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Anxiety after stroke: Time for an intervention

Article  in  International Journal of Stroke · July 2015

DOI: 10.1111/ijs.12493 · Source: PubMed

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Anxiety after stroke: time for an intervention
Ho-Yan Yvonne Chun, William N. Whiteley, Alan Carson, Martin Dennis, and Gillian E. Mead
Anxiety is common and persistent after stroke, and is associ-
ated with a poorer quality of life. Guidelines from numerous
countries, including the United Kingdom, recommend screen-
ing for poststroke emotional problems. Anxiety is a priority for
the National Institute for Health and Care Excellence, stroke
charities, and stroke survivors in the United Kingdom. Yet
there is little evidence to guide the management of anxiety
after stroke. New evidence-based interventions are needed to
improve the care of poststroke anxiety.
Key words: anxiety, disorder, intervention, screening, stroke, trial
Anxiety is common after stroke
Two-thirds of stroke survivors have symptoms of anxiety (1).
Anxiety is classified as a disorder when the symptoms of anxiety
are disproportionate and interfere with functioning. In a system-
atic review of 44 observational studies, 18% of stroke survivors
met the diagnostic criteria for an anxiety disorder, and 25% had a
‘probable anxiety disorder’ rated by a screening tool (2). Anxiety
disorders frequently coexist with depression, and may be more
common in women and younger stroke survivors (2). Patients
with a ‘probable anxiety disorder’ at three-months had a poorer
quality of life at one, three, and five-years poststroke after adjust-
ing for age, gender, and stroke severity (3). Anxiety symptoms
persisted for up to 10 years (3).
Are there effective treatments for anxiety
after stroke?
Developing interventions to help with ‘coming to terms with
having a stroke’ was ranked the second highest research priority
by stroke survivors, caregivers, and health professionals in a James
Lind Alliance research priority-setting exercise (4). There are a
range of treatments for anxiety in nonstroke populations, but it is
uncertain whether they are effective after stroke. For example,
psychological treatments may be poorly tolerated by patients,
perhaps because their efficacy is dependent on considerable
effort.
A recent Cochrane review of interventions for anxiety after
stroke included only two trials (n = 175), demonstrating statisti-
cally significant reduction in anxiety symptoms with paroxetine
in one trial, and buspirone in the other, in patients who had
comorbid depression (5). These studies were limited by small
Correspondence: Ho-Yan Yvonne Chun*, Centre for Clinical Brain
Sciences, University of Edinburgh, Chancellor’s Building, University of
Edinburgh, 49 Little France, Edinburgh EH16 4SB, UK.
E-mail: hchun@exseed.ed.ac.uk
Twitter: @DrYvonneChun
Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh,
UK
Conflict of interest: None.
DOI: 10.1111/ijs.12493
© 2015 World Stroke Organization
Leading opinion
sample size and inadequate description of their methods and
controls, and so are insufficient as a guide to treatment (5). One of
the biggest barriers to treatment is identification and initiation of
treatment, even in units that routinely screen patients. One
response to this has been the growth in managed care pathways
for, for example, depression. It is likely that efficient management
systems as well as efficacious treatments will be needed to address
anxiety after stroke.
Interventions in other disorders may not be
generalizable to stroke
The stepped-care model of psychological care was proposed by
the National Institute for Health and Care Excellence in recogni-
tion of the lack of psychological support after stroke (6). Level 1
consists of screening and assessment, followed by low-intensity
psychological interventions delivered by trained members of the
multidisciplinary team at Level 2. Escalation to high-intensity
specialist interventions at Level 3 is determined by patient’s
needs. A similar model has successfully reduced depressive symp-
toms in a randomized controlled trial in cancer patients with
major depression (7). The same model may not be generalizable
to stroke patients as they are older, more prone to fatigue, and
may suffer from anosognosias and communication difficulties.
The conceptualization of poststroke anxiety, screening process,
and outcome measures must first be defined prior to a clinical
trial of an intervention in stroke survivors.
Phobic vs. generalized anxiety disorder (GAD)
Phobic disorders (frequency of 8–16%) and GAD (frequency of
3–6%) were the commonest anxiety subtypes after stroke, albeit
reported in only 3 of the 44 studies reviewed (2). Phobic disorders
are characterized by anxiety out-of-proportion to the actual
threat, and GAD is characterized by excessive anxiety about every-
day life circumstances and difficulty controlling the worry (8).
Psychological therapy varies with anxiety subtype in the general
population. A stratified approach may be necessary to manage
poststroke anxiety. Stroke survivors may have fears amounting to
specific phobias that need defining.
Measuring anxiety
The Hospital Anxiety and Depression Scale is the only anxiety-
screening tool with adequate test accuracy in stroke (9). However,
it was not developed with stroke patients in mind, does not dis-
tinguish anxiety subtypes, and has no utility in aphasia or cogni-
tive impairment. Recently, a new observer-rated screening tool
has undergone preliminary validation (10).
Vol 10, July 2015, 655–656 655
 Leading opinion
Conclusion
We need to establish precisely the concept of poststroke anxiety in
order to screen for anxiety disorders after stroke and deliver inter-
ventions targeted to the specific subtypes. Future studies need to
include stroke patients with communication difficulties for gen-
eralizability, and a trial in patients with stroke is warranted.
References
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© 2015 World Stroke Organization