Aphasia, depression, and psychological therapy (ADaPT): A single case design evaluation of a modified cognitive behavioural therapy to treat depressive symptoms in stroke survivors with aphasia

Figures & data

Table 1. Structure of the treatment protocol.

Session	Therapeutic content
1	Introduction of the therapist, assessment of mood and key issues, explaining the intervention and setting goals
2	Implementation of activity scheduling
3	Monitoring of activity scheduling and implementation of thought identification
4	Development of thought identification technique
5	Introduction of thought disputation
6	Re-assess mood and review goals
7	Monitoring thought disputation technique
8	Monitoring change to helpful thinking style(s)
9	Monitoring change to helpful thinking style(s)
10	Evaluation of therapy and relapse prevention

Figure 1. Recruitment and flow of participants throughout the study. Notes: *An attempt was made to balance the range of aphasia severity among participants concurrently receiving intervention to ensure a manageable caseload for the clinician.

Vertical flowchart displaying the number of participants who expressed interest, underwent eligibility assessments, were excluded (and reasons for exclusion), enrolled in the study, withdrew, and received the full intervention.

Table 2. Participant demographic and baseline characteristics.

Variables	Participant
	AA	BB	CC	DD	EE	FF	GG	HH	II	JJ
Age (years)	64	64	39	59	79	71	58	70	46	69
Sex	Male	Male	Female	Male	Female	Female	Male	Male	Male	Female
Education (years)	16	9	16	12	10	17	15	17	17	15
Time since stroke (years)	1	0.4	2	2	2	1	3	1	2	5
Aphasia quotient (WAB-R)	20 (very severe)	93.5 (mild)	90.2 (mild)	86 (mild)	64 (moderate)	71.1 (moderate)	40.6 (severe)	78.2 (mild)	67.3 (moderate)	89.48 (mild)
Antidepressants	No	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes
EQ-5D Mobility Self-care Usual activities Pain/discomfort Anxiety/depression VAS	Some No Some Moderate Moderate 50	Some Some Some Extreme Moderate 60	Some Some Some Moderate Moderate 25	Some Some Some Moderate Moderate 50	Some No Some Moderate Moderate 60	No No No Moderate Moderate 50	No Some Some Moderate Moderate 50	No No Some Moderate Moderate 40	No No Some None Moderate 90	No No Some None Moderate 60
ALA (Total)	55	58	54	70*	57	62	47	69	58	63
Sessions attended by close other	8	Initial only	Nil	10	Initial only	Initial only	10	6	Nil	Nil

Notes: WAB-R: Western Aphasia Battery – Revised; EQ-5D: a subjective health-related quality of life scale assessing perceived level of difficulties within specific domains; VAS: Visual Analogue Scale assessing self-rated health state (out of 100); ALA: Assessment for Living with Aphasia assessing aphasia-related quality of life (out of 148). For all these scales, higher numbers indicate more desirable outcomes. *Three missing data points were extrapolated by using average scores across all other questions.

Table 3. Participant outcome summary: interpretation of results.

Participant	Baseline	Intervention	Follow up
Depression intensity scale circles
AA	Stable	No change*	Deterioration
BB	Declining	Deterioration*	No change
CC	Declining	Slight improvement	Deterioration**
DD	Stable	Slight deterioration	Improvement*
EE	Stable	No change	N/A
FF	Improving	Improvement**	Maintained*
GG	Improving	Deterioration	Improvement
HH	Improving^	No change	Slight improvement
II	Stable	Improvement	Maintained**
JJ	Improving^	No change*	Slight improvement
Stroke Aphasic Depression Questionnaire
AA	Stable^	Improvement***	Maintained
BB	Stable	Deterioration**	No change
CC	Stable^	No change***	Deterioration
DD	Declining	Slight improvement	Improvement*
EE	Stable	No change	N/A
FF	Stable	Improvement	Maintained**
GG	Stable	Slight improvement**	Maintained**
HH	Improving^	Improvement***	Maintained
II	Stable	Improvement**	Maintained**
JJ	Improving^	Improvement***	Maintained
Behavioural Outcomes of Anxiety
AA	Improving^	Improvement***	Maintained
BB	Stable^	No change	No change
CC	Stable^	No change***	Deterioration
DD	Stable	Slight improvement	Maintained**
EE	Stable	No change	N/A
FF	Stable	Improvement	Maintained*
GG	Stable	No change	No change
HH	Improving^	Improvement***	Maintained
II	Stable	Improvement**	Maintained***
JJ	Improving^	Improvement***	Maintained

Notes: Interpretation was primarily derived from visual analysis, with notations indicating the results of supporting statistical analysis. ^ = Baseline corrected in Tau-U analysis (due to improving trend > .20); * = Tau-U p < .05; ** = Tau-U p < .01; *** = Tau-U p < .001.

Figure 2. Participant AA’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Table 4. Tau-U analyses for subjective depressive symptoms, and depressive and anxiety symptoms as observed by close other.

Participant	Baseline corrected	Baseline vs. treatment	p value	Treatment vs. follow-up	p value
Depression intensity scale circles
AA	No	.56*	.046	.02	.919
BB	No	−.38*	.045	−.23	.341
Weighted		−.001	.996	−.10	.548
CC	No	.38	.068	−.80**	.001
DD	No	.37	.192	.56*	.016
Weighted		.37*	.033	−.10	.547
EE	^a	^a	^a	^a	^a
FF	No	.70**	.002	.49*	.036
GG	No	.02	.924	.37	.137
HH	Yes	.27	.249	.11	.665
Weighted		.14	.379	.24	.175
II	No	.41	.156	.68**	.004
JJ	Yes	.49*	.042	.20	.413
Weighted		.45*	.016	.44**	.009
Stroke aphasic depression questionnaire
AA	Yes	.98***	<.001	.27	.243
BB	No	−.60**	.002	−.03	.914
Weighted		.05	.775	.12	.454
CC	Yes	.78***	<.001	−.38	.118
DD	No	.20	.478	.50*	.031
Weighted		.53**	.002	.07	.674
EE	^a	^a	^a	^a	^a
FF	No	.32	.147	.78**	.002
GG	No	.61**	.004	.81**	.001
HH	Yes	.91***	<.001	−.23	.373
Weighted		.75***	<.001	.30	.097
II	No	.80**	.005	.72**	.003
JJ	Yes	.85***	<.001	.06	.801
Weighted		.83***	<.001	.39*	.021
Behavioural outcomes of anxiety
AA	Yes	.98***	<.001	.02	.946
BB	Yes	−.15	.445	−.33	.163
Weighted		.31	.069	−.16	.348
CC	Yes	.84***	<.001	−.14	.586
DD	No	.20	.478	.62**	.007
Weighted		.57**	.001	.25	.139
EE	^a	^a	^a	^a	^a
FF	No	.35	.117	.56*	.023
GG	No	−.01	.954	.42	.089
HH	Yes	.78***	<.001	−.47	.067
Weighted		.36*	.020	−.02	.924
II	No	.90**	.002	.82***	<.001
JJ	Yes	.88***	<.001	.19	.437
Weighted		.89***	<.001	.50**	.003

Notes: *Significance at p < .05; **Significance at p < .01; ***Significance at p ≤ .001.

^a Blank cells represent missing data due to participant withdrawal.

Figure 3. Participant BB’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 4. Participant CC’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 5. Participant DD’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 6. Participant EE’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 7. Participant FF’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 8. Participant GG’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 9. Participant HH’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 10. Participant II’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Figure 11. Participant JJ’s self-reported depression levels (DISCs) and observer-rated symptoms of depression (SADQ) and anxiety (BOA) across baseline, intervention, and follow-up phases. DISCs: Depression Intensity Scale Circles; SADQ: Stroke Aphasic Depression Questionnaire; BOA: Behavioural Outcomes of Anxiety. Notes: Higher scores denote worse depressive/anxiety symptoms. Dotted lines demarcate the different phases; grey shadings indicate treatment sessions; trend lines calculated using ordinary least squares estimation are superimposed on the raw data.

Table 5. Intervention elements and supported conversation techniques: frequency analysis.

Components of CBT intervention programme
Most frequently implemented	Least frequently implemented
Identify/review emotional experiences and drivers/triggers Document relapse prevention plan Review content of therapy Activity scheduling ABCs of CBT ➢ Identify emotions + behavioural consequences ➢ Identify trigger thoughts ➢ Demonstrate thought disputation/modification ➢ Set and review homework ➢ Emphasise effort and progress ➢ Identify barriers to activity participation ➢ Thought record sheet ➢ Clarify trigger thoughts ➢ Thought disputation/modification	Rate daily energy levels CBT-I techniques Relaxation techniques Problem solving techniques General rehabilitation techniques Discuss/identify core beliefs and values Cognitive rehabilitation techniques Changes in thinking styles (as part of homework review) Review therapy goals Reassess mood and reviewing progress with goals Reinforce helpful thinking
Supported Conversation Techniques: Most Frequently Used
Speak at a slower rate Use additional support materials (e.g., pictures) Give person with aphasia time to comprehend information Simplify information Ask one thing at a time Repeat questions as necessary Use closed questions (Yes/No; fixed choice) Paraphrase person with aphasia’s responses Monitor nonverbal communication (e.g., facial expression)

Notes: CBT: cognitive behavioural therapy. ABC: antecedents, beliefs, consequences. The most and least frequently implemented intervention components were determined by calculating the ratio of sessions covering each component to the maximum possible sessions for that component, as well as examining the number of participants who received each component. Supplementary Material 6 provides the raw data for this analysis.