The aetiology of depression after stroke is probably multifactorial. Depression may occur in any patient secondary (directly or indirectly) to the biopsychosocial stress of medical illness [13, 14]. It has been postulated that the greater the medical burden and the pre-existing vulnerability, the higher the risk of depression [9, 14, 15]. Several specific mechanisms for depression associated with physical illness, applicable to stroke patients, have been proposed [10, 13, 14]. These mechanisms include factors linked to the medical condition, any significant medical complication, and long-term dependence for activities of daily living [8]. Indeed, stroke and depression have risk factors in common, such as diabetes mellitus, and the onset of stroke and the uncertain or poor prognosis can have a negative impact on a patient’s mood [14, 16]. The involvement of psychological mechanisms for depression among patients with medical conditions such as stroke has also been reported [13, 14, 17–19]. These include the personal meaning of the illness for the individual, changes in sense of identity, alterations in body image, damaged self-esteem, dysfunctional attitudes (such as self-judgement on unrealistic standards) [10, 20], cognitive distortions [14], maladaptive coping strategies, and some types of personality [13, 14]. Biological mechanisms may also play a role in the association between stroke and depression [18, 19, 21]. These would include the damage on neurochemical pathways mediating mood [10, 13–15, 18, 21]. Finally, a number of sociological factors related to the physical disease may have an effect on patients’ mood as well [13]. These would include concerns about relatives, such as difficulties in the education of children depending on the patient, stigmatisation, isolation, financial worries, the loss of social roles, employment or professional status, relocation, or institutionalisation [22, 23]. There are also social factors for depression not directly linked to stroke but prevalent among stroke survivors, for example, the loss of a spouse [10, 13, 14].

Depression is more frequent among stroke survivors than in the general population [24–28]. It has a prevalence of around 30 % [2, 3], but at some point in the long term about 50 % of stroke survivors suffer from depression [29, 30]. Most patients develop their first symptoms shortly after the acute event and recover in the following months but have a high risk of recurrent depression in the long term [30]. Depression is not only a distressing condition for patients and families; it is also associated with higher rates of mortality, disability, anxiety, lower quality of life, poor life satisfaction, less efficient use of rehabilitation services, and need for institutional care [3, 6, 8].

There appears to be a benefit from adopting a holistic framework for the management of psychological problems after stroke. Interventions that address specific mood disorder tend to miss part of the complexity of life after stroke. Comprehensive-holistic rehabilitation programmes should integrate evaluations of cognition, behaviour, and mood to approach the individual’s difficulties [33]. Since depression and anxiety are often associated [6, 7], patients considered to have one of them should be assessed for other mood disorders [33]. Furthermore, specialist mental health teams should be involved in the management of patients with severe or persistent mood disorders.

Patients with mild or moderate problems should be provided with information, support, and advice about the mood disorder and the stroke [33]. The information may be provided with leaflets, workbooks, or verbal communication, including lectures or teaching sessions. Information is necessary to identify and act upon symptoms, manage exacerbations, facilitate access to effective treatments, and improve clinical outcomes [40]. A lack of information has a negative impact in compliance with stroke secondary prevention and psycho-social outcomes for both stroke patients and carers [41]. A Cochrane review reported that the provision of information to stroke patients and caregivers had no effect in depression rates, when depression was approached as a binary variable (depressed/not depressed), but it had a significant positive effect on depression scores [42]. The information provided in the trials included in the review contained at least one of the following components: the causes and nature of stroke, management and recovery from stroke, prevention or reduction of risk of recurrent strokes, and information on resources or services. Other interventions that may be considered for stroke survivors with mild or moderate depression are increased social interaction, increased exercise, goal setting, or other psychosocial interventions [33]. All stroke teams should have clinicians adequately trained to provide this care, although at this level the voluntary sector may be also involved.

If patients do not respond to information, support, and advice, then psychological or pharmacological treatments or a combination of both may be considered with the involvement of a clinician with expertise in managing mood disorder after stroke [33]. Whilst initial meta-analyses of randomised controlled trials (RCTs) found no evidence to support the routine use of pharmacotherapeutic or psychotherapeutic treatment for depression after stroke, subsequent RCTs and meta-analyses showed a small but significant effect of pharmacotherapy (but not psychotherapy) on treating depression but with an increase in gastrointestinal and neurological side effects [5, 43]. The National Institute for Health and Care Excellence (NICE) guidelines for depression in adults with chronic physical health problems recommend selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment, and a Cochrane review has shown SSRIs to improve not only depression but also dependence, disability, neurological impairment, and anxiety after stroke [44, 45]. However, there was heterogeneity between trials and methodological limitations in a substantial proportion of them. While this Cochrane review could find no evidence of an association between SSRIs and relevant side effects, some observational studies have reported an association between antidepressants and an increased risk of adverse outcomes including falls, fractures, upper gastrointestinal bleeding, self-harm, stroke, and all-cause mortality [46, 47]. The results of large, well-designed trials are needed to determine whether antidepressants should be given routinely to improve disability in stroke patients.

Patients prescribed antidepressants should be monitored for adverse effects, and treatment should be continued for at least 4 months beyond initial recovery. If the patient’s mood has not improved within a month of initiating treatment, compliance with medication should be checked, and a higher dose of the same drug, or another antidepressant, should be considered. Patients on antidepressants should have regular medication reviews to assess the need to continue with the treatment. In patients with aphasia or other impairments that complicate assessment, careful observations over time (including response to a trial of antidepressant medication) may be used [33].

The management of depression after stroke requires long-term follow-up to assess adherence and efficacy of therapy and to change doses or stop treatment where necessary [48]. Adequately coordinated clinical attention provided by stroke physicians, general practitioners, and sometimes psychiatrists would prevent the fragmentation of the long-term care of stroke patients with or at risk of depression. It has been suggested that health services may not have the resources to screen and treat all patients with post-stroke depression [48]. Nonetheless, depression is associated with negative health outcomes that would be costly for the health service in the long term. While further research into the benefit of psychological care after stroke is needed, there is already some evidence suggesting that effective management of depression after stroke may be a cost-effective policy [49].

A Cochrane review of pharmacological and psychological interventions to prevent depression after stroke reported that psychological interventions led to a small but significant improvement in depression, but no evidence of an effect of antidepressants was observed. There was no evidence of psychotherapy or antidepressants improving cognitive function, activities of daily living, or disability [50]. The trials that have been published since then showed some evidence of benefit for antidepressant drugs, although their addition to the Cochrane analyses is unlikely to change substantially the overall estimate of effect [5, 51–53]. In accordance with this evidence, RCP guidelines recommend that antidepressants should not be used routinely to prevent the onset of depression [33].

Most studies for prevention and treatment of depression after stroke address patients shortly after the acute event [43, 50]. However, depression has been observed to be a frequent problem up to 15 years after stroke [30]. Therefore, the development of screening, preventive, and therapeutic interventions for depression in the long term after stroke, involving primary care clinicians, is required. Primary care settings have an advantage over hospitals, when considering long-term interventions, as follow-up examination may be routine, brief, and easy to arrange and they are the place where the medical management of different problems is integrated. Ensuring a good coordination between primary and secondary care will be essential in the development of effective interventions for depression after stroke.

As well as the diagnosis, the management of depression after stroke should be approached holistically. It has been reported that patients with multi-morbidity often receive care from different teams in an uncoordinated way [54]. The results of studies of depression in the context of other diseases [55–59] suggest that depression may be relevant to patients affected by most long-term conditions [13]. An integrated approach to depression for all the chronically ill, including stroke survivors and also patients with less frequent and therefore less investigated problems, might be developed in the future.

Probably the biggest obstacle to routine use of psychological strategies is access to trained therapists, due to scarcity of services, long waiting lists for non-crisis cases, and financial cost. However, psychotherapeutic assistance may be provided not only through a formal process of psychotherapy but also in the context of the ongoing doctor-patient relationship. For many people with medical conditions, the relationship with a clinician who is prepared to listen to their experience is the most important component of their treatment [14]. Although the therapeutic relationship may be one of the most powerful tools to preserve and protect emotional well-being, this factor is often underestimated by practising clinicians. Appropriate training to make the relationship with the patient psychotherapeutic in itself could be suggested. Some medical patients who might benefit from psychotherapy may be relucant to accept a treatment that implies that they are ‘damaged’ in yet another way. These patients may prefer brief and periodic interventions that emphasise psychoeducation provided by their usual doctor.

Most predictors of depression after stroke are not purely biological but psychological and sociological as well. The multidisciplinary care that patients with depression after stroke need may also have to be delivered in cooperation with professionals working outside the health service. There is already a systematic review reporting positive effects of tele-counselling (mental health services by telephone) on depression in patients with disabling medical conditions, including stroke [60]. The tele-counselling was provided in an average of eight sessions of 30–90 min each, over a 3-month period. The programmes involved individual sessions held once a week to once a month. Significant improvements, not only in depression but also in coping skills and strategies, and community integration were observed.

Another systematic review reported that there is limited to moderate evidence supporting community-based rehabilitation interventions delivered by allied health professionals and/or nursing staff to have a positive effect on different outcomes such as quality of life, participation, and depression after stroke [61]. There is a need for trials looking at a broader range of treatment and prevention strategies, including talking interventions delivered by trained and supervised lay workers, the provision of combined and collaborative care interventions, and trials of guided self-help [48].

A large proportion of stroke patients do not develop depression, and this introduces the concept of resilience [2, 3, 14, 62]. The study of resilience has become more relevant as there has been a shift from a problem-oriented approach to one that stresses prevention and the nurturing of strengths. There are trials that have reported successful interventions enhancing resilience in patients with other medical conditions [63]. However, even though resilience is an interesting concept that opens a new way of looking at mental health problems in the medically ill, its routine application in clinical practice requires further research. A good conceptualisation of resilience and its potential role in stroke patients may help in the development of interventions to prevent and/or treat post-stroke depression.

Clinicians’, patients’, and carers’ beliefs about depression after stroke also influence the effectiveness of its management. Further qualitative research studies investigating what doctors, patients, and carers think about depression after stroke, and its possible clinical approach, may also help in the development of effective interventions. Finally, future studies describing the natural history, predictors, and outcomes of depression after stroke, and the effect of interventions in low- and middle-income countries, are also required [48].

A systematic review reported that the pooled prevalence of anxiety after stroke was 18 % when it was assessed by clinical interview and 25 % when a rating scale was used [1]. However, anxiety affects more than half of stroke patients at some point in the long term. A large cohort study observed that up to 57 % of stroke patients presented symptoms of anxiety at some point within 10 years of stroke, with 58 % of them developing their first symptoms in the first 3 months [7]. The observed annual incidence of anxiety was up to 24 % and prevalence 32–38 % within 10 years of the acute event [7]. The dynamic natural history of anxiety after stroke has also been observed in other studies that reported that up to 40 % of patients with anxiety in the first few months after stroke remained anxious 4–8 months later and up to 11 % of patients not anxious at 2 months became so 2–4 months later [66, 67]. Anxiety has also been reported to be associated with depression and poor quality of life in the long term after stroke [1, 7].