After a stroke: What are the options for managing depression?

Antidepressants may not work in the way they are expected to for older people who have had strokes. The drugs might cause adverse effects such as increasing the risk of falls, so care is needed with their use.

A stroke can have a major disabling effect, often limiting people's physical abilities and greatly reducing their independence, at least at first. The adjustment to these changes and the work needed to regain more independence are very challenging, both for the person who has had the stroke and the people around them - especially the people who are caring for them.

These changes in people's lives also affect their emotions, and grief and sadness are to be expected after a stroke. Although most people will not carry on feeling this way for months or longer, up to a third of the people who have a stroke could also become depressed. So-called "clinical depression" is under-diagnosed in older people with strokes. It can be very difficult even for doctors to tell the difference between an ordinary reaction and one that has developed into a depressive illness that is likely to remain. For some people who have had strokes, depression will get better by itself over time. However, for most, once they are depressed, the depression could continue if there is no treatment.

Stroke affects the body's functions, but it can also affect the mind. People may have trouble speaking or understanding, and they could have trouble sleeping. A person who has had a stroke might be more anxious than they were before. Sometimes, a person's behaviour changes as well after a stroke. This can happen because of the harm that the stroke has done inside the brain.

Researchers from the Cochrane Collaboration looked for trials that tested the impact of treatments for depression on people who have had strokes. It was important to look specifically at the results in people who have had strokes, because drugs and psychological treatments for depression generally may not have the same effects in them as they do in people with other forms of depression.

The researchers speculated that one of the reasons that depression is often undiagnosed or untreated in people with strokes might be that doctors have found it difficult to treat depression in the usual way. That would mean that because they are uncertain that treatments will work, they might not actively approach the problem. This means that patients or their carers might need to talk to their doctor about the possibility of depression.

The researchers found that there has not been enough testing of depression treatments for people with strokes. They found nine trials, but these tested a variety of treatments and the individual trials were small. Most of the studies were on antidepressants, with two trials of psychological treatments. The researchers found no trials of complementary (or "alternative") therapies.

There were less than 800 people in all the trials together. The people had very recently had strokes, but people who had some common stroke-caused disabilities like communication problems were not asked to participate in these trials. This means that more research is necessary to be sure about what might help or be more harmful for people who are depressed after a stroke.

Two different types of psychological treatment were tried, but the trials were small and the particular programmes in them did not have a major impact. Although there is more data on drug treatments in general, there is not enough research on any one drug. The trials on antidepressant medication provided some information to suggest that these drugs might not be as helpful as expected for people with strokes. Future research might show that there are particular drugs that can help to relieve depression, but this is not yet certain. Importantly, the balance of adverse effects with the amount of benefit needs to be studied carefully.

Adverse effects were quite common in the studies, although, again, more research is needed to be sure about these. Possible adverse effects might include confusion, tiredness, apathy and shaking. This could happen to up to one in 10 of the people who use them.

The researchers concluded that there is not enough evidence to know whether antidepressants are useful for people who have had strokes. Possible adverse effects of the medications were also not studied enough in these trials. For example, it is still not known to what extent antidepressants increase the rate of falls and other harm like seizures.

Because of this, the researchers urge caution in the use of antidepressants. If people are using these medications after a stroke, possible adverse effects need to be monitored. Different treatments can be tried, although it is not possible to say at this stage which antidepressants might be more suitable for people who have had strokes. All the antidepressants that can be used were not tested in these trials.

Our fact sheet explains more about coping psychologically after a stroke, including for carers of a person with stroke. You can also read more about some of the different therapies that have been shown to help people recover more independence after a stroke here.

© IQWiG (Institute for Quality and Efficiency in Health Care)