Mark R. Etherton, MD, PhD

Chun H-Y Y, Whiteley WN, Dennis MS, Mead GE, Carson AJ. Anxiety After Stroke: The Importance of Subtyping. Stroke. 2018

In this entry, I discuss a recent publication by Ho-Yan Yvonne Chun and colleagues exploring the prevalence and types of anxiety after stroke and how it relates to functional status.

Anxiety following stroke or TIA is common, occurring in up to 1/3 of patients, and can negatively impact stroke recovery and quality of life. The authors set out to characterize the proportions of specific anxiety subtypes and impact on functional outcomes and quality of life.

201 participants were enrolled between September 2015 and June 2016 after presenting with stroke or TIA symptoms. At 3 months, a telephone-based, semi-structured psychiatric interview (SCID) was conducted to assess anxiety and other neuropsychiatric disorders. Contemporaneous with the SCID, modified Rankin Scale and quality of life assessments were performed.

Twenty-two percent of the cohort had at least 1 anxiety disorder on follow-up, with phobic disorder being the most frequently observed (17%) and a significant percentage having overlapping generalized anxiety disorder and/or depression (see Figure). Importantly, the odds of having any anxiety disorder at 3 months post stroke/TIA decreased with age (aOR 0.64 per decade increase in age). Also, patients with a prior history of depression or anxiety disorder were at a higher risk of developing any anxiety disorder.

A, Number of cases (sample frequency) of phobic disorder and GAD, (B) comorbid depression in sample at 3 months (n=175). GAD indicates generalized anxiety disorder.

Figure. (A) Number of cases (sample frequency) of phobic disorder and GAD; (B) comorbid depression in sample at 3 months (n=175). GAD indicates generalized anxiety disorder.

Despite no difference between groups in stroke severity (assessed by admission NIHSS score) or location (defined as anterior or posterior or uncertain), participants with a post-stroke anxiety disorder had worse 90-day mRS (55% versus 29% mRS 3-5), more restriction in social participation and more problems with health-related quality of life.

This study is important for several reasons. First, it demonstrates that post-stroke anxiety disorders are common and associated with worse post-stroke outcomes. In addition, it provides information on the specific subtypes of anxiety disorder seen with stroke, with the phobic disorder being predominant, which is important from a treatment strategy perspective.

There are several considerations of this study that are important for generalizability. First, this was a study of minor stroke (7% NIHSS > 4) or TIA. Secondly, anxiety assessments were performed via telephone interview, which imparts certain biases, and 26 of the 201 participants did not follow up with the SCID assessment. Lastly, it is unclear why there was such a significant difference in 90-day mRS of 3-5 between groups given the relatively mild strokes/TIAs and no difference in admission NIHSS, stroke location, and younger age in the group with anxiety disorder. Future studies should explore a larger, more diverse patient population with more severe strokes and track premorbid functional status (mRS), stroke subtype, acute treatments received, and discharge destination.