What is the effectiveness of cognitive behavioural therapy compared with antidepressants for the treatment of post-stroke depression in adult stroke patients?

Stroke is a common disorder with profound lasting effects and is the UK’s fourth leading cause of morbidity. One important after-effect is post-stroke depression (PSD). PSD can impact overall recovery, however treatment guidelines remain unclear. Usual care generally consists of antidepressants despite cognitive behavioural therapy (CBT) being a first-line treatment for depression. This evidence review aims to assess the effectiveness of CBT compared with antidepressants for treating PSD in adult stroke patients. Evidence searches of MEDLINE, PUBMED, The Cochrane Library, PsycINFO and NICE Evidence Search were conducted using strict search terms. The results were screened and appraised. A reference list search was carried out on included reviews with these results also screened and appraised. Appraisals used the AGREE II tool for guidelines and the CASP systematic review and randomised controlled trial (RCT) frameworks. Each stage was carried out by two independent reviewers, with disagreements resolved by a third reviewer. After applying inclusion and exclusion criteria, two guidelines, four reviews and one RCT were included in the synthesis. One review found CBT effective for treating PSD. Two reviews found CBT combined with antidepressants more effective than antidepressants alone. One review concluded CBT was ineffective for treating PSD. A single RCT found CBT more effective than antidepressants if PSD onset was nine months post-stroke, but PSD onset six months post-stroke was most effectively treated by antidepressants. Results for less than six months post-stroke were inconclusive. The findings of this evidence review suggest it is not possible to definitively conclude whether CBT is more or less effective than antidepressants. A combination of both is likely to be most effective. Lack of research means conclusions for clinical practice are difficult to draw. More research is needed before specific guidelines can be compiled.