Stroke Patients May Develop Posttraumatic Stress Disorder

Allison Gandey

March 30, 2009

March 30, 2009 — A new study has shown that a surprising 37% of subarachnoid-hemorrhage patients met the diagnostic criteria for posttraumatic stress disorder (PTSD).

Researchers suggest the results, published in the December 2008 issue of Neurosurgery, may help explain why some stroke patients continue to experience a reduced quality of life despite relatively good clinical outcomes.

"The findings could have wider implications for the treatment of neurological diseases in general," lead author Adam Noble, a research assistant in psychology at Durham University, in the United Kingdom, said in a news release. "Brain damage is often seen as the cause of difficulties after a neurological illness, but for all these conditions, psychological problems may well be a vital element in the patients' poor recovery. This is something that needs further research."

Reduced Quality of Life

In an accompanying comment, Neil Kitchen, MD, from the National Hospital for Neurology and Neurosurgery, in London, the United Kingdom, writes, "This is a well-written and timely article from a well-established neurovascular center in England."

Dr. Kitchen suggests that psychosocial sequelae after subarachnoid hemorrhage are almost universal and should be considered a PTSD syndrome against the background of a recovering brain injury.

"This study brings to light an important issue that is frequently underestimated by the neurosurgeons involved in the clinical follow-up of patients," writes Neal Kassell, MD, from the University of Virginia, in Charlottesville.

"This association has been reported in some earlier studies," add Drs. James Pinkston and Anil Nanda from the Louisiana State University Health Sciences Center, in Shreveport, "but such a high incidence is somewhat alarming."

Most neurosurgeons have seen cognitive problems in stroke patients, they note, but to think that 1 in 3 patients will have PTSD is a serious reason for concern.

Cognitive Problems Factoring in

"Our research suggests that patients with PTSD are more likely to struggle in their attempts to adjust to a normal life after they survived the subarachnoid hemorrhage, and these patients will require more support and closer monitoring," coauthor Thomas Schenk, PhD, also from Durham University, told Medscape Neurology & Neurosurgery.

"Our results also suggest that PTSD is predicted by coping skills," he noted. "It might therefore be possible to support patients and their caregivers in developing more effective coping skills, thereby avoiding the development of PTSD and increasing the patients' long-term quality of life."

The researchers prospectively studied a representative sample of 105 subarachnoid-hemorrhage patients. They examined patients at approximately 3 and 13 months. These included assessments of PTSD, fatigue, sleep, and cognitive and physical outcomes as well as quality of life.

Investigators observed a fourfold increase in PTSD compared with the rate in the general population. Fatigue in patients was also consistently elevated, higher, in fact, than the fatigue level reported for cancer patients undergoing chemotherapy.

Fatigue Also High

"That PTSD was highly prevalent in our sample at both assessment points posthemorrhage and that most patients who warranted a diagnosis of PTSD at approximately 3 months still warranted the diagnosis at 13 months is in line with evidence that PTSD is often a persistent and chronic disorder," the researchers point out.

"Neurosurgeons are happy that their patients are alive and functional at follow-up, but no one is happy that they still suffer in certain aspects of their lives," Max Findlay, MD, from the University of Alberta, in Edmonton, writes in another accompanying comment.

"I suppose what we really need, in addition to reminders such as those contained in this excellent report, is something the authors allude to: good, practical advice, based on solid work and evidence, on how to best improve coping strategies in our survivors of subarachnoid hemorrhage," he adds.

Information from studies like this may lead to better treatments in the acute phase that improve outcome, note Drs. Javier Provencio and Peter Rasmussen from the Cleveland Clinic in Ohio. "Study of psychological outcome is clearly becoming more prominent in other intensive-care-unit populations, such as patients with acute respiratory-distress syndrome. This may herald a fundamental shift in the approach to evaluating patients."

This study was funded by the Clarke Lister Brain Hemorrhage Foundation and the Wolfson Development Fund.


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