Effectiveness of Psychological

Interventions in Chronic Stage of

Stroke: A Systematic Review
Swati Mehta, MA,1,2 Shelialah Pereira, PT, MSc,1,2 Shannon Janzen, MSc,1,2 Amanda
McIntyre, MSc,1,2 Andrew McClure, MSc,1,2 and Robert W. Teasell, MD, FRCPC1,2,3
1
Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London Ontario; 2St. Joseph’s Health Care,
Parkwood Hospital, London, Ontario; 3Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry,
University of Western Ontario, London, Ontario, Canada

Objective: To examine the effectiveness of interventions for psychological issues faced by individuals post stroke when
initiated in the chronic stage of stroke. Method: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched
from 1980 to July 2012. A study was included if (1) the study was a randomized controlled trial (RCT); (2) at least 50%
of individuals in the study were entered into the study at over 6 months post stroke; (3) the study examined the effect
of an intervention on psychological functioning; and (4) study participants were ≥18 years of age. Similar interventions
were grouped and results summarized. Data on the study design, participant characteristics, interventions, outcomes, and
adverse events were extracted from each of the selected studies. Results: Nine RCTs met inclusion criteria. All 9 studies
examined effectiveness on mood and 3 on adjustment. Repetitive transcranial magnetic stimulation had the strongest
evidence of effectiveness in improving mood followed by pharmacotherapy; whereas exercise appeared to be effective in
improving adjustment and coping among individuals in the chronic stage of stroke. Conclusion: Overall, interventions
provided in the chronic stage of stroke appear to be effective in improving mood and adjustment up to 3 months post
intervention. The use of multidisciplinary interventions and acceptance models may be important in the overall adjustment
process. Key words: long-term management, psychological, stroke

T
he long-term consequences of stroke, in-
cluding psychological disorders, can have a
debilitating effect on the affected individual.
Psychological distress including depression, anxi-
ety, decreased self-esteem, and decreased psycho-
logical well-being not only affect the individual’s
recovery and quality of life, but also the lives of
the caregivers. One review found rates of depres-
sion and anxiety to be higher among individuals in
the chronic stage of stroke when compared to the
general population.1
Many of the psychological consequences of
stroke have been shown to be underestimated and
often overlooked as they are seen to be normal
and short-lived effects of the stroke itself, either
due to the brain insult or as part of the subsequent
grief process.2 Bour et al3 found that symptoms
of depression generally ended within 3 months
post stroke; however, symptom reoccurrence
was seen in 30% of individuals 6 months post
stroke. Suenkeler4 found that the mental health
of individuals 3 months post stroke was not
population, whereas between 6 to 12 months
post stroke, there was significant deterioration in
mental health. Distinct differences between early
and late onset mood disorders post stroke have
been identified.4
In the acute and subacute phases, more physical
factors such as lesion volumes have been associated
with depression and other mood disorders.5 In the
chronic stage (>6 months), additional factors such
as an individual’s level of education, participation
in the community post stroke, acceptance of the
effects of the stroke, and even personality traits
have been associated with late onset of depression
and other mood disorders.6,7 Berg8 found that
18 months post stroke, men were more likely to
experience depressive symptoms than women; no
such trend was seen before 18 months.
Top Stroke Rehabil 2012;19(6):536–544
2012;19(5):536–544
© 2012 Thomas Land Publishers, Inc.
www.thomasland.com

significantly different from that in the general doi: 10.1310/tsr1906-536

10.1310/tscir1905-536

536

McKevitt et al9 reported that many individuals
post stroke found that specific services were
underdeveloped within their community, resulting
in unmet needs in the areas of mobility, falls,
incontinence, fatigue, and emotional well-being.
The study found that one-third of the responders
reported experiencing emotional problems after
stroke. Only one-third of these individuals felt that
they received an adequate amount of emotional
support in the community.9 To make the argument
for additional resources to meet perceived unmet
needs, it is important to examine the effectiveness
of psychological interventions provided during the
chronic stage of stroke.
Previous reviews and meta-analyses have
examined the effectiveness of interventions for
psychological disorders post stroke.10–14 Hackett
et al,11 in a pooled analysis of 4 randomized
controlled trials (RCTs), found that psychotherapy
had a small effect in preventing depression among
individuals post stroke. Other reviews found that
pharmacotherapy was effective in improving mood
post stroke.10,12–14 However, the studies in these
reviews primarily involved individuals in the acute
and subacute phases. The objective of this review
was to examine the effectiveness of interventions
initiated more than 6 months post stroke to help
manage psychological distress including mood
disorders, emotional incontinence, and problems
with coping and adjustment.
Methods
The following databases were searched for
entries from January 1, 1980 through July 31,
2012: MEDLINE, CINAHL, EMBASE, Scopus,
and PsycInfo. The search strategy used for each
database was (stroke) AND (depression OR
anxiety OR coping OR adjustment OR mood).
Reference lists of potentially relevant articles were
hand searched to supplement studies identified in
the electronic search. Only studies in the English
language were reviewed.
Studies identified for inclusion met the following
criteria: (1) the study was an RCT; (2) at least 50%
of study participants were entered into the study
≥6 months post stroke; (3) the study examined
the effect of an intervention on psychological
outcomes; and (4) study participants were ≥18
Psychological Interventions Six Months Post Stroke 537
years of age. Studies were excluded if they were
non-RCTs or nonclinical trials. One reviewer
examined references for inclusion on the basis
of the article’s title and abstract. Full texts of
selected references were further examined by the
2 reviewers. Discrepancies were resolved through
discussion.
Data from selected studies were extracted to
conduct a meta-analysis. However, due to the
substantial between-study heterogeneity and lack
of reporting detail required for a pooled analysis, a
post hoc analytic decision was made to undertake
a narrative systematic review instead. Information
on the study’s design, participant characteristics,
interventions, outcomes, and adverse events
was extracted from each of the selected studies
by a single reviewer. A quality assessment was
conducted for all RCTs by 2 blinded reviewers
(S.M., S.P.) using the Physiotherapy Evidence
Database (PEDro) tool.15 Rare scoring discrepancies
were resolved by a third blinded reviewer (S.J.).
The PEDro tool consists of quality ratings based
on a yes or no response, with a maximum score
of 10. Strength of evidence was assessed using
previously established guidelines developed for
the Evidence-Based Review of Stroke Rehabilitation.16
The guidelines considered scores between 9–10 as
methodologically “excellent,” 6–8 as “good,” 4–5
as “fair,” and below 4 as “poor” quality.
Results
The electronic database search resulted in 404
citations; titles and abstracts were then reviewed
resulting in 98 studies. Full text of these studies
was assessed, with 10 studies meeting inclusion
criteria.17–26 Two articles25, 26 reported on the same
data, and as such were treated as a single study. The
9 studies had a pooled sample size of 629 participants.
Study quality ranged from “fair” to “good.”
Participant characteristics
Mean age of study participants ranged from
53 to 73 years. Mean time since injury ranged
from 7 months to 3 years. Depressive symptoms
were assessed with a variety of self-report
measures including the Hamilton Depression
Rating Scale (HDS), Beck Depression Inventory
538 TOPICS IN STROKE REHABILITATION/NOV-DEC 2012
(BDI), Montgomery-Asberg Depression Rating
Scale (MADRS), Wakefield Depression Inventory
(WDI), and the Center for Epidemiological Studies
Depression Scale (CES-D). Burns et al24 excluded
participants with major depressive disorders post
stroke (based on the DSM-III-R), whereas Choi-
Kwon et al18 excluded individuals with a history
of depression or mood disorders prior to stroke
or who had previously received a prescription
for antidepressants. No study excluded patients
based on their baseline characteristics of other
psychological issues.
Study design
A detailed description of each study’s research
design is presented in Table 1. Most of the studies
included utilized a double-blind randomized
control design. 17–20,24 Three studies reported
blinding of the assessor only,21–23 whereas the
remaining study did not report any blinding.25,26
One study provided an intervention to both stroke
survivors and their caregivers.22 Participants were
asked to discontinue adjunct antidepressant
treatment in one study.19 Psychological outcomes
were primary outcomes in 7 studies,17–19,21,22,24–26
while the other 2 studies examined these as
secondary outcomes.20,23
Mood
The effect of an intervention on mood
(ie, depressive symptoms and/or emotional
incontinence) was examined in all 9 studies.
Of these, 3 studies utilized a pharmacological
treatment: nortriptyline, fluoxetine, or
sertraline.17,18,24 Lipsey et al17 examined depressive
symptoms as a primary outcome after the treatment
group received nortriptyline (6 weeks). The
authors reported significantly greater improvement
in depressive symptoms in the group treated with
nortriptyline when compared to a control group
based on the HDS (P = .005). The other 2 studies
reported on the effectiveness of fluoxetine and
sertraline in addressing depressive symptoms
as a secondary outcome (primary outcome was
emotional incontinence). These studies showed no
significant improvement in depressive symptoms
post intervention based on the MADRS24 or the BDI.18
Two studies examined the effect of repetitive
transcranial magnetic stimulation (rTMS) on
depressive symptoms when initiated more
than 6 months post stroke.19,20 Both studies
found significant improvement in depressive
symptoms post treatment based on either the
HDS (P < .001)19 or the BDI (P = .02).20 In both
studies, a number of minor adverse events such
as localized discomfort and transient headaches
were reported.19,20
The effect of a later exercise intervention
on depressive symptoms was examined in
2 studies.21,23 Lennon et al23 provided individuals
in the treatment group with cardiorespiratory
training, while Sims et al21 provided progressive
resistance training. Lennon et al23 found significant
improvement in depressive symptoms post
intervention based on the HADS (P < .01). Sims
et al21 found no significant difference based on
the CES-D.
The impact of psychological education as an
intervention in chronic stroke was examined
in one study.25,26 In this study, the treatment
group received a psycho-education intervention
consisting of problem-solving strategies and
service information provided by a social worker
over a 4- month period; the control group received
an information booklet only. No significant
improvement in depressive symptoms was seen
in the treatment group when compared to the
control group using the Wakefield Depression
Inventory (WDI).25,26
In the 2 pharmacological studies involving
administration of fluoxetine or sertraline for the
management of emotional incontinence, both
of the interventional groups showed significant
improvement in excessive crying or tearfulness
(P = .04124; P < .0118) when compared to the
control group. Choi-Kwon et al18 found that this
effect remained significant even 6 months post
intervention (P < .01); however, Burns et al24
found that the effect returned to nonsignificant
levels after the drug was discontinued. Choi-Kwon
et al18 also reported significant improvement in
proneness to inappropriate laughing and anger
up to 3 months post intervention (P < .01). At
6 months, proneness to inappropriate laughing
still showed significant improvement whereas
proneness to anger did not.
Table 1. Study characteristics

N Sex Psychological
outcome assessed
Study Exp Ctrl M F Treatments Control treatment Duration Primary outcome (results)
Lipsey et al17 14 20 22 12 Daily nortriptyline dosages Placebo 6 wk Depressive HDS (+)
symptoms
Choi-Kwon et al18 76 73 117 32 Daily fluoxetine dosages Placebo 3 mon Emotional Emotional
incontinence incontinence (+)
BDI (−)
Burns et al24 14 14 13 15 50 mg sertraline daily Placebo 8 wk treatment/2 wk Emotional Emotional
washout incontinence incontinence (+)
MADRS (−)
Jorge et al19 10 10 11 9 10 active prefrontal rTMS Sham left prefrontal 2 wk Depressive HDS (+)
sessions rTMS symptoms
Kim et al20 6 6 6 10 8 10 high frequency rTMS Sham stimulation: low 2 wk Cognition BDI (+)
sessions; 10 low frequency frequency stimulation
rTMS sessions where angle of the coil
was 90% perpendicular
to the skull rather than
tangential
Lennon et al23 24 24 28 20 16 cycle ergometry sessions of Usual physiotherapy and 10 wk Cardiac risk score HADS (+)
aerobic training intensity plus occupational therapy
2 stress management classes with no aerobic exercise
Sims et al21 23 22 27 18 10 high intensity progressive Wait listed with usual 10 wk Depressive CES-D (−)
resistance training sessions care with no PRT symptoms R-SES (+)
exercise
Harrington et al22 119 124 132 111 16 1-h exercise and 1- h Standard care and local 8 wk Physical and SIPSO (social
interactive education groups contact numbers Social Integration integration) (−)
Towle et al25, 26 21 23 25 19 Along with an information Research social worker 4 mon Depressive WDI (−)
booklet by a research social visits once a week visit symptoms GHQ (psychological
worker once a week and and given an information distress) (+)
a pragmatic approach to booklet
problems, benefits, services,
and local day centers and
counseling

Note: BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies Depression Scale; Ctrl = control; Exp = experimental; GHQ = General Health Questionnaire; HDS =
Hamilton Depression Rating Scale; MADRS = Montgomery and Asberg Depression Rating Scale; PRT = progressive resistance training; R-SES = Self-Esteem Scale; SIPSO = Subjective Index of
Psychological Interventions Six Months Post Stroke

Physical and Social Outcome; rTMS = repetitive transcranial magnetic stimulation; WDI = Wakefield Depression Inventory.
539
540 TOPICS IN STROKE REHABILITATION/NOV-DEC 2012
Adjustment
Three studies examined the effect of an
intervention initiated during the chronic stage
of stroke on adjustment (ie, psychological
distress, self-esteem, social integration). The one
study utilizing a psycho-education intervention
(problem solving and service information) found
no significant improvement in psychological
distress based on the General Health Questionnaire
(GHQ).25,26 Sims et al21 provided individuals in the
intervention group with high-intensity progressive
resistance training over 10 weeks. This study
found a significant improvement post treatment in
self-esteem (P < .05) among individuals receiving
an exercise intervention. Harrington et al 22
delivered exercise designed to improve balance
and endurance along with education on local
programs by health professionals to chronic stroke
survivors. No significant improvement in social
integration was seen based on the Subjective Index
of Physical and Social Outcome (SIPSO) scale.
Discussion
Psychological issues are a common consequence
of stroke. The stroke experience requires coping
with both loss and adaptation to change. The
objective of this review was to examine the
effectiveness of interventions for psychological
issues provided more than 6 months post
stroke. Based on the current review, 5 of the 9
interventions initiated more than 6 months post
stroke effectively improved participants’ mood. Of
the 3 pharmacological treatments, nortriptyline
appears to be effective in improving depressive
symptoms post stroke. In this study, dosing
was individualized up to 100 mg/day, however,
the study was over a short duration (6 weeks)
without long-term follow-up.17 In the 2 studies
examining fluoxetine and sertraline, dosages were
standardized and not individually adjusted.18,24
This may have limited the effectiveness of
treatment among the individuals.
In the 2 studies that did not demonstrate a
benefit in depressive symptoms post treatment,
Burns et al 24 excluded participants with a
major depressive disorder, while Choi-Kwon et
al18 excluded individuals who had previously
taken antidepressants. In both of these studies,
the primary outcome measure was emotional
incontinence and not assessment of depressive
symptoms. Hence, individuals with more severe
depression and those potentially more likely
to respond to antidepressant medications were
excluded. For both of these studies, there was
an improvement in emotional incontinence
symptoms in chronic stroke survivors for up to
3 months post intervention.
Significant improvement in depressive symptoms
was seen when rTMS was applied to individuals in
the chronic stage of stroke.19,20 Numerous studies
have shown that rTMS leads to improvements in
depressive symptoms in nonstroke individuals
with major depressive disorder27–30 and in the
elderly.31 Participants in the Jorge et al19 study
were resistant to pharmacotherapy; hence rTMS
appears to be an important option for persons
with poststroke depression who are resistant to
pharmacotherapy. Long-term effectiveness of
this treatment has yet to be assessed. The study
protocol, which consisted of rTMS treatments
5 times a week for 2 weeks, and the fact that rTMS
is still not readily available (it requires both the
technology and trained staff to operate) may mean
it is not yet pragmatic for all patients.
Two studies that examined the efficacy of
exercise training in reducing depressive symptoms
6 months post stroke reported conflicting
results.21,23 In the Sims et al21 trial, the intervention
was geared toward improving depressive
symptoms as a primary goal, while the Lennon
et al23 study aimed to improve cardiac fitness as
the primary outcome. Both studies were similar
in duration and involved peer interaction; two
participants exercised together in Lennon et al and
within a small group in Sims et al. Lennon et al
demonstrated a significant difference in depressive
symptoms while Sims et al did not. This may be
accounted for by the type of exercise training
provided. Lennon et al had participants engaging
in cardiorespiratory (aerobic) training; subjects
in the Sims et al study underwent progressive
resistance training. A previous Cochrane review on
physical activity among individuals across a wide
range of times since stroke reported conflicting
results for the improvement of depressive
symptoms. 32 Furthermore, a meta-analysis

examining improvement in depressive symptoms
among individuals with cancer found that only
those programs involving an increase in the weekly
volume of aerobic exercise resulted in a small but
significant effect on depressive symptoms.33 This
suggests that aerobic exercise may be more effective
in improving depressive symptoms than resistance
training. Hence, further studies examining specific
physical activities are needed to further examine
this relationship in the stroke population.
Our review found supporting evidence for
interventions designed to improve coping and
adjustment during the chronic stage of stroke.
Psychological adjustment to stroke continues
well into the chronic stage.4 Adjustment during
the chronic stage can become problematic,
because stroke survivors are seeing their physical
recovery plateau at a time when rehabilitation
resources are either absent or coming to an end.
The present review found that aerobic exercise
resulted in improved self-esteem.21 Improvement
in self-esteem and coping strategies designed to
improve locus of control has been shown to help
individuals post stroke gain a new self-concept and
facilitate their adjustment and recovery process.34
Based on one study,22 exercise training involving
balance, strength, and endurance did not result
in an improvement in social integration among
individuals in the chronic stage of stroke.
However, social integration is a complex concept
and is influenced by many other factors such
as personality of the individual, accessibility to
social activities, support systems, and physical
functioning. Landreville et al 35 found that
adaptation to stroke is influenced by various
factors during the different stages of stroke
recovery. At 6 months post stroke, adjustment is
directly linked to activity restriction in their social
roles. Therefore, despite the fact that individuals
showed significant improvement in self-esteem,
the lack of social integration may be an important
barrier to consider during this stage of stroke.
The use of acceptance models that aim to help
individuals distinguish between functional and
physical losses and self-worth may aid in the
adjustment process. Townend et al36 suggested
that letting go of unfavorable comparisons with
others or one’s own past and judging one’s ability
in the present may help individuals appreciate
Psychological Interventions Six Months Post Stroke 541
their present ability. Further, integrating new
activities and developing interests that can be
enjoyed presently may help develop a new social
role function for the individual.
Clinical relevance
Many chronic stroke survivors experience
significant psychological distress once they are in
the community where treatment resources are often
lacking. Dam et al1 reported on the prevalence of
treatment with antidepressants in stroke compared
to persons with other chronic illness and found
that those diagnosed with stroke had a 4.5 times
increased rate of antidepressant treatment during
the first 6 months and 2.1 times at 1 year or more
post stroke when compared to a similar group
diagnosed with osteoarthritis. Previous reviews
have found antidepressants to be effective in
preventing and treating depressive symptoms post
stroke11,12; however, at present there is not enough
research to determine whether this treatment is
effective in the treatment of depression in chronic
stage of stroke. There is no reason to believe it
would not be; however, only 1 of 3 studies in this
review examining antidepressant treatment actually
examined depression as a primary outcome. In
that study of nortriptyline, there was a significant
improvement in poststroke depression during
the chronic stage. Two other studies of selective
serotonin reuptake inhibitor (SSRI) medications
were designed to examine the impact on emotional
incontinence in chronic stroke and were able to
show a difference. However, they did not show
a difference in depressive symptoms that were
secondary outcomes in both studies; one possible
explanation is they excluded those subjects who
were most likely to respond to pharmacological
treatment. Obviously more research needs to be
done. Other treatments, such as psychological
counselling/education and aerobic exercise, also
need to be considered as important options.
Combination treatments, although not studied,
would be expected to have even greater benefit.
rTMS appears to be an exciting new treatment,
especially for persons who are resistant to other
treatments.
Improvement in psychological issues can also
cause improvements in function for individuals
542 TOPICS IN STROKE REHABILITATION/NOV-DEC 2012
post stroke. Feelings of social isolation, poor body
image, and demotivation can result in greater
inactivity and less participation in daily social
activities.37 Poststroke depression has been shown
to have a negative impact on stroke recovery, and
depressed stroke patients suffer poorer social
and functional outcomes when compared to
nondepressed patients.37,38 In a 2-year follow-up
study, depressed stroke patients were shown
to have a poorer recovery in their daily living
activities than nondepressed stroke patients.39
Hence, increased community psychological
support including acceptance of disability models
for individuals post stroke may help to provide
motivation for greater community activity and
integration, which theoretically should help them
stay in the community longer and maintain higher
levels of independence.
Limitations
There are several limitations to this study.
Although a comprehensive and systematic search
of the literature was conducted, it is possible that
some studies were not identified. The inclusion
of only RCTs runs the risk of missing important
findings from non-RCTs or cohort studies. Two
of the studies also examined psychological
issues as secondary outcomes. This limits the
interpretability of the effectiveness of the specific
intervention for the psychological outcome. Last,
assessing the effectiveness of various interventions
for psychological issues in chronic stroke was
based on 1 to 3 RCTs; given the importance of
psychosocial issues in chronic stroke, the paucity
of trials was a surprise and should be a focus of
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