|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 3 | Page : 106-112
Poststroke anxiety disorders in a Nigerian hospital: Prevalence, associated factors, and impacts on quality of life
Osunwale Dahunsi Oni1, Andrew T Olagunju2, Peter O Ogunnubi3, Olatunji F Aina2, Francis I Ojini4
1 Department of Psychiatry, Lagos University Teaching Hospital, PMB 12003, Lagos, Nigeria
2 Department of Psychiatry, Lagos University Teaching Hospital; Department of Psychiatry, College of Medicine, University of Lagos, PMB 12003, Lagos, Nigeria
3 Department of Psychiatry, College of Medicine, University of Lagos, PMB 12003, Lagos, Nigeria
4 Department of Medicine, Neurology Unit, Lagos University Teaching Hospital; Department of Medicine, College of Medicine, University of Lagos, PMB 12003, Lagos, Nigeria
|Date of Web Publication||17-Aug-2017|
Osunwale Dahunsi Oni
Department of Psychiatry, Lagos University Teaching Hospital, PMB 12003, Lagos
Source of Support: None, Conflict of Interest: None
Background and Purpose: Anxiety disorders impact negatively on morbidity and mortality poststroke. Few studies have, however, been done on poststroke anxiety disorders (PSAD), particularly in Africa. The study aims to determine the prevalence, associated clinicodemographic factors, and impact of PSAD on quality of life (QoL) among outpatients at a tertiary hospital in Nigeria. Methods: Seventy stroke survivors attending Outpatient Clinics at Lagos University Teaching Hospital, Nigeria, were recruited into the study. Participants were assessed using sociodemographic/clinical questionnaire, the modified Mini–Mental State Examination, the Modified Rankin Scale, the Schedule for Clinical Assessment in Neuropsychiatry, and the World Health Organization-QoL-Bref. Data collection took 5 months and analyzed using the Statistical Package for the Social Sciences (SPSS®) software version 17.0. Results: The mean age of respondents was 57.43 (±9.67) years and 38 respondents (54%) were male. Majority of the stroke survivors had infarctive stroke 55 (78.6%), right hemispheric lesions 37 (52.9%), and significant poststroke disabilities 57 (81.4%). The prevalence of PSAD was 10% and agoraphobia with panic attacks was elicited in 42.8% of those diagnosed with PSAD. Participants with PSAD were significantly more likely to be unemployed (P = 0.01) and pay more than ₦10,000 ($62.50 at December 2013) monthly for health care. The mean QoL scores were lower in participants with PSAD across all QoL spheres, and significantly so for overall health (P = 0.04), health satisfaction (P = 0.02), and physical health (P = 0.01) domains. Conclusion: PSAD, especially agoraphobia in association with unemployment and high health-care costs correlated with poor well-being among stroke survivors. Proactive measures to ensure prompt identification and management may potentially improve outcome and QoL after stroke.
Keywords: Africa, agoraphobia, correlates, poststroke anxiety disorders, quality of life, stroke survivors
|How to cite this article:|
Oni OD, Olagunju AT, Ogunnubi PO, Aina OF, Ojini FI. Poststroke anxiety disorders in a Nigerian hospital: Prevalence, associated factors, and impacts on quality of life. J Clin Sci 2017;14:106-12
|How to cite this URL:|
Oni OD, Olagunju AT, Ogunnubi PO, Aina OF, Ojini FI. Poststroke anxiety disorders in a Nigerian hospital: Prevalence, associated factors, and impacts on quality of life. J Clin Sci [serial online] 2017 [cited 2018 Mar 20];14:106-12. Available from: http://www.jcsjournal.org/text.asp?2017/14/3/106/213088
| Introduction|| |
Globally, anxiety disorders are the most common mental health problem  and may possibly be linked with stroke given that fear and significant uncertainty are frequently associated with the diagnosis of stroke., Stroke is one of those dreaded conditions that could provoke anxiety in survivors, especially when there is threat to functional capacity, independence, and potential vulnerability to reoccurrence. Anxiety disorders typically do not precede the first stroke but subsequent to recovery as the fear of a second stroke becomes prominent. While major loss is largely associated with depression and better researched in chronic disabling medical illnesses, anxiety disorders are considered to be common during early phase of major loss, threatening events, and less researched despite being the most prevalent mental health disorders in general.,, Although degree of stroke disability is usually dependent on factors such as health-care setting, type of stroke (hemorrhagic or ischemic), the location of stroke, and the extent of tissue damage, some recovery is usually made by a good number of stroke survivors; hence, severe physical loss may be transient. However, the potential of a reoccurrence often makes stroke to constitute a long-lasting threat. The possibility of future strokes, more permanent loss of function, and loss of independence are likely explanatory factors for predisposition of stroke survivors to the experience of anxiety.
In some instances, anxiety symptoms are functionally appropriate or even advantageous, especially when it prompts positive health behaviors and certain levels would be considered a normal reaction to the experience of life-threatening events such as stroke. On the other hand, anxiety disorders represent substantially elevated levels of anxiety that can negatively impact health.
The etiopathogenesis of poststroke anxiety disorders (PSAD) is probably multifactorial. Despite gaps in what is known about the role of stroke lesion location, available literature suggests that right hemispheric lesions are more associated with generalized anxiety disorder and right temporal lesions associated with panic disorder. Lesions affecting frontal-subcortical circuitry were associated with obsessive–compulsive disorders.
Johnson  suggested that major poststroke psychiatric disorders may actually be mixed anxiety-depressive conditions rather than a depressive condition alone. Burton et al., in a meta-analysis, found comorbid anxiety and depression poststroke in 23% of studies reviewed, with 17%–80% of depressed patients having anxiety symptoms. Related studies also found comorbid PSAD significantly worsening the clinical outcomes of poststroke depression. PSAD has been found to reduce quality of life (QoL), increase health-care utilization and functional recovery time, precipitate alcohol abuse, and influence and increase poststroke mortality.,,
In general, PSAD has received less attention compared to other psychological problems faced by survivors, particularly when compared with depression, and by extension largely ignored as a research interest in stroke survivors, especially in Sub-Saharan Africa. Reasons for limited studies on PSAD may be due to some early epidemiological studies that found low frequency of anxiety disorders after stroke. The Oxfordshire Community Stroke Project in 1991 appears to have been the first study to explore anxiety disorders as well as depressive disorders in stroke survivors. Since then, only a few studies, particularly in developing countries have researched the risk factors and possible impact of PSAD on QoL. The lack of research evidence may impair early detection and treatment of PSAD to prevent its negative impacts on stroke. It is in this light that our study evaluates the prevalence of PSAD, its associated clinical-demographic factors, and relationship with QoL among outpatients in a Nigerian hospital. We postulated that PSAD would be associated with putative clinicodemographic variables and negatively impacts on QoL scores.
| Methods|| |
Design and setting
Our study is a cross-sectional survey among adult stroke survivors attending Outpatient Neurology and Physiotherapy Clinics of the Lagos University Teaching Hospital (LUTH), Nigeria, between October 2013 and February 2014. Lagos is a metropolitan city, commercial nerve center, and second most populous state in Nigeria. Inclusion criteria for our study were adults, 18 years and above with diagnoses of either first ever or repeat strokes of varied lengths at interview. Exclusion criteria were stroke survivors with a history of other chronic medical conditions besides hypertension and uncomplicated diabetes, stroke survivors with preexisting anxiety disorders before current stroke, and stroke survivors with other mental disorders besides anxiety. Stroke survivors with severe cognitive deficits (modified Mini–Mental State Examination [MMSE] score <16) were also excluded from the study.
The diagnosis of stroke was made through the combination of clinical evaluation of attending neurologists and investigations using computerized tomography (CT) as well as magnetic resonance imaging (MRI) scans. Stroke subtyping was done based on CT/MRI scans and where such radiological scans were not done, stroke subtype was considered indeterminate. Again, stroke lateralization was decided using CT/MRI scans and clinical assessment of attending neurologist.
Ethical approval was also obtained from the Health Research and Ethics Committee of LUTH before the commencement of the study. Written informed consents were also sought before recruitment of participants.
Instruments and procedure
Our cohort of stroke survivors was administered the following instruments: sociodemographic/clinical questionnaires designed by the authors, the modified MMSE, the Modified Rankin scale,, the Schedule for Clinical Assessment in Neuropsychiatry (SCAN version 2.0), and the World Health Organization-QoL-Bref (WHO-QoL-Bref).
At both outpatient clinics (neurology and physiotherapy) of LUTH, an initial retrospective review of case records of participants was done to extract clinical characteristics at onset of current stroke which included details of radiological reports, stroke subtype, and lateralization. Participants were thereafter administered the Strengths and Difficulties Questionnaire to record other relevant clinicodemographic data. Participants were also administered the modified MMSE which assess the degree of cognitive deficits. Participants were then administered the modified Rankin scale (MRS) which measures disability and level of dependence in activity of daily living in individuals who have suffered stroke or other neurological disorders. All participants were interviewed with the anxiety modules of SCAN. The SCAN is a computer-based diagnostic tool that assists in evaluating and classifying psychopathology in adults. Classification of anxiety disorders using elicited phenomenology in participants was done using SCAN algorithm based on International Classification of Diseases 10th Edition diagnostic criteria. The authors were trained in the use of SCAN before data collection. Finally, the WHO-QoL-BREF, a 26-item scale that measures subjective health-related QoL within the previous 2 weeks was administered to the participants.
Data were coded and entered into the computer for analysis. Data were analyzed using the Data were coded and entered into the computer for analysis. Data were analyzed using the Statistical Package for Social Sciences (SPSS ®) for windows Version 17.0 by SPSS Inc., 233 South Wacker Drive, 11th floor, Chicago, IL. USA. Means, frequencies, and percentages were used to describe data following analyses. Independent t-test was used to assess for significant association between numerical variables. Chi-square test was used to test for significant relationship between categorical variables with Fisher's exact option used when Chi-square criteria were not met. A confidence interval of 95% was used which allows for 5% sampling error at significance of ≤0.05.
| Results|| |
A total of 82 stroke survivors were initially recruited for the study. However, 12 stroke survivors were excluded from the final analysis due to incomplete data (4), severe aphasia and modified MMSE <16 (2), presence of other chronic physical diseases besides hypertension and uncomplicated diabetes (5), and other mental comorbidities (1). A total of seventy stroke survivors were eventually involved in the final analysis.
Sociodemographic and clinical profile of participants
The mean age of stroke survivors was 57.43 (±9.67) years and consisted of 38 (54.3%) male respondents. Higher proportions of stroke survivors were married 56 (80.0%), unemployed 28 (40.0%), had at least secondary level of education 41 (58.6%), and paid more than ₦10,000 ($62.50 as at December 2013) monthly for health care 37 (63.9%) [Table 1]. Radiological investigations in the form of CT or MRI scans were done in 64 (91.4%) of stroke survivors. Majority 55 (78.6%) had infarctive stroke, whereas 9 (12.9%) had hemorrhagic stroke. Six (8.5%) stroke survivors, however, had no record of doing CT or MRI scans; hence, stroke subtypes could not be confirmed and recorded as indeterminate. Slightly above half of respondents 37 (52.9%) had right hemispheric lesions. All respondents were right handed. Majority 57 (81.4%) had significant poststroke disability according to the MRS and a higher proportion had stroke durations at interview of a year or more 40 (47.1%) [Table 2].
Prevalence and types of poststroke anxiety disorders
In total, seven participants were diagnosed with PSAD, with 10% prevalence of PSAD observed. As shown in [Figure 1], of those seven participants with PSAD, three (42.8%) had agoraphobia with panic attacks (F = 40.01) and one (14.3%) each had generalized anxiety disorder (F = 41.1), social phobia (F = 40.11), panic disorder (F = 41.0), and adjustment disorder (anxiety/depressive reaction) (F = 43.23).
|Figure1: Spectrum of specific anxiety disorders with International Classification of Diseases 10thEdition codes|
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Relationship between poststroke anxiety disorders and clinicodemographic factors
Stroke survivors with PSAD were significantly more likely to be unemployed (P = 0.01) and pay more than ₦10,000 ($62.50 as at December 2013) monthly for health care (P = 0.01) compared to those without PSAD. Higher proportions of respondents with PSAD trended toward being female 4 (57.1%) and older 58.57 (± 7.83) years, but the difference was not statistically significant [Table 3]. As shown in [Table 4], comparisons of clinical parameters of stroke survivors showed that there was no statistically significant difference between respondents with and without PSAD. However, stroke survivors with PSAD trended toward having infarctive stroke 5 (71.6%), right hemispheric stroke 4 (51.7%), and worse poststroke disabilities 7 (100%).
|Table 3: Comparison of sociodemographic profile of stroke survivors with and without poststroke anxiety disorder|
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|Table 4: Comparison of clinical characteristics of stroke survivors with and without poststroke anxiety disorder|
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Comparison of World Health Organization-Quality of Life-Bref mean scores in participants with and without poststroke anxiety disorders
The mean scores on WHO-QoL-Bref were lower across all spheres in stroke survivors with PSAD compared to those without. Stroke survivors with PSAD had statistically significant difference in mean scores with respect to overall health (P = 0.04), health satisfaction (P = 0.02), and physical health (P = 0.01) domains [Table 5].
|Table 5: Comparison of World Health Organization Quality of life-BREF mean scores in stroke survivors with and without poststroke anxiety disorder|
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| Discussion|| |
Findings from our study revealed that anxiety disorders, particularly agoraphobia, were fairly prevalent among survivors of stroke. Furthermore, stroke survivors with PSAD were significantly more likely to be unemployed and pay more for than 10,000 nairas ($62.50 as at December 2013) monthly for health care. Furthermore, those with PSAD were more likely to report poorer QoL scores.
The prevalence of PSAD in our study was 10%, which is within the prevalence range reported in existing literature. For example, our findings are similar to that obtained by Ajiboye et al. in Ilorin, who fielded a prevalence of 10.8%. However, a review by Burton et al. has reported a slightly higher mean overall PSAD prevalence of 18%. Reasons for inconsistencies across studies on prevalence rates for PSAD are unclear but may include methodological differences. Use of structured interviews, as done in our study, may report lower prevalence rates due to stringent diagnostic criteria when compared to assessments done with screening scales. Furthermore, most major diagnostic classification system use hierarchical approach where major mental disorders that may coexist with anxiety disorders are rated higher making it less likely for the diagnosis of anxiety disorders to be made.
In our study, phobic anxiety disorders (particularly agoraphobia with panic attacks) accounted for almost half of the anxiety disorders diagnosed. In a number of studies currently available, phobic disorders in the form of persistent agoraphobia and fear of falling were the most common anxiety disorders elicited in stroke survivors.,, These findings may have implications for motivation at physiotherapy and ability to keep up with clinic appointments that may ultimately affect illness course and morbidity.
Our study found stroke survivors with PSAD were more likely to be unemployed. This finding is consistent with other studies showing positive associations between PSAD and inability to resume work  and high levels of socioeconomic deprivation. These findings are not out of place, especially in developing countries where job loss could eventually lead to inability to meet financial obligations coupled with the lack of social services. Moreover, the 20.7% unemployment rate among participants with PSAD is much higher than the 12.1% jobless figures for Nigeria during the first quarter of 2016. Our study also found that PSAD was positively associated with higher health-care costs such that fear and apprehension of meeting up with financial obligations of higher out-of-pocket health-care costs may potentially have negative impact on poststroke recovery. There was a trend in this study as higher proportions of participants with PSAD were older and female, but these findings were not statistically significant. That said, inconsistent findings have been reported in other studies where demographic variables such as age and gender were investigated in relation to PSAD.,,,, Overall, there is a need for more elaborate studies in this area.
We found no significant association when clinical variables were compared between survivors with or without PSAD. This may be due to the relatively small sample size recruited. The wide inconsistencies in findings and tendencies toward weak or no associations,,,, when clinical factors were explored as putative risks for PSAD, validate the need for elaborate studies. A higher proportion of stroke survivors with PSAD tend to have longer stroke duration at interview and significant stroke disability. It is, however, worthy of note that stroke survivors with PSAD were overrepresented among those with worse functional disabilities, this was, however, not statistically significant. A study suggested that the relationship of PSAD has with functional outcomes poststroke should be weaker compared with poststroke depression. They argued that fear and anxiety of possible loss of financial, social, and functional status subsequent to future repeat strokes were more likely to precipitate PSAD. They also argued that the realization of actual permanent disability and handicap subsequent to current stroke was more likely to precipitate depression.
The mean scores across all the domains of QoL in our study were lower in stroke survivors with PSAD compared to those without and significantly so with respect to overall health, health satisfaction, and physical health wellbeing. There is a paucity of studies reviewing associations between PSAD and QoL. Donnellan et al. and Tang et al., however, found that high anxiety symptom scores had a negative effect on QoL among stroke survivors independent of depression.
The cross-sectional design of the study limits inferences that can be made about the trajectory of variables measured in stroke survivors over time. The exclusion of stroke survivors with more severe cognitive impairments and other comorbidities may also affect the generalizability of findings, but this design, however, excludes the use of proxy responses to questionnaires. The relatively small sample size may also limit possibilities of significant associations between variables measured.
| Conclusion|| |
Anxiety disorders after stroke, particularly phobic disorders were profiled in relation with sociodemographic factors such as unemployment and higher health-care cost. Given that anxiety disorders have been shown to significantly correlate with poor QoL among stroke survivors, proactive measures to ensure prompt identification and management may potentially improve outcome in stroke, particularly in developing countries where it is commonly neglected. There is a need for future elaborate studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]