P. W. Burvill

Five-Year Survival After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke Study

Background and Purpose Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke. This study aimed to determine the absolute and relative survival and the independent baseline prognostic factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth, Western Australia. Methods Between February 1989 and August 1990, all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. Results Three hundred seventy patients with first-ever stroke were registered, and 362 (98%) were followed up at 5 years, by which time 210 (58%) had died. In the first year after stroke the risk of death was 36.5% (95% CI, 31.5% to 41.4%), which was 10-fold (95% CI, 8.3% to 11.7%) higher than that expected among the general population of the same age and sex. The most common cause of death was the index stroke (64%). Between 1 and 5 years after stroke, the annual risk of death was approximately 10% per year, which was approximately 2-fold greater than expected, and the most common cause of death was cardiovascular disease (41%). The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent claudication (hazard ratio [HR], 1.9; 95% CI, 1.2 to 2.9), urinary incontinence (HR, 2.0; 95% CI, 1.3 to 3.0), previous transient ischemic attack (HR, 2.4; 95% CI, 1.4 to 4.1), and prestroke Barthel Index <20/20 (HR, 2.0; 95% CI, 1.2 to 3.2). Conclusions One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10% per year, which is twice the rate expected among the general population of the same age and sex. The most common cause of death is cardiovascular disease. Long-term survival after stroke may be improved by early, active, and sustained implementation of effective strategies for preventing subsequent cardiovascular events.

Long-Term Risk of First Recurrent Stroke in the Perth Community Stroke Study

BACKGROUND AND PURPOSE Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia. METHODS Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4). CONCLUSIONS Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28‐item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM‐III criteria. The GHQ‐28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ‐28 having an overall superiority. The performance of all 3 scales for screening post‐stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.

The prevalence of minor psychiatric morbidity in the community.

The method is described of a point-prevalence survey of minor psychiatric morbidity among a sample of healthy community residents. The General Health Questionnaire was used as the sole means of case identification. The demographic characteristics of the sample were compared in detail with those of the total population. The factors mainly responsible for sample bias were difficulty with the English language, the varying degree of personal contact made with residents, and the difficulty in contacting the employed population during working hours. The overall response rate of the survey was 66-2%. The demographic groups found to be at significantly higher risk for minor psychiatric morbidity included women, the young, non-British migrant women, and lower social class men.

Trends in the Incidence, Severity, and Short-Term Outcome of Stroke in Perth, Western Australia

BACKGROUND AND PURPOSE This report describes trends in the key indices of cerebrovascular disease over 6 years from the end of the 1980s in a geographically defined segment of the city of Perth, Western Australia. METHODS Identical methods were used to find and assess all cases of suspected stroke in a population of approximately 134 000 residents in a triangular area of the northern suburbs of Perth. Case fatality was measured as vital status at 28 days after the onset of symptoms. Data for first-ever strokes and for all strokes for equivalent periods of 12 months in 1989-1990 and 1995-1996 were compared by age-standardized rates and proportions and Poisson regression. RESULTS There were 355 strokes in 328 patients and 251 first-ever strokes (71%) for 1989-1990 and 290 events in 281 patients and 213 first-ever strokes (73%) for 1995-1996. In Poisson models including age and period, overall trends in the incidence of both first-ever strokes (rate ratio=0.75; 95% confidence limits, 0.63, 0.90) and all strokes (rate ratio=0.73; 95% confidence limits, 0.62, 0.85) were obviously significant, but only the changes in men were independently significant. Case fatality did not change, and the balance between hemorrhagic and occlusive strokes in 1995-1996 was almost indistinguishable from that observed in 1989-1990. CONCLUSIONS Our results, which are the only longitudinal population-based data available for Australia for key indices of stroke, suggest that it is a change in the frequency of stroke, rather than its outcome, that is chiefly responsible nationally for the fall in mortality from cerebrovascular disease.

RISK FACTORS FOR POST-STROKE DEPRESSION

Objective. To examine possible risk factors in post‐stroke depression (PSD) other than site of lesion in the brain.

Migrant suicide rates in Australia and in country of birth

BACKGROUND Various studies from Australia, Canada and the United States have shown significant rank correlations between the suicide rates of immigrants and those of their country of birth (COB). This study compares the rank ordering of age standardized suicide rates of immigrants in Australia for two periods, 1961-70 and 1979-90: (a) between each period; and (b) with their COB for each period. METHODS Data were obtained from the World Health Organization Annual Statistics and from the Australian Bureau of Statistics. Comparisons were made for 11 countries from England and Wales, Ireland and Europe, for which there was a sufficiently large number of immigrant suicides to warrant statistical analysis. RESULTS The data showed considerable heterogeneity in rates of immigrants from various countries, with increased rates in Australia compared with their COB. There were consistently significant Spearman rank correlations between the rates after immigration and those in their COB for each period, and between rates in the two periods for both immigrants and for their COB, despite increases in suicide rates, and considerable socio-economic demographic changes between the various countries over that time span. CONCLUSIONS The findings are used to argue two conclusions: (i) the important influence of premigrant social and cultural experiences in subsequent suicide rates in immigrants in their host country; and (ii) to support the case for the reliability of using international suicide data for comparative epidemiological research.

Which version of the General Health Questionnaire should be used in community studies

Literature pertinent to the use of the various versions of the General Health Questionnaire (GHQ) is briefly surveyed. The literature indicates that the 60-item version has the highest reliability and validity coefficients, the lowest misclassification rate, and the highest sensitivity and specificity. Using data from a previously published community survey in Perth using the 60-item GHQ, comparisons are made between use of the 60-, 30-, 20- and 12-item versions, including community prevalence rates, simultaneous identification of cases, disagreement rates and patterns of community rates with age. The 60-item version gives the lowest prevalence rates. It is argued that the 60-item GHQ is probably the best as it gives the lowest misclassification rates, the smallest standard error of estimated prevalence rates and allows measurement of certain subscales not contained within the shorter versions.

Contrasting demographic patterns of minor psychiatric morbidity in general practice and the community.

The 60-item General Health Questionnaire was completed by 90% of 4798 patients aged 15--69 years who consulted, on one day, the general practitioners of 97% of practices in the Perth Statistical Division. A point prevalence rate of minor psychiatric morbidity in various demographic groups was calculated in terms of the population at risk. The demographic pattern of morbidity was compared with that found in a probability sample of 2324 community residents drawn from the same population at risk, and surveyed at the same time using the same time using the same screening instrument. Widowed persons, British-born men who had recently migrated to Australia, and lower-social-class men with minor psychiatric morbidity were under-represented in general practice. Elderly men and women in upper-class occupations with minor psychiatric morbidity were over-represented in general practice. These differences, unlike others that were found, could not be explained by differing consulting habits or by differing completion rates of the screening instrument.

An Appraisal of the NIMH Epidemiologic Catchment Area Program

The Epidemiologic Catchment Area Program was a massive United States community survey of psychiatric illness, dwarfing all prior similar surveys. It has been described as a ‘landmark in the development of American contributions to the psychiatric knowledge base’. The results pose a number of challenges to psychiatry. This paper briefly describes the program and appraises it, raising considerable doubts regarding the validity and usefulness of the Diagnostic Interview Schedule as a measuring instrument for the diagnosis of psychiatric illness, especially in the elderly; the use of lay interviewers to measure psychiatric illness; whether it is possible to measure lifetime prevalence of psychiatric illness; some of the reported prevalence rates, especially of phobia; the failure to include generalised anxiety among the 15 psychiatric diagnoses measured; and the failure to compare the results with those reported elsewhere in the literature.