Nonpharmacological Interventions for Poststroke Depressive Symptoms: Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE: Nearly 30% of stroke patients develop depression, in either the acute or late stages (Hackett, Yapa, Parag, & Anderson, 2005). Considering the adverse impact of depressive symptoms on stroke recovery, previous studies have suggested various intervention options for depressive symptoms after stroke. Although pharmacotherapy is a common approach, it has several shortcomings such as expensive prescriptions, a long response time, potential adverse effects, and poor compliance (Paolucci, 2008). Alternatively, non-pharmacological interventions have been shown to be effective in reducing depressive symptoms (Hadidi, Wagner, & Lindquist, 2017). Occupational therapists in stroke rehabilitation need to develop and deliver effective non-pharmacological interventions for stroke survivors with depressive symptoms. Thus, the objective of this systematic review is to examine the effects of different types of non-pharmacological interventions to alleviate depressive symptoms after stroke and to provide evidence for the most effective approach.

DESIGN: This systematic review followed procedures outlined in the Preferred Reporting Items for Systematic-Reviews and Meta-analyses (PRISMA). An initial search of MEDLINE and CINAHL was preformed to compile a comprehensive list of non-pharmacological interventions and was followed by a second search for published studies from January 2000 to August 2018 of additional databases (Scopus, Cochrane, Academic Search, and LISTA). Search terms included depression, stroke, non-pharmacologic, and intervention.

METHOD: Randomized controlled trials (RCTs) that compared the effects of non-pharmacological and control interventions after stroke were selected and reviewed by two reviewers. The primary and secondary outcomes were depressive symptoms and quality of life (QOL), respectively. For meta-analysis, statistical heterogeneity and effect size of data were analyzed using Review Manager 5.3 software (Nordic Cochrane Centre, Cochrane Collaboration, 2014). Cochrane’s Q and I ² values were used to determine heterogeneity. Effect sizes were estimated by calculating the standardized mean difference (SMD) and 95% confidence interval (CI). Publication bias was evaluated using a funnel plot.

RESULTS: We identified 1703 records. One hundred fourteen full-text articles were assessed for eligibility, and 24 studies were included in narrative synthesis, of which 14 were eligible for meta-analysis. Non-pharmacological interventions used in 24 studies were categorized into five types: complementary and alternative therapy (n = 5), exercise (n = 6), psychosocial therapy (n = 8), multifactorial therapy (n = 3), and cranial stimulation (n = 2). Beneficial effects on depressive symptoms were specifically observed for complementary and alternative therapy and psychosocial therapy post-intervention (p < 0.05). We also found a long-term beneficial effect of psychosocial therapy on depressive symptoms at follow-up (p < 0.05). The overall beneficial effect, combining results of different types of interventions, was found to be significant for depressive symptoms at both post-intervention and follow-up (p < 0.05) but not for QOL (p > 0.05).

CONCLUSION: Our findings indicate that different interventions have differential impacts on depressive symptoms in stroke survivors. Complementary and alternative therapy appears to have positive effects on depressive symptoms in stroke survivors post-intervention. Psychosocial therapy appears to have both immediate and long-term effects on reducing depressive symptoms. However, none of the included interventions had effects on QOL that were more favorable than those of control interventions. Thus, we suggest that occupational therapists formulate intervention plans based on the target outcome.

References

Hackett, M. L., Yapa, C., Parag, V., & Anderson, C. S. (2005). Frequency of depression after stroke: a systematic review of observational studies. Stroke, 36(6), 1330-1340. doi: https://doi.org/10.1161/01.STR.0000165928.19135.35

Hadidi, N. N., Wagner, R. L. H., & Lindquist, R. (2017). Nonpharmacological treatments for post-stroke depression: An integrative review of the literature. Research in Gerontological Nursing, 10(4), 182-195. doi: https://doi.org/10.3928/19404921-20170524-02

Paolucci, S. (2008). Epidemiology and treatment of post-stroke depression. Neuropsychiatric Disease and Treatment, 4(1), 145