Title: Optimising Pathways of Psychological Care after Transient Ischaemic Attack and Minor Stroke
Funder: Health Education England

Abstract: Background Annually, 46,000 people have a Transient Ischaemic Attack (TIA) and 120,000 have a stroke in the UK. Both TIA and minor stroke are medical emergencies and may be early signs of a major stroke. There is a misconception, even among clinicians, that these result in no or minimal deficits. However, there is emerging research highlighting that TIA and minor stroke result in residual impairments including depression, anxiety, and cognitive decline. Little is known about the availability and delivery of psychological care post-TIA and minor stroke including what psychological, or other supportive interventions should be available. Aims and objectives This research aims to determine how we can best deliver psychological care to people with TIA and minor stroke in NHS stroke services. The objectives are to: 1. Review the evidence on psychological interventions for mood and cognitive difficulties after TIA and minor stroke. 2. Map current practices of psychological aftercare in TIA and minor stroke across the UK and, in detail, in two TIA/stroke services. 3. Develop an evidence-based psychological care pathway co-designed with patients, stroke professionals, commissioners and charity stakeholders. 4. Test the deployment of the newly developed clinical pathway in NHS services and to identify facilitators and barriers of delivery. Methods It will involve three iterative studies: Study 1: A review of systematic reviews ('meta-review') on psychological interventions for emotional and cognitive difficulties after TIA and minor stroke. This will generate data about the effectiveness of interventions and the context in which these can be delivered. Study 2: A UK-wide survey and interviews with a broad range of stakeholders about current practices of psychological care post-TIA and minor stroke. This will be an exploratory sequential design to investigate what works, for whom and in what circumstances. Data triangulation will produce a blueprint for the core-elements for a new psychological aftercare pathway for TIA and minor stroke, and will be used to co-design this pathway. Study 3: This will test the deployment of this newly developed pathway with people post-TIA/minor stroke (n=40) attending two TIA services. It will explore differences in patient outcomes and quality of care received. Multiple data will be collected before and after implementation from 20 patients receiving usual care and from another 20 patients experiencing the new pathway. Timelines for delivery Over 45 months. Year 1 will focus on meta-review, seeking ethical approvals, liaising with participating sites and setting up the next study. The next two years (Study 2) will focus on mapping existing pathways of care in TIA and minor stroke and co-designing the new psychological pathway. Study 3 will take place in the last two years and the final months will be used for further analysis, write up and dissemination. Anticipated impact and dissemination Annual dissemination activities, such as presentations at national and international stroke conferences will begin as study results are produced. High impact publications will support dissemination. We will work with our clinical-academic and PPI partners to create patient-friendly outputs including a video of overall findings and a monthly research blog.

Lay abstract: Background In the UK, 46,000 people have a Transient Ischaemic Attack (TIA) and 120,000 have a stroke every year. Both TIA (a temporary period of experiencing stroke symptoms) and minor stroke (a stroke causing no obvious or minimal impairments) are medical emergencies, with many patients urgently seen by specialist TIA clinics operating within hospital-based stroke services. These clinics focus mostly on medical treatments and prevention of future strokes. However, there is increasing evidence that people after TIA and minor stroke experience 'hidden' difficulties, such as depression or decline in thinking skills. Yet little consideration is given to these problems with increasing numbers reporting long-lasting impacts on their quality of life. This could be due to the variation of psychological services in stroke, but also because these patients are not routinely offered stroke rehabilitation. This research aims to improve support for people with TIA and minor stroke who have emotional and 'cognitive' (thinking/reasoning) difficulties. It will determine which psychological treatments, can help these patients to make their best possible recovery. It will identify gaps in the existing clinical pathways for improving psychological aftercare for TIA and minor stroke. Findings will inform the development of a new psychological care pathway and will explore how this could operate within NHS stroke services. Design and methodsThe research will be completed over 45 months in three studies, with each building on the last. A combination of methods will be used to synthesise the evidence on psychological treatments and existing pathways for emotional and thinking problems after TIA and minor stroke. This knowledge will be used to develop a pathway to improve psychological aftercare (from identification to treatment).Study 1: We will pull together data from already published literature summaries (reviews) of psychological treatments for post-stroke emotional and thinking problems. A comprehensive summary review will be produced about whether these treatments are appropriate and effective for people with TIA and minor stroke. This work will inform the next two studies. Study 2: This will involve two Work Packages (WPs). WP1 will describe and map current pathways of care for people with TIA and minor stroke across the UK, and in more detail in two NHS stroke services. Data will be collected by a survey and interviews with patients, families, clinicians, and service providers. In WP2, we will develop a new pathway from previous findings and our discussions with patient partners and stroke professionals. This will tell us what people with TIA and minor stroke want and what this pathway of psychological aftercare would look like. Study 3: We will adopt the newly developed pathway into practice in two NHS stroke services to find out whether, and how, this makes a difference to psychological care received by people diagnosed with TIA and minor stroke. Data will be collected using interviews, structured observations, and reviewing medical records. This will identify if the pathway is appropriate and sustainable for considering a future larger evaluation across multiple services. Patient and Public Involvement (PPI) People with TIA and minor stroke were involved in all stages of developing this proposal. A PPI stroke group in Nottingham gave us feedback on the design, methods, and potential impact and they will continue to support this research. Two PPI members will also be embedded in the study team with experience of TIA and minor stroke.Dissemination Summaries and newsletters will be developed for research participants and the general public driven by PPI support. Findings will be publicised in different and easily accessible formats including academic papers, annual conference presentations, the Stroke Association charity, social media, and a monthly research diary blog.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: STROKE;MENTAL HEALTH