Fatalism, optimism, spirituality, depressive symptoms and stroke outcome: A population-based analysis

Abstract

Background and Purpose

We sought to describe the association of spirituality, optimism, fatalism and depressive symptoms with initial stroke severity, stroke recurrence and post-stroke mortality.

Methods

Stroke cases June 2004–December 2008 were ascertained in Nueces County, Texas. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and non-organizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed NIHSS and Cox proportional hazards regression for recurrence and mortality.

Results

669 patients participated, 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (HR=1.41, 95%CI: 1.06, 1.88), marginally associated with risk of recurrence (HR=1.35, 95%CI: 0.97, 1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (HR=1.32, 95%CI: 1.02, 1.72), marginally associated with stroke recurrence (HR=1.22, CI: 0.93, 1.62), and with a 9.0% increase in stroke severity (95%CI: 0.01, 18.0). Depressive symptoms altered the fatalism-mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence or mortality.

Conclusions

Among patients who have already had a stroke, self-described pre-stroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations, and may be novel targets for intervention.

INTRODUCTION

Fatalism, optimism and spirituality are important psychological factors that are associated with health^1–4. Little attention has been paid to the role of these factors in stroke outcome. Potential mechanisms whereby these factors may influence stroke outcome include influencing medication adherence and behavioral strategies (eg. diet and exercise) to prevent recurrence, and assertiveness in seeking acute medical care. Depression may influence the association of these psychological factors with stroke outcome as depression is clearly associated with stroke outcome⁵ and is also associated with these psychological factors^{6, 7, 8}. Depression has also been linked to vascular disease pathophysiology⁹.

In a population-based study, we asked subjects who had recently had a stroke to provide information on pre-stroke fatalism, optimism and spirituality and examined associations with stroke outcome including initial stroke severity, stroke recurrence and all-cause mortality following stroke. We further wished to explore the role of pre-stroke depressive symptoms in the potential association of these psychological factors and the stroke outcome measures. We interviewed subjects soon after stroke and asked them to self-report their levels of pre-stroke fatalism, optimism, spirituality and depressive symptoms and then estimated associations between their responses to these measures with stroke outcome.

METHODS

This was a primary, pre-specified analysis of the Brain Attack Surveillance in Corpus Christi (BASIC) project.

Subjects and setting

This project was approved by the University of Michigan and both Corpus Christi Health Systems’ IRBs. Informed consent was obtained from all subjects. Stroke cases presenting between June 2004 and December 2008 were ascertained in Nueces County, Texas. The details of the BASIC methods were previously published¹⁰. Briefly, through active and passive surveillance BASIC ascertains all cases of acute cerebrovascular disease presenting to the emergency department or directly admitted to any of the seven hospitals in Nueces County. Trained and certified abstractors verify stroke diagnoses based on rigorous criteria. Stroke cases are validated by neurologists using source documentation following international clinical criteria. Abstractors obtain demographic and clinical information from the medical chart.

Interview Methods

At the time of their stroke hospital admission, patients were approached and asked to participate in an in-person, structured interview. Patients unable to answer a series of orientation questions asked before the interview were excluded from this study, as were patients with aphasia. Patients were queried on pre-stroke fatalism, optimism, spirituality and depressive symptoms using validated scales. Bilingual abstractors conducted the interview in English or Spanish depending on patient preferences. Subjects were eligible only with their first BASIC stroke.

Scales

A description of the scales used to measure fatalism, optimism, spirituality and depressive symptoms was previously reported¹¹. For each scale, an overall score was determined by summing responses to individual items. A modified version of the Mental Adjustment for Stroke Scale (MASS) and the Pearlin scale was used to assess Fatalism^{7, 12, 13}. Each item in the scale was scored with a Likert scale ranging from 1, strongly agree, to 5, strongly disagree (Cronbach’s α = 0.66). Scores can range from 8 to 40 with higher scores indicating more fatalism. Optimism was assessed with the revised Life Orientation Test (LOT-R)¹⁴. A Likert scale was used here as well. Items were reverse coded such that higher scores corresponded to more optimism, with possible scores ranging from 6 to 24 (Cronbach’s α = 0.72). The non-organizational religious items from the Strawbridge’s religiosity scale were used to assess spirituality¹⁵. These two items asked about the role of spirituality in defining one’s meaning in life and the importance of spirituality in one’s daily activities. A Likert scale ranging from 1 (very important) to 4 (not at all important) was used. The responses were reverse coded and summed to obtain a scale ranging from 2 to 8 with higher values indicating higher importance of spirituality. The Patient Health Questionnaire (PHQ-9) was used to evaluate depressive symptoms; a scale validated in stroke patients and Spanish speaking patients admitted to the hospital^{16, 17}. Scores range from 0, no depressive symptoms, to 27, all 9 symptoms occurring daily (Cronbach’s α = 0.82).

Identification of Initial Stroke Severity, Recurrent Stroke, and Mortality

Initial stroke severity was measured by chart abstracted presenting NIHSS; a previously validated measure¹⁸. Recurrent ischemic stroke, intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) was determined from BASIC surveillance. All-cause mortality was determined from the medical record for in-hospital mortality, or through Texas Department of Health (TDH) databases or the Social Security Death Index (SSDI). All-cause mortality and recurrence were ascertained thru December 31, 2009.

Statistical Analysis

Descriptive statistics were computed for demographic and clinical characteristics using means and standard deviations (sd) for continuous measures or frequencies and percents for categorical variables. The correlation among the fatalism, optimism, spirituality and depressive symptoms scales were calculated, as well as the skewness of the scales’ distributions.

The time until mortality was calculated by subtracting the date of the stroke from either the date of death or December 31, 2009. A similar procedure was done for time until recurrence; however, if a patient died without a recurrent stroke, then the time until recurrence was censored as of the date of death. Kaplan-Meier (KM) curves for recurrence and mortality were estimated.

The associations between individual fatalism, optimism, spirituality and depressive symptoms scales and stroke outcome were investigated using multiple linear regression with log-transformed NIHSS as the dependent variable and Cox proportional hazards regression for time to recurrence or mortality. All scales were treated as continuous predictors. Measures of association, i.e., percent increase in NIHSS or hazard ratios (HR), were expressed as the comparison of the 75^th with the 25^th percentile of the continuous scale. Models were estimated without adjustment, adjusted for demographics (continuous age, sex and ethnicity), and “fully” adjusted for demographics and clinically important outcome predictors. Clinical factors were chosen on the basis of being associated with both psychological factor (spirituality, optimism, spirituality) and the stroke outcomes, as informed on the basis of exploratory bivariate analyses. Clinical factors in the models were: history of hypertension, NIHSS, history of stroke/TIA, coronary artery disease, and diabetes; models of recurrence: history of stroke/TIA and diabetes; stroke severity models: smoking status. To evaluate the role of depressive symptoms on the psychological factor-outcome associations, models were estimated with additional adjustment for the depressive symptom scale, as well as models to evaluate effect modification (interaction) of the psychological factor effects by depressive symptoms. Because the models included both psychological factors and depression scales as continuous predictors (and their interaction), the psychological factor effect estimates were computed among those with zero depressive symptoms, and among those with a depression score of 15, the 90^th percentile of the depression scores in this sample for interpretation. Influence and residual diagnostics were employed to check model assumptions and fit, and cumulative sums of residuals were used to examine any potential lack of linearity between stroke outcome and the scales and continuous predictors. No violations from model assumptions were found. We conducted sensitivity analyses by adjusting models for comorbidity (operationalized as the count of the following conditions present in the patient: Hypertension, diabetes, coronary artery disease, atrial fibrillation, high cholesterol, excessive alcohol, smoker, history of stroke, congestive heart failure, end stage renal disease, any cancer, dementia and COPD).

RESULTS

A total of 3053 cerebrovascular patients were identified during the time frame, 2040 ischemic stroke, 335 ICH, 57 SAH, 11 unknown and 610 TIA. Of the events, 2439 were the first stroke captured by BASIC and eligible for this study (1623 ischemic stroke, 285 ICH, 56 SAH, 469 TIA, 6 unknown). Of these, a random sample of 1944 subjects were asked to participate in the structured interview and 1380 participated (970 ischemic stroke, 153 ICH, 28 SAH, 2 unknown, 227 TIA). Participants (13.9%) versus non participants (9.5%) had significantly (p=0.04) higher rates of atrial fibrillation, but no other risk factor differences were found. After exclusions due to inability to answer orientation questions or aphasia, 795 patient interviews were available (562 ischemic stroke, 48 ICH, 11 SAH, 174 TIA). Of these, 759 patient interviews had information on the psychological factor and depressive symptom scales, but 44 patients answered questions 6 months after their stroke and were excluded by pre-defined criteria, leaving 715 subjects. Because very few patients reported other ethnicities, only data from Mexican Americans or non Hispanic whites were included, for a study sample comprised of 669 patients (476 ischemic strokes, 42 ICH, 7 SAH, 144 TIA). The median (Q1-Q3) time from stroke to interview for participants was 13.4 days (3.6–52.6). Table 1 presents the demographic and clinical characteristics of the study subjects. Excluded (N=1380–669=711) participants had higher rates (p<0.01) of atrial fibrillation (17.8%), high cholesterol (33.8%) and history of stroke (28.2%), as well as be older (mean age 73.1) and higher severity (41.5% had NIHSS>7) compared to included participants. Median (IQR) length for follow up for recurrence and mortality were 1128 (719, 1505) and 1094 (708, 1491) days, respectively. Kaplan-Meier estimates of 2-year cumulative mortality and stroke recurrence were 10.7% and 9.1%, respectively (Figure 1).

Table 1.

Demographic and clinical information on study subjects.

Characteristic	Overall N(%)		Men N(%)		Women N(%)		p
Age, yr							0.92
45–59	227	33.9	116	33.8	111	34.1
60–74	253	37.8	132	38.5	121	37.1
>=75	189	28.3	95	27.7	94	28.8
Female Sex	326	48.7
Mexican American	358	53.5					0.24
Hypertension	516	77.1	259	75.5	257	78.8	0.31
High Cholesterol	286	42.8	161	46.9	125	38.3	0.03
Atrial fibrillation	61	9.1	28	8.2	33	10.1	0.38
Coronary artery disease	213	31.8	131	38.2	82	25.2	<0.001
Diabetes	276	41.3	143	41.7	133	40.8	0.82
Current smoking	137	20.6	82	24.1	55	17	0.02
History of stroke	149	22.3	69	20.1	80	24.5	0.17
Presenting NIHSS score							0.76
0–1	218	32.6	114	33.3	104	31.9
2–3	157	23.5	77	22.5	80	24.5
4–7	191	28.6	102	29.8	89	27.3
>7	102	15.3	49	14.3	53	16.3

Figure 1.

Kaplan-Meier survival curves (solid) and confidence intervals (dashed) for a) stroke recurrence, b) mortality

Median (IQR) scores for the depressive symptoms and fatalism, optimism were: depression: 4 (1–8); fatalism: 17 (13–21); optimism: 19 (16–22). The derived spirituality scale was strongly positively skewed as 67.5% of subjects obtained the highest score due to reporting strong agreement with both questions that religious or spiritual beliefs provide meaning in their life and their daily activities; scale median (IQR) was 8 (7–8) (Figure 2).

Figure 2.

Distribution of responses for the three psychological factor scales and depression. a) Fatalism, b) Optimism, c) Spirituality and d) Depression

Responses to questions about fatalism and optimism were highly, but not perfectly negatively correlated (r= −0.55) suggesting they provide distinct information. As expected, depression and optimism were also negatively correlated (r= −0.31). Depression was only moderately correlated with fatalism (r= 0.35).

In fully adjusted models (Table 2), an increase from the first to third quartile, i.e., an IQR increase, of depressive symptom scores was associated with increased mortality (HR=1.32, 95%CI: 1.02, 1.72), marginally associated with risk of stroke recurrence (HR=1.22, 95%CI: 0.93, 1.62), and with a 9.0% increase in stroke severity (95%CI: 1.0%, 18.0%).

Table 2.

The associations of depression and fatalism with mortality, stroke recurrence and initial stroke severity. Effect estimates represent relative change in outcome per inter quartile range increase in depression or fatalism.

Scale	Mortality		Recurrence		Stroke severity
	HR	95% CI	HR	95% CI	exp(β)	95% CI
Depression
Crude	1.19	(0.94, 1.51)	1.32	(1.01, 1.72)	1.09	(1.01, 1.18)
Adj. demographics¶	1.45	(1.13, 1.89)	1.31	(0.99, 1.72)	1.08	(0.99, 1.17)
Fully adjusted§	1.32	(1.02, 1.72)	1.22	(0.93, 1.62)	1.09	(1.00, 1.18)
Fatalism
Crude	1.57	(1.19, 2.09)	1.42	(1.02, 1.98)	1.05	(0.96, 1.15)
Adj. demographics¶	1.52	(1.15, 2.02)	1.43	(1.02, 1.98)	1.06	(0.96, 1.16)
Fully adjusted§	1.41	(1.06, 1.88)	1.35	(0.97, 1.88)	1.06	(0.97, 1.17)
Fully adjusted§ + Depression	1.17	(0.85, 1.62)	1.30	(0.90, 1.87)	1.02	(0.93, 1.14)
Fatalism effect modification at two levels of depression
Depression score = 0	1.48	(0.92,2.37)	1.16	(0.69, 1.95)	1.02	(0.88, 1.17)
Depression score = 15	0.84	(0.46,1.52)	1.49	(0.81, 2.75)	1.05	0.87, 1.27)

^¶Demographics include: age (continuous), sex, and race-ethnicity

^§In addition to demographics, stroke severity models included: smoking status; recurrence models included: history of stroke and diabetes; mortality models included: history of hypertension, NIHSS, history of stroke, coronary artery disease, and diabetes.

An IQR Increase in fatalism was associated with increased mortality (HR=1.41, 95%CI: 1.06, 1.88), and marginally associated with increased risk of recurrence (HR=1.35, 95%CI: 0.97, 1.88) (Table 2). The association between fatalism and severity was not significant. Depression may, at least in part, explain the relationship of fatalism with stroke mortality and recurrence since after adjustment for depressive symptoms, the fatalism-mortality and the fatalism-recurrence associations were attenuated and no longer significant (mortality: HR=1.17, 95%CI: 0.85, 1.62; recurrence: HR=1.30, 95%CI: (0.90,1.87). However, the role of depression in the fatalism-stroke outcome association may be more complex, since the effect of fatalism among patients reporting zero depressive symptoms was strong and marginally significant (HR=1.48, 95%CI: 0.92, 2.37), but not significant among patients with high depression scores.

Spirituality did not confer a significant effect on stroke severity, recurrence or mortality (Table 3). Optimism was not associated with any of the stroke outcome measures, although the direction of the observed associations was towards protective effects of increased optimism on both recurrence and mortality.

Table 3.

The association of spirituality and optimism with initial mortality, stroke recurrence, and stroke severity. Effect estimates represent relative change in outcome per inter quartile range increase in spirituality or optimism.

Scale	Mortality		Recurrence		Stroke severity
	HR	95% CI	HR	95% CI	exp(β)	95% CI
Spirituality
Crude	1.02	(0.91, 1.14)	1.07	(0.90, 1.26)	0.98	(0.94, 1.02)
Adj. demographics¶	0.96	(0.83, 1.11)	1.02	(0.86, 1.22)	0.98	(0.93, 1.02)
Fully adjusted§	0.97	(0.83, 1.12)	1.03	(0.86, 1.23)	0.98	(0.94, 1.03)
Fully adjusted§ + Depression	0.95	(0.82, 1.12)	1.05	(0.87, 1.27)	0.99	(0.95, 1.04)
Optimism
Crude	0.66	(0.40, 1.09)	0.88	(0.48, 1.60)	1.00	(0.84, 1.18)
Adj. demographics¶	0.65	(0.40, 1.07)	0.89	(0.48, 1.62)	1.00	(0.84, 1.18)
Fully adjusted§	0.70	(0.43, 1.15)	0.94	(0.51, 1.72)	1.00	(0.85, 1.18)
Fully adjusted§ + Depression	0.84	(0.50, 1.42)	1.05	(0.56, 1.98)	1.05	(0.88, 1.25)

^¶Demographics include: age (continuous), sex, and race-ethnicity

^§In addition to demographics, mortality models included: history of hypertension, NIHSS, history of stroke, coronary artery disease, and diabetes; recurrence models included: history of stroke and diabetes; stroke severity models included: smoking status.

The sensitivity analysis including an index of comorbidity in the models, based on N=555, detected only a change in the association of depression and initial stroke severity which was attenuated to a 6% increase in severity, 95%CI: −3%, 16%, versus 9% in the full sample.

DISCUSSION

Unconventional risk factors may explain some of the variability in stroke outcome observed in populations, and may be novel targets for intervention. In this study, pre-stroke depressive symptoms and fatalism, but not optimism or spirituality were associated with increased risk of stroke recurrence and mortality. The association of depressive symptoms with a 32% increase in mortality following stroke is modestly lower compared with other reports from longitudinal studies in Alameda County, California (HR=1.66, 95% CI 1.16–2.39)¹⁹, and in NHANES (RR=1.73, 95% CI 1.3–2.31)²⁰. Depressive symptoms were also associated with worsened initial stroke severity.

The association of fatalism and depressive symptoms with mortality following stroke was complex. Because depression was associated both with fatalism and stroke mortality, it attenuated the relationship of fatalism with mortality following stroke. Additionally, among subjects not reporting depressive symptoms, fatalism was associated with mortality following stroke, but this was not the case among subjects with more symptoms of depression.

More generally, this is the first study to associate pre-stroke fatalism with poor stroke outcome. Lewis et al. studied subjects who had survived more than six months post-stroke and found a significant association of fatalism with long-term mortality¹². We hypothesize that those with more fatalistic attitudes are less likely to practice behavioral strategies to prevent disease, comply with medication or aggressively seek acute care. However, some have questioned the causal relationship of fatalistic attitudes with health behavior². This is particularly true in Hispanic populations where concerns regarding cultural sensitivity of survey instruments have made some authors suggest that measurement error explains the robust association of fatalism with health behavior noted in Hispanic populations^{1, 21}. Whether fatalism and depression change or are modifiable through the life-course remains to be determined and could impact the usefulness of these variables as targets for intervention²².

Although the direction of the association of optimism with stroke outcome events were in the expected direction (i.e., protective effects of optimism), our findings were neutral. Optimism has not been evaluated in stroke studies in the past, but has been shown to be independently associated with reduced coronary heart disease risk²³. We also did not detect an association of spirituality with stroke outcome. The scale we used asked subjects about the role that spirituality had in their daily lives. We found that the overwhelming majority of subjects reported high spirituality (Figure 2). It may be difficult for patients facing an uncertain future to communicate negative feelings on spirituality even when asked about pre-stroke beliefs. In the future, studies that examine frequency of religious practice (praying or attending services) may be measures with greater variability and thus allow investigation of the association of religiosity with stroke outcome. Studies examining the association of stroke and spirituality have shown mixed results. One study of 112 subjects in stroke rehabilitation found no association of spirituality with any measure of stroke recovery²⁴. One study found an association of spirituality with reduced emotional distress following stroke²⁵. That study suggests that spirituality may reduce depression, which has been associated with poor stroke functional recovery²⁶.

This paper has important limitations. We asked participants to recall pre-stroke beliefs soon after stroke. This is subject to recall bias as the stroke event may alter one’s recall of their feelings. An alternative explanation for our findings is that post-stroke rather than pre-stroke depression and fatalism are associated with stroke outcome. We excluded subjects with severe deficits since we previously demonstrated that proxy reports for psychological measures correlated only fairly with subject responses²⁷. This means our current work speaks only to subjects with mild or moderate stroke and without aphasia. This study, while population-based, is from a single community of specific race/ethnic composition; generalizing the results to other communities may be inappropriate.

Summary/Conclusions

This study suggests that reported pre-stroke fatalism and depression are associated with stroke outcome measures. Further research is needed to better clarify this relationship. Using measures of religious practice rather than spirituality to detect a possible association with stroke outcome should also be studied.