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Anxiety and depression in incident stroke survivors and theircarers in rural Tanzania: A case-control follow-up study overfive years

Matthew P. Jones a, Suzanne C. Howitt a, Ahmed Jusabani b, William K. Gray a,Eric Aris c, Ferdinand Mugusi c, Mark Swai b, Richard W. Walker a,*

a North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear, NE29 8NH, UKb Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzaniac Department of Neurology, Muhimbili University Hospital, Dar-es-Salaam, United Republic of Tanzania

A R T I C L E I N F O

Article history:

Received 21 September 2011

Accepted 17 January 2012

Available online 16 February 2012

Keywords:

Stroke

Tanzania

Anxiety

Depression

Africa

Cerebrovascular disease

0941-9500/$ - see front matter � 2012 Elsevidoi:10.1016/j.npbr.2012.01.003

* Corresponding author. Address: DepartmNE29 8NH, UK. Tel./fax: +44 0191 293 2709.

E-mail address: Richard.walker@nhct.nhs

A B S T R A C T

Aims: To quantify the extent and nature of anxiety and depression in a representative

cohort of stroke survivors and their carers in rural Tanzania.

Design: A cross-sectional design was used and stroke cases were followed up at 6–60

months post-stroke. Levels of anxiety and depression in stroke survivors, their carers (for

physically dependent stroke survivors) and age- and sex-matched controls were assessed

using the hospital anxiety and depression (HAD) scale. Other data collected included age,

sex, time elapsed since stroke, quality of life, cognitive function, level of disability and

socioeconomic status.

Results: Levels of depression seen in our cohort of stroke survivors (53.0%) are high com-

pared to data from the developed and developing world. Anxiety levels (21.6%) are similar

to published data. Stroke survivors (n = 58, full data set n = 51) and carers (n = 27) were sig-

nificantly more anxious than controls (n = 58), whereas levels of depression were similar

across all three groups. High stroke survivor HAD scores correlated with lower scores in

physical health, psychological health and environment sections of the WHOQOL-Bref.

Increased carer anxiety and depression were associated with reduced informant-reported

levels of cognitive function in stroke survivors.

Conclusions: To our knowledge this is the first long term study of incident stroke cases in

sub-Saharan Africa which has investigated the psychological health of stroke survivors

and their carers. Our study highlights the growing need to develop community rehabilita-

tion services in the developing world, which address both physical and psychological

morbidity.

� 2012 Elsevier GmbH. All rights reserved.

1. Introduction

Although stroke has traditionally been viewed as a disease of

high-income countries, demographic and epidemiological

er GmbH. All rights reser

ent of Medicine, North Ty

.uk (R.W. Walker).

changes mean that it is becoming more common in other re-

gions, with 87% of stroke deaths now occurring in low to mid-

dle income countries.1 In addition to the serious physical

consequences that may be experienced after stroke, a large

ved.

neside General Hospital, Rake Lane, North Shields, Tyne and Wear,

N E U R O L O G Y, P S Y C H I A T R Y A N D B R A I N R E S E A R C H 1 8 ( 2 0 1 2 ) 1 2 2 – 1 2 8 123

proportion of patients also suffer from psychiatric sequelae

which may adversely affect quality of life and rehabilitation

outcomes.2 Such problems are not confined to stroke survi-

vors themselves, but are often experienced by their carers

who are under increased levels of emotional and physical

stress.3

Depression is common in stroke survivors, and has been

associated with reduced quality of life and poorer rehabilita-

tion outcomes.4,5 Patients with severe disability are at in-

creased risk of depression although this relationship is

likely to be bi-directional as depression may, in turn, hinder

physical recovery.6,7 A systematic review of 51 observational

studies showed that depressive symptoms were present in

33% of all stroke survivors at any time during follow-up.8 In

sub-Saharan Africa (SSA), the Ibadan stroke study in Nigeria

noted that negative feelings (including anxiety, fear and

depression) were present in 75% of 100 consecutive stroke pa-

tients presenting to hospital, although the spectrum of nega-

tive feelings assessed was wider than that of clinical

depression.9 Compared to symptoms of depression, post-

stroke anxiety has been much less well studied, despite the

considerable symptom overlap.10 A longitudinal community-

based Swedish study of 80 stroke survivors found that the

prevalence of generalised anxiety disorders after stroke was

28% in the acute stage, with no significant decrease through

3 years of follow-up.11 This Swedish study showed that gener-

alised anxiety disorders were strongly associated with depres-

sion, dependence in activities of daily living and stroke

survivors having a smaller social network.

Caring for a stroke survivor can prove burdensome, and re-

sult in stress and psychological morbidity for the caregiver.12

Several studies from high-income countries report adverse ef-

fects on health and well-being amongst carers for stroke sur-

vivors.12–15 In an Australian study investigating the impact of

caring for stroke survivors at one-year post stroke, almost

80% of caregivers reported a detrimental impact on their emo-

tional health, social activities and leisure time, and over half

reported negative effects on family relationships. The fear

and worry of leaving the stroke survivor alone was a central

theme.16 Increased psychological morbidity among caregivers

has been found to be associated with smaller social networks,

greater stroke severity and lower socio-economic status.12,14

Data are lacking on the psychiatric well-being of stroke sur-

vivors and their carers in low- and middle-income countries,

particularly SSA. Long-term follow-up studies in SSA have

been difficult to conduct due to poor infrastructure, limited pa-

tient records and other practical problems.17 Furthermore,

many studies have used hospital-based cohorts which may

lead to a selection bias, since results are only representative

of those who are able or willing to attend the hospital. Many

patients in the developing world do not present to hospital

due to limited financial resources, inadequate transport links

or because they seek alternative care from traditional healers.

Community-based research is therefore needed to assess the

psychiatric morbidity of the wider and more representative

population of stroke survivors and their carers.9,18–20

The aim of this study was to conduct a long term, commu-

nity-based study to investigate anxiety and depression among

a cohort of incident stroke survivors, carers and control

subjects in rural Tanzania.

2. Methods

A favourable ethical opinion was obtained from the National

Institute of Medical Research in Tanzania and from the New-

castle and North Tyneside Joint Ethics Committee.

2.1. Participants

Cases were recruited from survivors of a stroke incidence

study in the rural Hai district of northern Tanzania from June

2003 to June 2006, in addition to further cases identified in the

same region between June 2006 and December 2007.21 The

World Health Organization (WHO) criteria were used to clas-

sify stroke cases.22 Cases were assessed as part of the current

study between June and September 2008. A person was

deemed to be the primary carer of a stroke survivor if the

stroke survivor identified them as there carer and the stroke

survivor was physically dependent on the carer. If stroke sur-

vivors were physically independent then they were consid-

ered not to have a carer. The control subjects were selected

by local healthcare workers, by convenience sampling, from

within the Hai district. Relatives and carers of stoke patients

were not considered as potential controls. In total 58 stroke

patients and 58 controls were recruited to the follow-up study.

2.2. Assessment

Assessment was between 6 months and 5 years post-stroke,

depending on the date of their incident stroke. Assessment

and examination of stroke patients and carers were carried

out by research doctors (MPJ and SCH), with local healthcare

workers acting as translators and interpreters. Controls were

interviewed by either MPJ, SCH or one designated clinical

assistant who had been suitably trained.

2.2.1. Anxiety and depressionAnxiety and depression was measured in patients, controls

and carers of physically dependent patients using the hospi-

tal anxiety and depression scale (HAD).23 Physically depen-

dent patients were classified as patients with a Barthel ADL

index of less than the maximum score of 20. The HAD scale

asks seven questions relating to anxiety and a further seven

relating to depression. Responses are scored from 0 to 3. For

the purposes of this study, an anxiety or depression sub-score

of 0–7 was indicative of no symptoms, a score of 8–10 was

indicative of mild symptoms, a score of 11–15 moderate

symptoms and a score of 16–21 severe symptoms of anxiety

or depression. The HAD scale has been validated for use in

a hospital and community setting a Nigeria.24 The tool per-

formed well in both settings, although mis-classification rates

for both anxiety and depression were generally lower in the

community than in a hospital setting.

2.2.2. Other assessmentIn addition, each patient and control was assessed using a

series of well recognised scales and assessment tools during

a 1–2 h interview. A 10-item questionnaire, which covered

areas including housing and land ownership, was used to

determine the socio-economic status of patients and controls.

124 N E U R O L O G Y, P S Y C H I A T R Y A N D B R A I N R E S E A R C H 1 8 ( 2 0 1 2 ) 1 2 2 – 1 2 8

Quality of life was assessed using the WHOQOL-Bref.25 This

instrument measures overall QOL and satisfaction with

health. It provides summary scores in the domains of physical

health (domain 1), psychological health (domain 2), social

relationships (domain 3) and environment (domain 4). Further

details of its use by our study team have been described

previously.2 The CSI-D is a 34-item screening instrument for

dementia in developing countries, consisting of two parts;

one questionnaire directed at patients and the other at an

informant or carer.26 Scores from patients and informants

(carers) are weighted to give a global measure of dementia.

Information concerning demographics (name, age, sex,

abode, highest level of education) and medical care was also

obtained. In cases where patients were unable to respond

due to dysphasia or aphasia, demographic and other back-

ground information was sought from a relative or carer.

The Barthel index27 was used to assess patients but not

carers or controls. The scale measures the functional inde-

pendence of an individual with regard to their ability to carry

out activities of daily living (ADL). Muscle power was also

measured in patients by using the Medical Research Council

Scale28 and a language, speech and swallowing screen was

performed.

2.3. Statistics

The data were analysed using statistical software, PASW-18

for windows (PASW, Chicago, IL, USA). All variables were

non-normally distributed and, therefore, the Mann–Whitney

U test was used to characterise differences. Spearman’s corre-

lation test was used to assess associations between scores for

ordinal data and the point biserial correlation test was used

for dichotomous data. Due to the significant deviation from

normality in the data obtained from the HAD scale mean

and median values are not quoted. The data were categorised

as described in Section 2.2.1 and the frequency of each score

given.

3. Results

The initial incidence study21 identified 132 incident stroke

cases and a 52 further cases were identified between the

end of the incidence study and 31st December 2007, giving

184 cases in total. By the start of the current study on 1st June

2008, 102 cases had died, 16 cases were unable to participate

in a follow-up assessment due to co-morbidity or illness and 8

had left the study area or could not be traced. Therefore, 58

patients were followed up.

Details of the cohort have been described previously and

are summarised here.2,21 There was no significant difference

in age at stroke (U = 3114.5, z = )1.608, p = 0.108) or gender

(v2(1) = 0.047, p = 0.828) between those who were followed-up

and those not followed-up. Patients were assessed at a median

of 36 months post-stroke (range 6–60) post-stroke. The mean

age of patients was 67.1 years (range 30–88) and 28 (48.3%) were

male. The mean age of controls was 61.7 years (range 27–86)

and 30 (51.7%) were male. Although controls were, on average,

younger than patients the difference was not significant

(U = 1368.0, z = )1.596, p = 0.111). There was no significant dif-

ference in gender (v2(1) = 0.138, p = 0.853).

Carer HAD scores are based on responses from the 27

carers of physically dependent patients. The remaining pa-

tients were physically independent and were therefore classi-

fied as not needing a carer for the purposes of this study. Of

the 27 carers, only 4 were male, 11 were a spouse of the stroke

survivor, 14 were a son or daughter (including in-laws) and 2

were a grand-daughter. The average age was 47 years old

although the range of ages was 16–73 (SD 15.989). Seventeen

were employed or self-employed which included selling fruit

or crops at the market, and 4 were subsistence farmers.

Six patients were unable to give responses to the HAD due

expressive dysphasia or complete aphasia and one patient did

not wish to answer the HAD questions. He was subjectively

noted by researchers to have a very low mood and only spoke

a few words. No patients were excluded due to dementia. A

summary of patient and carer HAD scores are shown in Table

1. More patients (19.6%) and carers (22.2%) were classified as

having some form of anxiety, than controls (3.4%). Depression

was more common across all three groups, with 51.0% of pa-

tients and 40.7% of carers being depressed, compared to 53.4%

of controls. No patients and only one carer were defined as

having severe depression and anxiety.

3.1. Associations between predictors

Depression in stroke survivors, as measured on the HAD

scale, was associated with a number of tests of motor perfor-

mance in a number of functional tasks, see Table 2. Anxiety

was associated with WHOQOL-Bref domain 1 (physical

health) and domain 2 (psychological health) scores only. The

use of anti-hypertensive drugs post-stroke was associated

with lower anxiety (r = 0.284, p = 0.046) and depression

(r = 0.292, p = 0.040).

In patients, symptoms of anxiety and depression were not

associated with any of the 10 items measuring socio-eco-

nomic status. Reduced cognitive function (CSI-D patient inter-

view) was not associated with anxiety or depression, but a

lower informant ranked score of the patient’s cognitive func-

tion (CSI-D informant interview) was strongly associated with

anxiety in patients (r = 0.346, p = 0.016) and anxiety (r = 0.668,

p = 0.001) and depression in carers (r = 0.503, p = 0.017).

Patient age, sex, time elapsed since stroke, Barthel index

score, and speech, language and swallowing scores were not

associated with levels of anxiety or depression in patients or

carers.

4. Discussion

Although there has been considerable research from high-in-

come countries into psychiatric problems following stroke,

there have been few studies investigating these problems in

low and middle income countries, despite high levels of doc-

umented stroke related morbidity.29 The present study re-

veals that patients were significantly more anxious than

controls but had similar rates of depression. A weak associa-

tion was seen between levels of depression in patients and

their carers but no association in anxiety levels was found

Table 2 – Correlation between HAD scale scores and other variables in stroke cases.

HAD anxiety HAD depression HAD total

Motor function General mobility Correlation (r) 0.019 )0.264 )0.172Significance (p) 0.892 0.061 0.226

Bed mobility Correlation (r) 0.091 0.211 0.165Significance (p) 0.524 0.138 0.247

Sit to stand Correlation (r) 0.001 0.438* 0.288*

Significance (p) 0.995 0.001 0.041Bed to chair Correlation (r) )0.073 0.373* 0.208

Significance (p) 0.611 0.007 0.142Climbing 4 stairs Correlation (r) )0.113 0.210 0.091

Significance (p) 0.431 0.140 0.524Outdoor mobility Correlation (r) )0.134 0.286* 0.128

Significance (p) 0.348 0.042 0.372Standing balance Correlation (r) 0.000 0.437* 0.287*

Significance (p) 0.999 0.001 0.041Gait and mobility Correlation (r) )0.137 0.285* 0.126

Significance (p) 0.339 0.043 0.378

QOL WHOQOL domain 1 (physical health) Correlation (r) )0.292* )0.422* )0.407*

Significance (p) 0.038 0.002 0.003WHOQOL domain 2 (psychological health) Correlation (r) )0.321* )0.383* )0.389*

Significance (p) 0.022 0.006 0.005WHOQoL domain 3 (social relationships) Correlation (r) 0.092 )0.204 )0.100

Significance (p) 0.521 0.151 0.484WHOQOL domain 4 (environment) Correlation (r) )0.233 )0.294* )0.322*

Significance (p) 0.100 0.036 0.021

* Significant at p < 0.05 level

Table 1 – HAD scores for patients, controls and carers

HAD anxiety score* HAD depression score*

Patients (n = 51) Normal 41 (80.4%) 25 (49.0%)Mild 7 (13.7%) 14 (27.5%)Moderate 3 (5.9%) 12 (23.5%)Severe 0 0

Carers (n = 27) Normal 21 (77.8%) 16 (59.3%)Mild 4 (14.8%) 8 (29.6%)Moderate 1 (3.7%) 2 (7.4%)Severe 1 (3.7%) 1 (3.7%)

Controls (n = 58) Normal 56 (96.6%) 27 (46.6%)Mild 2 (3.4%) 16 (27.6%)Moderate 0 15 (25.9%)Severe 0 0

Patient vs Control (Mann–Whitney U test) U = 1122.5, z = )2.183, p = 0.029** U = 1357.5, z = )0.740, p = 0.459Patient vs carer (Spearman correlation) r = 0.390, p = 0.089 r = 0.455, p = 0.044**

Carer vs control ((Mann–Whitney U test) U = 735.5, z = )0.453, p = 0.651 U = 644.0, z = )1.318, p = 0.187

* 0–7 normal, 8–10 mild, 11–15 moderate, 16–21 severe.

**Significant at p < 0.05 level.

N E U R O L O G Y, P S Y C H I A T R Y A N D B R A I N R E S E A R C H 1 8 ( 2 0 1 2 ) 1 2 2 – 1 2 8 125

between these two groups. Higher levels of depression in pa-

tients were associated with reduced motor performance and

lower scores in the physical section of the WHOQOL-Bref,

indicating that physical impairment may contribute to higher

rates of post-stroke depression. This association has also

been noted by other authors.30

In the current study almost one fifth of patients reduced

HAD anxiety scores, compared to less than 5% of controls.

HAD depression scores were similar in patients and controls,

with around half having some form of depression and around

a quarter having moderate or severe depression.

A UK-based study noted that, of 96 stroke survivors com-

pleting the HAD, 32% of patients had some form of anxiety

and 37% some form of depression. In carers, 32% had anxi-

ety and 16% depression.15 These results are broadly in line

with our own, although levels of depression in our study

were generally higher, notably in carers. The high levels of

depression that we have documented bear comparison to

126 N E U R O L O G Y, P S Y C H I A T R Y A N D B R A I N R E S E A R C H 1 8 ( 2 0 1 2 ) 1 2 2 – 1 2 8

data from other world regions. A hospital-based study

which followed up 80 patients at 3–6 months after their

stroke in Malaysia found that 51% were mildly depressed

and 15% were severely depressed.31 The authors found the

presence of depression to be associated with greater age

and poorer performance in functional activities of daily liv-

ing. However, the cohort had a mean age of only 56.8 years

and therefore may not be representative of the wider stroke

community. A door-to-door survey of 45 stroke survivors in

rural China found that 62.2% were depressed, at a mean

interval of 5.7 years post-stroke32. Furthermore, 33.4% of

1471 people from the background population were also

depressed.

In our study, the use of regular antihypertensive medica-

tion was associated with reduced levels of anxiety and

depression. Hypertension is a risk factor for stroke and has

been associated with poor outcomes.33 Research has also

shown that patients diagnosed with hypertension who

regularly use antihypertensive drugs prior to stroke have less

severe strokes and more favourable outcomes.34 Our results

indicate that the benefits of antihypertensive medication

may extend beyond physical effects and may improve psy-

chological wellbeing, possibly by helping to reassure patients

that they are taking positive action to reduce their risk of

further stroke.

Amongst carers, rates of anxiety and depression were

similar to those noted by Wilkinson et al.15 and lower than

levels noted in an Australian study by Anderson et al.35 The

Australian study looked at factors affecting distress in carers

for stroke survivors at one year post-stroke and found high

levels of anxiety (58%) and depression (50%) using the HAD

scale.35

Although very little research has been conducted in low-

income countries, a hospital-based Nigerian study noted that

22.3% of stroke caregivers had clinically significant anxiety

symptoms compared with 11.7% of controls.36 Moreover,

24.3% of caregivers reported depressive symptoms in compar-

ison with 13.6% of controls.

Interestingly, in our study increased carer anxiety and

depression levels were associated with lower informant-re-

ported cognitive function of patients, suggesting poor cogni-

tive function in patients may cause symptoms of anxiety and

depression in carers. This relationship has been noted by other

authors.35

This study has certain limitations. Firstly, the medical

care received by the cohort may not be truly representative

of the wider population of stroke survivors in SSA, as they

were involved in an incidence study and transport to hospi-

tal for assessment at the time of stroke was paid for by the

study. Secondly, people in both the case and control groups

struggled to grade their emotions and physical and mental

health status on a rating scale (HAD and WHOQOL-Bref

scores). A large number of participants had never been

asked to do this before and the reason for doing so was

not always clear to them. However, both of these scales

have previously been used to assess post stroke survivors

in SSA and the HAD has been validated in Nigeria.24 Six pa-

tients did not complete the HAD due to aphasia or dysphasia

and one patient, who was noted to have a very low mood re-

fused to complete it. It may be that these patients, who were

more severely affected by their strokes, had higher levels of

anxiety and depression but were unable to express their emo-

tions. This missing data could have influenced the signifi-

cance of our results and conclusions. However, it is likely

that all studies on the psychiatric sequelae of stroke would

have a similar limitation. Interestingly, no patients were ex-

cluded due to having dementia. We feel this may reflect the

fact that many stroke cases who had dementia may have died

prematurely prior to follow-up. This observation requires fur-

ther investigation. Finally, we recognise that there was a large

variation between cases in time since stroke. Although this is

far from ideal, and may have lowered the degree of homoge-

neity in our data, it is interesting that nether anxiety of

depression score were associated with the time elapsed since

stroke.

5. Conclusions

Low- and middle-income countries endure more than two

thirds of the worldwide stroke burden which means that a

greater understanding of stroke and its wider impact on psy-

chological health is needed to allow the planning of effective

stroke services.37 To our knowledge this is the first long-term

follow-up study of incident stroke cases in SSA which has

examined the psychological health of stroke survivors and

their carers. This research helps to characterise the impact

of post stroke anxiety and depression among a representa-

tive cohort of stroke survivors and their carers in rural

Tanzania.

Our results, together with those from other world regions,

emphasise the need for community-based rehabilitation ser-

vices. Such services should not only consider the stroke sur-

vivor but also the caregiver’s medical, social and emotional

needs. Local health workers could receive training to allow

them to identify stroke patients and carers with psychological

morbidity. This might be achieved through community-based

screening for mental health problems. Appropriate interven-

tions and treatment could then be offered to the relevant

stroke survivors and carers, including self-help guides, coun-

selling and pharmacological therapy. Additional support

through community organisations and the patient’s wider

family might also be developed to help reduce the stress

and burden on the main caregiver and allow time for leisure

and social activities.

As SSA continues to undergo demographic transition,

stroke is emerging as a leading cause of death and disability

and there is a need to develop effective rehabilitation services

in both the hospital and the community.38 These services

should not only address the physical effects of stroke but

must also tackle psychological morbidity among patients

and their carers. National and international bodies should

encourage the development of these services in order to

offset the high social and economic cost which is likely to re-

sult from the rising prevalence of stroke in the developing

world.

6. Conflicting interests

None.

N E U R O L O G Y, P S Y C H I A T R Y A N D B R A I N R E S E A R C H 1 8 ( 2 0 1 2 ) 1 2 2 – 1 2 8 127

7. Funding

This work was funded by a grant from the Wellcome Trust,

UK. They had no role in study design; in the collection, anal-

ysis and interpretation of data; in the writing of the report;

and in the decision to submit the article for publication.

Acknowledgements

We would like to thank all health-care workers, officials,

carers and family members who helped in the identification

of patients, the inputting of data and in the examination

and assessment process. We would also like to acknowledge

Professor Nigel Unwin and Professor George Alberti, who

were part of the TSIP study group, for their helpful advice.

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