Mental Health of Persons with Aphasia during the COVID-19 Pandemic: Challenges and Opportunities for Addressing Emotional Distress

Aphasia refers to the acquired language deficits, most commonly caused by a stroke, that affect one’s verbal understanding, oral expression, reading, and writing. Approximately 31% of stroke survivors exhibit depression or some depressive symptoms that can impede functional recovery. Since the onset of the COVID-19 pandemic in March 2020, many reports have discussed its psychological and mental impacts on different people worldwide, including both unimpaired individuals and those with chronic illnesses or medical conditions. At present, relatively little has been published on the topic of mental health changes, distress, and/or concerns among persons with aphasia (PWA). Nevertheless, the current evidence reported thus far suggested that PWA had equally suffered from emotional symptoms as a result of the coronavirus outbreak, similar to other disorder populations. With reference to recent reports, the challenges posed to management of aphasia are summarized. Some potential opportunities to address PWA’s needs, with an emphasis on their emotional distress, amid and after the pandemic are proposed and discussed.


COVID-19 and Its Psychological Impacts
These investigations have commonly reported a wide array of psychological consequences provoked by the pandemic-fear, anxiety, depression, stress, indignation, boredom, and helplessness. There were a range of sources that had contributed to these negative feelings, such as prolonged home-stay, concerns for family members and friends, existing health conditions, worry about health and loved ones, quarantine and lockdown measures, disruption of daily life and normal routine, reduction of leisure and social activities, and discrimination.
Risk factors that might worsen existing poor psychological well-being included lower socioeconomic status, contraction of COVID-19, lack of up-to-date and accurate COVID-related information, social isolation, reduced peer and family support, and social stigma.

Effects of COVID-19 on Persons with Aphasia
At present, relatively little has been published on the topic of mental health changes, distress, and/or concerns among persons with aphasia (PWA). Regular social engagement as well as meaningful relationships and activities are important to promote and maintain positive psychosocial well-being in PWA (Bronken et al., 2012). However, the evolving regulatory measures on social distancing in response to the COVID-19 pandemic have broadly disrupted and limited these opportunities. Adoption of new activities or schedules may be needed in some PWA. More critically, the ongoing societal disruptions since its rapid onset more than a year ago have posed a huge challenge to conventional face-to-face, facility-based management of aphasia (e.g., speech and language therapy assessment and training sessions, community support group meetings and gatherings) and to PWA's community activities (e.g., leisure peer interactions, recreation and sport activities); these could subsequently lead to difficulties in ensuring a good mood, psychosocial well-being, and quality of life in PWA (Lee, Lee, Choi, & Pyun, 2015).
One of the very few reports was a recent retrospective interview-based study that investigated how the psychosocial difficulties experienced by Italian PWA have worsened due to COVID-19 (Pisano et al., 2020). A group of 73 chronic PWA previously discharged from rehabilitation services before the COVID-19 emergency were interviewed twice, one month before and one month after the COVID lockdown. With reference to the results of the hospital anxiety and depression scale (Rishi et al., 2017), the PWA demonstrated a significantly higher level of depression and anxiety at the second interview. There was also a significant deterioration in their self-rated quality of life, as reflected by the results of the stroke and aphasia quality of life scale (Hilari et al., 2003). What needs to be highlighted was that the observed negative changes did not vary as a function of factors such as PWA's aphasia severity (mild, moderate, and severe), age, education, or gender, possibly indicating that COVID-19 had equally affected various subgroups of PWA.
Similar findings have been reported by another comparable investigation focusing om chronic PWA residing in Hong Kong . Specifically, a survey study was conducted to determine whether and how social distancing measures implemented to mitigate COVID spread have impacted PWA's mental health and psychosocial well-being. The adapted scales of psychological well-being (SPWB; Ryff, 1989) was implemented to reflect six dimensions of PWA's mental functioning, including 1) autonomy, 2) purpose in life, 3) environmental mastery, 4) personal growth, 5) positive relations with others, and 6) self-acceptance.
Preliminary results based on 15 PWA suggested more distress in the first two dimensions of SPWB in PWA, on top of their higher degree of induced anxiety, depression, and stress than 7 control participants.
In summary, COVID-19 had an elevated risk for exacerbating social isolation and associated negative psychological symptoms in PWA, who inherently are dealing with pre-existing struggles of communication, social, cognitive, and/or intellectual disabilities. As concluded by a recent review article (Kong, 2021), there are still significant knowledge gaps about the short-and long-term impacts of COVID-19 on PWA; this warrants special attention given by different stakeholders to adequately address the psychosocial and rehabilitation needs of PWA during and after the COVID-19 era.

Challenges and Opportunities for Addressing Emotional Distress in Aphasia
With no doubt, the COVID-19 pandemic has led to dramatic and unprecedent- • To conduct more research investigations to examine the shortand long-term effects of COVID-19 on PWA's psychosocial well-being (Kong, 2021) • To review and expand existing phone or online outreach programs or "check-in" services (e.g., Ryan, 2020) to supplement regular aphasia therapy 2. Telepractice for PWA • Telehealth for PWA has been around for years but has not been the most popular option (Kurland, Liu, & Stokes, 2018) • Some PWA might not be able to transition to teletherapy amid COVID due to digital inequality (Menger, Morris, & Salis, 2016) • To continue to advocate and promote the application of telepractice, with reference to the COVID-related public health guidance and telehealth policy changes • To explore application of online programs that treat and prevent stress-related disorders in PWA (e.g., Weiner et al., 2020) • To monitor the sudden and unexpected growth of telepractice during COVID, which may evolve and prompt a new trend of remote or virtual PWA care in the future

Use of technology
• COVID-19 prompted more PWA to turn to mobile applications and online resources for conducting home-based practice • Available "Aphasia apps" are still limited (Vaezipour, Campbell, Theodoros, & Russell, 2020) and predominantly available in English (National Aphasia Association, 2015) • To explore the use and effectiveness of digital tools (e.g., evidence-based websites, smartphone applications, or conversational agents) by PWA to ameliorate psychological symptoms (Zhang & Smith, 2020) • To develop more aphasia-specific applications in the future (Vaezipour, Campbell, Theodoros, & Russell, 2020

Conclusion
The COVID-19 pandemic has negatively influenced PWA in many ways but, at the same time, provides unique opportunities for robust evaluation of pre-outbreak interventions. Most treatment studies in the literature of Aphasiology have focused on improving the communication aspect. With the psychological implications to PWA, more research is warranted to help us understand the short-and long-term effects of COVID-19 on PWA's psychosocial well-being.