Pharmacological, non‐invasive brain stimulation and psychological interventions, and their combination, for treating depression after stroke (Review)

Abstract

Review question
Do pharmacological treatments, non-invasive brain stimulation (electrodes are placed on the scalp and a finely controlled electric current is applied to change brain activity), psychological treatments, or combination treatments reduce the proportion of people with depression or the extent of depressive symptoms after stroke?

Background
Depression is common after stroke yet often is not detected or is inadequately treated.

Search date
We identified studies by searches conducted on 8 February 2022. This is a living systematic review. We search for new evidence every two months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Study characteristics
We included trials that reported on the use of pharmacological, non-invasive brain stimulation, psychological, and combined interventions to treat depression after stroke. We described the main outcomes as the number of people meeting the criteria for depression (scoring above a predefined scoring threshold) and inadequate response (scoring below 50% of the predefined scoring threshold). Average age of participants ranged from 54 to 78 years. Studies were from Asia (39), Europe (12), America (6), South America (1) and Australia (3).

Key results
We included 65 trials (72 comparisons) involving 5831 participants. Pharmacological treatments resulted in fewer people meeting the study criteria for depression at end of treatment and with inadequate response to treatment. Non-invasive brain stimulation did not reduce the number of people meeting the study criteria for depression at end of treatment and with inadequate response to treatment. Psychological therapy reduced the number of people meeting the study criteria for depression at end of treatment. The combination of pharmacological treatment and non-invasive brain stimulation resulted in fewer people meeting the study criteria for depression but did not affect those with inadequate response to treatment. More people in the pharmacological treatment group reported central nervous system (e.g. confusion, sedation, tremor; in five trials) and gastrointestinal side effects (e.g. constipation, diarrhoea; in four trials) than in the placebo groups. Information on side effects of other treatments was not provided.

Certainty of the evidence
Estimates of treatment effects were imprecise due to small numbers in most studies and recruitment of people with very different baseline characteristics. We rated the certainty of evidence as low to very low due to these and other limitations in study design.

Conclusion
Antidepressant drugs may benefit people with persistent depressive symptoms after stroke, but care is required in their use, as little is known about their effects on overall stroke recovery. Non-invasive brain stimulation may not be of benefit while psychological and combination therapies may offer a treatment option. Future research should include a broader group of people with stroke.