Artikkel skrevet av Hilde Bergersen publisert i The journal of stroke and cerebrova…

7/30/2019 Artikkel skrevet av Hilde Bergersen publisert i The journal of stroke and cerebrova

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Anxiety, depression and psychological well being

two to five years post stroke

Hilde Bergersen1, Kathrine Frey Frslie

1,2, Katharina Stibrant Sunnerhagen

1,3, Anne-

Kristine Schanke1

1. Sunnaas Rehabilitation Hospital and Medical Faculty, University of Oslo, Norway.

2. Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo,

Norway.

3. Institute of Neuroscience and Physiology, Section of Clinical Neuroscience and

Rehabilitation Medicine, University of Gothenburg, Sweden.

Financial support was given in part by Sunnaas Rehabilitation Hospital. Moral support and

encouragement was given by the staff.

Corresponding author

Hilde Bergersen, Sunnaas Rehabilitation Hospital, 1450 Nesoddtangen, Norway

Telephone: +47 66 96 96 39; Mobile: +47 92 61 27 01

Telefax: +47 66 91 25 76

E-mail: [email protected]

Short title: Psychological well being long time after stroke


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ABSTRACT

Objectives: To explore psychological well being and the psychosocial situation in persons

with stroke, two to five years after discharge from a specialized rehabilitation hospital.

Material and methods: The Hospital Anxiety and Depression Scale (HADS), the General

Health Questionnaire (GHQ-30) and a questionnaire were mailed to 255 former patients.

Results: Sixty-four percent answered (36% women), and the average age was 58 years.

HADS identified problems in 47% (anxiety in 36% and depression in 28%) and GHQ-30 in

54%. About half had experienced periods of anxiety and/or depression since discharge. Most

were satisfied with support by family/friends (88%), home ward (68%) and community

therapy services (57%). Marital status was as in the general population.

Conclusions: A long time after stroke almost half of the investigated stroke patients had

psychiatric problems according to the questionnaires. This is higher than in the general

population but is comparable with some other chronic, somatic populations in Norway.


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INTRODUCTION

It is well documented that depression is common after stroke (1, 2), although the numbers for

many reasons vary greatly between studies (3, 4). The relationship between stroke and

psychological disorders other than depression has been given little attention in the literature

(5). The long term well being of stroke patients discharged from specialized rehabilitation is

not documented.

Findings suggest that post stroke anxiety problems are common and both more stable and

persistent than post stroke depression (6). strm (7) found generalized anxiety in 19 % three

years after stroke, and a review (8) showed that two studies reported 17-18 % generalized

anxiety after two years. Comorbid depression is common in stroke survivors with generalized

anxiety disorder, and the existence of the anxiety disorder can negatively affect the prognosis

of the depression (7).

The prevalence of depression decreases during the first year after stroke in both community

studies and in institutionalized patients (3). However, as Hackett et al. (8) noted, there are also

reports of long term follow-ups where possible depression was found in 18-38 % two to five

years after stroke, depending on the study. The question remains of how common these

problems are in the general stroke population. In a large scale Norwegian population survey,

possible anxiety disorders, measured with the Hospital Anxiety and Depression Scale

(HADS), were found in 16 % in the age group of 47-70 and possible depression in 13 %

(Bjelland 2007, personal communication). In the subpopulation with prior stroke, possible

anxiety disorders were found in 21% and possible depression in 27 % (9), and 11 % had

comorbid anxiety/depression.


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Long term emotional outcome in stroke survivors has also been studied with concepts such as

quality of life or health related quality of life (HRQoL) (10). HRQoL is severely impaired

in most stroke survivors two years post stroke (11) and has been found to be very low in 20 %

still five years after stroke (12). Some studies have also found relatively satisfactory long term

life quality (13), however, indicating that many stroke survivors adapt to their disabilities and

dependency (14, 15).

Quality of life is still influenced by mental health in stroke survivors two to four years after

stroke (10, 11, 16). Anxiety and depression are independent determinants of handicap (17),

which again is associated with quality of life (11).

The aim of the study was to explore stroke survivors mental health, psychological well being

and psychosocial situation two to five years after discharge from a specialized rehabilitation

hospital.

MATERIALS AND METHODS

The subjects were patients admitted to Sunnaas Rehabilitation Hospital for stroke. The

hospital is a specialized inpatient rehabilitation centre located close to the capital city, Oslo.

From the hospitals archives, 255 persons who had stayed at the hospital during 1998-2001,

were identified as having had a stroke diagnosis (WHO criteria by a stroke physician and/or

CT or MR verified).

A questionnaire was sent out by mail and a reminder sent out a few weeks later. The

questionnaire contained the Hospital Anxiety and Depression Scale (HADS) (18), the General

Health Questionnaire, 30 items (19, 20), and some structured questions regarding


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psychosocial situation (marital status, employment, drivers licence and satisfaction with

support from family and friends, help from the home ward and with the community therapists)

and a self-report of psychological functioning in the period since discharge (existence of

periods of anxiety and/or depression, contact with professionals for these problems and an

evaluation of the helpfulness of this). For comparison, marital status data from the Norwegian

statistical database were used (21). Demographic and medical information was collected from

the patients medical journal at the hospital. The modified Rankin scale (22) was used to

describe disability.

The Hospital Anxiety and Depression Scale, HADS, is a questionnaire with 14 items

intermingled on two subscales (anxiety, HADS-A, and depression, HADS-D). It has good

psychometric value (23) and general population norms and performs well in assessing

symptom severity and meeting the criteria of anxiety disorders and depression, both in

somatic, psychiatric and primary care patients (23). Zigmond and Snaith (18) suggested

scores below 8 as within normal limits and above 10 as definite cases of anxiety or

depression, and we used the generally accepted and recommended cut-off of 7/8, where a

score of 8 or above suggests possible psychiatric morbidity. An authorized Norwegian version

was used.

The General Health Questionnaire (GHQ) has been suggested to be suitable for screening

mild psychopathology and quality of life (24). GHQ-30 contains more items on quality of life

and fewer on somatic symptoms compared to the other versions of GHQ and is regarded as

well suited for patients in primary care and in somatic hospitals. Each item can be recoded to

0 or 1. A total sum score over 5 indicates psychopathology (case). An authorized

Norwegian version was used.


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The respondents were also asked whether they had been through periods of anxiety and/or

depression since discharge from the rehabilitation hospital, whether they had sought

professional help for these problems and, potentially, the helpfulness of this. In addition they

were asked whether they were satisfied with emotional and practical support of family and

friends, and the range and service of primary health care and therapists in the community.

STATISTICAL ANALYSES

Statistical Packages for Social Sciences (SPSS), 15.0, was used for the statistical analyses.

Descriptive statistics were counts and percentages of categorical data. Mean and standard

deviation (SD) or median and quartiles were used as summary measures for numerical data.

Comparisons of responders and non-responders were made by Pearsons 2 test (gender) and

two-sample t-test (age). Correlations between measures were explored in scatter plots and

estimated by Pearsons correlation coefficient (r). Factor analysis with varimax rotation was

used to explore the two scales of the HADS. The agreement between HADS and GHQ-30

when they were used as diagnostic tests based on their respective cut-offs was explored in

cross tables and quantified by Cohens .Kappa coefficients in the range 0.40-0.80 are

considered moderate to good and those exceeding 0.80 very good, while values below 0.40

are fair to poor (25). A p-value less than 0.05 was considered statistically significant.

ETHICS

Approval was obtained from the Ethics Committee of the Norwegian social science and data

services and the Regional Committee for Ethics in Medical Research (REK I). The study was

conducted according to Norwegian legislation on information gathering and storing.


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RESULTS

The answering process is described in figure 1. In 27 cases of comprehension deficits,

proxies informed of having assisted, which was explicitly allowed for in a letter

accompanyingthe questionnaire. Three responders answered by phone and one in a personal

meeting. In the case of missing items, the responders were either phoned or mailed to

complete missing items. In the end, four of these had to be omitted since they could not give

information on the missing items even after contact. The final sample consisted of 162

persons (63.5%). These are referred to as responders. Information on the non-responders

age and gender was available in the hospital administrative system, enabling comparison

between responders and non-responders.

The respondents had had their stroke on average 3.5 years earlier (SD=1.2). Twelve percent

(n=20) had also had a prior stroke. As usual, infarctions were the most common cause, but in

this sample 14 % of the respondents had experienced a subarachnoidal haemorrhage (table

1). About 1/5 were diagnosed as having aphasia, severely affecting communication in

everyday activities at the time of discharge from rehabilitation.

Almost a third of the respondents was moderately severely disabled and in need of

assistance for mobility and own bodily needs, scoring 4 on the Modified Rankin Score

(MRS). The median MRS score was 3, indicating moderate disability; requiring some help,

but able to walk without assistance. A comparison with the group of non-responders

revealed no significant differences regarding gender or age. The majority was either in early

retirement due to disablement (52 %) or age (29 %) at time of follow-up (table 2). Twenty-

nine persons, none above the age of 61, were working, and 14 of these had a reduction in

work time or adjusted vocational situation. Drivers licence had been permanently

withdrawn in 44 % as a consequence of the stroke. The number of divorces was as expected


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for the general Norwegian population in the same age group. The majority was satisfied with

psychosocial and practical support of proxies and the community (see table 3). Some

commented that they were more satisfied with their familys support than with their friends.

Eighty-seven respondents (54.5 %) reported having been through periods of anxiety (32.6 %)

or depression (48.2 %) during the period since discharge (table 4), and almost half of these

reported having experiencedboth (n=42). Of those reporting of periods of psychological

problems, 53 % (n=52) had consulted professionals for this reason and the majority (38/52)

had found this helpful. However, in spite of this, 86 % of those reporting periods of anxiety or

depression some time during the period since discharge still suffered from possible

psychiatric problems.

According to HADS, 36.4 % of the respondents had possible anxiety disorder (scores > 7),

and 27.8 % had possible depression (see figure 2). The overlap was large, as 17.3 % of the

respondents had comorbid anxiety disorder and depression according to HADS, meaning that

nearly half of the depressed and two-thirds of the respondents with an anxiety disorder also

had a possible comorbid psychiatric disorder. The average score in HAD-A was 5.8 (SD=5.0)

and in HAD-D 5.6 (SD=4.0). Definite cases of anxiety or depression (cut-off 10/11) were

16.7 % and 8.0 %, respectively.

A total of 54 % of the respondents had a case score (score >5) on GHQ-30, indicating low

quality of life and possible psychiatric morbidity. The two clearly most common case

answers were about having a reduced social life (56 % cases) and being able to participate

in a useful way (50 %).


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GHQ-30 was correlated with both HAD scales (HAD-A: r=0.69; HAD-D: 0.69; p


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severe disability than community based studies, which might explain the higher prevalence of

depression in the hospital and rehabilitation samples than in the community based studies.

Severe and complex disability is a prerequisite for rehabilitation at Sunnaas Hospital. The

patient group studied scored relatively high on the Modified Rankin scale (MRS), indicating

physical impairments, and 20 % had aphasia that seriously affected communication, which is

higher than expected in a stroke population (30). This might explain the relatively high

psychiatric morbidity in our population compared to community based studies and studies of

populations taken from general hospitals (stroke units).

Studies of the psychometric properties of HADS specifically in stroke populations(19, 31-33)

indicate that lower cut-off values than the cut-off values originally suggested by Zigmond and

Snaith (18) may be better in these populations. If this is correct, our estimates of psychiatric

morbidity based on the original cut-off values may underestimate the problem.

In this study we noted co-existing anxiety and depression in 17 %. Half of the depressed

persons also had an anxiety disorder, and more than two-thirds of the respondents with an

anxiety disorder had depression as well. This possibly indicates that the HAD scores reflect a

general psychological distress (5). This can be considered to be in accordance with an earlier

Norwegian study of the general population (9), where somatic health problems were more

strongly associated with co-existing anxiety and depression than with anxiety or depression

each alone. An explanation of this might be, in accordance with Williams and Evans (34), that

somatic illness contributes to an increased load of stressors that make subsyndromal

depressions clinically significant. For whatever reason, it seems that the complex situation in

the stroke population needs to be assessed as a whole.


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In our sample the agreement between HAD scales and GHQ-30 was rather low. The

relatively low agreement means that some stroke survivors with possible psychiatric

morbidity report their quality of life to be satisfying and some survivors with no psychiatric

morbidity report low quality of life, indicating that other factors than mental health add to

explaining stroke survivors long term total quality of life.

Stroke survivors have been found to have greater contact with mental health care compared

with the general population (35). Although many of the respondents in this sample reported

having been through periods of anxiety and/or depression since discharge from the hospital,

only half of these people had consulted health care professionals about this. These results

suggest that they had not received the necessary help for their mental health problems.

Perhaps health personnel should actively screen for these problems since the persons do not

actively seek help.

In this population requiring specialized rehabilitation post stroke, mental distress was present

years after discharge to a much higher degree than in the healthy population. The level was

however in general accordance with some other chronic, somatic populations in Norway. One

finding is that many persons with mental health problems did not seek or receive support from

the health services for this.

References

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associated with poor outcome. J Neurol Neurosurg Psychiatry 2000 Jan;68(1):47-52.

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3. Aben I, Verhey F, Honig A, et al. Research into the specificity of depression

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12. Paul SL, Dewey HM, Sturm JW, et al. Thrift AG. Prevalence of depression and

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22. Burn JP. Reliability of the modified Rankin Scale. Stroke 1992 Mar;23(3):438.

23. Bjelland I, Dahl AA, Haug TT, et al. The validity of the Hospital Anxiety and

Depression Scale. An updated literature review. J Psychosom Res. 2002 Feb;52(2):69-77.

24. Goldberg D, Bridges K, Duncan-Jones P, et al. Detecting anxiety and depression

in general medical settings. Bmj. 1988 Oct 8;297(6653):897-899.

25. Altman D. Practical statistics for medical research. London: Chapman & Hall,

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26. Fjaertoft H, Indredavik B, Lydersen S. Stroke unit care combined with early

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27. Silvestrelli G, Parnetti L, Tambasco N, et al. Characteristics of delayed

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32. Johnson G, Burvill PW, Anderson CS, et al. Screening instruments for

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33. Tang WK, Wong E, Chiu HF, et al. Rasch analysis of the scoring scheme of the

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Figure legends

1. Flow chart of the recruitment process.

2. Scatter plot of the Hospital Anxiety and Depression Scale. The upper right quadrant

depicts those persons with both depression and anxiety. The lower left quadrant

shows those with neither depression nor anxiety. The upper left identifies a

dominance of anxiety and the lower right a dominance of depression.


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Table 1. Clinical characteristics of the 162 respondents

n

Cause of stroke

Infarction

Left: n=45 (45 %)

Right: n=33 (33 %)

Other: n=23 (23 %)

Haemorrhage

Subarachnoidal

Both infarction and haemorrhage

Unknown

101 (62 %)

30 (19 %)

22 (13 %)

4 (3 %)

5 (3 %)


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Table 2. Demographic characteristics of the respondents at follow-up

n Mean SD

Male 104 (64 %)

Female 58 (36 %)

Years since stroke 3.5 1.2

Age (22-85) 58.3 11.8

Education (7-18) 11.5 3.0

Marital status

Married/cohabitant

Divorced

Widow/widowers

Single, never married

107

25

10

20

(66 %)

(15 %)

(6 %)

(12 %)

Drivers licence revoked 67 (44 %)

Income

Retirement

Disability pension

Employment

same job: n=11 (7 %)

reduced time: n=14 (9 %)

new job: n=4 (3 %)

47

86

29

(29 %)

(53 %)

(18 %)


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Table 3: Self-reported satisfaction

Satisfied, n Partly satisfied, n Not satisfied, n

Psychosocial support from proxies 142 (88 %) 20 (12 %)

Community rehabilitation 89 (57%) 37 (24 %) 31 (20 %)Practical help from home ward 103 (68 %) 32 (21 %) 17 (11 %)


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Table 4: Self-reported psychiatry in the period since discharge (n, %)

Periods with anxiety only 10 (6 %)Periods with depression only 35 (22 %)

Both anxiety and depression 42 (26 %)

No depression or anxiety 73 (46 %)


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Figure 1

n= 255 questionnaires

n=10 persons with severeaphasia according to proxies

n=4 questionnaires withmissing items

n=79 non-responders

n=162 in the study


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Figure 2: The respondents scores on HADS. The horizontal and vertical lines represent

the cut-off values for anxiety and depression (7/8), respectively.

HADS, Depression scale

20151050

HADS,

Anxietyscale

20

15

10

5

0

1

2

3

4

5

6

7

Number ofpersons

Depression onlyn=17 (11 %)

Anxiety onlyn=31 (19 %)

Anxiety anddepressionn=28 (17 %)

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