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This is an author produced version of a paper published in International Journal
of Stroke.
White Rose Research Online URL for this paper:
http://eprints.whiterose.ac.uk/75639/
Published paper:
Campbell Burton, CA, Murray, J, Holmes, J, Astin, F, Greenwood, D and Knapp,
P (2012) Frequency of anxiety after stroke: a systematic review and meta-
analysis of observational studies. International Journal of Stroke.
http://dx.doi.org/10.1111/j.1747-4949.2012.00906.x
Anxiety after stroke
1
Full Title: Frequency of Anxiety After Stroke: A Systematic Review and Meta-Analysis
of Observational Studies
Cover Title: Anxiety after stroke
Authors: C. Alexia Campbell Burton MHSc
1
, Jenni Murray PhD
2
, John Holmes MD
2
,
Felicity Astin PhD
1
, Darren Greenwood PhD
3
, Peter Knapp PhD
4
1. University of Leeds, School of Healthcare, Baines Wing Rm 3.35, Leeds UK LS2
9JT
2. University of Leeds, Institute of Health Sciences, Leeds UK LS2 9LJ
3. University of Leeds, Centre for Epidemiology & Biostatistics, Leeds UK, LS2 9JT
4. University of York, Department of Health Sciences, York UK, YO10 5DD
Corresponding Author: Alexia Campbell Burton, hccac@leeds.ac.uk ph#: +44 113
343 7185, fax#: +44 113 343 1378
Keywords: stroke, epidemiology, rehabilitation, systematic review, meta-analyses,
anxiety
Anxiety after stroke
2
Abstract
Background and purpose
Negative psychological outcomes occur frequently after stroke, however there is
uncertainty regarding the occurrence of anxiety disorders and anxiety symptoms after
stroke. A systematic review of observational studies was conducted that assessed the
frequency of anxiety in stroke patients using a diagnostic or screening tool.
Summary of review
Databases were searched up to March 2011. A random effects model was used
to summarize the pooled estimate. Statistical heterogeneity was assessed using the I
2
statistic. Forty-four published studies comprising 5,760 stroke patients were included.
The overall pooled estimate of anxiety disorders assessed by clinical interview was 18%
(95%CI 8% - 29%, I
2
= 97%), and was 25% (95% CI 21%-28%, I
2
= 90%) for anxiety
assessed by rating scale. The Hospital Anxiety and Depression Scale- Anxiety
subscale (HADS-A) probable and possible cut-off scores were the most widely used
assessment criteria. The combined rate of anxiety by time after stroke was: 20% (95%
CI 13%-27%, I
2
= 96%) within one month of stroke; 23% (95% CI 19%-27%, I
2
= 84%) 1
to 5 months after stroke; and 24% (95% CI 19%-29%, I
2
= 89%) 6 months or more after
stroke.
Conclusion
Anxiety after stroke occurs frequently although methodological limitations in the
primary studies may limit generalizability. Given the association between prevalence
Anxiety after stroke
3
rates and the HADS-A cut-off used in studies, reported rates could in fact under-
represent the extent of the problem. Additionally risk factors for anxiety, its impact on
patient outcomes, and effects in tangent with depression remain unclear.
Introduction
Globally, anxiety disorders are the most common mental health problem (1). In
some instances anxiety is functionally appropriate and even advantageous when it
prompts protective health behavior, and a certain level would be considered a normal
reaction to experiencing a life threatening event such as stroke. However, anxiety
disorders and substantially elevated levels of anxiety symptoms are associated with
reduced quality of life (2), lead to increased healthcare utilization, and risk of disabling
health conditions (3, 4), and may even augment risk of death (5).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(6) classifies
anxiety disorders as a collection of individual syndromes that include generalized
anxiety disorder (GAD), panic disorder (with or without agoraphobia), agoraphobia (with
or without panic), specific phobia, social phobia, obsessive compulsive disorder (OCD),
posttraumatic stress disorder (PTSD), acute stress disorder, anxiety disorder due to a
general medical condition, substance induced anxiety disorder, and anxiety disorder not
otherwise specified. Each disorder has certain distinct features yet they all share similar
hallmark characteristics of excessive and irrational fear, feeling apprehensive and tense,
Anxiety after stroke
4
and difficulty and distress in managing daily tasks. Certain physiological symptoms
such as palpitations, dizziness or trembling may also be present.
Anxiety has received substantially less attention relative to other psychological
problems that occur post-stroke (7-9). Several reasons attribute to its neglect. Early
population-based prevalence studies found that the frequency of anxiety disorders after
stoke was low (10). This would seem to be in keeping with epidemiologic studies in the
general adult population that suggest that anxiety disorders are uncommon among older
adults, and approximately three quarters of stroke patients are over 65 years of age (11).
However, one of the diagnostic challenges for assessing mood in stroke patients is that
some symptoms of disorder, such as sleep disturbance or fatigue, are common
consequences of stroke itself. This may have the effect of falsely reducing reported
rates of mood disorder when using DSM criteria (12).
As a result of these diagnostic challenges the study of anxiety symptoms
assessed by rating scales and not meeting full DSM criteria has proved extremely
relevant. Studies have shown that people with sub-threshold symptoms and diagnosed
anxiety disorders are similarly affected by the anxiety (12). Many stroke patients report
substantial fears (possibly indicative of phobic disorders) about recurrent stroke, falling,
or returning to work (13-15) that would be unlikely to constitute diagnosis of an anxiety
or related mental health disorder, yet appear to impact significantly on daily living.
Additionally co-morbidity of anxiety and depression is well documented (16).
Traditional diagnostic and treatment approaches have used a hierarchical approach
