Treatment of Post-Stroke Depression

  • Sergio E. StarksteinEmail author
  • Bradleigh D. Hayhow
Cerebrovascular Disorders (D Jamieson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cerebrovascular Disorders


Purpose of review

This review presents a critical appraisal of current therapeutic strategies for patients with post-stroke depression (PSD). We present the reader with the most recent evidence to support pharmacological, psychosocial, and neuromodulation interventions in PSD. We also discuss the relevance of using antidepressants and psychotherapy to prevent PSD and discuss evidence that antidepressant treatment may reduce mortality after stroke.

Recent findings

Neuroinflammation and decrease neurogenesis and plasticity may play an important role in the mechanism of PSD. The strongest predictors of PSD are stroke severity, early physical disability, and severity of loss of functioning. Nevertheless, populations at risk for PSD are yet to be identified. Recent meta-analysis examined the efficacy of pharmacotherapy and psychotherapy. There is consensus that antidepressants such as escitalopram and paroxetine produce a significantly greater response and remission rate of PSD than placebo. Randomised controlled trials (RCTs) using psychotherapy are fewer, but recent meta-analysis tend to suggest efficacy for this treatment modality. Neuromodulation using repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS), as well as novel psychosocial interventions are potentially useful treatments in need of further research.


Pharmacological therapy with antidepressants and psychotherapy should be considered as first line of treatment for PSD. The most effective antidepressants are the selective serotonin reuptake inhibitors escitalopram and paroxetine, whereas cognitive behavioural therapy is the most effective psychotherapeutic intervention.


Stroke Depression Anxiety Pharmacotherapy Psychotherapy Neuromodulation 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.PubMedGoogle Scholar
  2. 2.
    Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke Statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–66.CrossRefGoogle Scholar
  3. 3.
    Robinson RG, Jorge RE. Post-stroke depression: a review. Am J Psychiatry. 2016;173(3):221–31.CrossRefGoogle Scholar
  4. 4.
    Hackett ML, Anderson CS, House AO. Interventions for treating depression after stroke. Cochrane Database Syst Rev. 2004;3:1–48.Google Scholar
  5. 5.
    Hackett ML, Pickles K. Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014;9(8):1017–25.CrossRefGoogle Scholar
  6. 6.
    Ayerbe L, Ayis S, Wolfe CD, Rudd AG. Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis. Br J Psychiatry. 2013;202(1):14–21.CrossRefGoogle Scholar
  7. 7.
    Mitchell AJ, Sheth B, Gill J, Yadegarfar M, Stubbs B, Yadegarfar M, et al. Prevalence and predictors of post-stroke mood disorders: a meta-analysis and meta-regression of depression, anxiety and adjustment disorder. Gen Hosp Psychiatry. 2017;47:48–60.CrossRefGoogle Scholar
  8. 8.
    Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, et al. Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48(2):e30–43.CrossRefGoogle Scholar
  9. 9.
    Hackett ML, Anderson CS, House A, Xia J. Interventions for treating depression after stroke. Cochrane Database Syst Rev. 2008;4:CD003437.Google Scholar
  10. 10.
    Deng L, Qiu S, Yang Y, Wang L, Li Y, Lin J, et al. Efficacy and tolerability of pharmacotherapy for post-stroke depression: a network meta-analysis. Oncotarget. 2018;9(34):23718–28.CrossRefGoogle Scholar
  11. 11.
    Karaiskos D, Tzavellas E, Spengos K, Vassilopoulou S, Paparrigopoulos T. Duloxetine versus citalopram and sertraline in the treatment of poststroke depression, anxiety, and fatigue. J Neuropsychiatr Clin Neurosci. 2012;24(3):349–53.CrossRefGoogle Scholar
  12. 12.
    Sun Y, Liang Y, Jiao Y, Lin J, Qu H, Xu J, et al. Comparative efficacy and acceptability of antidepressant treatment in poststroke depression: a multiple-treatments meta-analysis. BMJ Open. 2017;7(8):e016499.CrossRefGoogle Scholar
  13. 13.
    Cui M, Huang CY, Wang F. Efficacy and safety of citalopram for the treatment of poststroke depression: a meta-analysis. J Stroke Cerebrovasc Dis 2018;27(11):2905–2918.CrossRefGoogle Scholar
  14. 14.
    Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ. 2011;343:d4551.CrossRefGoogle Scholar
  15. 15.
    Alexopoulos GS, Wilkins VM, Marino P, Kanellopoulos D, Reding M, Sirey JA, et al. Ecosystem focused therapy in poststroke depression: a preliminary study. Int J Geriatr Psychiatry. 2012;27(10):1053–60.CrossRefGoogle Scholar
  16. 16.
    Mitchell PH, Veith RC, Becker KJ, Buzaitis A, Cain KC, Fruin M, et al. Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial. Stroke. 2009;40(9):3073–8.CrossRefGoogle Scholar
  17. 17.
    Thomas SA, Walker MF, Macniven JA, Haworth H, Lincoln NB. Communication and low mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia. Clin Rehabil. 2013;27(5):398–408.CrossRefGoogle Scholar
  18. 18.
    Wang SB, Wang YY, Zhang QE, Wu SL, Ng CH, Ungvari GS, et al. Cognitive behavioral therapy for post-stroke depression: a meta-analysis. J Affect Disord. 2018;235:589–96.CrossRefGoogle Scholar
  19. 19.
    •• Jorge RE, Moser DJ, Acion L, Robinson RG. Treatment of vascular depression using repetitive transcranial magnetic stimulation. Arch Gen Psychiatry. 2008;65(3):268–76 Landmark prospective study showing the efficacy of rTMS for patients with PSD refractory to pharmacological treatmentCrossRefGoogle Scholar
  20. 20.
    Shen X, Liu M, Cheng Y, Jia C, Pan X, Gou Q, et al. Repetitive transcranial magnetic stimulation for the treatment of post-stroke depression: a systematic review and meta-analysis of randomized controlled clinical trials. J Affect Disord. 2017;211:65–74.CrossRefGoogle Scholar
  21. 21.
    Bucur M, Papagno C. A systematic review of noninvasive brain stimulation for post-stroke depression. J Affect Disord. 2018;238:69–78.CrossRefGoogle Scholar
  22. 22.
    Cheng C, Liu X, Fan W, Bai X, Liu Z. Comprehensive rehabilitation training decreases cognitive impairment, anxiety, and depression in poststroke patients: a randomized, controlled study. J Stroke Cerebrovasc Dis. 2018;27(10):2613–22.CrossRefGoogle Scholar
  23. 23.
    Robinson RG, Jorge RE, Moser DJ, Acion L, Solodkin A, Small SL, et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial. JAMA. 2008;299(20):2391–400.CrossRefGoogle Scholar
  24. 24.
    Salter KL, Foley NC, Zhu L, Jutai JW, Teasell RW. Prevention of poststroke depression: does prophylactic pharmacotherapy work? J Stroke Cerebrovasc Dis. 2013;22(8):1243–51.CrossRefGoogle Scholar
  25. 25.
    • Jorge RE, Robinson RG, Arndt S, Starkstein S. Mortality and poststroke depression: a placebo-controlled trial of antidepressants. Am J Psychiatry. 2003;160(10):1823–9 Landmark study showing that PSD increases long-term mortality.CrossRefGoogle Scholar
  26. 26.
    Robinson RG, Jorge RE, Long J. Prevention of poststroke mortality using problem-solving therapy or escitalopram. Am J Geriatr Psychiatry. 2017;25(5):512–9.CrossRefGoogle Scholar
  27. 27.
    Mikami K, Jorge RE, Moser DJ, Arndt S, Jang M, Solodkin A, et al. Increased frequency of first-episode poststroke depression after discontinuation of escitalopram. Stroke. 2011;42(11):3281–3.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Psychiatry, School of MedicineUniversity of Western AustraliaFremantleAustralia
  2. 2.School of MedicineUniversity of Notre DameFremantleAustralia

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