Date Presented 3/30/2017
An ischemic stroke survivor who persistently reports anxiety or depression feelings throughout the 1st year poststroke is 12.6 times more likely to require assistance for daily activities compared with a survivor who makes no such report, results that suggest a need for enhanced screening and treatment.
Primary Author and Speaker: Scott Hutchison
Contributing Authors: Michelle Woodbury, Annie Simpson
PURPOSE: Annually, ∼795,000 people experience a stroke in the United States (Mozaffarian et al., 2015). Stroke is a leading cause of disability; the majority of survivors are left with long-term functional impairments. Approximately 33% of survivors report feelings of anxiety and depression during the first 5 yr poststroke (Hackett & Pickles, 2014). Many studies have shown that feelings of anxiety and depression can be a consequence of disability (Willey et al., 2010); however, fewer studies have explored how disability can be a consequence of having an anxious or depressed mood. The aim of this study was to determine the relationship between self-reports of anxiety and depression and the level of disability within the first year poststroke. We hypothesized that survivors reporting anxiety or depression would have higher levels of disability because those symptoms may interfere with functional recovery.
DESIGN: A retrospective analysis was conducted of existing data collected for a study by the Interventional Management of Stroke III Investigators from 58 sites comparing two acute ischemic stroke interventions, intravenous tissue plasminogen activator (t-PA) with and without an endovascular procedure (Broderick et al., 2013).
METHOD: The following data were extracted: The Modified Rankin Scale (mRS) collected at 12 mo poststroke measured disability. Item 5 from the EuroQOL collected at 3, 6, 9 and 12 mo poststroke measured participant-reported anxiety and depression. The National Institutes of Health Stroke Scale collected at discharge from the acute hospital measured stroke severity. Incomplete records were removed using a listwise deletion method. mRS data were dichotomized to differentiate participants who required daily assistance from those who did not. Participants were categorized into a group who reported anxiety or depression at every time point (Persistent Report, n = 175), a group that gave some reports (Intermittent Report, n = 526), and a group that gave No Report (n = 137). Descriptive statistics were performed using chi-square for categorical variables and simple linear regression for continuous variables. Shapiro–Wilk and Kolmogorov–Smirnov normality testing was performed to assess assumptions. A predictive model using multiple logistic regression with reported adjusted odds ratios were generated. All tests were performed controlling for stroke severity, intervention group, age, and gender. Analyses done with SAS Version 9.4 (SAS Institute, Cary, NC), alpha < .05.
RESULTS: Complete data sets were available for n = 712 (12% removed due to missing data; 55% male, M age = 63.4 ± 12.8 yr). Data were normally distributed. Logistic regression showed that compared with the No Report group, the Intermittent Report group (β = 1.75 ± .49, p = .0003) and the Persistent Report group (β = 2.53 ± .58, p < .0001) demonstrated significantly greater need for daily assistance. Odds ratio analysis showed that compared with the No Report group, the Intermittent Report group had 5.7 times (95% confidence interval [CI] [2.20, 14.89], p = .0003) higher odds and the Persistent Report group had 12.6 times (95% CI [4.01, 39.64], p < .0001) higher odds of needing daily assistance at 12 mo poststroke. All reported results were adjusted controlling for the effects of stroke severity, intervention group, age, and gender.
CONCLUSION: A stroke survivor who persistently reports anxiety or depression feelings throughout the first year poststroke is statistically more likely to require assistance for daily activities compared with survivors who make no report, even after controlling for stroke severity, age, and gender. Our results emphasize the importance of repeatedly screening for and addressing anxiety and depression during the stroke rehabilitation process because survivors reporting feelings of anxiety and depression may be at risk for remaining disabled in the long term.
References
Broderick, J. P., Palesch, Y. Y., Demchuk, A. M., Yeatts, S. D., Khatri, P., Hill, M. D., . . . Interventional Management of Stroke III Investigators. (2013). Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. New England Journal of Medicine, 368, 893–903. https://doi.org/10.1056/NEJMoa1214300
Hackett, M. L., & Pickles, K. (2014). Part I: Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. International Journal of Stroke, 9, 1017–1025. https://doi.org/10.1111/ijs.12357
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., . . . Turner, M. B. (2015). Heart disease and stroke statistics—2015 update: A report from the American Heart Association. Circulation, 131(4), e29–e322. https://doi.org/10.1161/cir.0000000000000152
Willey, J. Z., Disla, N., Moon, Y. P., Paik, M. C., Sacco, R. L., Boden-Albala, B., . . . Wright, C. B. (2010). Early depressed mood after stroke predicts long-term disability: The Northern Manhattan Stroke Study (NOMASS). Stroke, 41, 1896–1900. https://doi.org/10.1161/STROKEAHA.110.583997
