Stroke is described as a neurological impairment due to a non-traumatic brain injury caused by cerebral infarction, or hemorrhage, which is categorized into intracerebral and subarachnoid bleeding (Easton et al., 2009). According to the “Global Burden of Diseases” (GBD), this cerebrovascular accident is rated as the second source of death and as the third most mutual root for disability worldwide (Cheah et al., 2016).

Stroke leads to various complications including musculoskeletal pain, pulmonary embolism, deep vein thrombosis, shoulder subluxation, pressure sores, spasticity, swallowing difficulties, urinary infections, and psychological problems (Kuptniratsaikul et al., 2013). According to the study of Sackley et al. (2008) that was conducted over a year after stroke, the prevalent types of complication experienced were falls (73%), contractures (60%), pain (55%), shoulder pain (52%), emotional distress (50%), and pressure sores (22%) (Sackley et al., 2008). Moreover, hemiparesis and hemiplegia are frequent and widely recognized impairments of stroke where they affect over 65% of stroke survivors (Bindawas et al., 2017). Following this cerebrovascular accident, the ability to perform daily life activities is greatly affected by physical disability, essentially upper extremities involvement, and cognitive impairment fluctuating between minor vascular cognitive impairment (VCI) and vascular dementia (VaD) (Arauz et al., 2014; Kwakkel et al., 2015). Another consequence is participation restrictions represented by loss or decline in social engagement (Scott et al., 2012). The inability to perform daily life activities and social isolation might lead to increased psychiatric complications (Bartoli et al., 2013; Hara, 2015). Diagnostic and Statistical Manual (DSM) IV defined Post-stroke depression (PSD) as a “mood disorder with the specifiers of depressive features, major depressive-like episodes, manic features or mixed features” (American Psychiatric Association, 2000; Shi et al., 2017). PSD is the most common post-stroke neuropsychiatric disorder. Depression in these patients is more prevalent than in the general population (Hackett et al., 2014; Shi et al., 2017). PSD negatively affects functional recovery, survival, cognitive and social functions. It is associated with disorders affecting attention, memory, psychomotor speed, orientation, language, and executive/motor functions (Bolla-Wilson et al., 1989; Kauhanen et al., 1999). It was demonstrated that the reported prevalence of PSD ranges between ~20 and 40% (Barker-Collo, 2007; De Wit et al., 2008; Ayerbe et al., 2011, 2013; Vansimaeys et al., 2017).

Stroke severity, deficiency of communal or household support, anxiety, and genetic factors are predisposing factors for developing depression in stroke survival patients (Ayerbe et al., 2013). Depression represents a significant load on the rehabilitation process efficacy, where it leads to more limitations in daily life activities, higher risk of intellectual deficiency, elevated chance of recurrent stroke, and greater death chance (Gillen et al., 1999; Yuan et al., 2012; Bartoli et al., 2013).

Post-stroke anxiety is another common neuropsychiatric outcome of stroke characterized by excessive anxiousness or worries, and difficulties in controlling worries. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Kim, 2016), post-stroke anxiety is associated with the following symptoms: restlessness, insomnia, fatigue, discomfort, low concentration, and nervous tension (Castillo et al., 1995; Schultz et al., 1997; Kim, 2016). Many studies mentioned the persistence and mutuality of post-stroke anxiety (Cumming et al., 2016). Stroke survival patients are at risk of recurrent strokes, disabilities, lack of independence, and mortality, therefore, predisposing patients to develop anxiety (Johnson, 1991). Moreover, anxiety can have a detrimental effect on someone's life and lead to depression (Rafsten et al., 2018). An rate of 20% of stroke patients develop anxiety within the first 30 days following a cerebrovascular event, up to 23% in 5 months, and it reaches a value of 24% within a 6 months' length (Campbell Burton et al., 2013). Therefore, the anxiety level increases in the direction of the enduring phase of stroke (Burton et al., 2013; D'Aniello et al., 2014). Anxiety severity in this population is independent of gender. However, a negatively affected lifestyle following a stroke is linked to more severe anxiety (Rafsten et al., 2018).

Regarding the MENA (Middle East and North Africa) region, 34 studies stated the prevalence of post-stroke depression (Kaadan and Larson, 2017). The lowest rates are reported in Saudi Arabia (17%) (Hamad et al., 2011) and Iran (18% to one-third of stroke patients) (Ahangar and Hosseini, 2009; Iranmanesh, 2010), whereas higher rates are reported in Algeria (56.1%) (Layadi et al., 2013), Israel (63%) (Heruti et al., 2002), Jordan (64%) (Alghwiri, 2016), and Morocco (73.2%) (Riah et al., 2013).

Regarding Lebanon, several published studies shed the light on the prevalence, incidence, symptoms, and the needed therapeutics for stroke (Jurjus et al., 2009; El Sayed et al., 2014; Farah et al., 2015). Smoking, hypertension, diabetes mellitus, and physical inactivity were linked to a higher risk of stroke in published Lebanese studies (Lahoud et al., 2017; El-Hajj et al., 2019). Death is known as one of the major consequences of stroke, a recent study done by Abdo et al. (2019) confirmed that the cumulative mortality rates of Lebanese stroke patients increased from ~1 over 7 at 1 month to 1 over 5 at 1 year post-stroke (Abdo et al., 2019). However, no study has shed the light on the challenges faced by Lebanese surviving stroke patients.

In the light of the aforementioned literature, this study explores post-stroke neuropsychiatric complications in Lebanon and identifies their potential correlations.

Anxiety and depression are common and major consequences following stroke. About 30% of stroke survivors experience depression, while anxiety prevalence is around 20–25% (Fang et al., 2017). This study aimed to investigate the psychological consequences of a stroke among Lebanese survivors 3 months following the event and to identify their correlates. At the end of the first 3 months, 89 (76.1%) of the patients experienced depression and 51.3% experienced anxiety. Anxiety, neuropathic pain, physical activity, and NHISS scale were correlated with depression. However, sedentary life style, neuropathic pain, and NHISS scale during the first 3 months post-stroke were significantly associated with anxiety.

Previous studies indicated that post stroke depression is the commonest mental disorder in survivors. Our study indicated a high level of depression (76.1%) recorded 3 months following stroke compared to other studies conducted in western countries which indicated a prevalence of 45.6% (Barker-Collo, 2007), and 39% (Hosking et al., 2000). A possible explanation for this difference could be the general poor feature of life following stroke, especially among the Lebanese population, which are deprived of good care and rehabilitation facilities, physical and social restrictions following stroke, and lack of additional training for healthcare professionals on the symptoms of depression (Kaadan and Larson, 2017). Another possible explanation could be the usage of different methods of assessment (Hackett et al., 2005).

Depression has negative effects on functional recovery, survival, cognitive and social functions, where it is usually associated with several factors (Bolla-Wilson et al., 1989; Kauhanen et al., 1999). We further investigated the elements affecting depression. Our results revealed that physical activity acts as a protective factor against depression 3 months following stroke. It improves the patient's self-esteem, increases their sense of comfort, and happiness due to elevated serotonin and noradrenergic synthesis following exercise, which consequently diminish depression levels (Anderson and Shivakumar, 2013). Similarly, these results have been reported by two recent systematic reviews, thus spotting the light on the importance of intervention to increase physical activity (Pengpid and Peltzer, 2019). Neuropathic pain revealed a significant association with depression as well. These findings are similar to a previous review of 40 studies indicating that pain is a causative factor for depression (Woo, 2010). This could be clarified by the fact that pain could lead to impaired functioning, and thus causes social isolation, which in turn upsurges depression levels (Mushtaq et al., 2014). Furthermore, our study indicated a correlation between anxiety and depression, which was consistent with previous studies (Fang et al., 2017). Researchers have tested hypotheses of shared genetic etiologies as a potential basis of this relationship (Hettema, 2008). Moreover, our results showed that there is a significant association between NHISS scale and depression 3 months after stroke (p-value <0.001), which was consistent with the study of Ilut et al. (2017) that showed that higher NIHSS scores were associated with severe depression (Ilut et al., 2017).

Post-stroke anxiety is another common neuropsychiatric consequence prevalent after stroke. About one-quarter of stroke survivors experience post-stroke anxiety that affects their rehabilitation due to its negative impact on quality of life (QOL) (Li et al., 2019). It is associated with immobility, fatigue and poor self-control (Fang et al., 2017). Many studies indicated the persistence and mutuality of post-stroke anxiety (Cumming et al., 2016). Through our investigation, the frequency of anxiety (51.7%) was not consistent with other studies that demonstrated lower frequency after 3 months of stroke, with an estimated prevalence ranging between 18 and 38% (Barker-Collo, 2007; Ayerbe et al., 2014; Vansimaeys et al., 2017). The high level of anxiety in Lebanon could be related to the lack of rehabilitative services following stroke, the lack of social and psychological support for the survivor, and the high burden of physical disability on them.

The severity of anxiety syndrome after a stroke is usually linked to a general poor feature of life following stroke (Rafsten et al., 2018). Our study indicated a relationship between anxiety and sedentary duration (p-value = 0.01), which was confirmed by a previous systematic review (Teychenne et al., 2015). Long sedentary behavior seems to be related to anxiety at the biological and the psychosocial levels. Biologically, sedentary behavior might lead to central nervous system arousal, sleep disturbances, or poor metabolic health. Alternatively, prolonged sedentary behaviors may be linked to social withdrawal theory. For example, prolonged television viewing, may lead to social solitude and withdrawing from interpersonal relationships, which has been linked to increased feelings of social anxiety (Teychenne et al., 2015). Furthermore, our study confirmed a direct relation between anxiety and pain. This is explained by the fact that stroke survivors who suffer from pain usually pay increased attention toward threat, which increases their anxiety levels toward any physical work (de Heer et al., 2014). Moreover, our results showed that there is a significant association between NHISS scale and anxiety three months after stroke (p-value <0.001), which was consistent with the study of Lee et al. (2019) that revealed that post stroke anxiety was significantly associated with a higher NIHSS score.

To the best of our knowledge, this is the first prospective study examining post-stroke consequences done among first-ever stroke survivors in Lebanon. The data is collected through a face-to-face interview and completed by the investigator himself, and thus, the degree of bias usually resulting from self-completed questionnaires due to a misunderstanding of the questions was declined. However, regarding the limitations, our study had a small sample size, and the risk of selection bias due to the convenience sampling method used to select patients might have restricted the capacity to generalize our findings to all the Lebanese stroke survivors. It should be mentioned we have used the Arabic validated version of the HADS (Al Aseri et al., 2015), Dn4 (Terkawi et al., 2017), FSS (Al-Sobayel et al., 2016), NHISS (Hussein et al., 2015) which is considered a strength with regard to information bias. Nevertheless, additional studies are required to confirm the current study results.

Neuropsychological disorders are generally debilitating for patients and they impose a socioeconomic burden on these patients and their caregivers. The current study provides pioneer information about the consequences of stroke 3 months following the event, mainly neuropsychiatric events affecting functional recovery. Special care should be provided for patients presenting risk factors for anxiety and depression, such as extended sedentary durations, low physical activity, and high pain rates. These psychiatric events represent a major complication in front of the recovery mechanism where they could lead to less compliance to medications, higher fatigue levels, and therefore poorer outcomes. The high frequency of neuropsychiatric complications provided by this study in Lebanon will give much more attention on post-stroke complications and highlight the need for further investigations into the pathogenesis, prevention, and treatment. Thus, necessary protocols should be established for early detection and treatment, and an action plan should be conducted to prevent, manage stroke during the acute phase, evaluate its outcome, and organize the rehabilitation services concerning the consequences following stroke. The rehabilitation process needs to be considered in its broadest context, and include an equal focus on the social, psychological and physical aspects. Additionally, the inclusion of community-based rehabilitation workers is critical to the success of any comprehensive, cost-effective rehabilitation paradigm.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Neuroscience Research Committee, at the NRC, Lebanon. The patients/participants provided their written informed consent to participate in this study.

WK, MT, and CB undertook the data collection process. WK and MT undertook data management, statistical analysis, and drafted the manuscript. LA-A critically revised the data analysis part. NS, PS, and LA-A contributed to the final draft of the manuscript and gave final approval for submission. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.