Clinical Rehabilitation 2010; 24: 555564

Feeling sad and useless: an investigation into personal acceptance of disability and its association with depression following stroke
Ellen Townend, Deborah Tinson, Joseph Kwan and Michael Sharpe School of Molecular and Clinical Medicine, University of Edinburgh with participants from The Western General Hospital, Edinburgh, Edinburgh, UK Received 1st September 2009; returned for revisions 20th September 2009; revised manuscript accepted 28th October 2009.

Objectives: To study the association of acceptance of disability with depression following stroke and its ability to predict depression at follow-up. Design: A prospective cohort mixed (quantitative and qualitative) design was used. Setting and subjects: Patients admitted to a stroke unit were consecutively recruited. Eighty-nine participated at one month and 81 were followed up nine months post stroke. Main measures: Depressive disorder was assessed using a structured clinical interview. Disability and acceptance of disability were measured using self-report scales. At one month post stroke, 60 consecutive participants also participated in open-ended interviews exploring their individual concerns about having had a stroke and their responses were analysed qualitatively. Results: One-third of participants were found to have depression (29/89; 33% at one month and 24/81; 30% at nine months). Non-acceptance of disability remained associated with depression after controlling for age, gender, original stroke severity and current disability at one month (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.091.47) and nine months (OR 1.46, 95% CI 1.221.75). Also, non-acceptance of disability measured at one month independently predicted depression measured at nine months (OR 1.19, 95% CI 1.051.35). The qualitative findings illustrated a self-reproachful element to non-acceptance of disability. Patients with depression often said that they should still be capable and sometimes referred to themselves as useless; whereas patients who were not depressed commonly reported having accepted stroke-related disability. Conclusions: These finding suggest that personal beliefs about accepting disability are associated with and predict emotional adaptation following stroke.

Introduction
We know that a third of people who have a stroke suffer from depression in the following
Address for correspondence: Ellen Townend, NHS Fife, Department of Psychology, Stratheden Hospital, Stratheden, Cupar, Fife, KY15 5RR, UK. e-mail: Ellen.Townend@nhs.net

16 months,1 but we know relatively little about the psychological causes and maintaining factors of such depression. Although they have been extensively studied, stroke lesion location and size have not been well supported as major aetiological factors.2,3 While many studies have found a positive association between depression and physical disability, the severity of disability has not adequately accounted for the occurrence of
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E Townend et al. reported details of excluded participants previously16). A further assessment was conducted one month after the stroke to verify exclusion of those with substantial cognitive impairment or aphasia defined by scores of (a) 7/10 on an abbreviated cognitive screening test,17 and (b) 12/20 on the comprehension and expression subsets of the Frenchay Aphasia Screening Test.18 Reasons for non-participation at this one-month stage were as follows: 1 had died, 1 had moved without leaving a forwarding address, 4 were too unwell, 18 failed the cognitive screen, 6 declined, and 2 were too distressed to complete interviews. The final sample consisted of 89 participants of whom 22/89 (25%) had had a prior stroke (other details of stroke diagnoses have been reported previously16). The local research ethics committee approved the study and all participants gave their written informed consent to participate. A research psychologist interviewed participants at home, or in a private room in the hospital. The one-month interview had two parts: (1) a structured interview that yielded quantitative data that was conducted with all 89 participants and (2) a semi-structured interview that yielded qualitative data that was conducted with a subsample of 60 participants (participants 2180 inclusive). Recruitment for the qualitative subsample was consecutive and its commencement was delayed only until the research psychologist had completed her specialist interview skills training. We chose a relatively large sample size and to avoid additional selection of participants for the qualitative study to: capture enough participants with depression to compare to those without; and to increase our confidence in making comparisons between the quantitative and qualitative findings via some quantification of the qualitative findings.19 Participants were followed up and had a repeat structured interview that yielded quantitative data at nine months post stroke. This was considered to be a time by which most individuals recovery would have peaked and they would have had time to reflect upon the impact of their stroke. Eighty-one of the original 89 participants were followed up at this time (2 had died, 4 were too unwell and 2 declined). The structured interview comprised a structured diagnostic interview for depression and verbal

depression, leaving much of the variance unexplained.3,4 The role of personal beliefs and values in depression after stroke has been relatively neglected.5,6 Evidence from other populations suggests that individuals personal evaluations of themselves, their acceptance of their condition and beliefs about their future may be associated with and maintain depression.7 Studies of stroke have examined personal beliefs about future recovery and found that individuals who report greater hope, confidence and control regarding recovery tend to be less emotionally distressed.810 Many stroke patients, however, remain disabled to some degree,1113 and the issue is then one of adjusting to that disability. Acceptance of disability theory highlights the importance of being able to accept oneself as an intrinsically worthy person despite having disability in achieving psychological adjustment.14,15 We aimed to study the association between depression and stroke patients acceptance of their disability. We hypothesized that lower acceptance of disability would be associated with depression and remain associated when stroke severity, disability and demographic factors were controlled for.

Methods
Participants were NHS patients who had been admitted with a definite diagnosis of stroke to the Western General Hospital, Edinburgh, a university hospital with a specialist stroke unit. Only patients who had survived one month and were free of substantial cognitive impairment or aphasia were included. This was ascertained largely by means of an initial medical assessment of stroke severity that was routinely conducted on consecutive patients admitted with suspected stroke. Patients were selected from initial assessment if they: (a) had a definite stroke diagnosis and were considered likely to survive; (b) were able to understand and respond sufficiently to give permission for subsequent contact. One hundred and twenty-one potential participants were recruited and referred at this stage (we have

Acceptance of disability and depression post stroke administration of self-report scales to measure disability and personal beliefs about accepting disability. Depressive symptoms were assessed with the Structured Clinical Interview for the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV).20 Diagnoses of depressive disorder were made by consensus between the research psychologist and her consultant psychiatrist supervisor (who was blind to the patients disability status). The final depression diagnosis was categorized into: no depression, minor depression and major depression according to DSM-IV.21 Stroke severity was measured with the National Institute for Health Stroke Severity Scale for which scores may range from 0 to 36 and higher scores indicate greater severity.22 Disability in personal activities of daily living such as dependence in bathing was measured with a reverse scored Barthel Index (Barthel ADL)23 for which scores may range from 0 to 20. This was reverse scored so higher scores indicated more disability and zero indicated independence.23 Disability in extended activities of daily living (e.g. writing a letter or travelling by bus) was measured with a reverse scored Nottingham Extended Activities of Daily Living Scale (Nottingham EADL).24 This was also reverse scored so that higher scores indicated more disability and scores could range from 0 to 21. Non-acceptance of disability was assessed using an adapted version of the eight-item Acceptance of Illness Questionnaire.25 It was considered to address personal acceptance and adapted to stroke-related disability by substituting the word illness with the effects of my stroke, or stroke (see Appendix). As items are all phrased to reflect self-devaluating beliefs about disability (see Appendix) it is essentially a measure of nonacceptance of disability. Responses to items are Likert scaled and overall scores may range from 0 to 32 with higher scores indicating a lower level of acceptance. Associations between depression (major or minor) and other variables were examined using, t-tests or MannWhitney U-tests, and, Pearson or Spearman correlations, as appropriate. Logistic regression with depressive disorder as the dependent variable was conducted to investigate the relative contribution of the variables.

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Some multicollinearity between stroke severity, disability and non-acceptance of disability was to be expected, therefore a conservative approach to testing for the independent contribution of non-acceptance of disability was taken. At the first block, all the other variables were entered simultaneously, regardless of their univariate significance, in order to control for potential confounding. Non-acceptance of disability was then entered in the second block using the stepwise procedure. We conducted analyses using SPSS for Windows version 13 (SPSS Inc., Chicago, IL, USA). In their semi-structured interview, participants were asked about their main concerns regarding having had a stroke using a semi-structured format. Once topics of concern were established, further probe questions were used to elicit thoughts and feelings about these and other subsidiary issues. The interviewer ended interviews by summarizing and checking what participants had said. Qualitative interviews tended to take about half an hour, they were audio-taped, transcribed and content-analysed using the Frameworks method.19 The research psychologist developed preliminary codes (minor themes) via constant comparisons or identification of theoretical concepts, which were grouped into frameworks (major themes). The consultant psychiatrist and clinical psychologist (who were blind to other data collected within the study) reviewed transcripts of the interviews and then they reviewed the preliminary codes identified by the research psychologist. New codes were developed, or existing ones modified through further extensive discussion between the research psychologist and clinical psychologist and pilot coding exercises using relevant data. We were attentive to patterns that may emerge between beliefs and participant demographic or stroke characteristics, such as having had a prior stroke. The final coding scheme used produced good consensus agreement between all three qualitative analysts. We have previously reported our findings regarding fear of recurrence and beliefs about prevention.16 The findings here relate to beliefs participants expressed about their disabilities, related personal meanings and ways of coping with these. A secondary analysis was then conducted taking depression status into account to

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E Townend et al. extended activities. Disability in both Barthel ADLs and Nottingham EADLs was statistically significantly associated with depression (Table 1). Non-acceptance of disability scores were wide ranging and normally distributed. Participants with depression reported significantly higher non-acceptance than other participants and these variables were statistically significantly correlated (Table 1). They more often agreed with items 2, 3, 4 and 6, indicating that they: had had a hard time adjusting; missed doing things they had enjoyed previously; felt useless; and felt inadequate respectively. After adjustment for other variables in a logistic regression, non-acceptance of disability remained strongly and statistically significantly associated with depressive disorder (Table 2).

study associations between depression and qualitative concerns and these results are summarized in the Results section.

Results
Quantitative results at one month post stroke Participants mean age was 70.13 (11.29) years and ranged from 32 to 90 years. The number of male participants (63/89 60%) was greater than that of females. Depressive disorder was diagnosed in a third (29/89; 33%) of participants, with approximately equal proportions meeting criteria for major depression (14/89; 16%) and minor depression (15/89; 17%). Five participants reported currently taking antidepressants, which had been prescribed prior to stroke (three of these met criteria for major depression and two were not depressed). Age was not statistically significantly associated with depression; however, being female was (see Table 1). Stroke severity scores were relatively mild with a mean of 4.48 (3.35) and it was not associated with depression (Table 1). Barthel ADL scores suggested that most participants were only mildly disabled in personal ADLs and just over half of participants (49/89; 55%) scored zero, indicating functional independence.26 Nottingham EADL scores indicated a wide range of disability in extended daily activities and a slight bi-modality in the distribution of scores was observed that reflected more disability for outdoor than indoor

Table 2 Logistic regression at one month post stroke with major or minor depressive disorder as dependent variable (n 89) Odds ratio Age Gender Stroke severity Barthel ADLa Nottingham EADLa Non-acceptance of disability 0.984 2.946 0.936 1.151 1.020 1.270 Significance level 0.519 0.081 0.538 0.452 0.852 0.001 95% CI Lower 0.929 0.876 0.749 0.798 0.829 1.097 Upper 1.042 9.905 1.169 1.661 1.255 1.49

a These measures were reversed scored so that they reflected disability.

Table 1 Descriptive data for independent variables and their univariate and bivariate associations with major or minor depressive disorder one month post stroke (n 89) Variable (min to max score) Depressed (n 29) 70.38 17 4 1 10.7 17.3 (10.07) (59%) (118) (014) (5.50) (4.62) Not depressed (n 60) 70.02 19 3 0 6.4 11.5 (11.91) (32%) (014) (08) (5.09) (5.60) MannWhitney U, chi or t-test and significance level t 0.15  5.897 U 641 U 602 t 3.63 t 4.88 0.881 0.021 0.11 0.01 0.001 0.001 Pearson or Spearman correlation and significance level 0.15 0.26 0.18 0.27 0.36 0.46 0.888 0.015 0.110 0.009 0.001 0.001

Age Gender (female) Stroke severity (036), median (range) Barthel ADLa (020), median (range) Nottingham EADLa (021), mean (SD) Lack of acceptance of disability (032), mean (SD)
a

These measures were reversed scored so that they reflected disability.

Acceptance of disability and depression post stroke Its addition to the model increased the hit-rate for correctly identifying whether or not participants were depressed from 71% to 78% (with a by-chance hit-rate of 69%). Quantitative results at nine months post-stroke At the nine-month assessment, just under a third of participants (24/81; 30%) were found to be depressed with equal proportions of minor and major depression. Most (19/24; 79%) of these participants had been depressed at one month. Seven participants now reported taking antidepressants (four met criteria for major and one for minor depression). Depression was not bivariately associated with age, gender or stroke severity measured at nine-month follow-up. The associations between depression and Barthel ADL and Nottingham EADL disability at this time were not statistically significant. Participants with depression were more personally non-acceptant of disability at nine months (mean for depressed was 19.04 (4.60), cf. mean for not depressed was 9.75 (5.81), t 6.96, P50.001) and this association remained highly significant after adjustment for the other variables (Table 3). Its addition to this model increased the hit-rate for correctly identifying whether or not participants were depressed from 71% to 87% (with a by-chance hit-rate of 69%). Depression at nine months was also predicted by non-acceptance of disability at one month but not by initial stroke severity or disability at one month (Table 4).
Table 3 Logistic regression with major or minor depressive disorder at nine months post stroke as dependent variable and independent variables measured at nine months post stroke (n 81 participants) Odds ratio Significance 95% CI level Lower Upper Age Gender Stroke severity Barthel ADLa Nottingham EADLa Non-acceptance of disability 0.973 2.048 0.895 0.761 1.031 1.457 0.481 0.355 0.408 0.165 0.790 0.001 0.900 0.449 0.687 0.518 0.825 1.216 1.051 9.342 1.165 1.119 1.287 1.746 Age Gender Stroke severity Barthel ADLa Nottingham EADLa Non-acceptance of disability

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Its addition to this model increased the hit-rate for correctly identifying whether or not participants were depressed from 70% to 76% (with a by-chance hit-rate of 69%).

Qualitative findings Participants often reported concern about their disability and Being like this emerged as a major theme for which feeling negative, or not was a subtheme. Ways of coping with both limitations and the uncertainty of recovery were also voiced. In the secondary analysis that took depression diagnoses into account and applied basic quantification, patterns between qualitative themes and depression status were found.

Feeling negative, or not Many participants reported feeling sad (e.g. a wee bit disappointed) or (e.g. a bit cheesed off). Participants depressed tended to describe stronger feelings such as being trapped.

somewhat frustrated who were or darker

Once you have it, its like being in prison. I wont even put a dog in prison. (P55, male, 66 years, depressed) Damn this stroke and damn all this carry on. (P65, male, 42 years, depressed) In contrast, nearly a third of participants, none of whom were depressed, reported having no
Table 4 Logistic regression with major or minor depressive disorder at ninemonths poststroke as dependent variable and independent variables measured at one month post stroke (n 81 participants) Odds ratio 0.978 1.644 1.008 0.909 1.019 1.190 Significance level 0.415 0.383 0.943 0.549 0.833 0.007 95% CI Lower 0.928 0.538 0.801 0.667 0.856 1.048 Upper 1.032 5.018 1.269 1.240 1.212 1.350

a These measures were reversed scored so that they reflected disability.

a These measures were reversed scored so that they reflected disability.

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E Townend et al. roles (such as looking after grandchildren or giving lifts to wives or grandchildren). All my life its [the housework] been I like it just so. Its not just so at the moment . . . Two times now my second cousin has come and done the house. I dont want to trouble her I dont want her to make a habit of this. (P62, female, 86 years, depressed) As a result [wifes Menie`res disease] shes lost confidence about going out on her own. I used to take her out and now I cant . . . . Well these are just the thoughts of someone stuck in a chair who feels they should be up doing things. (P58, male, 80 years, depressed) Nearly every participant who reported feeling they should still be carrying out roles was depressed. Negative personal meanings versus acceptance or efforts to accept disability Participants often spoke about their capabilities as being not right, not as good, or less normal, whereas before they could do things without a seconds thought. I cant grip my left hand normally and normal daily life, for example, using a knife and fork properly. (P59, male, 75 years, depressed) Reliance on others made some participants feel helpless. I dont like to ask . . . as Im very independent. I dont like to be beholden. (P62, female, 87 years, depressed) Some even described themselves as useless. Their self-reproach often related to ideas that they should still be carrying out family or home roles. What on earth am I doing lying here [hospital] for when I could be doing something useful? (P59, male, 75 years, depressed) Id hate to think their life was looking after their old man . . . . Its me who should be looking after them. (P64, male, 74 years, depressed) In contrast, some participants appeared accepting. Some seemed to be helped by fatalistic beliefs such as thats life and others argued that they had

concerns and a few pointed out that they were just not worriers. Im not concerned about anything. (P23, male, 71 years, not depressed) I think that once you get to eighty years old that unless youre the worrying type youre not suddenly going to get depressed or sad. (P27, female, 80 years, not depressed) Being like this Over two-thirds of participants reported some Cant do issue as a main concern. Those few people with more severe disability reported basic physical issues (e.g. walking) as concerns. Others reported concern about reduced day-to-day activities (such as grocery shopping, housework or do-it-yourself); leisure pursuits (such as reading, writing, knitting, baking, golfing, bowling, bridge or bingo); socializing with friends or family (such as walking, shopping, driving, going to the pub or theatre). A few reported being just too tired or running out of energy. You sit here, you go to get up and you cant walk. (P71, female, 81 years, depressed) Ive started reading a book but only read 50 pages so far, but I would have had it finished. I miss that. (P36, female, 79 years, not depressed) Its the fact you cant get the energy to do thing . . . I just feel sleepy, Oh Im sleepy again. (P69, male, 65 years, not depressed) Some used emotive language and metaphors that emphasized negative feelings about missing activities. Thats a bit disappointing and cuts you and you think What can you do? Lifes got to carry on, but Ive been enjoying it [fishing] for 40 years. (P55, male, 66 years, depressed) I was out in the car every day of my life, local shopping, the theatre, for meals . . . and now Im afraid thats taken a back seat . . . . Thats me, it puts you out the picture for now. (P59, male, 75 years, depressed) Some participants suggested they should be still able to carry out activities. They seemed to feel morally obligated in household (such as housework, DIY or paying bills) or caregiving

Acceptance of disability and depression post stroke never really cared about certain activities and so didnt mind their loss. I feel a bit curtailed, but happy with my lot . . . not particularly bothered, more acclimatized to it. (P67, male, 66 years, not depressed) Its a case of things are going to happen and you cant make alterations. Anything like, someone in life has died, you cant do anything so theres no point in being unhappy. (P61, male, 69 years, not depressed) I werent that into it [bingo] it was just a place to go. (P47, female, 82 years, not depressed) I dont miss it . . . Im quite happy in the house. (P73, female, 74 years, not depressed) Many other participants reported various compensatory ways of coping with their restrictions. They reported regarding restrictions as temporary and so OK for now, or they focused on what they could at least still do and perhaps did more of now, or how they still got things done in different ways. Reading used to help pass the time . . . Ive got some reading glasses to come and hopefully theyll be OK. I just accept it the now. (P47, female, 82 years, not depressed) At least I can still walk, I just will never be able to run or kick a ball. (P54, male, 62 years, not depressed) I felt rotten about getting someone in [to fix a sliding door], but still pleased I was getting it done. (P45, male, 76 years, not depressed) Less common compensatory beliefs seemed to involve thinking how it could be worse, joking about problems, or reminiscing about what they did do. Ive had it lucky compared to some folk who cant do a thing. (P63, female, 83 years, not depressed) At least my stroke has given us another talking point, which is a change from hips etcetera! (P58, male, 80 years, depressed) Theres something of me in the countryside that wouldnt be there apart from me [retired forestry commissioner] . . . I still look back with pleasure, although I cant do. (P68, male, 88 years, not depressed) Participants with depression were more likely to report objecting to reliance on others and much

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more likely to report feeling useless about being unable to carry out roles. Only participants who were not depressed reported that they had accepted changes. Compensatory ways of coping with restrictions were reported by participants with and without depression.

Discussion
Depression was prevalent in the sample and affected one in three participants at both one and nine months following stroke. Disability was only weakly associated with depression; however, non-acceptance of disability was strongly associated with depression in both qualitative and qualitative findings. The acceptance of disability scale, adapted for use in stroke, was sensitive to a range of personal reactions to disability from high levels of acceptance to strongly negative views in which people endorsed comments that they felt inadequate and useless. Once initial stroke severity and current disability were controlled for, non-acceptance of disability remained independently associated with depression in multivariate analyses. The qualitative findings complemented these results. While many participants reported missing activities, participants with depression expressed stronger thoughts and emotions of sadness and frustration such as feeling/thinking of themselves as trapped or helpless in relation to their dependence on others. Their accounts were often self-reproachful as they felt they should still be able to fulfil roles in their family or home, and this seemed to be largely why they tended to describe themselves as useless. The qualitative analysis also highlighted various ways participants tried to accept stroke-related restrictions (OK for now, at least I still can, could be worse, joking, did do). Some of those participants who were not depressed seemed to have come to terms with their disability and often reported simply being not worried or having accepted their circumstances. One strength of the study was the combination of methods: qualitative interviews strengthened the quantitative findings and also offered further insights.27 Evidence for the relevance of the acceptance of disability measure in stroke was provided

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E Townend et al. depressed individuals described themselves as useless and reported thinking that they should still be capable of family or household roles. It is as if they derogated themselves as disabled persons whereas others could distinguish the difference between their identity and disability. Dembo and colleagues14 propose that the key to maintaining ones own self-worth is to engage in Transformation from comparative values to asset values (i.e. to let go of unfavourable comparisons with others or ones own past ability and to judge oneself in light of what one can realistically do now). Participants who found different ways of enjoying themselves or getting things done could be seen to have transformed their views successfully. Our findings are also consistent with cognitive theories of emotional adaptation that would predict that, rather than disability per se, it is subjective negative beliefs about oneself and ones condition (disability) that are most important in determining emotional responses.7,33 One previous study into the cognitions about stroke also found a strong association between depression and negative cognitions such as I feel inadequate and helpless.34 They also reported an inverse association between two positive cognitions (Im optimistic about the future, I feel I have a lot left to give) and depressive symptoms. Our results support a strong association between non-acceptance of ones disabled self and depression. By nine months post stroke, the role of personal acceptance (or its lack) had a stronger association with depression relative to stroke severity and disability that did not even correlate with depression in bivariate analyses. Also, depression at follow-up was statistically predicted by non-acceptance of disability at one month. Therefore, being unable to accept oneself as worthy in spite of ones disability appears to be emotionally detrimental both in the short and longer term post stroke. However, these analyses cannot conclusively establish the direction of causation (i.e. whether not accepting ones disabled self caused depression or vice versa). Further research could aim to disentangle the direction of such relationships. Our findings suggest that for some patients it might be important to address their personal beliefs about disability when intervening to reduce

by the qualitative findings and this measure could be used in future quantitative stroke studies. Also, the use of face-to-face interviewing avoided missing/inaccurate data due to post-stroke or age-related reading, visual or mild cognitive impairment. There were also weaknesses: first, participants may have biased their accounts of their situation toward what they perceive as socially desirable responses. Second, although stroke severity was assessed by a clinician, disability was assessed only by self-report and some participants, particularly those who were not depressed,28 may have underreported their disability. Finally, our results may also only be confidently generalized to stroke patients who have been admitted to hospital and who survived without aphasia, or severe cognitive impairment. As far as we are aware this is the first study to have investigated personal acceptance of disability amongst stroke patients. Previous studies have found an association between acceptance of disability and self-esteem among adults with a range of physical or mental disabilities,29 and between acceptance and distress among adults with acquired deafness.30 A small number of qualitative studies of views of self after stroke have suggested that stroke profoundly disrupts patients sense of their bodies and personal identity.31,32 Our findings suggest that individuals vary substantially in their personal adjustment to stroke-related disability. Parallels may be drawn between some of the compensatory strategies reported by our participants and value change processes considered to facilitate acceptance outlined by Dembo and Wrights (1956) theory.14 Enlargement of the scope of values could include appreciating how one is relatively lucky (could be worse) or able to accept change (thats life) if only because it is viewed as temporary (OK for now). Subordination of physique relative to other values (i.e. an enhanced appreciation of ones positive unaffected characteristics and roles) could be applied to participants ability to gain satisfaction with what they at least still can do or did do. According to the theory successful acceptance of oneself involves Containing the effects of disability (i.e. to be able to mentally distinguish between functional losses and ones own self-worth). Most participants appeared to have achieved this but

Acceptance of disability and depression post stroke depression following stroke. It would be interesting to study whether a successful reduction in depression following intervention was accompanied by a concordant increase in acceptance of disability. A psychological approach to facilitating acceptance of disability may involve eliciting and challenging self-reprimanding thoughts of uselessness and underlying should imperatives related to pre-stroke roles and stroke-related disability. Some patients may also benefit from being encouraged to consider adaptive compensatory beliefs about unaffected abilities, characteristics and roles such as those outlined by acceptance of disability theory. Specialist psychological therapeutic expertise would be required to implement these clinical and research suggestions. Therefore, the present lack of psychological support to stroke units in Western countries3538 would need to be reversed. Clinical messages  This study has found that depression following stroke is associated with patients sense of uselessness regarding their disabilities.  The acceptance of disability scale could be used as a brief valid measure of patients sense of uselessness regarding their disabilities.

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Acknowledgements The study was conducted as part of a UK MRC studentship. We would like to thank our participants, their clinicians and carers for their participation.

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Appendix Acceptance of Disability Scale adapted for stroke

Strongly Disagree Neutral Agree Strongly disagree agree 1) I have had a hard time adjusting to the limitations of my stroke 2) Because of the effects of my stroke I miss the things I like to do most 3) The effects of my stroke make me feel useless at times 4) The effects of my stroke make me more dependent on others than I want to be 5) The effects of my stroke make me a burden on my family and friends 6) The effects of my stroke make me feel inadequate 7) I will never be self-sufficient enough to make me happy 8) I think people are often uncomfortable being around me because of the effects of my stroke 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0

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