3182

See related article, p 3360.

Posttraumatic stress disorder (PTSD) is defined based on exposure to actual or threatened death, injury, or violence and

the presence for ≥30 days postevent of intrusive symptoms (eg, flashbacks), persistent avoidance of stimuli, negative alteration in mood and cognition, and marked alteration in arousal and reactiv-ity (eg, hypervigilance).1 Although diagnostically distinct, PTSD symptoms overlap with symptoms of depression and anxiety, making it complex to evaluate the unique associations between these different conditions and their contribution to disease tra-jectory or outcome. In patients with cerebrovascular disease, depression and anxiety have been much more frequently investi-gated than PTSD, with prevalence estimates for these conditions typically ranging from 20% to 30% in the poststroke period,2–4 leading to recommendations to screen all stroke patients for depression in the early poststroke period.5 A sprinkling of studies of mixed populations of both stroke and transient ischemic attack (TIA) patients have reported estimates of PTSD ranging from 10% to 25%,6,7 with higher prevalence estimates when based on self-rated measures than by interview. While evidence-based interventions for PTSD after more traditional traumatic precipi-tants exist,8 these limited data in stroke or TIA have not been suf-ficient to support routine PTSD awareness, screening, diagnosis, or management activities after cerebrovascular events.

The prospective, cross-sectional study of Kiphuth and col-leagues9 used the Posttraumatic Stress Diagnostic Scale, a self-rated symptom measure that maps onto DSM criteria, to assess PTSD occurrence at 3 months after TIA. Findings were an ≈10× higher occurrence of PTSD (=29.6%) at 3 months after TIA relative to the general population prevalence in Germany; even if all those lost to follow-up were projected to not have PTSD, the estimated prevalence (15%) was still 5× that of the general population. Co-occurring depression and anxiety symptoms were common in those who were classified

as having PTSD. Further, PTSD at 3 months post-TIA was associated with maladaptive coping, higher perceived risk of stroke, and aspects of health-related quality of life, but not with knowledge about stroke.

There is a relatively robust literature on PTSD after a variety of acute medical events, so it is not clear if PTSD after TIA or stroke is a different phenomenon than what might be seen with other acute healthcare-related situational stressors. The occurrence of PTSD post-TIA in the present study is consistent with PTSD prevalence after cardiac events, intensive care unit admissions, and other stressful medical events.10 A recent review of research on PTSD after acute coronary events emphasized that although a range of patient factors have been associated with PTSD onset after these events, external and modifiable systems-level factors also appear to be at play, for example, greater emergency department crowd-ing.11 Importantly, a pooled meta-analysis reported that a positive PTSD screen after acute coronary syndrome was associated with a doubling of the risk of a subsequent event, either recurrent car-diovascular event or death, raising the possibility for significant adverse outcomes for cerebrovascular patients, as well.12

Although the specificity of the association between TIA and PTSD is not fully understood, the study in this issue of Stroke raises awareness that TIA may fairly commonly initiate or exac-erbate bothersome psychological symptoms after the event that are independent from any change in physical function. This finding is clinically important because psychological symptoms after stroke and TIA are known to be associated with adverse outcomes, including increased risk of subsequent vascular events and mortality.13,14 It will be critical to explore the mechanisms mediating any associations of PTSD and stroke or TIA outcomes; for example, one study of PTSD and stroke patients found that poststroke self-reported medication nonadherence was 67% among those screening positive for PTSD, compared with 35% for those without PTSD symptoms, according to the checklist that was administered.15 Future work should include larger pro-spective, longitudinal cohort studies that include diagnostic mea-sures of PTSD, depression, and anxiety poststroke to elucidate the unique influence of these conditions on patient outcomes and modifiable factors mediating those associations and to provide guidance on application of existing evidence-based interventions that are tailored to specific, clinically predominant symptoms.

DisclosuresNone.

References 1. American Psychiatric Association. Diagnostic and Statistical Manual

of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013.

Posttraumatic Stress Disorder After Cerebrovascular EventsBroadening the Landscape of Psychological Assessment

in Stroke and Transient Ischemic Attack

Barbara G. Vickrey, MD, MPH; Linda S. Williams, MD

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

From the Department of Neurology, University of California, Los Angeles (B.G.V.); Department of Neurology, Greater Los Angeles Veteran's Administration HealthCare System, Los Angeles, CA (B.G.V.); Department of Neurology, Indiana University School of Medicine, Indianapolis (L.S.W.); Department of Neurology, Richard L. Roudebush Veteran's Administration Medical Center, Indianapolis, IN (L.S.W.); and Regenstrief Institute, Inc, Indianapolis, IN (L.S.W.).

Guest Editor for this article was Eric E. Smith, MD, MPH.Correspondence to Barbara G. Vickrey, MD, MPH, UCLA Neurology,

C109 RNRC, 710 Westwood Plaza, Los Angeles, CA 90095. E-mail bvickrey@ucla.edu

(Stroke. 2014;45:3182-3183.)© 2014 American Heart Association, Inc.

Stroke is available at http://stroke.ahajournals.orgDOI: 10.1161/STROKEAHA.114.006865

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Vickrey and Williams PTSD After Cerebrovascular Events 3183

2. Ayerbe L, Ayis S, Wolfe CD, Rudd AG. Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analy-sis. Br J Psychiatry. 2013;202:14–21.

3. De Wit L, Putman K, Baert I, Lincoln NB, Angst F, Beyens H, et al. Anxiety and depression in the first six months after stroke. A longitudinal multicentre study. Disabil Rehabil. 2008;30:1858–1866.

4. Burton CAC, Murray J, Holmes J, Astin F, Greenwood D, Knapp P. Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies. Int J Stroke. 2013;8:545–559.

5. Miller EL, Murray L, Richards L, Zorowitz RD, Bakas T, Clark P, et al; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplin-ary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41:2402–2448.

6. Sembi S, Tarrier N, O’Neill P, Burns A, Faragher B. Does post-traumatic stress disorder occur after stroke: a preliminary study. Int J Geriatr Psychiatry. 1998;13:315–322.

7. Favrole P, Jehel L, Levy P, Descombes S, Muresan IP, Manifacier MJ, et al. Frequency and predictors of post-traumatic stress disorder after stroke: a pilot study. J Neurol Sci. 2013;327:35–40.

8. Jonas DE, Cusack K, Forneris CA, Wilkins TM, Sonis J, Middleton JC, et al. Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD). Comparative Effectiveness Review No. 92. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 13-EHC011-EF. Rockville, MD:

Agency for Healthcare Research and Quality; April 2013. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed August 24, 2014.

9. Kiphuth IC, Utz KS, Noble AJ, Köhrmann M, Schenk T. Increased prevalence of posttraumatic stress disorder in patients after transient ischemic attack. Stroke. 2014;45:3360–3366.

10. Tedstone JE, Tarrier N. Posttraumatic stress disorder following medical illness and treatment. Clin Psychol Rev. 2003;23:409–448.

11. Edmondson D, Cohen BE. Posttraumatic stress disorder and cardiovas-cular disease. Prog Cardiovasc Dis. 2013;55:548–556.

12. Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y. Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS ONE. 2012;7:e38915.

13. Ghose SS, Williams LS, Swindle RW. Depression and other mental health diagnoses after stroke increase inpatient and outpatient medical utilization three years poststroke. Med Care. 2005;43:1259–1264.

14. Williams LS, Ghose SS, Swindle RW. Depression and other mental health diagnoses increase mortality risk after ischemic stroke. Am J Psychiatry. 2004;161:1090–1095.

15. Kronish IM, Edmondson D, Goldfinger JZ, Fei K, Horowitz CR. Posttraumatic stress disorder and adherence to medications in survivors of strokes and transient ischemic attacks. Stroke. 2012;43:2192–2197.

KEY WORDS: Editorials ◼ anxiety ◼ outcome ◼ transient ischemic attack

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Barbara G. Vickrey and Linda S. Williamsof Psychological Assessment in Stroke and Transient Ischemic Attack

Posttraumatic Stress Disorder After Cerebrovascular Events: Broadening the Landscape

Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2014 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/STROKEAHA.114.006865

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