Neurology ยท Medical Literature
Ranking psychological interventions for post-stroke depression: A systematic review and network meta-analysis.
Abstract
Post-stroke depression (PSD) is the most common neuropsychological complication in stroke survivors. While psychological interventions are promising non-pharmacological treatments, the most effective intervention type, as well as their mid- to long-term efficacy and effectiveness across PSD severity levels, remains unclear. This study aims to compare the efficacy of psychological interventions for PSD, focusing on overall effectiveness, mid- to long-term efficacy, and effectiveness across PSD severity levels. We systematically searched seven databases for randomized controlled trials (RCTs) of psychological interventions targeting depression in stroke survivors. The primary outcome was depression symptom reduction. Post-intervention, mid- to long-term data were analyzed. A frequentist network meta-analysis (NMA) with random effects was conducted in Stata 17.0. Subgroup analyses by PSD severity were performed. Thirty-eight RCTs involving 3106 participants were included. Post-intervention, third-wave therapies (Hedges' g = -1.08, 95% CI: -1.62 to -0.55) significantly improved PSD compared to treatment as usual. At mid- to long-term follow-up, third-wave therapies (Hedges' g = -0.82, 95% CI: -1.25 to -0.39) maintained significant effects. Relaxation therapy significantly ameliorated mild PSD (Hedges' g = -0.77, 95% CI: -1.27 to -0.27); for moderate-to-severe PSD, no significant effects were observed. Third-wave therapies are potentially effective for PSD, showing sustained mid- to long-term benefits. Relaxation therapy seems to be most effective for mild PSD, while no significant effects were observed for moderate-to-severe PSD. However, the NMA showed high heterogeneity and generally low to very low evidence certainty for most comparisons, the findings should be interpreted with caution.
Clinical relevance
Post-stroke depression (PSD) is the most prevalent neuropsychological complication among stroke survivors, yet the comparative efficacy of psychological interventions across intervention types, severity strata, and time horizons has remained poorly defined. This network meta-analysis of 38 RCTs (n = 3,106) directly addresses that evidence gap by simultaneously ranking multiple non-pharmacological approaches and examining durability of effect. Given the risks of polypharmacy and antidepressant side effects in this neurologically vulnerable population, identifying effective psychological treatments is of immediate clinical priority.
Key findings
1. Third-wave therapies (e.g., mindfulness-based cognitive therapy, acceptance and commitment therapy) demonstrated the largest post-intervention effect for PSD compared to treatment as usual (Hedges' g = -1.08, 95% CI: -1.62 to -0.55), representing a large effect size. 2. The benefit of third-wave therapies was sustained at mid- to long-term follow-up (Hedges' g = -0.82, 95% CI: -1.25 to -0.39), indicating durable, clinically meaningful depression symptom reduction beyond the acute intervention period. 3. Relaxation therapy demonstrated significant efficacy specifically for mild PSD at post-intervention assessment (Hedges' g = -0.77, 95% CI: -1.27 to -0.27). 4. No psychological intervention showed statistically significant effects for moderate-to-severe PSD in subgroup analyses, highlighting a critical treatment gap in this higher-acuity subgroup. 5. The NMA incorporated 38 RCTs with 3,106 total participants identified through systematic search of seven databases, with a frequentist random-effects model used to generate comparative estimates. 6. Overall evidence certainty for most comparisons was rated as low to very low, and the NMA demonstrated high heterogeneity, necessitating cautious interpretation of all effect estimates.
Practice implications
Clinicians should consider third-wave psychological therapies (e.g., mindfulness-based or acceptance-based interventions) as a first-line non-pharmacological option for PSD, particularly given their sustained mid- to long-term efficacy, making them suitable for integration into post-stroke rehabilitation pathways. For patients with mild PSD, relaxation therapy represents an accessible, lower-intensity alternative with demonstrated benefit, whereas patients with moderate-to-severe PSD may require pharmacological augmentation or more intensive multimodal approaches given the absence of significant psychological intervention effects in that subgroup. The high heterogeneity and low evidence certainty across comparisons underscore the urgent need for adequately powered, standardized RCTs stratified by PSD severity to guide definitive treatment selection.