A telemedicine-based cognitive behavioral therapy (CBT) program was effective for the treatment of anxiety after stroke, according to findings published in Stroke. In a randomized clinical trial of patients with prior stroke, remotely administered CBT was associated with a greater reduction in anxiety symptoms than relaxation therapy.

Ho-Yan Yvonne Chun, PhD, of the Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, and colleagues enrolled community-dwelling adults with prior stroke or transient ischemic attack (TIA) and current anxiety. Patients received either CBT or guided relaxation via telemedicine. The primary outcome was reduction in anxiety, measured using electronic self-report surveys. Symptoms were assessed at baseline, 6 weeks, and 20 weeks. All participants were invited to use a wrist worn actigraphy sensor to measure objective anxiety symptoms during the trial.

Patients in the CBT condition received 6 weekly telephone sessions with a stroke physician trained in psychotherapy. They were also prescribed a weekly CBT task and given access to online psychoeducational videos. Patients allocated to the “relaxation” arm received a single telephone session during which they were educated on relaxation techniques. They were then instructed to practice a relaxation task for 5 minutes daily.

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The study cohort comprised 27 patients (mean age at enrollment, 65±10 years; 56% men) with prior stroke (63%) or TIA (37%). The median time since stroke or TIA was 19 weeks. Whereas 14 patients were assigned to CBT, 13 received relaxation therapy. All 14 patients in the intervention arm completed 6 weeks of CBT sessions, supporting the feasibility of therapy administered via telemedicine. The relaxation arm also had high adherence, with none lost to follow-up.

Compared with the relaxation arm, the CBT group had lower levels of anxiety at both 6 and 20 weeks. Specifically, the CBT group had lower scores on the 7-item Generalized Anxiety Disorder scale (median score at 20 weeks, 2 vs 7) and the Fear Questionnaire agoraphobia subscale (median score at 20 weeks, 1.5 vs 12.6). All 27 participants consented to wearing an actigraphy sensor with a mean wearing time of 33±15 days for the first sensor. Per sensor measurements, patients in the CBT condition had lower sleep activity than patients in the relaxation condition.

These data support the feasibility and efficacy of telemedicine CBT for the treatment of anxiety in stroke survivors. Wrist based actigraphy was also a feasible option for measuring objective symptoms of anxiety, including sleep disturbance and heart rate.

The small cohort size limits generalizability; further study of telemedicine CBT is necessary to confirm these findings.

“Our preliminary feasibility data from the current study support a larger definitive clinical trial and the use of wrist-worn actigraphy sensor in anxious stroke survivors,” the investigators wrote.


Chun HY, Carson AJ, Tsanas A, et al. Telemedicine cognitive behavioral therapy for anxiety after stroke: proof-of-concept randomized controlled trial [published online June 24, 2020]. Stroke. doi: 10.1161/STROKEAHA.120.029042