the aim of this study was to describe the lived experience as it develops over time of stroke survivors suffering from depressive symptoms in the acute phase .
the specific research questions were : 
 what is the nture of depression as experienced by post - stroke patients at 6 , 12 , and 18 months?how do the experiences of psd change over time?what are the impacts of depression on post - stroke patients everyday life ?
what is the nture of depression as experienced by post - stroke patients at 6 , 12 , and 18 months ?
this longitudinal , qualitative study is methodologically grounded in hermeneutic phenomenology , as described by van manen and ricoeur ( kristensson uggla , 1992 ; lindseth & norberg , 2004 ; ricoeur , 1976 , 2002 ; van manen , 1997 ) . the descriptive methodology of phenomenology has been described as how one orients to lived experience , and the interpretative methodology of hermeneutics as how one interprets the  texts  of life ( van manen , 1997 ) .
all stroke patients were systematically screened and potential participants requested from several hospital stroke units and rehabilitation units in southern norway .
the inclusion criteria were : adults ; first - ever stroke ; beck depression inventory ii ( bdi ii ) score>14 or judged to be depressed by their physician ; cognitively able to participate in interviews ; and proficient in norwegian .
the exclusion criteria were : pre - existing diagnosis of terminal disease ; receiving medical antidepressant treatment prior to stroke ; or treatment for a bipolar diagnosis at the onset of stroke .
bdi ii is a well - known and frequently used 21-item questionnaire for measuring depressive symptoms in stroke patients ( carson et al . , 2000
; hackett & anderson , 2006 ; kouwenhoven , kirkevold , engedal , & kim , 2011a ) according to the bdi ii manual , a score of 1419 indicates mild depression , 2028 indicates moderate depression , and 2963 indicates severe depression ( beck & steer , 1971 , 1996 ) .
the recruitment process resulted in a sample of nine participants with various backgrounds generating a rich and substantial material ( table i ) .
. notes : in order to make the participants confidentiality , fictive names were chosen . between the acute phase and 18 months after the stroke . between the acute phase and 18 months after the stroke .
the participants were assured that participation in the project would not influence their treatment , that they could withdraw from the study at any time and that confidentiality would be maintained .
ethical approval was obtained from the south norway regional committee for medical research ethics ( s-07264a , july 2007 ) .
the interviewer carefully considered the situation of each participant and ended some interviews because the participant appeared very tired .
she recognised that topics could be difficult to talk about , and she treated the participants hope and expectations with respect .
repeated in - depth interviews with open - ended questions were performed guided by a thematic interview guide ( table ii ) .
the first interview took place in the acute phase after stroke and is described elsewhere ( kouwenhoven et al . , 2011b ) .
follow - up interviews were conducted at 6 , 12 , and 18 months after the stroke .
the interviews lasted between 30 and 90 min , primarily took place in the participants homes , and two at the participants work - place .
two of them because in one case the participant did not want the interviewer to come to her home at that point , and in the other because it was impossible to find a mutually convenient date and time .
the interviews were conducted by the first author . during most of the interviews only the participant and the interviewer were present in the room . in two interviews though , the wife of a participant went in and out of the room during the interview commenting and underscoring some of the themes the participant and the interviewer talked about .
the participant was a man who said little and often gave keywords or surface descriptions .
his wife helped him to provide a more detailed description and if he disagreed with her description , he said so .
this paper is based on the 6- , 12- , and 18-month interviews conducted between january 2008 and march 2010 .
interpretation occurred at three levels ( lindseth & norberg , 2004 ) : ( 1 ) nave reading ; ( 2 ) structural analysis ; and ( 3 ) comprehensive understanding .
first , to uncover the self - understanding of the interviews and describe the phenomenon from the perspective of the participants , every interview was read several times in order to grasp the meaning as a whole ( nave reading ) .
the main findings of every interview and the understanding of every participant 's story were summarised in a short text of 9001400 words . during the structural analysis ,
the texts were then thematically structured in order to identify and formulate more general themes .
the meaning units behind every theme were read in order to grasp their essence and reveal sub - themes .
this process led to a deeper understanding of essential themes in the text . during the nave reading and structural analysis of the longitudinal data
, we discovered the two main themes found in the acute phase interviews to be essential later on .
the themes vacillated from  being trapped  to  being free  , and from  losing oneself  to  being oneself  . in the third comprehensive understanding phase ,
the texts were discussed in relation to the four lifeworld existentials of van manen : lived body , lived space , lived time , and lived relation to others .
van manen maintains that when the experience of one existential is changed , the experience of the lifeworld as a whole will be different ( van manen , 1997 ) .
applying van manen 's lifeworld existentials as reflective guides helped us to separate themes , as well as to see the complexity as a whole .
from a longitudinal perspective , some of the informants obtained their original colours , some continued to live in shades of grey , while for some the colours turned clearer and showed distinct contrasts .
another metaphor was the journey in oneself , a metaphor also used by others ( bauman , 2005 ) .
different journeys could be seen as travelling in well - known scenery , travelling without control and being on a mission of rehabilitation .
the metaphors were useful for capturing the essence of the longitudinal perspective and grasping the complexity of the stories of each participant .
this longitudinal , qualitative study is methodologically grounded in hermeneutic phenomenology , as described by van manen and ricoeur ( kristensson uggla , 1992 ; lindseth & norberg , 2004 ; ricoeur , 1976 , 2002 ; van manen , 1997 ) . the descriptive methodology of phenomenology has been described as how one orients to lived experience , and the interpretative methodology of hermeneutics as how one interprets the  texts  of life ( van manen , 1997 ) .
all stroke patients were systematically screened and potential participants requested from several hospital stroke units and rehabilitation units in southern norway .
the inclusion criteria were : adults ; first - ever stroke ; beck depression inventory ii ( bdi ii ) score>14 or judged to be depressed by their physician ; cognitively able to participate in interviews ; and proficient in norwegian .
the exclusion criteria were : pre - existing diagnosis of terminal disease ; receiving medical antidepressant treatment prior to stroke ; or treatment for a bipolar diagnosis at the onset of stroke .
bdi ii is a well - known and frequently used 21-item questionnaire for measuring depressive symptoms in stroke patients ( carson et al .
, 2000 ; hackett & anderson , 2006 ; kouwenhoven , kirkevold , engedal , & kim , 2011a ) according to the bdi ii manual , a score of 1419 indicates mild depression , 2028 indicates moderate depression , and 2963 indicates severe depression ( beck & steer , 1971 , 1996 ) .
the recruitment process resulted in a sample of nine participants with various backgrounds generating a rich and substantial material ( table i ) . demographic characteristics of each participant at 18 months .
notes : in order to make the participants confidentiality , fictive names were chosen . between the acute phase and 18 months after the stroke . between the acute phase and 18 months after the stroke .
the participants were assured that participation in the project would not influence their treatment , that they could withdraw from the study at any time and that confidentiality would be maintained .
ethical approval was obtained from the south norway regional committee for medical research ethics ( s-07264a , july 2007 ) .
the interviewer carefully considered the situation of each participant and ended some interviews because the participant appeared very tired .
she recognised that topics could be difficult to talk about , and she treated the participants hope and expectations with respect .
repeated in - depth interviews with open - ended questions were performed guided by a thematic interview guide ( table ii ) .
the first interview took place in the acute phase after stroke and is described elsewhere ( kouwenhoven et al . , 2011b ) .
follow - up interviews were conducted at 6 , 12 , and 18 months after the stroke .
the interviews lasted between 30 and 90 min , primarily took place in the participants homes , and two at the participants work - place .
two of them because in one case the participant did not want the interviewer to come to her home at that point , and in the other because it was impossible to find a mutually convenient date and time .
the interviews were conducted by the first author . during most of the interviews only the participant and the interviewer were present in the room . in two interviews though , the wife of a participant went in and out of the room during the interview commenting and underscoring some of the themes the participant and the interviewer talked about .
the participant was a man who said little and often gave keywords or surface descriptions .
his wife helped him to provide a more detailed description and if he disagreed with her description , he said so .
this paper is based on the 6- , 12- , and 18-month interviews conducted between january 2008 and march 2010 .
all stroke patients were systematically screened and potential participants requested from several hospital stroke units and rehabilitation units in southern norway .
the inclusion criteria were : adults ; first - ever stroke ; beck depression inventory ii ( bdi ii ) score>14 or judged to be depressed by their physician ; cognitively able to participate in interviews ; and proficient in norwegian .
the exclusion criteria were : pre - existing diagnosis of terminal disease ; receiving medical antidepressant treatment prior to stroke ; or treatment for a bipolar diagnosis at the onset of stroke .
bdi ii is a well - known and frequently used 21-item questionnaire for measuring depressive symptoms in stroke patients ( carson et al . , 2000 ; hackett & anderson , 2006 ; kouwenhoven , kirkevold , engedal , & kim , 2011a ) according to the bdi ii manual , a score of 1419 indicates mild depression , 2028 indicates moderate depression , and 2963 indicates severe depression ( beck & steer , 1971 , 1996 ) .
the recruitment process resulted in a sample of nine participants with various backgrounds generating a rich and substantial material ( table i ) .
notes : in order to make the participants confidentiality , fictive names were chosen . between the acute phase and 18 months after the stroke . between the acute phase and 18 months after the stroke .
the participants were assured that participation in the project would not influence their treatment , that they could withdraw from the study at any time and that confidentiality would be maintained .
ethical approval was obtained from the south norway regional committee for medical research ethics ( s-07264a , july 2007 ) .
the interviewer carefully considered the situation of each participant and ended some interviews because the participant appeared very tired .
she recognised that topics could be difficult to talk about , and she treated the participants hope and expectations with respect .
repeated in - depth interviews with open - ended questions were performed guided by a thematic interview guide ( table ii ) .
the first interview took place in the acute phase after stroke and is described elsewhere ( kouwenhoven et al . , 2011b ) .
follow - up interviews were conducted at 6 , 12 , and 18 months after the stroke .
the interviews lasted between 30 and 90 min , primarily took place in the participants homes , and two at the participants work - place .
two of them because in one case the participant did not want the interviewer to come to her home at that point , and in the other because it was impossible to find a mutually convenient date and time .
the interviews were conducted by the first author . during most of the interviews only the participant and the interviewer were present in the room . in two interviews though , the wife of a participant went in and out of the room during the interview commenting and underscoring some of the themes the participant and the interviewer talked about .
the participant was a man who said little and often gave keywords or surface descriptions .
his wife helped him to provide a more detailed description and if he disagreed with her description , he said so .
this paper is based on the 6- , 12- , and 18-month interviews conducted between january 2008 and march 2010 .
analysis and interpretation occurred at three levels ( lindseth & norberg , 2004 ) : ( 1 ) nave reading ; ( 2 ) structural analysis ; and ( 3 ) comprehensive understanding .
first , to uncover the self - understanding of the interviews and describe the phenomenon from the perspective of the participants , every interview was read several times in order to grasp the meaning as a whole ( nave reading ) .
the main findings of every interview and the understanding of every participant 's story were summarised in a short text of 9001400 words . during the structural analysis ,
the texts were then thematically structured in order to identify and formulate more general themes .
the meaning units behind every theme were read in order to grasp their essence and reveal sub - themes .
this process led to a deeper understanding of essential themes in the text . during the nave reading and structural analysis of the longitudinal data
, we discovered the two main themes found in the acute phase interviews to be essential later on .
the themes vacillated from  being trapped  to  being free  , and from  losing oneself  to  being oneself  . in the third comprehensive understanding phase , the themes were summarised and reflected upon in order to reach an interpreted whole .
the texts were discussed in relation to the four lifeworld existentials of van manen : lived body , lived space , lived time , and lived relation to others .
van manen maintains that when the experience of one existential is changed , the experience of the lifeworld as a whole will be different ( van manen , 1997 ) .
applying van manen 's lifeworld existentials as reflective guides helped us to separate themes , as well as to see the complexity as a whole .
from a longitudinal perspective , some of the informants obtained their original colours , some continued to live in shades of grey , while for some the colours turned clearer and showed distinct contrasts .
another metaphor was the journey in oneself , a metaphor also used by others ( bauman , 2005 ) .
different journeys could be seen as travelling in well - known scenery , travelling without control and being on a mission of rehabilitation .
the metaphors were useful for capturing the essence of the longitudinal perspective and grasping the complexity of the stories of each participant .
the aim of this study was to describe the lived experience as it develops over time of stroke survivors suffering from early depressive symptoms .
the comprehensive analysis of the 6- , 12- , and 18-month interviews revealed patterns in which the participant 's experiences developed over time : ( 1 ) finding a restored self ; ( 2 ) trapped in a different life ; and ( 3 ) fighting to regain self .
the stories of four of the participants reflected this pathway ; nora , sigrid , jon , and ingrid .
for this group , having a stroke was threatening and a shock that made them  lose their footing  for a while , however , they soon regained balance and found a restored self .
six months after stroke the participants described few and mild depressive symptoms , which persisted throughout the period .
the depressive symptoms were expressed as tiredness and fatigue , sleepiness , and the experience of being labile .
jon was a truck driver , for whom getting his driving license back was the central goal . for his family and friends
these seemed unattainable , but 12 months after the stroke he had regained his driving licence for regular cars , which gave him an immense feeling of freedom . at 18 months he was in a customised programme , and had started to work as a  henchman  on the truck he used to drive .
crucial physical and cognitive limitations could still be observed . despite these obvious changes , jon and
his wife had accepted the situation : 
 researcher : if you think back on how your life was before you had the stroke , is your life very different now?jon : no , i would n't say so (  ) wife : things do take a little longer .
they do.jon:yes.wife:and then there are some lapses in the short - term memory . otherwise , it 's the same .
just a few extra challenges along the way.researcher:like what , do you think?wife : that things take a little longer and  the right arm does n't work properly quite yet (  ) researcher : but otherwise , your life is the same as it was before?wife : yes.jon : yes . uh - huhwife : and i just have to learn that things take a little longer ( 18 months ) all the participants described episodes of increased exhaustion and tiredness .
before , she could do housework for hours , now her abilities were limited and family members helped her doing the heavy tasks in the house .
she described herself as an old lady and she accepted the situation as a natural development .
acceptance also included the necessity of doing things in a different way after stroke in order to reach the same goal .
nora experienced great difficulties understanding the content of texts as quickly as she did before .
this created much frustration in the acute phase , particularly when it came to different tests during her rehabilitation .
although she still found it challenging to read at 18 months , she had accepted the necessity of reading a document several times in order to understand it .
after stroke she had episodes where she all of a sudden turned angry , yelled at her husband or children , and then started crying .
however , her relatives accepted the episodes and treated her with care . support and understanding from the surroundings were crucial to all of the participants .
the experience of a close and supportive relationship with their spouses and/or families was common to all .
the experience of being free distinct from being dependent on others was crucial to the participants .
regaining the driving licence was an important part of achieving independency and being able to do the things they did before .
nora said :  i felt like the walls were falling down on me (  ) before i got my driving licence back .
the participants emphasised the importance of being able to participate , contribute , and do something useful in their daily life . at 12 months ,
vicious cycle:i do notice that i became very happy and very  i changed a lot when i started working .
it 's just so lovely getting out  away ! and to know that i 'm useful .
doing something positive or productive , or anything , yeah . just staying around here at home , that 's not me ! (  ) the more you stay at home and do nothing , the worse it becomes . 
 
it 's just so lovely getting out  away ! and to know that i 'm useful . doing something positive or productive , or anything ,
(  ) the more you stay at home and do nothing , the worse it becomes .
the experience of finding a restored self included two main aspects : ( a ) the participants gradually improved and regained most of their functions ; and ( b ) by accepting the limitations and finding new solutions they were no longer trapped , but had the ability to do more or less the same things they did before the stroke . at 18 months nora said : 
 in addition , several of the participants described having a stroke as a positive reminder .
they became aware of what they described as the important things in life : being grateful for the things they have achieved , taking care of own health , and being together with their loved ones .
 the experiences of three of the participants reflected this pathway ; peter , ellen and anne .
they felt like they were victims and had lost themselves to the stroke ; they were trapped in a different life . compared to group 1 , the participants in groups 2 and 3 experienced more severe physical and cognitive consequences after stroke . but
unlike group 3 , this group received no treatment and rehabilitation after returning to their homes .
the participants in group 2 continued to show approximately the same depressive symptoms during the entire period .
the symptoms were related to sadness , loss of pleasure , indecisiveness , self - criticism , loss of energy , changes in sleep patterns , and suicidal thoughts .
while the participants in group 1 managed to take action and regain command , the participants in group 2 were passive bystanders , and seemed to have given up .
the participants could decide and plan to do something , but were not able to pull themselves together to actually doing it .
being tired and having a lack of energy was a problem throughout the entire period .
she said :  well , i am probably able to , but i do n't feel like doing it  .
ellen was dependent on a walker and lived in an apartment on the second floor without an elevator . before the stroke she often went shopping and visiting cafs with her girl friends .
now she only left home when it was crucial , and only with help from others .
her daughter visited twice a week , but except for this she hardly had visitors .
you get used to it (  ) so it 's just watching tv a lot .
no , i ca n't manage to do anything , really  ( 18 months ) .
after stroke peter regained some of his walking capacity and at 6 months he was able to walk short distances using ski poles .
six months later his condition was even worse , and he was no longer able to do everyday chores he previously considered simple and obvious . he was trapped in a life of diseases and he was frustrated : i ca n't really manage anything , so i feel .
after that stroke , it seems to have spread to my entire body . in the fingertips , even .
after that stroke , it seems to have spread to my entire body . in the fingertips , even .
i ca n't do it right , the way i used to . having a stroke changed the way the participants felt about themselves .
they were old , living alone , and received restricted community support in relation to solving everyday issues .
she did not want to be a burden , and pretended that her life was under control . in every interview ,
peter talked about life before stroke and things he had achieved . by highlighting the past and comparing with the present ,
peter expressed the experience of being less attractive , being of less use , and therefore less valued .
he was afraid that he would not be able to take full responsibility for himself . 

peter : i would like to travel , but i do n't dare to because i feel a little insecure .
that would've been lovely  to feel the sun on my body . but  i'm uncertain of whether i can cope with it .
i do n't know if i dare , quite frankly.researcher:what are you afraid of not being able to 
researcher : do you feel that this is different after your stroke?peter : sure , i do notice that if there 's a lot of people i feel more uncertain.researcher:why do you feel uncertain ?
do you know why?peter : there 's a lot of chit - chat . a lot of noise.researcher:does that tire you , or do you have trouble following what is said?peter : no
well , it 's okay really  but sometimes i have the feeling that i do n't dare to stand up , if i may use that expression.researcher:do you behave differently in social settings now ; compared to before you had the stroke?peter : yes .
i have noticed , i 'm more uncertain , a lot ( 12 months ) . 
 
she avoided social gatherings and situations where she had to talk to people who were not close to her .
she was afraid of not being able to answer correctly and making a fool of herself .
eighteen months after her stroke she still avoided these situations , even though her communication skills improved : 
but i do n't go out if i know that i 'll meet somebody and all that . 
the experience of being trapped included several aspects : ( a ) the consequences after the stroke mainly continued ; ( b ) additional diseases worsened the situation ; ( c ) it was difficult to take action , and they experienced indecisiveness ; ( d ) lack of energy was dominant ; ( e ) the experience of self - criticism and insecurity in relation to others were crucial ; and ( f ) life was experienced as empty .
the stories of two of the participants , hedda and erik , reflected this pathway .
compared to groups 1 and 2 , these participants received the most extensive treatment involving several healthcare professionals over a longer period of time .
a lot was at stake in terms of work , economical situation , and families .
six months after the stroke the participants described approximately the same depressive symptoms as in the acute phase ; sadness , depressive thoughts , loss of energy and changes in sleep patterns . in addition
other symptoms were present , such as irritability , agitation , loss of pleasure , and loss of interest in sexuality .
at the same time the participants revealed a  fighting spirit  ; they were focusing on the goal of regaining self . at the 12-month interview the situation seemed brighter and
hedda described returning to work life as heavy and restricted : my friends who see me often , they say that they can see that i 've lost the spirit that i had for thinking positively .
and i think it 's very hard , it 's hurting my marriage , it 's hurting 
cause i do n't feel like doing anything at all (  ) i really just like to be on my own .
and i have never been like this before (  ) i started , like , thinking about how much i 've lost because of all this .
i feel that i 've lost so much  in terms of work , and  less money , and  because my pay was cut in half .
my friends who see me often , they say that they can see that i 've lost the spirit that i had for thinking positively .
and i think it 's very hard , it 's hurting my marriage , it 's hurting  most things .
cause i do n't feel like doing anything at all (  ) i really just like to be on my own .
and i have never been like this before (  ) i started , like , thinking about how much i 've lost because of all this .
i feel that i 've lost so much  in terms of work , and  less money , and  because my pay was cut in half .
it 's tiresome ( 18 months ) . at the 18-month interviews both described the depressive symptoms as deeper and more dominant .
it seems like the process of accepting the consequences after stroke first started at 12 months for these participants . to erik ,
the role as a leader in a big company was a large part of his identity .
after the stroke erik experienced cognitive changes in relation to problem solving , concentrating , and strategically thinking .
on one hand , he believed that everything would be as before :  the whole period i have been fighting for my rehabilitation so that i could be able to come back .
on the other hand , he realised he was a different man :  the problem is that you are not the one you used to be 
you have got some injuries ! (  ) well , the super quick and most intelligent and skilled man , he is not here right now 
( 18 months ) . in the 18-month interview hedda described that her feelings towards herself had changed .
she had become more self - critical : i have a bad relationship to myself because of all this .
i feel like i 'm different from everybody else  i'm kind of not so happy about the person i 've become .
i sort of feel that i  like yesterday i felt like a  kind of a geek . with a poor balance and stuff . 
 
i feel like i 'm different from everybody else  i'm kind of not so happy about the person i 've become .
i sort of feel that i  like yesterday i felt like a  kind of a geek . with a poor balance and stuff .
the participants experienced different challenges in terms of meeting and dealing with the expectations of others .
erik felt degraded as an employee and a man , because his colleagues , leaders , healthcare professionals , friends , and family did not support his goals of returning to work .
and i 'm more aggressive , sometimes (  ) more of that frustration over not being  treated like  before . not being surrounded by the same respect , y'know .
i was a boss that everybody came running to , and then suddenly it 's over and nobody 's talking to you and you 're completely isolated and neutralised ( 18 months ) . 
 
and i 'm more aggressive , sometimes (  ) more of that frustration over not being  treated like  before . not being surrounded by the same respect , y'know .
i was a boss that everybody came running to , and then suddenly it 's over and nobody 's talking to you and you 're completely isolated and neutralised ( 18 months ) .
the relationship between hedda and her husband had been difficult for several years . after the stroke
his expectations , particularly in terms of sexual activity , increased and things became more and more difficult as time passed by .
she was not able to take action , so she just waited for him to move out .
she experienced being on a different level compared to him , occupied with totally different aspects of life .
the emotional process she had gone through increased the space between them : after my stroke , the differences between us have started to stand out . really .
i think much more than he does about lots of things that leave him cold . compared to me
and we have totally different views on everything ! (  ) how can i give him so much attention and love , when i ca n't even love myself ?
i'm fully occupied by looking after myself and keeping myself up  he does n't understand that .
after my stroke , the differences between us have started to stand out . really .
i think much more than he does about lots of things that leave him cold . compared to me
and we have totally different views on everything ! (  ) how can i give him so much attention and love , when i ca n't even love myself ?
i'm fully occupied by looking after myself and keeping myself up  he does n't understand that .
tiredness and a lack of energy were dominant for both erik and hedda during the entire period .
when erik started working , all his energy was put into work , and he had no energy left for his spare time , his wife and family . in social gatherings erik was so tired that he was not able to focus , concentrate , and be an active part of a conversation .
this was experienced as : i'm really not accustomed to that , because i think it 's unacceptable compared to what i used to be like .
being social and active was always my strong point , so that  that 's a little annoying , not having that anymore ( 6 months ) . 
 
i 'm really not accustomed to that , because i think it 's unacceptable compared to what i used to be like .
being social and active was always my strong point , so that  that 's a little annoying , not having that anymore ( 6 months ) . during the time period between 6 and 18 months
hedda and erik fought hard to regain self and to become as they were before the stroke .
after 12 months they started to question their expectations and at 18 months the situation was still uncertain .
they were still in the middle of the difficult process of accepting and dealing with the consequences of stroke and the experience of depressive symptoms had increased .
the experience of fighting to regain self included several challenges : ( a ) the experience of hope versus realism ; ( b ) own expectations versus the expectations of others ; ( c ) lack of energy versus desire for effort ; and ( d ) the challenges of external structures .
the stories of four of the participants reflected this pathway ; nora , sigrid , jon , and ingrid . for this group , having a stroke was threatening and a shock that made them  lose their footing  for a while , however , they soon regained balance and found a restored self .
six months after stroke the participants described few and mild depressive symptoms , which persisted throughout the period .
the depressive symptoms were expressed as tiredness and fatigue , sleepiness , and the experience of being labile . the physical and cognitive changes after stroke improved early .
jon was a truck driver , for whom getting his driving license back was the central goal . for his family and friends
these seemed unattainable , but 12 months after the stroke he had regained his driving licence for regular cars , which gave him an immense feeling of freedom . at 18 months he was in a customised programme , and had started to work as a  henchman  on the truck he used to drive .
crucial physical and cognitive limitations could still be observed . despite these obvious changes , jon and
his wife had accepted the situation : 
 researcher : if you think back on how your life was before you had the stroke , is your life very different now?jon : no , i would n't say so (  ) wife : things do take a little longer .
they do.jon:yes.wife:and then there are some lapses in the short - term memory . otherwise , it 's the same .
just a few extra challenges along the way.researcher:like what , do you think?wife : that things take a little longer and  the right arm does n't work properly quite yet (  ) researcher : but otherwise , your life is the same as it was before?wife : yes.jon : yes . uh - huhwife : and i just have to learn that things take a little longer ( 18 months ) all the participants described episodes of increased exhaustion and tiredness .
before , she could do housework for hours , now her abilities were limited and family members helped her doing the heavy tasks in the house .
she described herself as an old lady and she accepted the situation as a natural development .
acceptance also included the necessity of doing things in a different way after stroke in order to reach the same goal .
nora experienced great difficulties understanding the content of texts as quickly as she did before .
this created much frustration in the acute phase , particularly when it came to different tests during her rehabilitation .
although she still found it challenging to read at 18 months , she had accepted the necessity of reading a document several times in order to understand it .
after stroke she had episodes where she all of a sudden turned angry , yelled at her husband or children , and then started crying .
however , her relatives accepted the episodes and treated her with care . support and understanding from the surroundings were crucial to all of the participants .
the experience of a close and supportive relationship with their spouses and/or families was common to all .
the experience of being free distinct from being dependent on others was crucial to the participants .
regaining the driving licence was an important part of achieving independency and being able to do the things they did before .
nora said :  i felt like the walls were falling down on me (  ) before i got my driving licence back .
the participants emphasised the importance of being able to participate , contribute , and do something useful in their daily life . at 12 months ,
it 's just so lovely getting out  away ! and to know that i 'm useful . doing something positive or productive , or anything , yeah . just staying around here at home , that 's not me ! (  ) the more you stay at home and do nothing , the worse it becomes . 
 
i do notice that i became very happy and very  i changed a lot when i started working .
it 's just so lovely getting out  away ! and to know that i 'm useful . doing something positive or productive , or anything , yeah . just staying around here at home , that 's not me ! (  ) the more you stay at home and do nothing , the worse it becomes .
the experience of finding a restored self included two main aspects : ( a ) the participants gradually improved and regained most of their functions ; and ( b ) by accepting the limitations and finding new solutions they were no longer trapped , but had the ability to do more or less the same things they did before the stroke . at 18 months nora said : 
i feel like i am the one i was .  in addition , several of the participants described having a stroke as a positive reminder .
they became aware of what they described as the important things in life : being grateful for the things they have achieved , taking care of own health , and being together with their loved ones .
the experiences of three of the participants reflected this pathway ; peter , ellen and anne .
they felt like they were victims and had lost themselves to the stroke ; they were trapped in a different life . compared to group 1 ,
the participants in groups 2 and 3 experienced more severe physical and cognitive consequences after stroke . but unlike group 3 , this group received no treatment and rehabilitation after returning to their homes .
the participants in group 2 continued to show approximately the same depressive symptoms during the entire period .
the symptoms were related to sadness , loss of pleasure , indecisiveness , self - criticism , loss of energy , changes in sleep patterns , and suicidal thoughts .
while the participants in group 1 managed to take action and regain command , the participants in group 2 were passive bystanders , and seemed to have given up . the participants could decide and plan to do something , but were not able to pull themselves together to actually doing it .
being tired and having a lack of energy was a problem throughout the entire period .
she said :  well , i am probably able to , but i do n't feel like doing it  .
ellen was dependent on a walker and lived in an apartment on the second floor without an elevator . before the stroke she often went shopping and visiting cafs with her girl friends .
now she only left home when it was crucial , and only with help from others .
her daughter visited twice a week , but except for this she hardly had visitors .
you get used to it (  ) so it 's just watching tv a lot .
no , i ca n't manage to do anything , really  ( 18 months ) .
after stroke peter regained some of his walking capacity and at 6 months he was able to walk short distances using ski poles . at the 12-month interview
six months later his condition was even worse , and he was no longer able to do everyday chores he previously considered simple and obvious . he was trapped in a life of diseases and he was frustrated : i ca n't really manage anything , so i feel .
after that stroke , it seems to have spread to my entire body . in the fingertips , even .
after that stroke , it seems to have spread to my entire body . in the fingertips , even .
i ca n't do it right , the way i used to . having a stroke changed the way the participants felt about themselves .
they were old , living alone , and received restricted community support in relation to solving everyday issues .
she did not want to be a burden , and pretended that her life was under control . in every interview ,
peter talked about life before stroke and things he had achieved . by highlighting the past and comparing with the present , peter expressed the experience of being less attractive , being of less use , and therefore less valued .
another example was anne experiencing that close acquaintances stopped contacting her after the stroke . due to this
he was afraid that he would not be able to take full responsibility for himself . 

peter : i would like to travel , but i do n't dare to because i feel a little insecure .
i do n't know if i dare , quite frankly.researcher:what are you afraid of not being able to 
?peter : to pay attention properly ( 18 months ) . 
  after having a stroke
researcher : do you feel that this is different after your stroke?peter : sure , i do notice that if there 's a lot of people i feel more uncertain.researcher:why do you feel uncertain ?
do you know why?peter : there 's a lot of chit - chat . a lot of noise.researcher:does that tire you , or do you have trouble following what is said?peter : no
well , it 's okay really  but sometimes i have the feeling that i do n't dare to stand up , if i may use that expression.researcher:do you behave differently in social settings now ; compared to before you had the stroke?peter : yes .
i have noticed , i 'm more uncertain , a lot ( 12 months ) . 
 
she avoided social gatherings and situations where she had to talk to people who were not close to her .
she was afraid of not being able to answer correctly and making a fool of herself .
eighteen months after her stroke she still avoided these situations , even though her communication skills improved : 
but i do n't go out if i know that i 'll meet somebody and all that . 
the experience of being trapped included several aspects : ( a ) the consequences after the stroke mainly continued ; ( b ) additional diseases worsened the situation ; ( c ) it was difficult to take action , and they experienced indecisiveness ; ( d ) lack of energy was dominant ; ( e ) the experience of self - criticism and insecurity in relation to others were crucial ; and ( f ) life was experienced as empty .
the stories of two of the participants , hedda and erik , reflected this pathway .
compared to groups 1 and 2 , these participants received the most extensive treatment involving several healthcare professionals over a longer period of time .
a lot was at stake in terms of work , economical situation , and families .
six months after the stroke the participants described approximately the same depressive symptoms as in the acute phase ; sadness , depressive thoughts , loss of energy and changes in sleep patterns .
in addition other symptoms were present , such as irritability , agitation , loss of pleasure , and loss of interest in sexuality .
at the same time the participants revealed a  fighting spirit  ; they were focusing on the goal of regaining self . at the 12-month interview the situation seemed brighter and
the depressive symptoms were less dominant . but shortly after the 12-months interview , the rehabilitation process was seriously challenged .
hedda described returning to work life as heavy and restricted : my friends who see me often , they say that they can see that i 've lost the spirit that i had for thinking positively .
and i think it 's very hard , it 's hurting my marriage , it 's hurting  most things .
cause i do n't feel like doing anything at all (  ) i really just like to be on my own .
and i have never been like this before (  ) i started , like , thinking about how much i 've lost because of all this .
i feel that i 've lost so much  in terms of work , and  less money , and  because my pay was cut in half .
my friends who see me often , they say that they can see that i 've lost the spirit that i had for thinking positively .
and i think it 's very hard , it 's hurting my marriage , it 's hurting  most things .
cause i do n't feel like doing anything at all (  ) i really just like to be on my own .
and i have never been like this before (  ) i started , like , thinking about how much i 've lost because of all this .
i feel that i 've lost so much  in terms of work , and  less money , and  because my pay was cut in half .
it 's tiresome ( 18 months ) . at the 18-month interviews both described the depressive symptoms as deeper and more dominant .
it seems like the process of accepting the consequences after stroke first started at 12 months for these participants . to erik ,
the role as a leader in a big company was a large part of his identity .
after the stroke erik experienced cognitive changes in relation to problem solving , concentrating , and strategically thinking .
on one hand , he believed that everything would be as before :  the whole period i have been fighting for my rehabilitation so that i could be able to come back .
on the other hand , he realised he was a different man :  the problem is that you are not the one you used to be 
you have got some injuries ! (  ) well , the super quick and most intelligent and skilled man , he is not here right now 
( 18 months ) . in the 18-month interview hedda described that her feelings towards herself had changed .
she had become more self - critical : i have a bad relationship to myself because of all this .
i feel like i 'm different from everybody else  i'm kind of not so happy about the person i 've become .
i sort of feel that i  like yesterday i felt like a  kind of a geek . with a poor balance and stuff . 
 
i feel like i 'm different from everybody else  i'm kind of not so happy about the person i 've become .
i sort of feel that i  like yesterday i felt like a  kind of a geek . with a poor balance and stuff .
the participants experienced different challenges in terms of meeting and dealing with the expectations of others .
erik felt degraded as an employee and a man , because his colleagues , leaders , healthcare professionals , friends , and family did not support his goals of returning to work .
and i 'm more aggressive , sometimes (  ) more of that frustration over not being  treated like  before .
i was a boss that everybody came running to , and then suddenly it 's over and nobody 's talking to you and you 're completely isolated and neutralised ( 18 months ) . 
 
and i 'm more aggressive , sometimes (  ) more of that frustration over not being  treated like  before . not being surrounded by the same respect , y'know .
i was a boss that everybody came running to , and then suddenly it 's over and nobody 's talking to you and you 're completely isolated and neutralised ( 18 months ) .
the relationship between hedda and her husband had been difficult for several years . after the stroke
his expectations , particularly in terms of sexual activity , increased and things became more and more difficult as time passed by .
she was not able to take action , so she just waited for him to move out .
she experienced being on a different level compared to him , occupied with totally different aspects of life .
the emotional process she had gone through increased the space between them : after my stroke , the differences between us have started to stand out . really .
i think much more than he does about lots of things that leave him cold . compared to me
, he has a very narrow range of interests . and we have totally different views on everything ! (  ) how can i give him so much attention and love , when i ca n't even love myself ?
i'm fully occupied by looking after myself and keeping myself up  he does n't understand that .
after my stroke , the differences between us have started to stand out . really .
i think much more than he does about lots of things that leave him cold . compared to me
and we have totally different views on everything ! (  ) how can i give him so much attention and love , when i ca n't even love myself ?
i'm fully occupied by looking after myself and keeping myself up  he does n't understand that .
tiredness and a lack of energy were dominant for both erik and hedda during the entire period .
when erik started working , all his energy was put into work , and he had no energy left for his spare time , his wife and family . in social gatherings erik was so tired that he was not able to focus , concentrate , and be an active part of a conversation .
this was experienced as : i'm really not accustomed to that , because i think it 's unacceptable compared to what i used to be like .
being social and active was always my strong point , so that  that 's a little annoying , not having that anymore ( 6 months ) . 
 
i 'm really not accustomed to that , because i think it 's unacceptable compared to what i used to be like .
being social and active was always my strong point , so that  that 's a little annoying , not having that anymore ( 6 months ) . during the time period between 6 and 18 months
hedda and erik fought hard to regain self and to become as they were before the stroke .
after 12 months they started to question their expectations and at 18 months the situation was still uncertain .
they were still in the middle of the difficult process of accepting and dealing with the consequences of stroke and the experience of depressive symptoms had increased .
the experience of fighting to regain self included several challenges : ( a ) the experience of hope versus realism ; ( b ) own expectations versus the expectations of others ; ( c ) lack of energy versus desire for effort ; and ( d ) the challenges of external structures .
in the previous section , we presented three patterns in which lived experiences of stroke survivors suffering from depression in the acute phase might develop over the time period of 6 , 12 , and 18 months .
the question of gender was not a main focus of our study and the material did not reveal gender specific topics . during the acute phase interviews
, we discovered that the depressive symptoms were not explicitly described , but were woven into the stories ( kouwenhoven et al . , 2011b ) .
to the participants , the experience of depression was not understood as meaningful on its own .
depressive symptoms formed the backdrop whereas the experience of stroke was in front of the stories . the lived experience of stroke interacted with the experience of depressive symptoms , and resided in the stroke survivors shaping of their daily life .
the depressive symptoms developed in line with how the participants related to themselves and the rehabilitation process . having a stroke has been characterised as  a small death 
( wade et al . , 1985 ) , or a personal catastrophe ( backe et al . ,
a stroke is a disruptive event involving the person 's biography and self - concept , demanding a mobilisation of resources ( bury , 1982 ; romsland , 2009 ) . suffering a stroke though
might not be seen as an abrupt psychosocial process , but as a process gradually evolving and prolonged over time ( kirkevold , 2002 ) .
kirkevold ( 2002 ) has described the illness trajectory within the first year after stroke in four phases starting with a trajectory onset characterised by surprise and suspense .
continue with an initial rehabilitation phase focusing on hard physical work , and a continued rehabilitation phase characterised by psychosocial and practical adjustment .
the fourth phase takes place from approximately 6 months after stroke and is described as a semi - stable phase when the focus shifts from the stroke and its treatment to daily life activities .
the stroke survivor is going on with life ( kirkevold , 2002 ) . having a stroke is  a continuum  and a stroke must be characterised as a chronic disease , as all consequences after stroke rarely can be cured or terminated ( kirkevold , 2002 ; wahl & hanestad , 2002 ) . the process of  going on with life
a stroke is often considered as  minor  or  mild  if the physical consequences are limited and the language is intact .
for example , problems in remembering and thinking strategically , concentration difficulties , lability , or tiredness , could cause depressive symptoms and major changes in the experience of the lifeworld .
kay , newman , cavallo , ezrachi , and resnick ( 1992 ) reported that even after mild traumatic brain injury a shallow sense of self would occur ( kay et al . ,
1992 ) , and becker and kaufman ( 1995 ) stated that during the first months after a stroke , survivors might come to terms with the dysfunction and failure to return to  normal  and then move towards a redefinition of self ( becker & kaufman , 1995 ) . to our participants ,
the different ways of shaping the lifeworld over time was tied to the notions of  self  which was at the core of lived experience .
there was a distinct relationship between the experience of the lived body  the ability of  doing  , and the concept of self  the experience of  being  . according to paterson ( 2001 ) living with a chronic disease
could be described as an on - going , continually shifting process in which the individual experiences a complex dialectic between themselves and their  world  .
the model has two main perspectives : either the  illness in the foreground  and  wellness in the background  , or vice versa .
perspective is characterised by a focus on sickness , suffering , loss , and the burden , whereas the  wellness in foreground-perspective includes an appraisal of the chronic illness as an opportunity for meaningful changes in relationship to others . within the second perspective , the individual attempts to create consonance between self - identity and the new identity created by the disease ( paterson , 2001 ; sutton & treloar , 2007 ) . the rehabilitation process after the stroke balances between reclaiming what has been lost , and dealing with permanent losses .
loss and grieving in relation to stroke has been described by several ( alaszewski et al . , 2004 ; horwitz & wakenfield , 2007 ; niemeier & burnett , 2001 ; thomas & siller , 1999 ) .
the experience of loss after stroke will influence the lifeworld and notion of self in different ways . during the period from 6 to 18 months
post - stroke the experience of the lived body developed differently in the three groups .
compared to groups 2 and 3 , group 1 experienced less severe physical and cognitive changes , and shortly after the stroke they had attained much of their bodily functions .
group 1 dealt with the loss by accepting the limitations and finding new and suitable solutions . to these participants the  wellness in foreground  perspective became dominant .
some even looked at the stroke as a positive reminder that made them think about the important things in life .
the group maintained the experience of being trapped in a changed body and a different life .
they were occupied with their losses . in addition , the participants were self - critical , felt less valued and were afraid of being a burden .
it seems as though this group was caught in the perspective of  illness in foreground  .
the goal of group 3 was to regain the bodily functions , or as much as possible , to get their former life back .
it seems as if this group did not enter what paterson calls  the ongoing shifting process  within the first year . between the 12 and 18 months
post - stroke period they seriously began for the first time to relate to the things they had lost , and the  illness in foreground 
as described by paterson might be important in order to  come to terms with  the stroke .
a rehabilitation process after a stroke could be seen as the process of dealing with and healing the disruption caused by the stroke , creating continuity between the past , the present , and the future .
biderman , daniels - zide , reyes , and marks ( 2006 ) explored reconstruction of  ego - identity  after a brain injury .
they emphasise the persistence of the sense of sameness within oneself as one of the distinguishing components of the concept of ego - identity ( biderman et al . , 2006 ) .
in relation to the three groups of our study , the lifeworld after stroke was shaped differently according to how the participants anchored the pre - stroke lifeworld in their present life .
group 1 was the only group with a view for the future . shortly after the stroke the participants went on with life .
the participants in group 2 were stuck in the present , not being able to overcome the barriers and move on .
the third group of participants were hoping , longing , and fighting to become the ones they were , and regaining their former lives .
they appeared to be fixated in the past . in a study of the experiences of individuals suffering from cognitive impairment after acquired brain injury , romsland ( 2009 ) found that several of the participants struggled so hard with their chaotic present , that they were not able to think of or relate to the future ( romsland , 2009 ) .
our study emphasised two groups that were particularly vulnerable . whereas the participants in group 3 were determined to fight , group 2 reacted with resignation . even though they had ambitions in terms of their recovery process , they were not able to do what was necessary . compared to group 3 , the participants in the second group experienced fewer obligations in their lives .
to group 3 a lot was at stake in terms of work , economical situation , and family life , whereas group 2 was on a pension and lived alone .
being old complicated by having a stroke may lead to a loss of strength , a reduced capacity , and the experience of less to fight for  or to fight with .
group 3 received extensive treatment in the time period from 6 until 18 months , while group 2 received nothing .
it seems as though the community healthcare service had no ambition on behalf of them .
also when it comes to lived relation to others , the groups differ . while group 3 described close relationships and experienced challenges in terms of meeting and dealing with the expectations of others , group 2 described more distant relationships to others .
they experienced insecurity in social settings , became isolated , and nobody was there to kindled their hope .
these were closely linked to meaning of the contexts of the participants ' lives in relation to everyday living , family and social networks , and work .
the experience of post - stroke lifeworld from the longitudinal perspective is divergent on two accounts  the perspective with which people with stroke experience self and self - identify , and the experiences in the life context .
malterud ( 2001 ) highlights three main areas of importance when it comes to evaluation of qualitative studies : reflexivity , transferability , and interpretation of analysis . by transferability malterud
emphasises the possibility of sharing and applying the findings beyond the study setting , and by interpretation of analysis she underscores the importance of identification of the systematic procedure . by reflexivity
she means that the researcher 's background and position will affect the study , e.g. , the topics chosen , the angle of investigation , the methods , the meetings between participants , and researchers , etc .
openness and reflection in relation to all steps of the research process are required ( malterud , 2001 ) .
the question of trustworthiness was taken into account in all stages of the process according to the character of our phenomenological study . in order to ensure that our participants suffered from depressive symptoms ,
studies have found that screening tools for depressive symptoms after stroke have some weaknesses ( kouwenhoven et al .
, 2011b ; hackett , hill , hewison , anderson , & house , 2010 ;
during the acute phase interviews some of the questions in the bdi ii formula were  explained  or interpreted by the stroke survivors as stroke - related factors rather than experienced as expression of depression ( kouwenhoven et al . , 2011b ) .
this might have an influence on the sample of this study and the credibility of the material .
no gold standard exists for screening assessment for depressive symptoms after stroke , and none of the screening tools is particularly developed for stroke survivors and their special situation ( carson et al . , 2000 ; kouwenhoven et al . , 2011a ) .
ricoeur claims that to become open , the researcher must seek to put the judgement about the factual  in brackets  ( lindseth & norberg , 2004 ) .
( dahlberg , 2006 ; dahlberg , dahlberg & nystrm , 2008 ) the interviews were conducted by the first author who also is a registered nurse .
her clinical experience , the literature of previous research , and the analysis of the former participant interviews informed her pre - understanding . in both the data collection and data analysis
she attempted to be sensitive , with an open attitude to allow participants to freely describe their unique experience in a natural and candid way . to seek the self - understanding of the text , the researchers attempted to be open - minded and allow the text to speak . to validate the findings , two of the researchers read the texts separately and discussed their understanding repeatedly throughout the analytic process ( sek and mk ) . when presenting the findings we have  stayed close to 
our findings are based on interviews with a limited sample of participants within a norwegian context .
however , our findings are consistent with a number of other studies that have explored the subjective experience of patients following a stroke .
malterud ( 2001 ) highlights three main areas of importance when it comes to evaluation of qualitative studies : reflexivity , transferability , and interpretation of analysis . by transferability malterud
emphasises the possibility of sharing and applying the findings beyond the study setting , and by interpretation of analysis she underscores the importance of identification of the systematic procedure . by reflexivity
she means that the researcher 's background and position will affect the study , e.g. , the topics chosen , the angle of investigation , the methods , the meetings between participants , and researchers , etc .
openness and reflection in relation to all steps of the research process are required ( malterud , 2001 ) .
the question of trustworthiness was taken into account in all stages of the process according to the character of our phenomenological study . in order to ensure that our participants suffered from depressive symptoms ,
studies have found that screening tools for depressive symptoms after stroke have some weaknesses ( kouwenhoven et al .
, 2011b ; hackett , hill , hewison , anderson , & house , 2010 ; kouwenhoven et al . , 2011a ) .
during the acute phase interviews some of the questions in the bdi ii formula were  explained  or interpreted by the stroke survivors as stroke - related factors rather than experienced as expression of depression ( kouwenhoven et al . , 2011b ) .
this might have an influence on the sample of this study and the credibility of the material .
no gold standard exists for screening assessment for depressive symptoms after stroke , and none of the screening tools is particularly developed for stroke survivors and their special situation ( carson et al . , 2000 ;
ricoeur claims that to become open , the researcher must seek to put the judgement about the factual  in brackets  ( lindseth & norberg , 2004 ) .
( dahlberg , 2006 ; dahlberg , dahlberg & nystrm , 2008 ) the interviews were conducted by the first author who also is a registered nurse .
her clinical experience , the literature of previous research , and the analysis of the former participant interviews informed her pre - understanding . in both the data collection and data analysis ,
she attempted to be sensitive , with an open attitude to allow participants to freely describe their unique experience in a natural and candid way . to seek the self - understanding of the text
, the researchers attempted to be open - minded and allow the text to speak . to validate the findings
, two of the researchers read the texts separately and discussed their understanding repeatedly throughout the analytic process ( sek and mk ) .
our findings are based on interviews with a limited sample of participants within a norwegian context .
however , our findings are consistent with a number of other studies that have explored the subjective experience of patients following a stroke .
our findings revealed two groups of stroke survivors were particularly vulnerable and should receive special attention : ( a ) old adults living alone ; and ( b ) adults with commitments to work , family , and children . according to
our material old adults received limited support from their community services and no help related to rehabilitation .
the reason for this may be the limited recourses , lack of knowledge , limited potential , because they did not ask for help , or some combination of these .
the younger adults received intensive healthcare during the whole period of 18 months . according to their high ambitions and the experience of failure 1 year after stroke , one might ask : was the healthcare good enough ? or , according to all the elements at stake ; was the process simply delayed making the participants not able to deal with the situation at an earlier time point or more expediently ?
our findings reveal that it might not always be a matter of how one copes with illness , body functions and rehabilitation , but also on how one relates to the changed body and the new life situation , and the ability to find meaning in the situation .
younger adults might need support later in the process , especially when returning to work or experiencing other demands .
we believe that rehabilitation after stroke must be considered a long - term process of adjustment .
measuring depressive symptoms in the acute phase is of no use unless the healthcare system has the ability to follow - up over time .
this process could not be standardised , but must be based on the person 's experience of his or her lifeworld .
this study was supported by buskerud university college and partially by the research council of norway .
 purposethe aim of the study was to describe the lived experience as it develops over time in stroke survivors suffering from early depressive symptoms.methodthis paper presents a phenomenological hermeneutical interview - study of nine participants at 6 , 12 , and 18 months after stroke.findingsthe participants related the depressive symptoms to the consequences of the stroke , and the experience of loss was crucial . 
 depressive symptoms was not meaningful on its own , but formed the backdrop of the experience of stroke . 
 our findings revealed three patterns of experience : ( 1 ) finding a restored self ; ( 2 ) trapped in a different life ; and ( 3 ) fighting to regain self.two groups of stroke survivors are particularly vulnerable and should receive special attention : ( a ) old adults living alone ; and ( b ) adults experiencing serious threats to their commitments such as to work , family , and children.conclusiondepressive symptoms have a severe impact on life after stroke . 
 life circumstances , degree of residual impairment from a stroke , and social context were found to influence people to move along different paths . 
 older adults living alone and adults experiencing serious threat to their commitments should receive special attention , in terms of further research and in terms of follow - up in clinical practice.more studies investigating the experience of post - stroke depression ( psd ) over time and the association between depressive symptoms and loss / grieving are needed . 
 there is also a need for continued empirical research on the identification of effective interventions aimed at prevention or improved coping with psd . 
The study
Design
Participants
Ethical considerations
Data collection
Data analysis
Findings
Finding a restored self
Trapped in a different life
Fighting to regain self
Discussion
Trustworthiness
Conclusion
Conflicts of interest and funding