation and randomized controlled trial.It will contribute to enriching the connotation of the research on mental health at the dyadic level,and providing empirical evidence and new ideas for the post-stroke dyadic psychological intervention and the dyadic health research of patients and caregivers with other diseases.Objectives1.To clarify the occurrence and change of dyadic psychological distress over time,and to analyze the correlation between dyadic psychological distress and perceived social support and co-rumination;2.To explore the interaction and action path of dyadic psychological distress between stroke patients and caregivers;3.To construct a non-pharmaceutical intervention for psychological distress and validate its effectiveness by a randomized controlled trial.Methods1.Study on interactive effects of psychological distress among stroke patients-caregiver dyadsThe method of longitudinal study was adopted.First-episode stroke patients and their informal caregivers in stroke centers of two third-class hospitals in Jilin Province were conveniently selected between December 2021 and April 2022.The Hospital Anxiety and Depression Scale,Co-rumination Questionnaire and Perceptive Social Support Scale were used to investigate stroke patients in the acute stage and three months after discharge.Descriptive statistical analysis,variance analysis and chi-square test were used to analyze the occurrence of dyadic psychological distress.Stepwise disordered multinomial logistic regression was used to analyze the influencing factors of dyadic psychological distress.Pearson correlation was used to analyze the correlation between dyadic psychological distress,co-rumination and perceived social support at different time points.The interaction and action path of the dyadic psychological distress were analyzed using the actor-partner interdependence mediation model and cross-lag model.2.Construction of non-pharmaceutical intervention for psychological distress after strokeA combinative method of meta-analysis and expert argumentation was adopted.Firstly,the network meta-analysis was used to evaluate the non-pharmaceutical intervention of psychological distress after stroke.The effect of different interventions was ranked by Surface under the cumulative ranking curve to determine the most effective non-pharmaceutical intervention measure.Secondly,the specific implementation parameters of this non-pharmaceutical intervention were summarized through meta-analysis.The effects of different intervention durations and the duration of each time were compared through subgroup analysis to provide a basis for constructing the intervention program.Finally,the applicability and feasibility of the preliminary intervention program were improved and modified through the expert group meeting,and the final non-pharmaceutical intervention program for psychological distress after stroke was constructed.3.Efficacy of guided imagery for psychological distress in stroke patients and caregivers.A randomized controlled trial was used.Fifty dyads of patients and caregivers with psychological distress after the first stroke were selected and randomly divided into intervention and control groups using a random number table between August 2022 and January 2023.The control group received usual health education and management after stroke,and the intervention group received non-pharmaceutical intervention(guided imagery)based on usual health education and management.After 4 weeks of intervention,chi-square test,two independent samples t-test,Mann-Whitney U test,or paired t-test were used to evaluate the differences in psychological pain,shared rumination,and perceived social support levels between the two groups of study subjects before and after intervention.Results1.Status and interaction of dyadic psychological distress between stroke patients and caregivers1.1 Status of dyadic psychological distress,perceived social support and co-rumination in stroke patients and caregiversA total of 548 first-episode stroke patients and caregivers dyads were investigated.The prevalence of psychological distress was 44.5%in acute stroke patients and 38.9%in caregivers.Taking the patient and caregiver as a whole,the prevalence of dyadic psychological distress was 28.8%.At three months after discharge,a total of 544 patients and caregivers were followed up.The level of psychological distress of stroke patients and caregivers showed a decreasing trend.The declining trend of the dyadic psychological distress group was the weakest(-1.21±3.78).The perceived social support was mainly at the family level.Compared with patients and caregivers who did not present psychological distress,patients and caregivers in the state of dyadic psychological distress had a lower level of perceived social support(patients:47.4±9.2 vs.55.1±12.4,P<0.01;caregivers:50.0±9.3 vs.55.8±11.7,P<0.01),and a higher level of co-rumination(patients:27.4±6.0 vs.21.9±7.7,P<0.001;caregivers:27.6±6.1 vs.24.1±8.4,P<0.001).1.2 Influencing factors of dyadic psychological distress of stroke patients and caregiversThe results of stepwise multinomial logistic regression showed that the younger age of the patient(OR=0.94,95%CI:0.91,0.97),the emergency admission(OR=2.99,95%CI:1.94,4.84),the female caregiver(OR=1.85,95%CI:1.09,3.13),the higher level of perceived social support(patients:OR=0.94,95%CI:0.92,0.96;caregivers:OR=0.94,95%CI:0.92,0.96)and the lower level of co-rumination(patients:OR=1.11,95%CI:1.07,1.14;caregivers:OR=1.07,95%CI:1.04,1.11)were the influencing factors of dyadic psychological distress.1.3 Correlation between dyadic psychological distress,co-rumination and perceived social support in stroke patients and caregiversThe results of correlation analysis showed that the psychological distress of patients and caregivers was only negatively correlated with their own perceived social support,and positively correlated with the co-rumination level of themselves and the other side.The psychological distress level of acute stroke patients and caregivers was positively correlated with the co-rumination of themselves and the other three months after discharge.A dyadic psychological distress interaction model was established with co-rumination as the mediating variable.The results showed that the actor effects of psychological distress of acute stroke patients and caregivers on their psychological distress three months after discharge were statistically significant(patients:β=0.216,P=0.001;caregivers:β=0.249,P<0.001).The partner effect of psychological distress of acute stroke patients on caregiver psychological distress at three months after discharge was significant(β=0.210,P=0.001).Co-rumination had a statistically significant actor effect on the psychological distress of both patients and caregivers(patients:β=0.109,P<0.001;caregivers:β=0.026,P=0.01),and a statistically significant partner effect on caregivers(β=0.074,P<0.01).2.Construction of the non-pharmaceutical intervention program for psychological distressIn the network meta-analysis of non-pharmaceutical intervention for psychological distress after stroke included 46 randomized controlled trials,involving 15non-pharmaceutical intervention measures in four categories.The results of the network meta-analysis showed that the inconsistent factors ranged from 0.53 to 1.31,and theχ~2was close to 0.There was no significant difference between direct evidence and indirect evidence.For post-stroke depression,guided imagery was most likely to rank first.For post-stroke anxiety,only behavior intervention was effective.Due to the small number of intervention studies on post-stroke anxiety(n=5).Guided imagery was finally adopted as an intervention strategy to relieve psychological distress after stroke.A total of 25 randomized controlled trials were included in the meta-analysis of the effects of guided imagery on medical populations.The results of subgroup analysis showed that the intervention time≤4 weeks,the total number of interventions<40 times and the duration of each intervention>20 minutes may alleviate the psychological distress more effectively.Based on the above results,the construction of the guided imagery script was modified through expert group meeting and pre-experiment to form the final guided imagery intervention program for psychological distress after stroke.The subjects listened to the guided imagery audio file once a night through the mhealth app before going to bed,about 23 minutes each time,for a total of one month.3.The effect of guided imagery on the psychological distress of stroke patients and caregiversResults were analyzed by intention to treat.The patients and caregivers in the intervention group received training 6.02 and 5.89 times a week,respectively.The overall compliance was ideal.After adjusting for age,sex,education level and baseline data,the level of psychological distress and co-rumination of patients and caregivers in the intervention group were significantly lower than those in the control group(P<0.05),and the total score of perceived social support and other dimensions were significantly higher than those in the control group(P<0.05).Conclusions1.The psychological distress of stroke patients and caregivers should not be ignored.The prevalence of psychological distress was 44.5%in acute stroke patients and 38.9%in caregivers.The prevalence of dyadic psychological distress was 28.8%.At three months after discharge,the level of psychological distress showed a decreasing trend.The declining trend of the dyadic psychological distress group was the weakest,and still in a state of psychological distress.2.The dyadic psychological distress of stroke patients and caregivers has an interaction effect.The dyadic psychological distress in the acute stage of stroke will affect their psychological distress three months after discharge through co-rumination between them.3.A universal guided imagery intervention based on evidence-based methods is applicable to both stroke patients and caregivers,effectively alleviating the psychological distress and co-rumination of stroke patients and caregivers,and improving their perceived social support.Provide empirical evidence for the management of post-stroke psychological distress.It also provides a reference for the intervention and research on the psychological distress of patients and caregivers with other diseases. |
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