(Stroke. 2001;32:1640.)
© 2001 American Heart Association, Inc.
Original Contributions |
Negative Attitudes Among Short-Term Stroke Survivors Predict Worse Long-Term Survival
From the Department of Clinical Neurosciences, University of Edinburgh (Scotland).
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose—Patients respond to serious illness in different ways. We wished to determine whether different attitudes toward illness are associated with survival after stroke.
Methods—Three hundred seventy-two stroke patients were identified and medically assessed as part of a randomized trial to evaluate a stroke family care worker. They had all survived 6 months from randomization. A research psychologist visited each patient and administered the Mental Adjustment to Stroke Scale (a self-rated attitude scale based on the Mental Adjustment to Cancer Scale). Disability and dependence (Barthel Index, modified Rankin Scale) and mood (Hospital Anxiety and Depression Scale, General Health Questionnaire 30) were also assessed. Patients were followed up in 1998 (3 to 5 years after the initial stroke) to establish their survival. We modeled the relationship between Mental Adjustment to Stroke scores and survival, adjusting for other factors associated with stroke survival.
Results—Eighty-two patients (22%) died within 3 years. After adjustment for other significant factors, fatalism and helplessness/hopelessness were both associated with decreased survival (P=0.03 and 0.04, respectively), but fighting spirit, anxious preoccupation, and denial/avoidance were not. Mood was not associated with survival.
Conclusions—Patients’ attitudes toward their illness seem to be associated with survival after stroke. Patients who feel that there is nothing they can do to help themselves 6 months after a stroke have a shorter survival. These findings need to be confirmed and any causal relationship between attitude and survival further explored in a randomized controlled trial to "improve" the attitude of stroke patients toward their illness.
Key Words: adaptation, psychological • cerebral infarction • proportional hazards models • survival analysis
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Patients’ attitudes toward illness vary, and questionnaires have been developed to identify them. The Mental Adjustment to Cancer (MAC) Scale categorizes the attitudes of cancer patients toward their illness into fighting spirit, helplessness/hopelessness, anxious preoccupation, fatalism, and denial/avoidance.1 An attitude of fighting spirit or denial/avoidance, as opposed to helplessness/hopelessness or fatalism, predicts a greater likelihood of remaining alive and free of recurrence in patients with breast cancer for up to 15 years.2 3 A more recent study showed that helplessness/hopelessness was associated with decreased survival in breast cancer patients followed up for at least 5 years.4 We adapted the MAC Scale for use in stroke patients. We sought to test the hypothesis that helplessness/hopelessness and fatalism are also associated with reduced survival after stroke and to examine whether these effects are independent of demographic, physical, and mood factors that have been associated with poor outcomes after stroke.5 6 7
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Patient Selection
We identified patients as part of a randomized trial to evaluate the effect of a stroke family care worker8 (the trial showed no statistically significant effect of the family care worker on patients’ outcome). They were eligible for inclusion into the trial if they were referred to our hospital as an inpatient or outpatient between October 1993 and September 1995, within 30 days of an acute stroke. They were excluded if they had a subarachnoid hemorrhage, lived >25 miles away, were unlikely to survive the acute stroke, or had another disease, such as cancer, that was likely to dominate their care. Over the study period, 65% (417 of 643) of all patients referred to our hospital with an acute stroke were included in the trial. Patients were included in the present observational study if they survived 6 months from entry into the trial.
Initial Assessment
In part 1, a study neurologist performed a clinical
assessment of each patient on arrival at the hospital, including
routine blood tests, an ECG, and a CT brain scan.
In part 2, a research psychologist visited each surviving
patient (usually at the patient’s normal residence) 6 months after the
part 1 assessment and administered the following measures: (1) modified
Rankin Scale; (2) Barthel Index (modified version); (3) Hospital
Anxiety and Depression Scale (HAD); (4) General Health Questionnaire 30
(GHQ30); and (5) Mental Adjustment to Stroke Scale (MASS). The modified
Rankin Scale9 is an
observer-rated ordinal scale indicating patients’ overall level of
symptoms and dependence on others. A high score indicates greater
dependence. The Barthel Index (modified
version)10 is an
observer-rated 10-item ordinal scale indicating patients’ degree of
independence in activities of daily living. A high score indicates
greater independence. The
HAD11 is a widely used
self-rated scale for symptoms of depression and anxiety developed for
use in the medically ill. A high score indicates greater anxiety and
depression. The GHQ3012 is a
self-rated measure of psychiatric morbidity. A high score indicates
greater psychiatric morbidity. The MASS is a self-rated scale developed
for our study by rewording the MAC
scale,1 replacing the word
cancer with
stroke. It includes 5
subscales: fighting spirit, helplessness/hopelessness, anxious
preoccupation, fatalism, and denial/avoidance
(Table 1
). Patients with fighting spirit are determined
to get well and are optimistic. Patients with feelings of
helplessness/hopelessness are overwhelmed by knowing they have had a
stroke and are afraid they are dying. Patients with anxious
preoccupation seek information and worry about their symptoms. Patients
with a fatalistic attitude acknowledge their stroke but seek no further
information and carry on with their lives. Patients with
denial/avoidance either deny they have had a stroke or minimize its
seriousness. For fighting spirit, a high score indicates a more
positive attitude, but for the other subscales, a high score indicates
a more negative attitude.
|
Because we had altered the scale and because it had not been
previously used for stroke, we assessed its test-retest reliability
over 1 to 2 weeks in the first 97 patients entered into the study. The
values for individual questions ranged from 0.18 to 0.89
(Table 1
) but were generally satisfactory. The internal
consistency of the scales was assessed with the use of
Cronbach’s 
(Table 1), which suggested reasonable internal
consistency.
The Barthel Index, modified Rankin Scale, and GHQ30 were completed at the part 2 (6-month) interview, while the HAD and MASS were left with the patient to complete independently.
Follow-Up
Patients were followed up in 1998 (3 to 5 years after
the initial stroke) to establish their survival.
Statistical Methods
The statistical package SAS
was used.13 Pearson
correlation coefficients were calculated for the relationships between
the MASS subscales and the mood measures (HAD and GHQ30). Survival was
modeled with Cox proportional hazards
regression.14 Variables
included from the part 1 assessment were as follows: age, sex, diabetes
mellitus, ischemic heart disease, peripheral
vascular disease, living alone before the stroke, prestroke dependence
(modified Rankin Scale score of >2), urinary incontinence, inability
to lift both arms, inability to walk, and verbal deficit according to
the Glasgow Coma Scale.15
Variables included from the part 2 assessment were as follows:
modified Rankin Scale, Barthel Index, HAD subscales, GHQ30, and MASS
subscales.
We used a forward selection procedure with the level of significance for entry into the model set at 0.2. Entry into the model was determined by the change in magnitude of the log likelihood. Variables describing age, stroke severity, and comorbidity were entered first, and when no more were statistically significant, the psychological factors were entered into the model. In the regression procedure, missing values for each variable were set equal to the mean value of the nonmissing data for that variable (ie, the mean value of the other patients’ values). The quantity of missing data depended on the variable, but the maximum was 93 patients (25%) for MASS denial/avoidance. We also analyzed the data excluding patients with any missing data, and it made little difference to the overall results.
The MASS subscales were analyzed as continuous variables of raw scores. We also ran the analysis breaking the subscales into categories, and the results were very similar.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
We included 372 of the 417 randomized trial patients in this observational study. Reasons for exclusion were dying before the 6-month assessment (n=41), brain tumor (n=1), refusing follow-up (n=2), and emigration (n=1). Forty-seven of the 372 patients (13%) had a total anterior circulation syndrome, 147 (40%) a partial anterior circulation syndrome, 103 (28%) a lacunar syndrome, 60 (16%) a posterior circulation syndrome, and 15 (4%) an unknown syndrome.16 CT or MR scans were performed on 342 patients (92%); 312 (84%) had ischemic strokes, and 30 (8%) had primary intracerebral hemorrhage. Table 2
shows the characteristics of the patients at
the part 1 (stroke onset) assessment.
Table 3 shows the variables measured at the part 2
(6-month) assessment, including the proportion of patients from whom we
obtained data. The main reasons for missing data were patients’
cognitive and communication problems and turning over 2 pages at once
when completing self-report questionnaires.
|
|
Relationships Between the Psychological Measures at
Part 2 (6-Month) Assessment
Correlation coefficients between the HAD subscales, the
GHQ30, and the MASS subscales are shown in
Table 4.
|
Survival
Eighty-two of 372 patients (22%) died within 3 years
of the initial stroke assessment (ie, within 2.5 years of the
assessment of attitude and mood). A univariate Cox
proportional hazards regression demonstrated strong associations
between several demographic and clinical features and survival
(Table 5). It also demonstrated that fighting spirit
was associated with increased survival, while helplessness/hopelessness
and fatalism were associated with decreased survival. Anxious
preoccupation, denial/avoidance, and mood were not significantly
associated with survival.
|
We entered the explanatory variables collected at the
part 1 and part 2 assessments into the regression analysis
using a forward selection procedure. In the final model, older age,
diabetes, ischemic heart disease, peripheral
vascular disease, prestroke dependence, inability to walk at initial
assessment, and living alone were all associated with decreased
survival. After adjustment for these factors, the association of
helplessness/hopelessness and fatalism with survival remained
statistically significant
(P=0.04 and 0.03,
respectively), but the association of fighting spirit did not
(P=0.2)
(Table 6). Anxiety and depression, as measured by the
HAD subscales and the GHQ30, did not add significantly to this model
irrespective of whether the MASS subscales were included.
Table 6 also shows the relative magnitude of the effects of
the MASS subscales, after adjustment for other prognostic factors.
Patients who had one of the highest 10% of fighting spirit scores were
39% more likely to die at any given time than patients with one of the
lowest 10% of fighting sprit scores.
|
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
In our study reduced survival is predicted by negative attitudes toward illness but not by depression or anxiety, even after stroke severity and other prognostic variables have been accounted for.
The MASS has not been used elsewhere, and confirmatory observational studies are needed. However, Watson et al4 found that helplessness/hopelessness was a predictor of decreased survival in breast cancer. They did not find a significant association between fatalism and survival. In lung cancer, depressive coping (measured by the Freiburg Questionnaire of Coping With Illness) has been associated with decreased survival.17 Depressive coping was characterized by brooding, arguing with fate, pitying oneself, acting impatiently, and taking it out on others.
Depression has been previously linked with increased
mortality after stroke. Morris et
al18 followed up a cohort of
103 stroke patients and found that patients with depression were 3
times more likely than others to die within 10 years, even after
adjustment for other prognostic variables. They identified
depression using the Present State Examination and measured its
severity with the Hamilton Rating Scale. Arfken et
al19 showed a similar
relationship among 455 medically ill older adults followed up for 1
year. They used the Geriatric Depression Scale and showed that moderate
depression (odds ratio, 5.0) and male sex (odds ratio, 3.4) were
independent risk factors for dying. Frasure-Smith et
al20 followed up 222
patients after myocardial infarction and showed that the Beck
Depression Inventory was significantly associated (odds ratio comparing
scores of 
10 to scores of <10=6.6;
P=0.003) with 18-month
mortality after adjustment for other predictors of mortality. Our
failure to find an association between depression and survival could be
explained if the HAD and GHQ30 were not good measures of depression in
our population. However, we have previously shown that the HAD and GHQ
are reasonable measures of depression in a subgroup of 105 (25%) of
the patients included in the present
study.21
We studied the HAD scale together with the MASS to explore
the differences between anxiety and depression and "attitude."
There was some overlap between what the HAD scale and the MASS
measured, as shown by the correlations in
Table 4. Although our data suggest a relationship between
HAD depression and helplessness/hopelessness, the latter is not purely
a measure of depression since it predicted survival, whereas HAD
depression did not. On the other hand, anxious preoccupation showed
associations similar to HAD anxiety, in terms of both correlations with
other MASS subscales and a lack of association with survival, and
perhaps they are measuring the same entity. The MASS clearly contains
items that reflect mood. However, our data suggest that it seems to
capture something distinct from mood, at least as measured by the HAD
and GHQ30, given that only the MASS was associated with survival. There
was a substantial amount of missing data for the MASS. Different
methods of dealing with the missing data made no difference to the
overall results.
There are several plausible explanations for our observations. Patients’ attitudes toward their stroke may change over time. For instance, if a patient with a severe stroke recovered a great deal of function in the first few months, he/she may then have a more positive attitude 6 months after the stroke. A patient with a stroke of similar severity who had not recovered much function may have felt very negative after 6 months. Thus, the MASS may be related to the amount of recovery a patient had made thus far, which in turn might be a good predictor of survival. We attempted to control for this by adjusting for other predictive factors, including the patient’s functional status at 6 months after the stroke (which was significantly related to survival in a univariate analysis but not in a multivariate analysis after adjustment for more strongly significant variables).
The relationships between survival and aspects of the MASS held after adjustment for other prognostic factors, although the relationships were weakened. This could indicate that negative attitudes hasten death, or we may have simply failed to adjust fully for stroke severity. It is possible that patients intuitively know how severe their disease is, in a way that simple clinical variables cannot match. This may not detract from the usefulness of attitude in prognostic models, but it would undermine the notion of causality. It is also possible that a particular attitude could in some way cause a patient to have more severe stroke symptoms, which in turn might cause the patient to survive for a shorter time. If this is the case, then in our multivariate analysis we will have adjusted for something that is between attitude and survival on the causal pathway. In other words, we may have hidden important relationships between attitude and survival in our multivariate analyses.
A causal relationship is biologically plausible, although mechanisms remain speculative. In experimental animals, Spiegel22 has shown that acute stress affects hypothalamic function, which leads to glucocorticoid receptor hypersensitivity and causes immunosuppression. The functions of the hypothalamus and pituitary adrenal axis have been associated with both mood and survival after stroke.23 Rozanski et al24 outline possible mechanisms in cardiovascular disease.
There is no evidence that any intervention can alter a patient’s attitude to stroke. However, if such an intervention could be developed, its effect on survival could be tested in a randomized trial. A positive trial would establish a causal link between attitude and survival.
Conclusion
Patients’ attitudes to their stroke are associated
with survival. Patients who are fatalistic and feel helpless or
hopeless, ie, who feel that there is nothing they can do to help
themselves, do not survive as long as other patients. This seems to
remain true even when physical factors, such as stroke severity, are
accounted for. We now need to confirm this observation in further
observational studies and then examine whether any intervention can
decrease feelings of fatalism and helplessness and in turn improve
survival after
stroke.
|
Acknowledgments |
|---|
This work was supported by grants from the Chief Scientist’s Office (Scotland) and Chest, Heart, and Stroke Scotland.
|
Footnotes |
|---|
Reprint requests to Dr S.C. Lewis, Bramwell Dott Building, Department of Clinical Neurosciences, Western General Hospital NHS Trust, Crewe Rd, Edinburgh EH4 2XU, UK.
Received January 18, 2001; revision received March 8, 2001; accepted March 12, 2001.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
- Watson M, Greer S, Bliss JM. Mental Adjustment to Cancer (MAC) Scale Users’ Manual. 1989.
- Greer S, Morris T, Pettingale KW. Psychological response to breast cancer: effect on outcome. Lancet. 1979;2:785–787.[Medline] [Order article via Infotrieve]
- Greer S, Morris T, Pettingale KW, Haybittle JL. Psychological response to breast cancer and 15-year outcome. Lancet. 1990;335:49–50.[Medline] [Order article via Infotrieve]
- Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. Influence of psychological response on survival in breast cancer: a population-based cohort. Lancet. 1999;354:1331–1336.[Medline] [Order article via Infotrieve]
-
Lai SM, Alter M,
Friday G, Sobel E. Prognosis for survival after an initial stroke.
Stroke. 1995;26:2011–2015.
[Abstract/Free Full Text] - Counsell CE. The Prediction of Outcome in Patients With Acute Stroke [PhD thesis]. Cambridge, UK: Girton College; 1998:138–143.
- Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG. Predicting survival for 1 year among different subtypes of stroke: results from the Perth Community Stroke Study. Stroke. 1994;25:1935–1944.[Abstract]
-
Dennis M, O’Rourke
S, Slattery J, Staniforth T, Warlow C. Evaluation of a stroke family
care worker: results of a randomised controlled trial.
BMJ. 1997;314:1071–1077.
[Abstract/Free Full Text] - Bamford JM, Sandercock PAG, Warlow CP, Slattery J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1989;20:828.[Medline] [Order article via Infotrieve]
- Wade DT. Activities of Daily Living (ADL) and Extended ADL Tests: Measurement in Neurological Rehabilitation. Oxford, UK: Oxford University Press; 1992:175–194.
- Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361–370.[Medline] [Order article via Infotrieve]
- Goldberg DP. The Detection of Psychiatric Illness by Questionnaire: A Technique for the Identification and Assessment of Non-psychotic Psychiatric Illness. London, UK: Oxford University Press; 1972. Maudsley Monograph No. 21.
- SAS Version 6.12. Cary, NC: SAS Institute Inc; 1997.
- Cox DR. Regression models and life-tables. J R Stat Soc B. 1972;34:187–220.
- Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–84.[Medline] [Order article via Infotrieve]
- Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521–1526.[Medline] [Order article via Infotrieve]
-
Faller H,
Bulzebruck H, Drings P, Lang H. Coping, distress and survival among
patients with lung cancer. Arch Gen
Psychiatry. 1999;56:756–762.
[Abstract/Free Full Text] -
Morris PLP,
Robinson RG, Andrzejewski P, Samuels J, Price TR. Association of
depression with 10-year poststroke mortality.
Am J Psychiatry. 1993;150:124–129.
[Abstract/Free Full Text] - Arfken CL, Lichtenberg PA, Tancer ME. Cognitive impairment and depression predict mortality in medically ill older adults. J Gerontol. 1999;54A:M152–M156.
-
Frasure-Smith N,
Lesperance F, Talajic M. Coronary heart disease/myocardial
infarction: depression and 18-month prognosis after myocardial
infarction. Circulation. 1995;91:999–1005.
[Abstract/Free Full Text] -
O’Rourke S,
MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after
stroke: comparison of the GHQ and the HAD scale.
Stroke. 1998;29:980–985.
[Abstract/Free Full Text] -
Spiegel D.
Healing words: emotional expression and disease outcome.
JAMA. 1999;281:1328–1329.
[Free Full Text] - Mitchell AJ. Clinical implications of poststroke hypothalamo-pituitary adrenal axis dysfunction: a critical literature review. J Stroke Cerebrovasc Dis. 1997;6:377–388.[Medline] [Order article via Infotrieve]
-
Rozanski A,
Blumenthal JA, Kaplan J. Impact of psychological factors on the
pathogenesis of cardiovascular disease and implications
for therapy. Circulation. 1999;99:2192–2217.
[Abstract/Free Full Text]
This article has been cited by other articles:
 |
|
 |
|
  A. L. Ai, C. L. Park, Bu Huang, W. Rodgers, and T. N. Tice Psychosocial Mediation of Religious Coping Styles: A Study of Short-Term Psychological Distress Following Cardiac Surgery Pers Soc Psychol Bull, June 1, 2007; 33(6): 867 - 882. [Abstract] [PDF]
|
|
|
|
 |
|
 X. Zhang, S. L. Norris, E. W. Gregg, Y. J. Cheng, G. Beckles, and H. S. Kahn Depressive Symptoms and Mortality among Persons with and without Diabetes Am. J. Epidemiol., April 1, 2005; 161(7): 652 - 660. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. L. Ai and C. L. Park Possibilities of the Positive Following Violence and Trauma: Informing the Coming Decade of Research J Interpers Violence, February 1, 2005; 20(2): 242 - 250. [Abstract] [PDF]
|
|
|
|
 |
|
 L. S. Williams, S. S. Ghose, and R. W. Swindle Depression and Other Mental Health Diagnoses Increase Mortality Risk After Ischemic Stroke Am J Psychiatry, June 1, 2004; 161(6): 1090 - 1095. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. L. Ai, C. Peterson, T. N. Tice, S. F. Bolling, and H. G. Koenig Faith-based and Secular Pathways to Hope and Optimism Subconstructs in Middle-aged and Older Cardiac Patients J Health Psychol, May 1, 2004; 9(3): 435 - 450. [Abstract] [PDF]
|
|
|
|
 |
|
 M. Dennis an imperfect compromise BMJ, July 31, 2003; 327(7409): 286 - 286. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Schenkman, T. M. Cutson, C. W. Zhu, and K. Whetten-Goldstein A Longitudinal Evaluation of Patients' Perceptions of Parkinson's Disease Gerontologist, December 1, 2002; 42(6): 790 - 798. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Appelros, I. Nydevik, A. Seiger, and A. Terent Predictors of Severe Stroke: Influence of Preexisting Dementia and Cardiac Disorders Stroke, October 1, 2002; 33(10): 2357 - 2362. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. H. Friedman Letters to the Editor: Re: Socioeconomic Status and Ischemic Stroke Stroke, November 1, 2001; 32(11): 2725 - 2725. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||