Stroke survivors with PTSD more likely to avoid treatment

(Press-News.org) New York, NY — A new survey of stroke survivors has shown that those with post-traumatic stress disorder (PTSD) are less likely to adhere to treatment regimens that reduce the risk of an additional stroke. Researchers found that 65 percent of stroke survivors with PTSD failed to adhere to treatment, compared with 33 percent of those without PTSD. The survey also suggests that nonadherence in PTSD patients is partly explained by increased ambivalence toward medication. Among stroke survivors with PTSD, approximately one in three (38 percent) had concerns about their medications. Results of the study, led by Columbia University Medical Center researchers, are published today in the British Journal of Health Psychology.

According to data from the American Stroke Association, nearly 795,000 Americans each year suffer a new or recurrent stroke. Stroke is the fourth-leading cause of death and the top cause of disability in the United States. Survivors of strokes are often prescribed treatment regiments, including antiplatelet agents, antihypertensive agents, and statins, which help reduce the risk of subsequent strokes. Previous research has shown that PTSD triggered by medical events—which affects 18 percent of stroke survivors—may impair recovery.

"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," said Ian M. Kronish, MD, MPH, assistant professor of medicine (Center for Behavioral Cardiovascular Health) and one of the study's authors.

"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."

The researchers asked 535 stroke survivors about PTSD symptoms, adherence to medications, and beliefs or concerns about medications. Participants were recruited between March 2010 and January 2012 as part of Mount Sinai Medical School's Preventing Recurrence of All Inner City Strokes through Education (PRAISE) clinical trial in Harlem and the Bronx. Participants were eligible for the trial if they were at least 40 years old and self-reported a history of stroke or transient ischemic attack (TIA) in the prior 5 years (average was 1.9 years after most recent stroke or TIA).

Compared with stroke patients without PTSD symptoms, patients with PTSD felt more ambivalence toward medication, worried more about the long-term effects of medication, and complained about the way medication disrupted their lives. Furthermore, PTSD was associated with somewhat increased belief in the general harm and overuse of medications in the medical system.

Previous research with the same cohort had found that stroke survivors with the most severe PTSD symptoms were nearly three times as likely as those without PTSD symptoms 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," said Donald Edmondson, PhD, assistant professor of behavioral medicine (Center for Behavioral Cardiovascular Health) and first author of the paper. "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."

### The paper is titled, "Concerns About Medications Mediate the Association of Posttraumatic Stress Disorder With Adherence to Medication in Stroke Survivors." The other contributors, from Mount Sinai School of Medicine, are Carol R. Horowitz, Judith Z. Goldfinger, and Kezhen Fei.

Dr. Edmondson is supported by grants KM1 CA-156709 and HL-088117 from the National Institutes of Health, Bethesda, Maryland. Dr. Horowitz, Dr. Goldfinger, and Ms. Fei received support from the National Institute of Minority Health and Health Disparities (P60MD00270), and Dr. Horowitz received funding from the National Center for Research Resources (UL1RR029887). Dr. Kronish received support from the National Heart, Lung and Blood Institute (K23 HL098359).

The authors declare no financial or other conflicts of interest.

The Center for Behavioral Cardiovascular Health at Columbia University Medical Center is an interdisciplinary team of more than 40 scientists dedicated to understanding how and why behaviors, psychological factors, and societal forces influence hypertension and cardiovascular disease. The center conducts basic, translational, and clinical research and provides educational opportunities for health care professionals interested in this area.

Columbia University Medical Center provides international leadership in basic, pre-clinical, and clinical research; medical and health sciences education; and patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the College of Physicians and Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Established in 1767, Columbia's College of Physicians and Surgeons was the first institution in the country to grant the MD degree and is among the most selective medical schools in the country. Columbia University Medical Center is home to the largest medical research enterprise in New York City and State and one of the largest in the United States. Its physicians treat patients at multiple locations throughout the tri-state area, including the NewYork-Presbyterian/Columbia campus in Washington Heights, the new ColumbiaDoctors Midtown location at 51 W. 51st St. in Manhattan, and the new ColumbiaDoctors Riverdale practice. For more information, visit www.cumc.columbia.edu or columbiadoctors.org.