Prevalence of Post-stroke Emotional Disorders in Saudi Arabia

Abstract

The occurrence of Post-Stroke Anxiety (PSA) and Post-Stroke Depression (PSD) has been linkedto cognitive impairment and reductions in functional recovery and social activity. This study examined the prevalence of post-stroke anxiety and post-stroke depression in one hundred (100) Saudi stroke patients (76 men, mean age 60.53 years) in the rehabilitation wards or outpatient clinics at three Saudi medical facilities: King Abdulaziz Medical City, Sultan Bin Abdulaziz Humanitarian City and King Fahad Medical City. An Arabic version of the Hospital Anxiety and Depression Scale was used to assess anxiety and depression. The Barthel Index was used to assess independence in personal day-to-day activities. The findings of subgroups confirmed the presence of PSA in 36% of participants (mean score 7.8 SD= 5.09). The prevalence of PSA was found to be significantly affectedby age (. 60 and . 61 years), level of education (literate and illiterate) and the length of time elapsed since the stroke (. 6 and . 7 months). Further, PSD was identified in 44% of participants (mean score 7.87 SD= 4.77). The results from the post-hoc analysis using the Mann-Whitney test for PSD indicated that differences in level of education and time since stroke between subgroups showed significant effects, whereas other characteristics (gender, treatment site, side of weakness) did not. There was a significantnegative correlation between scores on the Barthel Index and the prevalence of anxiety and depression. Seventy patients were reassessed after three months, of whom13 (18.6%) were found to suffer from emotional disorders. The results of the Mann-Whitney test showed significant differences in PSA and PSD prevalence between subgroups according to gender (male and female) and level of education (literate and illiterate).

Keywords: Post-Stroke Emotional Disorders; Post-Stroke Anxiety; Post- Stroke Depression; Hospital Anxiety and Depression Scale; The Barthel Index

Abbreviations

PSA: Post-Stroke Anxiety; PSD: Post-Stroke Depression; HADS: The Hospital Anxiety and Depression Scale; BI: The Barthel Index

Introduction

Stroke is a medical condition caused by the disruption of cerebral blood flow leading to chronic neurological impairments [1]. Clinical evidence confirms that stroke attributes are not only associated with physical disabilities of survivors but can also engender critical emotional and cognitive outcomes, which can range from low severity to unbearable conditions [2]. In this context, post-stroke emotional disorders have been identified as one of the biggest challenges to public health due to their potential for affecting the quality of lives of patients as well as those of their caregivers [3]. It has been observed that stroke patients often suffer from emotional disorders that can have adverse or aggravating effects on their post-stroke recovery [4]. These disorders increase mortality and disability rates, as well as lengthen the duration of patients’ hospital stay [5]. It is also observed that the interactions among interlinked physical and psychological qualities of health and apparent Quality of Life (QoL) of individuals indicate that those patients often require a re-evaluation of their life in terms of individual goals, guidelines and directions, as well as review their social activities in order to take into account stroke-induced physical and cognitive insufficiencies [6, 7].

Post-stroke anxiety

The term ‘anxiety disorder due to a general medical condition’ is commonly used to describe symptoms of anxiety that are gauged to be a direct physiological consequence of a medical ailment, such as a stroke [8]. However, most studies usually use the term ‘Post- Stroke Anxiety Disorder’ (PSA) to describe a worried mood caused by a stroke [9, 10]. PSA is clinically characterised by symptoms such as restlessness, being easily fatigued, difficulty concentrating or frequently experiencing the mind going blank, irritability, muscle tension and sleep disturbance [8]. In addition, a range of other symptoms are also considered to indicate anxiety in stroke patients, such as a fear of falling, avoiding people in meetings, and experiencing memories and flashbacks of the stroke [11].

While PSA can occur at any period after the stroke in about 20 to 25% of [12] patients, the length of time elapsed since the stroke is a vital factor in the prevalence of PSA. Indeed, it has been found that anxiety seems to be associated with a greater impairment of physical and cognitive abilities during the acute phase of the poststroke period. Barker-Collo, et al. [13] found a 21.1% prevalence of PSA, from moderate to severe anxiety, among patients three months after the stroke. Meanwhile, D’Aniello, et al. [14], who examined the prevalence of PSA based on the length of time elapsed since the stroke, found that PSA incidence rates increased most notably during the chronic stage of the stroke, with prevalence levels reaching 20%, 23% and 24% after one, five and six months after the stroke, respectively.

Moreover, the rate of prevalence for PSA varies depending on the assessments used. The prevalence of Anxiety disorders was found to be 18% when assessed by clinical interviews but increased to 25% when assessed using the rating scale [12]. It has also been observed that PSA occurs in females more than in male patients. For example, Burvill, et al. [15] found the prevalence to be 5% in men and 19% in women when measured separately.

Post-stroke depression

PSD is a term used to identify mood disturbances among patients diagnosed with cerebral or haemorrhagic stroke. Corresponding or comparable terms from previous studies include ‘depressive mood’, ‘mood disorder’, ‘emotional disorder’, and ‘psychological distress.’ Medically, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Classification of Mental & Behavioural Disorders (ICD-10) criteria are used to diagnose PSD, which is classified as a ‘mood disorder due to a general medical condition’.

According to the literature, PSD is observed in approximately 29% to 52% of stroke patients [16]. However, inconsistencies in the findings across the range of existing studies may reflect differences in the samples and assessments used. Furthermore, a number of studies have examined various contributing factors that might influence the occurrence or prevalence of PSD. For instance, damage to specific brain sites has been investigated as one factor behind this disorder [17]. In particular, the left hemisphere is generally considered to be more significantly associated with the presence of PSD. However, systematic reviews [18, 19] found these findings to be inconclusive suggesting that both hemispheres could be linked to PSD. Another significant factor in this regard is the length of time elapsed since the stroke [20]. For instance, a systematic review by Hackett and Pickles [21] found that PSD was present in 28% of stroke patients within the first month of stroke, 36% after a 2-5 months period, 31% after 6-9 months, 33% after the first year, 25% after 2-4 years, 23% at 5 years, and 31% beyond 5 years after the stroke.

In addition to the stroke’s lesion location and the duration of time since it took place, further demographic factors relating to aspects and elements of PSD have also been considered. Overall, depressive survivors tended to have lower education levels [22] and severe language problems [23], while female patients were significantly associated with depression [24, 25].

Post-Stroke emotional disorders in Saudi Arabia

While numerous studies have examined the prevalence of stroke in Saudi Arabia, relatively few of these have focused on investigating PSA or PSD. Indeed, only one study, conducted by Hamad et al. [26], has examined PSD in a Saudi sample, finding incidences of depression in 17% of stroke survivors during the first month after stroke. Similar studies undertaken in a western context cannot be generalised because of the significant cultural and demographic differences between the two different geographical contexts. As such, the study by Hamed et al. [26] is unique in being the only one to date that examined demographic factors such as age, gender, level of education, time since stroke, treatment setting (hospital or rehabilitation unit) and side of weakness (left or right) within the Saudi Arabian population in order to identify the frequency and severity of PSA and PSD among participants.

The limited scope and depth of existing research literature on Saudi Arabian healthcare highlights the need for an investigation into the prevalence of post-stroke anxiety and post-stroke depression in the country. This is because a country-specific version will help take into account the crucial cultural and social factors influencing PSD and PSA. By considering both post-stroke anxiety and post-stroke depression, the present study thus aims to provide a much-needed contribution to the current limited body of research on PSA and PSD disorders in Saudi Arabia.

Objectives

As mentioned above, the prevalence of post-stroke emotional disorders is higher for specific patient subgroups/characteristics, such as being older (> 60 years), female, having a lower educational level, having a left-sided site of injury and a shorter period time elapsed (= 6 months) since the stroke. Research literature on the prevalence of both PSA and PSD in Saudi Arabia remains very limited, notably in terms of patients’ demographic characteristics. We hypothesised that the prevalence of emotional disorders is consistent with patterns observed in a Western context and, with that in mind, examined six demographic factors potentially contributing to this prevalence. In particular, this study aimed (1) to explore the prevalence of poststroke anxiety disorder in Saudi Arabia, (2) to explore the prevalence of post-stroke depression disorder in Saudi Arabia, (3) to examine the relationships between post-stroke emotional disorders and dependency, (4) to identify the main factors affecting the prevalence of post-stroke emotional disorders and (5) to compare post-stroke emotional disorders at baseline and after a three months follow-up period.

Method

An observational study was undertaken to identify the prevalence of emotional disorders one month or more following an ischemic or haemorrhagic stroke. A follow-up assessment, after three months, was also carried out to explore any variations within the observed frequencies of PSA and PSD. Key sub-groups were identified based on six major variables, so as to collect the necessary information based on a pre-determined protocol.

• Age: The mean age of the Saudi population was used to divide study participants into two groups of patients: those aged 60 or under, and those over 61, respectively.
• Gender: Male and female.
• Level of education: It was considered necessary to divide the sample into ‘literate’ and ‘illiterate’subgroups, since a significant segment (18% approximately) of the over-60 populationin Saudi Arabia is illiterate. In this study, the level of education of participants was assessed based on their ability to read and write. In this context, the term ‘Illiterate’refers toa participant unable to read and/or write, while ‘literate’ indicates a participant who was able to read and write, or who had received a level of formal education.
• Time since stroke: The sample was divided into two subgroups, patients with 6 months or less since their stroke and those with 7 months or more. This study variable was designed based on evidence from past studies showing that the first 6 months after the stroke are highly crucial compared to the period after the 7-months mark [27].
• Side of weakness: Left and right.
• Treatment Setting: Hospital and rehabilitation unit.

Participants

The sample of participants included patients who had been diagnosed by neurologists with ischemic or haemorrhagic stroke according to either CT scans or MRI results, and who had been treated for at least one month following their first-ever stroke, either at out-patient clinics or in stroke units based at one of three medical centres in Riyadh, the capital city of Saudi Arabia. Approximately 300 stroke patients are annually admitted to the King Abdulaziz Medical City’s National Guard stroke programme, of whom 85% present cases of ischemic stroke, while around 10-15% of all patients die within the acute phase of the stroke.

It has been observed that half of all stroke patients may be subsequently referred to the rehabilitation unit due to severe physical disabilities, and usually remain in hospital for six (6) weeks. A structured database for the acute stroke unit has been maintained at the King Fahad Medical City since 2005, where over 1600 patients are admitted and around 200 patients treated for stroke each year. For its part, the Prince Sultan Bin Abdulaziz Humanitarian City is a rehabilitation centre where more than 280 patients are admitted annually (70% male, 30% female) 90% of whom are ischemic stroke patients who are allowed to stay for up to 12 weeks.

Procedures

In order to recruit participants, clinical staff first determined whether the patients were suitable for taking part in accordance with the study criteria. The recruitment procedure was divided into outpatient and in-patient recruitment, respectively.

- Outpatient Recruitment

For those in an outpatient clinic, the consultant neurologist notified suitable patients and invited them to speak to the researcher. Those who agreed were referred to an investigation room.

-In-Patient Recruitment

Ward staff identified patients who had been already admitted into the rehabilitation centre and who might be eligible to participate in this study. With their permission the researchers would subsequently visit them in their hospital room to discuss their contribution.

Inclusion Criteria

Participants had received a definitive diagnosis of ischemic or haemorrhagic stroke; were at least one month post onset of stroke; and must have been assessed to be conscious, orientated, and able to sufficiently comprehend and communicate informed consent.

Exclusion Criteria

Patients were excluded if their case satisfied a number of conditions. These included the presence of severe dementia, a history of alcohol or drug abuse; and/or chronic psychiatric or other concurrent neurological disorders. Blind or deaf patients were also excluded to ensure the standardised administration of neuropsychological assessments. Finally, patients who were unable to speak or understand Arabic; were medically instable; or suffered from bilateral weakness, were all excluded.

Clinical assessment protocol

The researcher met with each participant, either in an examination room or their admission room (if still hospitalised), to provide them with information sheet as well as verbally brief them about the study. The researcher explained the aims and objectives of the study and addressed any questions the patients or their partners raised. Patients who agreed to take part were asked to sign a consent form. Participants were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Berthel Index (BI). Demographic data was collected, both from patients during the assessment as well as from medical staff after wards.

With regards to patients who were either illiterate or suffered from reading difficulties, their legal representatives assisted them with reviewing the information sheet before signing the consent form on their behalf.

Measures

The hospital anxiety and depression scale (HADS)

The Hospital Anxiety and Depression Scale was devised for the purposes of a brief measurement of both anxiety and depression disorders, and comprises 14 items (seven assessing depression and seven assessing anxiety) [28]. In the present study, the Arabic version of the HADS [29] was used. El-Rufaie and Absood [29] found that this scale was reliable and showed significant levels of sensitivity and specificity. Similarly, Malasi, Mirza and EI-Islam [30]also concluded that the Arabic version of HADS enjoyed high sensitivity and specificity scores (79% and 87% respectively).

According to the literature, the recommended cut-off points for stroke patients varied between 4/5 and 5/6 for anxiety and from 4/5 to 7/8 for depression [2]. However, for researchers using the Arabic version of HADS, El-Rufaie and Absood [31] suggested cut-off points of 8/9 (sensitivity = 65.9% and specificity = 92.3%) for anxiety and of 5/6 (sensitivity = 69.8% and specificity = 93.3%) for depression, and these cut-off points were therefore adopted in this study.

The barthel index (BI)

The Barthel Index (BI) [32] was used to assess the level of dependence in personal day-to-day activities. Scale items used in the BI include mobility, bathing, walking, hygiene, feeding, toileting, personal grooming, negotiating stairs, bladder and bowel control.

Statistical analysis

All statistical analyses were performed using the SPSS (version 22) software. For the prevalence of PSD and PSD, percentages (%) were used once participants were classified into six subgroups based on their age, gender, level of education, time since stroke, side of weakness and treatment setting, with each group divided into two subgroups: age (= 60 and = 61 years), gender (male and female), level of education (literate and illiterate), time since stoke (= 6 and = 7 months), side of weakness (left and right), setting (hospital and rehabilitation).

The Mann-Whitney test was performed in order to compare differences in HADS scores between the subgroups. The means, SDs, percentiles are calculated for the HADS scores, and a Z-score was measured to confirm whether the observed value differed from the mean. X2 was performed after re-grouping all participants into two subgroups, ‘anxious’ and ‘non-anxious’. Six demographic characteristics were compared for these two groups. Moreover, this analysis was performed after participants were categorised into ‘depressed’ and ‘non-depressed’ groups. To evaluate whether emotional disorders correlate with dependency, Pearson’s correlation analysis was performed between HADS and BI. A linear regression analysis was undertaken to examine whether demographic characteristics and dependency predicted the occurrence of emotional disorders, with PSA and PSD used as dependent variables, and age, gender, level of education, time since stroke, side of weakness, treatment setting and BI scores adopted as independent variables. A p-value of = 0.05 was defined as statistically significant.

Ethical considerations

The study was approved by the Faculty of Medicine and Health Sciences (FHMS) Research Ethics Committee, University of Nottingham, UK.

Results

Results from baseline assessment

Characteristics of patients: In the period from 1-12-2013 to 31-3-2014, 263 patientswho had suffered ischemic or haemorrhagic strokeshad their medical charts examined. Of these, 144 (43.4%) patients had been hospitalised for an acute stroke at the rehabilitation ward or outpatient clinics at King Abdul-Aziz Medical City. Similarly, 48.28% were admitted to stroke units at the Sultan Bin Abdul-Aziz Humanitarian City, while 22 (8.36%) patients were admitted to the acute stoke unit, rehabilitation centre or neurology clinics at King Fahad Medical city. Based on the exclusion criteria, 181 participants were deemed eligible to participate, of whom 72 (39.77%) patients or their family representatives declined to take part. Meanwhile, 9 (4.97%) patients withdrew from the study during the psychological assessment. In total, one hundred (100) patients were accepted to take part in this study. The data collected on the patients’ characteristics comprises demographic facts such as age, gender, level of education, side of weakness (left or right); treatment setting (hospital or rehabilitation unit) and the time elapsed since the stroke. Table 1 presents an overview of these characteristics.