Post-stroke depression (PSD) constitutes an important complication of stroke, affecting approximately one-third of stroke patients. PSD decreases rehabilitation motivation, delays function recovery, and increases the family and social burden of stroke patients. Motivational interviewing (MI) may be an effective and practical intervention strategy, but its effectiveness in improving PSD remains uncertain.

A parallel two-group quasi-experimental study was conducted. Patients with early PSD were recruited from the neurology department of a hospital in southeast China and were allocated to the control group and intervention group by wards. Patients in the intervention group received one session of face-to-face motivational interviewing and three sessions of telephone motivational interviewing, while patients in the control group received routine nursing and follow-up of the neurology department. Outcomes including depression, sleep quality, and quality of life were evaluated at baseline (T0), after intervention immediately (T1) and three months after intervention (T2). Descriptive statistics, t-test, Mann-Whitney U test, Wilcoxon signed rank sum test and generalized estimating equation were used to analyze data.

There were no significant differences in patients’ sociodemographic and clinical information between the intervention and control groups at baseline. The scores for depression were statistically different between the two groups (Z=-5.757, p < 0.001) at T1 and T2 (t=-7.964, p < 0.001). The scores for sleep quality were statistically different between the two groups at T1 (Z=-2.840, p = 0.005). The result of the generalized estimating equation modeling analyses indicated that interaction effects were statistically significant in depression and sleep quality scores. The intervention group showed a significantly higher rate of decrease in the depression score from T0 to T1 (95% CI: -11.227 to -7.748, p < 0.001) and T0 to T2 (95% CI: -11.683, -6.170, p < 0.001), compared with the control group; the intervention group had a greater reduction in the sleep score from T0 to T1 (95% CI: -2.502 to -0.962, p < 0.001), compared with the control group.

MI could effectively improve depression and sleep quality in patients with early PSD. However, MI failed to improve quality of life in patients with early PSD. These findings provide a foundation for future large-scale randomized controlled trials to further evaluate the efficacy of MI in patients with early PSD.

Retrospectively Registered, Chinese Clinical Trial Registry (http://www.chictr.org.cn|| ChiCTR2200064386|| Registration Date: 2022/10/06).

The interventions for early PSD were numerous, including drug management, mind-body interventions, acupuncture therapy, neuromodulation interventions, psychosocial management, and virtual reality-based interventions [9,10,11,12,13,14]. Early prophylactic use of antidepressants in stroke patients improves their cognitive function and reduces the incidence of early PSD [11]. However, the antidepressants have side effects and its effectiveness is modest [15]. Mind-body interventions include mindfulness-based stress reduction, Tai chi, yoga, and so on. Studies have reported that mind-body interventions can reduce depressive symptoms in stroke patients, but their effectiveness is often limited by the degree of depression in stroke patients before intervention and the duration of the interventions [9]. Acupuncture therapy and neuromodulation interventions are specialized techniques, and their therapeutic effects on PSD are influenced by the skill level of the implementer, and the choice of therapy, and both lack generalizability [10]. Psychosocial management includes cognitive-behavioral therapy, behavioral activation therapy, and so on, but their effectiveness in the treatment of PSD is not yet consistent [16]. In addition, as an emerging human-computer interaction technology, virtual reality (VR) has been applied to pain management, psychotherapy, rehabilitation training and other practical fields [13]. VR-based interventions have been shown to have potential in relieving PSD [17]. However, a systematic review and meta-analysis showed no significant improvement in PSD after VR-based intervention compared to traditional rehabilitation [17]. Therefore, more appropriate intervention strategies need to be sought for the management of patients with early PSD, and MI may be an effective and practical intervention strategy.

MI is a patient-centered intervention that enhances the internal motivation for behavior change by exploring and resolving patients’ conflicting psychology [18]. The positive effects of MI on reducing negative emotions (including depression, anxiety, etc.) have been validated in patients with cancer, coronary heart disease, diabetes and stroke. Specifically, a systematic review and meta-analysis showed that MI had a positive effect on reducing depression and anxiety in cancer patients [19]. MI played a favorable role in managing depressive symptoms and improving QOL in patients with coronary heart disease, and the effectiveness of a single use of MI was superior to that of cognitive-behavioral therapy [20, 21]. MI can effectively improve metabolic control and negative emotions in the management of diabetic patients [22]. A study involving 411 acute stroke patients showed that patients who received MI had more normalized mood at 3 and 12 months of follow-up compared with those who received usual care [23]. However, several studies pointed out that MI had no significant effect on improving mood, including depression and anxiety, in stroke patients [24, 25]. Thus, the effectiveness of MI on patients with early PSD needs to be further explored. In addition, several studies have confirmed the significant effect of MI on improving patients’ sleep quality and enhancing their QOL [26, 27], suggesting that sleep quality and QOL can be used as outcome indicators to measure the effect of MI intervention. Therefore, in this study, PSD was used as the primary outcome, and sleep quality and QOL were used as the secondary outcome to jointly investigate the impact of MI on patients with early PSD.

In summary, there are numerous intervention methods for early PSD, but their effectiveness is uncertain. Although MI has been shown to have a positive effect on improving mood in stroke patients, its effectiveness in improving PSD remains uncertain. Meanwhile, the effectiveness of MI in simultaneously reducing depression and improving sleep quality and QOL remains unclear. Therefore, according to the disease characteristics of the population with PSD, we designed a 4-week MI intervention program guided by the transtheoretical model (TTM) to explore its effectiveness in improving depression, sleep quality, and QOL in patients with early PSD. The specific hypotheses of this study were: compared with the control group, patients with early PSD who received MI would, at immediately after intervention (T1) and 3-months after intervention (T2): (1) have significant improvement on depression (primary outcome); (2) have significant improvement on sleep quality and QOL (secondary outcomes).

This was a parallel two-group quasi-experimental study.

This study was conducted at a university-affiliated hospital in southeast China. A purposive sampling method was used to recruit participants. Patients hospitalized in the Neurology Department were assessed for eligibility from May 2022 to October 2022 by electronic medical record and self-report. Patients were included if they: (1) had conformed to the diagnostic criteria for stroke and confirmed through CT or MRI; (2) were aged ≥ 18 years old; (3) Within 1 month after the stroke; (4) had a standard score of ≥ 53 on the Self Rating Depression Scale (SDS standard score ≥ 53 indicates depressive symptoms). Patients who: (1) had severe cognitive and communication barriers; (2) had a personal or family history of mental disorder (evaluated by asking the patients that whether they had any previous psychiatric disorders, such as anxiety or depression); (3) had severe illness or unstable physical condition; (4) had received psychological intervention or clinical psychological intervention (evaluated by asking the patients that whether they had received psychological interventions), were excluded. The required sample size was estimated based on the primary outcome variable of depression. Referring to the means and standard deviations (\({\bar X_1} = 8.5\), S₁ = 2.3; \({\bar X_2} = 6.5\), S₂ = 2.8) of depression in Yang’s study [28], the \(\:{\delta\:}\) was obtained as \(\:{\delta\:}={{\mu\:}}_{1}\)-\(\:{{\mu\:}}_{2}\)=8.5–6.5=2.0 and the \(\:{\sigma\:}\) was calculated as \(\:{\sigma\:}\)= (S₁+S₂)/2=2.6. In this study, we took two sides \(\:{\alpha\:}\)=0.05, \(\:{\beta\:}\)=0.10, with \(\:{\mu\:}_{\alpha\:}\)=\(\:{\mu\:}_{0.05/2}\)=1.96 and \(\:{\mu\:}_{\beta\:}\)=\(\:{\mu\:}_{0.10}\)=1.282. All the above values were substitute into the sample size estimation formula for two sample means comparison [29], \({n_1} = {n_2} = 2{\left[ {\frac{{\left( {{\mu _\alpha } + {\mu _\beta }} \right)\sigma }}{\delta }} \right]^2} + \frac{1}{4}\mu _\alpha ^2\), and the sample size was calculated as n₁=n₂=35. Taking into account a 10% dropout rate, the total sample size for this study needed to be at least 80 cases, with at least 40 cases in the control and intervention group, respectively.

Hospital staff who did not involve in the recruitment process allocated patients to two neurology wards for treatment. Subsequently, these two wards were randomly assigned as the intervention site and the control site using opaque and sealed envelopes. Notably, this randomization was conducted at the ward level, not at the level of individual participants. Patients were then recruited after being assigned to the neurology wards. Participants recruited from the intervention site were included in the intervention group, and those recruited from the control site were included in the control group. Specifically, the researcher identified potential participants from the medical records and assessed their eligibility. Eligible participants were asked to participate in this study, and written informed consent were obtained from the participant who agreed to participate.

Control group

The control group were given routine neurological care by the researchers, including admission education, ward system education, disease-related knowledge education, psychological care, discharge education and post-discharge telephone follow-up. The specific contents are as follows: (1) Admission education: the handling nurses introduce the doctor and nurse in charge and the environment of the department, etc. to the patients, helping the patient familiar with the hospital environment as soon as possible; (2) Ward system education: patients are required to have a chaperone and are forbidden to leave the hospital without permission; and they are taught about fall prevention and choking prevention, emphasizing the importance of safety, etc.; (3) Disease-related knowledge education: nurses introduce the drug usage, dosage, function, and its adverse effects and instruct patients on early rehabilitation training, etc.; (4) Psychological care: nurses pay attention to the mental health status of patients, identify adverse emotions promptly, and alleviate patients’ tension, anxiety, and depression; (5) Discharge education: nurses assist patients with discharge procedures, emphasize taking medication as prescribed and regular reviews; (6) Post-discharge telephone follow-up: nurses conduct weekly telephone follow-up for, three times, learning about the patients’ physical recovery, medication intake, sleep quality and psychological status, and answering the patients’ questions about disease recovery, etc.

Intervention group

The patients in the intervention group received the same routine nursing care in the neurology department as the control group as well as the MI intervention program. The researcher was a postgraduate nursing student in the field of stroke care and was trained in MI prior to intervention implementation. The MI intervention program was constructed under the guidance of TTM, which considers an individual’s behavioral change occurring as a series of steps based on the individual’s level of motivation [30]. TTM consists of four components: stages of change, processes of change, self-efficacy, and decisional balance. Among them, the stages of change is the core of TTM, which can be divided into precontemplation, contemplation, preparation, action and maintenance stages based on the individual’s level of motivation. Therefore, the researchers designed the MI intervention program based on the stages of change in TTM by the following steps: (1) developed patient-specific interview draft for the different stages of change through a literature review and in conjunction with the MI Intervention Manual for Stroke Patients written by Suzanne Barker-collo et al. [25]; (2) revised the intervention draft through an expert meeting. The six experts have been engaged in clinical stroke, stroke nursing, and medical psychology for more than 10 years, respectively, and all of them have master’s degrees or above. Specifically, the researchers introduced the theme, purpose, content, precautions of the meeting, and reported the content and questions of the intervention program. Then the experts were asked to review and discuss the program from the aspects of scientificity, feasibility and effectiveness. The researchers collected the opinions of the experts and modified the interview draft accordingly. (3) improved intervention draft further through a pilot study. The pilot study was conducted to test the feasibility and acceptability of the intervention draft and to collect feedback from the participants. Subsequently, the draft intervention was further adjusted and refined based on the feedback, resulting in the final intervention draft. The final interview draft included 4 MI interventions, once a week for 4 weeks. The first MI intervention was conducted during hospitalization by face-to-face interviews, which lasted approximately 60 min. The remaining 3 MI interventions were conducted after the patients were discharged using telephone or face-to-face interviews, which lasted approximately 30 min. Supplementary materials shows details of the MI intervention program.

Sociodemographic and clinical information

The participants’ sociodemographic and clinical information was collected at baseline using a questionnaire developed by the research team based on the study purpose. The Sociodemographic information included the participants’ age, gender, marital status, educational level, living arrangement, medical insurance and per capita monthly family income. The clinical information included the participants’ stroke type, stroke classification, stroke location, stroke history, diabetes, hypertension, coronary heart disease, hyperlipidemia, atrial fibrillation, smoking, drinking, neurological function, activities of daily living and duration of this stroke. To be specific, the neurological function and the activities of daily living was respectively assessed by the National Institutes of Health Stroke Scale (NIHSS) and Barthel Index (BI).

Self-Rating depression scale (SDS)

The SDS was developed by Zung [31] and translated into Chinese by Wang [32] to evaluate depressive symptoms in the past week. The scale consists of 20 items, including 10 reversely scored items. Each item is designed as a 4-point Likert scale (range: 1 to 4). The total rough score is obtained by adding up the scores of each item, and the standard score is obtained by multiplying the rough score by 1.25 and taking the integer part. The higher the standard score, the more severe the depressive symptoms are. In addition, a standard score more than 53 points indicates the presence of depressive symptoms [33]. The Chinese version of the SDS showed good reliability with a Cronbach’s alpha of 0.787 [34], and the Cronbach’s alpha was 0.878 in this study(Calculated based on baseline data).

Pittsburgh sleep quality index (PSQI)

The PSQI was compiled by Buysse [35] and translated into Chinese by Liu, Tang [36] to assess sleep problems in the past month. The scale consists of 19 self-assessed and 5 other-assessed items, with the 19th self-assessed item and the 5 other-assessed items not participating in the scoring. The remaining 18 self-assessed items were used to calculate seven component scores reflecting subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleeping medication, and daytime dysfunction. The 18 self-assessment items participating in the scoring constitute seven components, and each component was scored from 0 to 3. The total score is obtained by summing up each component score, which ranges from 0 to 21 points, with higher scores indicating worse sleep quality. The validated Chinese version of the PSQI showed good reliability with a Cronbach’s alpha of 0.84 [37], and the Cronbach’s alpha was 0.763 in this study(Calculated based on baseline data).

Stroke specific quality of life (SS-QOL)

The SS-QOL developed by Williams [38] and translated to Chinese by [39] was used to assess stroke patients’ health-related quality of life. It contains 49 items, and 12 dimensions named energy, family role, language, activity, emotion, character, self-care ability, social role, thinking ability, upper limb function, vision, and work/labor ability. Each entry is scored according to level 1 to 5, and each item is accumulated, which is the total score, and the total score range is 49 to 245 points. A higher total score indicates a better QOL. The Chinese version of the SS-QOL shows good reliability (The Cronbach’s alpha coefficient was > 0.76) [39]. And the Cronbach’s alpha was 0.807 in this study (Calculated based on baseline data).

The data was collected at three time points: (1) before intervention (T0); (2) after intervention immediately (T1); and (3) three months after intervention (T2). The data at T0 was collected on the day when the patients were enrolled in face-to-face interviews. Participants were asked to complete the questionnaires by themselves. If the participants were not able to fill in the questionnaire due to treatment or other reasons, the investigators read out the items of the questionnaire and recorded the answers of the participants. The data collection at T1 and T2 were conducted by telephone interviews. Specifically, the investigators read out the items of the questionnaire and recorded the answers of the participants. The sociodemographic and clinical information was collected at baseline only, while all the other outcome variables (SDS, PSQI, SS-QOL) were evaluated at all time points. Questionnaires were carefully reviewed once completed, and multiple attempts were made to contact the participants who had missing responses to minimize the amount of missing data.

SPSS 26.0 was applied for statistical analysis. Descriptive analyses were used to describe participants’ sociodemographic and clinical information and the outcome variables at each time point. Measurement data were tested by the Shapiro-Wilk (S-W) test to check normality. Means (standard deviations) were used to describe continuous measurement data that were normally distributed; otherwise, medians (interquartile ranges) were used. Counting data were described as frequencies (percentages). Either the t-test, Mann-Whitney U test, chi-square test, or Fisher’s exact test, as applicable, was used to compare the differences on sociodemographic and clinical information and outcome variables at each time point between the two groups. Appropriate statistical tests, including paired t-test and Wilcoxon signed rank sum test, were used to compare the outcome variables at each time point within the two groups. Generalized Estimating Equations (GEEs) with exchangeable working correlation structure assumption were used to compare the differential changes in each outcome variable (depression, sleep quality, and QOL) at T1 and T2 with respect to T0 between groups. All statistical tests were two-sided with the level of significance set at 0.05.

Ethical approval was obtained from the ethics committee of the First Affiliated Hospital of Wenzhou Medical University (committee’s reference number: KY2022-073). All participants signed the informed consent. And this study was retrospectively registered on 6th October 2022 in the Chinese Clinical Trial Registry (http://www.chictr.org.cn||ChiCTR2200064386).

A total of 517 patients were assessed for eligibility. Of these, 391 did not meet the inclusion criteria and 39 declined to participate. Finally, 87 eligible participants were successfully recruited and divided into the intervention site (intervention group: n = 43) and the control site (control group: n = 44) from May to October 2022. For the intervention group, one participant was lost during the follow-up, and one participant needed to withdraw from the study due to a diagnosis of another malignant disease; for the control group, one participant refused to participate during the follow-up, and two participants were lost during the follow-up. Ultimately, 82 participants (control group: n = 41; intervention group: n = 41) remained for the final analysis with an overall retention rate of 94.25%. The participant flow chart is shown in Fig. 1.

Flow chart of recruitment, allocation, reasons for withdrawal and number of participants for data analysis

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Table 1 presents the demographic and clinical information of the 82 participants. The participants’ mean age was 56.39 (SD = 10.13) years, the median NIHSS score was 1 (IQR = 4), the median BI score was 80 (IQR = 41.2), and the median duration of this stroke was 9 days (IQR = 2). Most of the participants were married (89.02%), had medical insurance (92.68%), did not live alone (93.9%), had undergone stroke for the first time (82.93%), had a stroke site in the brain (85.37%), and were diagnosed with ischemic stroke (85.37%) and hypertension (75.61%), but not hyperlipidemia (81.71%), coronary heart disease (96.34%), or atrial fibrillation (96.34%). More than one third of the patients had a high school education (42.68%) and were still smoking (34.15%) and drinking (37.8%). Nearly two-thirds of them had a per capita monthly family income of 3,000–5,000 Chinese Yuan (approximately 417.90-695.50 Dollars) (64.63%), were not diagnosed with diabetes (62.20%). More than two thirds of them were male (74.39%) and had large-artery atherosclerosis (68.57%). Additionally, no significant difference was found in participants’ demographic and clinical information between the two groups at baseline (p > 0.05).

Table 2 shows the results of the within-group and between-group comparisons of the intervention and control group at baseline and the two follow-ups. There was no significant difference in depression (z=-0.499, p = 0.654) between the intervention and control groups at baseline. Compared with the control group, participants in the intervention group had significantly lower depression level at T1 (z=-5.757, p < 0.001) and T2 (t=-7.964, p < 0.001). The depression scores at T1 and T2 were significantly lower than those at T0 in both the intervention and control groups, and the depression score at T2 were also significantly lower than those at T1 in both two groups (p < 0.001).

The results of the GEEs showed that the group effect, time effect, and interaction effects were statistically significant in depression scores (p < 0.001). The depression score of the intervention group was significantly different from the control group, indicating that the group effect affected the depression score. The depression scores changed significantly from T0 to T1 (B=-4.854, p < 0.001) and T0 to T2 (B=-14.049, p < 0.001) in both groups, indicating that time effect affected the depression scores. The level of depression decreased significantly over time in both groups (p < 0.001) but at different rates in the two groups. Specifically, compared with the control group, the intervention group showed a significantly higher rate of decrease in the depression score from T0 to T1 (95% CI: -11.227 to -7.748, p < 0.001) and T0 to T2 (95% CI: -11.683, -6.170, p < 0.001) (Table 3). Figure 2 shows the trend in depression scores for the two groups.

The trend of SDS scores in the intervention group and the control group (a); the trend of PSQI scores in the intervention group and the control group (b); the trend of SS-QOL scores in the intervention group and the control group (c)

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In summary, the results of the between-group comparisons demonstrated that MI could reduce depression at T1 and T2 in the intervention group. The results of within-group comparisons indicated that the level of depression decreased significantly over time in both groups. The results of GEEs showed that the depression level dropped more significantly in the intervention group at T1 and T2. Therefore, MI could effectively improve depression in patients with early PSD.

As shown in Table 2, there was no statistically significant difference in sleep score (t = 0.630, p = 0.530) between the two groups at baseline. Participants in the intervention group reported significant improvement in sleep quality (z=-2.840, p = 0.005) compared with the control group at T1; however, the difference was not significant at T2 (z=-0.527, p = 0.598). In the intervention group, sleep scores in T2 and T1 were lower than T0, and the differences were statistically significant (p < 0.001); however, the differences between T2 and T1 scores were not statistically significant (z = 0.625, p = 0.531). In the control group, the sleep score of T2 was lower than T1, and the score of T1 was lower than T0, and the differences were statistically significant (p < 0.001).

The GEEs showed that the group effect was not significant (p = 0.429); and the time effect (p < 0.001) and interaction effects were statistically significant in sleep scores (p < 0.001). The sleep score of the intervention group was not significantly different from the control group (B = 0.390, p = 0.523), indicating that the group effect failed to affect the sleep score. The sleep scores changed significantly from T0 to T1 (B=-1.146, p < 0.001) and T0 to T2 (B=-2.146, p < 0.001) in both groups, indicating that time effect affected the sleep scores. Participants in the intervention group had a greater reduction in the sleep score from T0 to T1 (95% CI: -2.502 to -0.962, p < 0.001), compared with participants in the control group (Table 3). Figure 2 presents the trend in sleep score for the two groups.

In summary, the results of the between-group comparisons demonstrated that MI could reduce sleep score at T1. The results of the within-group comparisons indicated an overall decreased trend in sleep scores in both groups. The results of GEEs showed that the score of sleep dropped more significant in the intervention group at T1. Therefore, MI could effectively improve sleep quality in patients with early PSD.

As shown in Table 2, there was no statistically significant difference (z=-1.480, p = 0.139) in SS-QOL score between the two groups at baseline, and no significant differences were observed between the two groups in SS-QOL at T1 (z = < 0.001, p = 1.000) and T2 (z=-0.594, p = 0.552). The SS-QOL scores at T2 and T1 were significantly lower than those at T0 in both the intervention and control groups, and T2 scores were also significantly lower than those at T1, and the differences were statistically significant (p < 0.001).

The GEEs analysis showed that the time effect of the SS-QOL score was significant (p < 0.001), but the group effect and interaction effects were not significant (p = 0.296). The SS-QOL score of the intervention group was not significantly different from the control group (p = 0.116), indicating that the group effect failed to affect the SS-QOL. The SS-QOL scores changed significantly from T0 to T1 (B = 32.975, p < 0.001) and T0 to T2 (B = 50.146, p < 0.001) in both groups, indicating that time effect affected the SS-QOL scores. The rate of improvement in SS-QOL was not significant between the two groups (Table 3). Figure 2 shows the trend in SS-QOL scores for two groups.

In summary, the results of the between-group comparisons showed that MI had no impact on SS-QOL at T1 and T2. The results of the within-group comparisons proved that the level of SS-QOL increased significantly over time in both groups. The results of GEEs showed that there was no significant improvement in SS-QOL in the intervention group, compared to the control group. Therefore, MI failed to improve SS-QOL in patients with early PSD.

In this study, we examined the effectiveness of a 4-week MI intervention at improving depression, sleep quality, and QOL in patients with early PSD. The results indicated that patients with early PSD who received the MI intervention reported improved depression and sleep quality than those in the control group; however, their QOL was not significantly improved compared to the control group. Therefore, MI intervention may be an effective strategy to simultaneously improve depression and sleep quality in patients with early PSD.

This study found that MI could effectively improve depression in patients with early PSD. This finding is consistent with previous studies, which have validated the effectiveness of MI in acute stroke patients [40, 41]. MI can improve depression in stroke patients may have the reason that MI enhances patients’ confidence in adjusting and adapting to personal rehabilitation goals, leading to an improvement in their psychological state [42]. In addition, during the implementation of MI, the patients’ intrinsic motivation is stimulated, which leads to optimistic acceptance of the disease and relief of depression. However, Barker-Collo, Krishnamurthi [25] found MI had no positive effect on depression in stroke patients, which is inconsistent with our finding. The reason for the inconsistency may be due to the frequency of MI as participants in Barker-Collo’s study received an average of 3 to 12 interviews, with a frequency interval of approximately 1 month. In addition, a previous study completed three motivational interviews with depressed post-stroke patients during hospitalization within one week, but failed to effectively improve depression [24]. This finding is also contrary to ours, and the time of intervention may explain the inconsistency. During the hospitalization, the patient dwelled more on physical functional deficits and may not have fully engaged in the MI conversations [24]. However, MI in our study was completed within four weeks after the stroke, during which time patients were primarily focused on recovery [42]. Therefore, the frequency and time of intervention in MI may have an impact on the outcome of the intervention, and further researches are needed to explore appropriate intervention time and frequency.

This study found that MI could effectively improve sleep quality in patients with early PSD. Several recent studies on MI have also revealed improvements in the sleep quality of people with essential hypertension and liver cancer which is consistent with our study [26, 43]. Given the positive association between sleep disorders and depression in healthy and brain-injured populations [44, 45], the improvement in sleep quality may relate to reductions in depression. MI could stimulate the patients’ internal initiative, relieve the patients’ psychological stress, increase the patients’ hope and thus reduce sleep disturbances caused by negative emotional awakening nerve centers [27, 43, 46, 47]. However, a previous study of patients with heart failure found that MI had no effect on sleep quality and sleep quality may not be directly amenable to interventions aimed at changing volitional behavior [48]. Therefore, further research is needed to clarify the effects of motivational interviewing on sleep and its mechanisms.

This study found that MI failed to improve SS-QOL in patients with early PSD. This finding is consistent with Kerr and his colleagues’ research [24], which also failed to find the effectiveness of MI on quality of life in PSD patients during the three-month follow-up period. The reason may be that MI aims to reinforce the patients’ intrinsic motivation for behavioral change by addressing the patients’ ambivalence. The quality of life in patients with PSD is influenced by various factors, including physical, psychological, social, and environmental factors, which were not addressed in the motivational interviews [49]. However, considering the positive impact of MI on depression in our study, and the negative association between depression and SS-QOL among stroke patients [50], the finding that MI failed to improve the SS-QOL in patients with early PSD is surprising. The length of follow-up may be responsible for the ineffectiveness of MI. One study in heart failure patients showed that improvements in QOL from MI was not seen until 9–12 months after the intervention [48], thus the benefit of MI may be delayed. Therefore, future studies with longer follow up time are needed to detect the impact of MI on the QOL in patients with early PSD.

MI could effectively improve depression and sleep quality in patients with post-stroke depression. However, MI failed to improve quality of life in patients with early PSD. These findings provide a foundation for future large-scale randomized controlled trials to further evaluate the efficacy of MI in patients with early PSD.

Our study confirmed that MI improved both depression and sleep quality in PSD patients, which provided a way for clinical staff to simultaneously manage depression and sleep disorders after stroke. Thus, a series of training can be provided for clinical staff to incorporate MI into routine clinical care, increasing the likelihood and sustainability of applying MI to stroke patients in the environment of receiving treatment and care. Additionally, this study found that the frequency and time of intervention in MI may have an impact on the outcome of the intervention. Therefore, clinical staff should choose the appropriate time and frequency of intervention rationally based on the patients’ psychological needs when applying MI to patients with early PSD.

Several limitations of the study should be noted. Firstly, participants were only recruited from one hospital in southeast China, limiting the generalizability of the study findings. Hence, multi-center studies are needed to investigate the effects of MI in the future. Secondly, the sample size included was relatively small, which may not adequately represent the characteristics of the entire target population. Thus, future studies are needed to include more patients to improve the representativeness of the sample. Thirdly, only a portion of the subjects had sleep disorders at baseline. Therefore, patients with post-stroke sleep disorders can be selected as the study subjects to further confirm the effect of motivational interviewing. Finally, follow ups were only conducted immediately after intervention and three months after intervention. Future studies should include one month after intervention and other long-term follow-ups to better evaluate the impact of MI on patients with early PSD.

BI:

Barthel Index

GEEs:

Generalized Estimating Equations

IQR:

Interquartile Range

MI:

Motivational Interviewing

NIHSS:

National Institute of Health Stroke Scale

PSD:

Post-Stroke Depression

PSQI:

Pittsburgh Sleep Quality Index

QoL:

Quality of Life

SDS:

Self-rating Depression Scale

SS-QOL:

Stroke Specific Quality of Life

SD:

Standard Deviation

TTM:

the transtheoretical model

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Author notes

YJ F: research design and paper writing; Y Z: research design and implementation; QY D: data collecting and analysis, result interpretation; YN W: result analysis and interpretation, provided consultation; SY S, Z W, LY X: critical review and revision; Y L, BB L: research site and materials provision and implementation oversight; JF L: research design and manuscript revising. YJ F, Y Z, QY D and YN W contributed equally to this work. All authors read and approved the final manuscript.

Correspondence to Beibei Lin, Yun Li or Jufang Li.

Ethical approval was obtained from the ethics committee of the First Affiliated Hospital of Wenzhou Medical University (committee’s reference number: KY2022-073). All participants completed the written consent form. The study was conducted in accordance with relevant guidelines and regulations.

Not applicable.

The authors declare no competing interests.

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