Psychological associations of poststroke fatigue: a systematic review and meta-analysis

Abstract

Background and purpose: Fatigue is common after stroke but has no effective treatments. Psychological interventions improve fatigue in other conditions by targeting psychological factors such as mood. If psychological factors correlate with fatigue in stroke, this would justify the development of similar interventions for poststroke fatigue (PSF). We used systematic review and meta-analysis to determine psychological associations of PSF.

Methods: We systematically searched for studies that reported psychological associations of PSF. We used odds ratios (ORs) to estimate the strength of associations and random-effects modeling to calculate summary estimates of ORs. We used stratified meta-analysis to investigate the impact of study design and conducted sensitivity analyses limited to studies that excluded patients with clinical depression and to studies that used depression scales without fatigue items.

Results: Thirty-five studies (n=9268) reported the association between PSF and ≥1 psychological factor. For PSF and depressive symptoms, we identified 19 studies (n=6712; pooled OR=4.14; 95% confidence interval, 2.73-6.27); this association existed in patients without clinical depression (pooled OR=1.39; 95% confidence interval, 1.27-1.53) and in studies using depression scales without fatigue items (pooled OR=5.41; 95% confidence interval, 1.54-18.93). For PSF and anxiety, we identified 4 studies (n=3884; pooled OR=2.34; 95% confidence interval, 0.98-5.58). Two studies (n=123) found an association with poor coping styles and 1 study (n=167) with loss of control. Six studies (n=1978) reported other emotional or behavioral associations.

Conclusions: PSF is associated with depressive symptoms, anxiety, poor coping, loss of control, emotional, and behavioral symptoms. These factors are potential targets for treatment of PSF.

Keywords: behavior; fatigue; rehabilitation; stroke.

Figure 1.

Electronic search, study selection, and data analysis. ORs indicates odds ratios.

Figure 2.

Random-effects meta-analysis for the association between poststroke fatigue and depressive symptoms. The horizontal axis is the odds ratio (OR) comparing the occurrence of depressive symptoms in patients with and without fatigue after stroke. Horizontal error bars represent the 95% confidence interval (CI) of OR in individual studies, and vertical gray bar represents the 95% CI of the summary estimate of OR. Symbol size represents the log of the number of participants in that study. *The upper limit of the 95% CI of OR beyond 34 did not show in the plot.

Figure 3.

Funnel plot for publication bias. The horizontal axis represents the log odds ratios (ORs) for the association between poststroke fatigue and depressive symptoms, and the vertical axis represents the inverse SE. The vertical bar represents the pooled estimate of ORs.