PTSD in Stroke Survivors May Hamper Secondary Prevention

Caroline Cassels

January 24, 2013

Posttraumatic stress disorder (PTSD), a common phenomenon after stroke, may significantly hamper secondary prevention efforts and impair recovery because of survivors' lack of adherence to medication regimens, new research suggests.

Investigators at Columbia University Medical Center in New York found that 65% of stroke survivors with PTSD failed to adhere to treatment vs 33% of their counterparts without PTSD. They also found that concerns about medications were a primary barrier to treatment adherence.

"Unfortunately, too many stroke survivors are not compliant with these regimens, even though we know that adherence to post-stroke treatment regimens is one of the most important components of reducing the risk of a future stroke," study author Ian M. Kronish, MD, PhD, said in a statement.

"For those with PTSD, this study shows that concerns about medications are a significant barrier to treatment adherence. Stroke survivors should be assessed for concerns about medications and PTSD symptoms, so that interventions may be introduced as early as possible to get patients back on track to avoid future stroke events," he added.

The study is published online January 7 in the British Journal of Health Psychology.

PTSD Common After Stroke

Frequently a consequence of acute life-threatening events, including acute coronary syndrome (ACS), cancer, and stroke, PTSD is estimated to affect up to18% of stroke survivors.

It is also known that PTSD is associated with worse outcomes, including increased risk for occurrence in ACS, although it is not known whether this tenet also holds true for stroke-induced PTSD.

Increased blood pressure, endothelial dysfunction, and systemic inflammation have been proposed as potential biological mechanisms for the link between PTSD and poor outcomes in patients with ACS, and the investigators hypothesized that behavioral mechanisms, including medication nonadherence, may also play a role in other cardiovascular diseases, particularly stroke.

"In survivors of strokes and transient ischaemic attacks…adherence to risk-reducing medications, including antiplatelet agents, antihypertensive agents, and statins, is especially important for preventing subsequent strokes," they write.

They hypothesized that greater concerns, but not lower perceptions of the importance of medications, among stroke survivors with PTSD may mediate the association between PTSD symptoms and nonadherence to medication in a large sample of stroke survivors.

Unpleasant Reminder

The study included 535 participants from the Preventing Recurrence of All Inner City Strokes through Education (PRAISE) clinical trial recruited between March 2010 and January 2012. Patients were 40 years or older (mean age, 63 years) and had had at least 1 stroke or transient ischemic attack in the previous 5 years.

The data for the study analysis were part of the baseline interview for the trial. Symptoms of PTSD were assessed by using a modified version of the 17-item PTSD checklist-specific (PCL-S), using the stressor stroke or mini-stroke.

In addition, select items from the Patient Health Questionnaire (PHQ) were also used to assess PTSD.

Patients were asked about PTSD symptoms, medication adherence, and beliefs or concerns about medications.

Compared with stroke patients without PTSD symptoms, patients with PTSD were more ambivalent toward medication, were more concerned about its potential long-term effects, and complained about the way medication disrupted their lives. In addition, PTSD was associated with an increased belief in the general harm and overuse of medications in the medical system.

Previous research with the same cohort showed that stroke survivors with the most severe PTSD were almost 3 times as likely as their counterparts without PTSD to be nonadherent to medications.

"We believe that these findings suggest that stroke survivors with PTSD do not see their medications as helpful, but rather as reminders of their stroke, and that they avoid taking them as a way to avoid thinking about their stroke," first author Donald Edmondson, PhD, said in a statement.

"We need to conduct further research to determine whether treating a stroke survivor for PTSD would alleviate medication concerns that lead to avoidance, or if additional interventions should be designed to address both issues," Dr. Edmondson added.

The authors are supported by the National Institutes of Health, ; the National Institute of Minority Health and Health Disparities; the National Center for Research Resources; and the National Heart, Lung, and Blood Institute. The authors have disclosed no relevant financial relationships.

Br J Health Psychol. Published online January 7, 2012. Abstract