Introduction
Health-related quality of life (HRQoL) is an important indicator of outcome in health care. Several studies have shown that HRQoL is reduced in groups of individuals after experiencing aneurysmal subarachnoid haemorrhage (SAH) [
5,
12,
15,
25,
32,
43]. It is, however, well established that the outcome after SAH differs widely between individuals. An early clinical marker of good outcome and recovery is normal or only slightly affected consciousness on admission, see e.g. [
35]. In general, poorer neurological status at admission [
24], depression, anxiety and fatigue in the aftermath are known to be related to decreased HRQoL [
43]. Furthermore, there is evidence that HRQoL is also reduced in patients with an expected good recovery [
2].
In general, recurrent psychiatric disorders have a negative impact on quality of life [
10]. Moreover, a psychiatric history has a significant impact on HRQoL after several somatic conditions [
3,
14] and after surgery [
1,
30,
41]. We have recently shown that a lifetime history of affective and anxiety disorders increases the risk of depression and posttraumatic stress disorder (PTSD) in the aftermath of SAH (Hedlund et al., to be published). Whether or not a history of psychiatric disorder also influences HRQoL after SAH has yet to be explored.
The psychological adaptation process after stroke contains the individual’s ability to cope with the stressful event [
6]. Coping could be described as the individual’s
‘efforts to manage psychological stress’ [
20] and is a process that varies over time and in different situations [
9] or as a dispositional trait [
6]. Coping deals with what an individual is ‘thinking and doing’ to handle a stressful situation and involves efforts to alter the stressful situation (i.e. problem-focused coping) as well as efforts to regulate the emotional distress associated with the situation (i.e. emotion-focused coping). Although people use both problem- and emotion-focused coping in most stressful episodes [
20], current research suggests that some coping strategies are more beneficial than others in order to facilitate adaptation after trauma [
27]. The use of active coping is associated with successful recovery after surgery [
18]. Other coping strategies, such as emotive, evasive and palliative coping strategies are associated with ineffectiveness in handling illness [
21].
Previous studies on stroke patients’ use of coping strategies have involved a wide variety of coping instruments, a wide variety of assessment times and variations in study populations [
6]. Some studies suggest that there are no specific coping strategies used by stroke patients, while other studies indicate that there are [
6]. In particular, it is suggested that depressed stroke patients use coping strategies with less behavioural action than non-depressed stroke patients, which has a negative influence on their participation in the recovery process [
33]. Furthermore, dispositional use of maladaptive coping strategies is associated with development of PTSD after SAH [
25].
Taking this into consideration, we hypothesised that HRQoL after an aneurysmal SAH in patients with an expected good prognosis for recovery was related both to the type of coping used and to a history of psychiatric morbidity. We also hypothesised that a possible explanation could be that those with a history of psychiatric morbidity use different coping strategies than those without such history.
Results
Out of 129 patients who met criteria for inclusion during the study period, 36 (28%) were lost before screening, three declined participation and 33 were not approached due to administrative reasons. The remaining 93 patients (72%) were included. Fifty-nine (63%) of these returned completed SF-36 questionnaires and 53 (57%) returned completed JCS questionnaires. There were no statistically significant differences between the included patients and the remaining eligible cases regarding age, sex, RLS85 at intake or discharge, Fisher grade or WFNS (data not shown).
Thirty patients, 51% of the patients, turned out to have a psychiatric history, either before and/or after the SAH (Table
2). Affective and anxiety disorders were equally common, each affecting close to a third of the patients. Seven of these 30 patients had ongoing antidepressant therapy at the SAH onset.
Table 2
Prevalence rates of psychiatric diagnoses in 59 patients
Any affective disorder | 18 | 31 | 12 | 20 | 21 | 36 |
Any anxiety disorder | 12 | 20 | 16 | 27 | 20 | 34 |
Psychosis UNS | 1 | 2 | 0 | 0 | 1 | 2 |
Any substance use disorder | 7 | 12 | 1 | 2 | 7 | 12 |
Eating disorder | 1 | 2 | 1 | 2 | 1 | 2 |
At least one axis I disorder | 26 | 44 | 22 | 37 | 30 | 51 |
At 7 months after SAH, only six out of the 30 patients with a psychiatric history had returned to work, whereof two worked part time. Five had received psychotropic medication and/or psychological treatment due to SAH-related psychiatric sequels.
Viewed as a group, and in line with previous studies [
5,
15,
25], patients with SAH had a significantly lower HRQoL in all eight domains of the SF-36 compared to the general Swedish population (Table
3). The lower HRQoL was almost entirely in the subgroup of patients with a psychiatric history. Thus, those without a psychiatric history had a lower HRQoL in only one of the eight domains, the physical domain role—physical, while those with psychiatric morbidity experienced a lower HRQoL for all eight domains. When comparing those with and those without a psychiatric history, there were significant differences in HRQoL for all but one of the eight domains, physical functioning (Table
3).
Table 3
Health-related quality of life in patients with aneurysmal subarachnoid haemorrhage presented for each domain and for those with and without a psychiatric history at any time
Physical functioning | 87.9 (19.6) | 74.9 (24.2)*** | 81.4 (22.4) | 68.6 (24.6)*** |
Role—physical | 83.2 (31.8) | 43.6 (44.9)*** | 60.3 (46.1)* | 27.5 (38.0)***(b) |
Bodily Pain | 74.8 (26.1) | 65.2 (28.3)* | 73.7 (31.1) | 57.2 (23.3)*** (a) |
General health | 75.8 (22.2) | 65.9 (22.3)*** | 74.6 (22.8) | 58.1 (18.9)*** (b) |
Vitality | 68.8 (22.8) | 52.5 (26.7)*** | 68.0 (22.7) | 38.0 (21.7)*** (c) |
Social functioning | 88.6 (20.3) | 76.1 (26.7)*** | 88.8 (23.7) | 63.8 (23.8)*** (c) |
Role—emotional | 85.7 (29.2) | 57.9 (43.4)*** | 79.8 (34.4) | 36.8 (41.2)*** (c) |
Mental health | 80.9 (18.9) | 66.6 (24.8)*** | 81.7 (17.4) | 52.5 (22.4)*** (c) |
N
| 8,930 | 59 | 29 | 30 |
As seen in Table
4, HRQoL was strongly, but differentially, correlated to the use of coping. The more physical domains physical functioning, role—physical and bodily pain were, thus, less affected by the use of coping than the more mental domains, mental health, role—emotional, social functioning and vitality. The emotional coping styles, evasive, emotive and palliative, affected all SF-36 domains more than other coping styles.
Table 4
Non-parametric correlations between SF-36 domains (columns) and coping scales (rows)
Confrontative | −0.15 | −0.25 | −0.26 | −0.23 | −0.32* | −0.33* | −0.18 | −0.32* |
Evasive | −0.43** | −0.44*** | −0.47*** | −0.46*** | −0.64*** | −0.55*** | −0.45*** | −0.73*** |
Optimistic | −0.17 | −0.20 | −0.16 | −0.15 | −0.35* | −0.25 | −0.20 | −0.38** |
Fatalistic | −0.28* | −0.27 | −0.35* | −0.38** | −0.50*** | −0.47*** | −0.35* | −0.52*** |
Emotive | −0.40** | −0.43*** | −0.42** | −0.52*** | −0.61*** | −0.60*** | −0.43** | −0.69*** |
Palliative | −0.39** | −0.41** | −0.45*** | −0.44*** | −0.62*** | −0.53*** | −0.43** | −0.65*** |
Supportive | −0.22 | −0.24 | −0.34* | −0.40** | −0.39** | −0.36** | −0.16 | −0.44*** |
Self-reliant | −0.31* | −0.20 | −0.32* | −0.30* | −0.41** | −0.42** | −0.12 | −0.47*** |
The most used coping styles were the problem solving style confrontative, and the emotional styles optimistic and self-reliant. The least used were the emotional styles evasive, fatalistic, emotive and palliative and the problem solving style supportive. Those with a psychiatric history used more coping than the remainder with respect to all emotional coping scales, but not for the problem solving scales confrontative and supportive (Table
5). The difference was most pronounced for the coping styles evasive, fatalistic, emotive and palliative.
Table 5
Use of coping in all patients and divided into those with and without psychiatric history
Confrontative | 1.23 (0.88) | 1.05 (0.99) | 1.44 (0.72) |
Evasive | 0.93 (0.66) | 0.62 (0.61) | 1.27 (0.54)*** |
Optimistic | 1.72 (0.88) | 1.41 (1.01) | 2.07 (0.56)* |
Fatalistic | 1.08 (0.78) | 0.81 (0.75) | 1.40 (0.74)** |
Emotive | 0.62 (0.60) | 0.39 (0.50) | 0.86 (0.63)** |
Palliative | 0.79 (0.57) | 0.55 (0.53) | 1.06 (0.48)*** |
Supportive | 0.77 (0.68) | 0.63 (0.61) | 0.92 (0.73) |
Self-reliant | 1.28 (0.80) | 0.99 (0.82) | 1.59 (0.67)* |
Finally, an attempt was made to use a multiple regression strategy to reveal to what extent the use of coping and the presence of a psychiatric history were independently related to the different HRQoL domains (Table
6).
Table 6
Final models in backward multiple regressions with health-related quality of life assess the domain scores in SF-36 as dependent variables and use of coping, the presence of a psychiatric history and clinical predictors as independent variables
Physical functioning | Evasive | −12.3 | 0.012 | 0.10 |
Role—physical | Evasive | −30.6 | 0.001 | 0.18 |
Bodily pain | Evasive | −20.0 | <0.001 | 0.21 |
General health | Evasive | −16.5 | <0.001 | 0.21 |
Vitality | Evasive | −18.2 | <0.001 | 0.47 |
Psychiatric history | −20.3 | 0.003 | |
Social functioning | Emotive | −18.6 | 0.001 | 0.34 |
Psychiatric history | −16.5 | 0.015 | |
Role—emotional | Psychiatric history | −39.2 | 0.001 | 0.34 |
Emotive | −19.4 | 0.034 | |
Mental health | Evasive | −33.9 | <0.001 | 0.71 |
Psychiatric history | −18.6 | <0.001 | |
RLS85a
| −10.1 | 0.025 | |
Optimistic | 13.2 | <0.001 | |
In those regressions, the explained variance was higher for mental domains, e.g. an adjusted R
2 of 0.71 for mental health and 0.34 for each social functioning and role—emotional, compared to an adjusted R
2 of 0.10 for physical functioning and 0.18 for role—physical. Furthermore, evasive coping itself or emotive coping in combination with the presence of a psychiatric history were the covariates significantly related to most SF-36 domains. A clinical covariate was only included in the final model for mental health, where a high RLS85 at intake was significantly related to a worse HRQoL concerning mental health, e.g. symptoms of anxiety and depression at 7 months.
Acknowledgements
We are very grateful to Professor Lennart Persson, M.D., Ph.D., former Head of the Department of Neurosurgery, Uppsala University Hospital for the initiative to commence this study, for participation during its design and for support during the process. Financial support was provided by the Swedish Research Council, the Uppsala County Council, the Uppsala University Faculty of Medicine, the Nasvell Foundation, the Stroke Foundation, the Anna-Britta Gustafsson Foundation and the Selander Foundation.
In their paper, the authors wanted to test if HRQoL after SAH is related to the type of coping and the history of psychiatric morbidity. They hypothesised that patients with a history of psychiatric disease use different strategies than those without history. They finally could include 59 patients in the prospective study and found that most of the reduction of HRQoL occurs in patients with a former psychiatric history. This is an interesting study showing that prior psychiatric history has an influence on the outcome after SAH on a quite personal level for the patient. This study is in line with many others that emphasise that the sequelae of SAH for the single patient have many aspects and that these are to be seen in the context of earlier patient's history.
Alexander Brawanski
Regensburg, Germany
It is nicely shown in the present study that SAH patients have lower HRQoL than the general population and almost entirely in the subgroup of patients with a previous psychiatric history. This makes sense. SAH is a devastating and seemingly sudden illness in working-age people with high morbidity and mortality. Those who survive often have cognitive or other neurological deficits and may not be able to work despite showing relatively good performance at a neurosurgeon’s out-patient visit after treatment. If we had unlimited resources, all SAH patients would undergo neuropsychological testing before the out-patient visit to exclude memory or psychological disorders. During a short out-patient visit, they may go unnoticed by a neurosurgeon if family members do not provide us other information. Going back to normal activities and work before the patient is ready may lead to difficulties and thereafter even for increased depression in patients. Especially SAH patients with a previous psychiatric history should therefore be thoroughly examined and further treatment and rehabilitation provided at an early phase.
Mika Niemelä
Juha Hernesniemi
Helsinki, Finland