Dr Georgeis a research coordinator, Department of Research at Cleveland Clinic Akron General and clinical assistant professor of Obstetrics and Gynecology, Northeast Ohio Medical University.

Estee George, PhD

First used decades ago, virtual psychiatric health care has been established as a viable alternative to in-person psychiatric services. In 2016, Hubley and colleagues performed a review of available research and concluded that a “large evidence base supports telepsychiatry as a delivery method for mental health services.”

 Luo et al established electronically delivered cognitive behavioral therapy (eCBT) as noninferior to in-person cognitive behavioral therapy (CBT) with respect to a variety of outcomes. They also found that eCBT is actually more effective than face-to-face CBT for reducing depression symptom severity.

While implementation of telepsychiatric care had been steadily increasing, barriers to widespread use remained. The 2 primary barriers were regulatory burdens and logistical difficulties associated with reimbursement, according to Keesara et al.

 Then, in spring 2020, the COVID-19 pandemic necessitated virtual care, and these barriers were rapidly removed. The pandemic prompted a shift in outpatient psychiatry services from primarily face-to-face to primarily virtual. Given the unprecedented nature of this paradigm shift, literature from the pre-COVID-19 era has lost some degree of relevance. However, a wealth of research on telepsychiatric health care has been performed since March 2020.

Chen et al described early experiences, reviewed key regulatory changes enabling widespread telepsychiatry, and provided clinical insights and suggestions.

 Yellowlees and colleagues detailed anecdotal experience at University of California, Davis Health and described generally positive experiences from both the provider and patient points of view.

 Another group of investigators published a nationwide multisite survey on patient attitudes. Of the 14,000 patients who were surveyed, approximately 3000 responded and results generally favored use of telepsychiatry.

In a retrospective cohort study of nearly 39,000 patient surveys, Ramaswamy et al found satisfaction with video visits to be significantly higher than satisfaction with in-person visits (94.9% versus 92.5%; p < 0.001).

 Additionally, Serhal and colleagues developed and validated a survey on patient satisfaction. They found that access, timeliness, and safety were predictors of patient satisfaction.

 Finally, a review on determinants of satisfaction showed the main determinants to be convenience and cost.

 It stands to reason that telepsychiatric care provides benefits associated with access, timeliness, safety, convenience, and cost, and current research generally indicates patient preference for virtual health care visits.

The psychiatric outpatient experience at Cleveland Clinic Akron General (CCAG) and its resident-run clinic has been rapidly and dramatically changed in response to the COVID-19 pandemic. Patient attitudes toward these changes (in particular, telepsychiatric care) have not been assessed. As such, our goal was to gather and report feedback—in both a quantitative and a qualitative manner—from our patients regarding their attitudes toward the conversion to virtual psychiatric care. We hope this feedback will allow us to improve delivery of care and other patient outcomes in the future.

The CCAG Institutional Research Review Board approved use of the minimum necessary protected health information for the conduct of this quality assurance initiative. Psychiatric patients at CCAG and its resident-run clinic who attended virtual visits (by video or phone conference) from April 1, 2020, to December 31, 2020, were identified by a review of electronic medical records. Email addresses for these patients were extracted. A short anonymous survey including a demographics section and a questionnaire was emailed to patients via the Research Electronic Data Capture (REDCap®) application, a secure web-based platform that automatically collects and stores responses. The questionnaire included 4 multiple-choice questions and 1 open-ended prompt and was designed to assess difficulty setting up video software/telephone, quality of visit, convenience, and overall preference (

Descriptive statistics were performed for data analysis using IBM SPSS (Version 24.0, Armonk, NY) statistical software. Frequencies with percentages, measures of central tendency, and measures of spread were presented as appropriate. Qualitative data in the form of responses to open-ended questions were also reported.

A total of 1259 surveys were administered, and 120 (9.5%) patients responded. Self-reported demographics are presented in 

One hundred one (84.2%) patients indicated setup was no challenge or only mildly inconvenient, and 18 (15.0%) indicated they had significant setup difficulties. Forty-eight (40.0%) patients felt virtual visits were of higher quality, 32 (26.7%) expressed neutrality, and 40 (33.3%) indicated in-person visits were of higher quality. Ninety-four (78.3%) patients indicated virtual visits were more convenient, 8 (6.7%) indicated neutrality, and 16 (13.3%) indicated in-person visits were more convenient. Lastly, 65 (54.2%) patients expressed an overall preference for virtual visits, 19 (15.8%) expressed no preference, and 36 (30.0%) expressed a slight or significant preference toward in-person visits (

. Patient perceptions of difficulty setting up virtual software/phone for visit (top left), quality of visit (top right), convenience (bottom left), and overall preference (bottom right).

Of the 120 respondents, 69 (57.5%) provided responses to the open-ended prompt. Of these, 32 (46.4%) expressed a preference for virtual visits, commented only on benefits of virtual visits, or commented only on drawbacks to in-person visits. Of their comments, 24 (75%) included language on convenience, 12 (37.5%) included language on comfort, 6 (18.8%) included language on safety (largely with respect to the COVID-19 pandemic), and 7 (21.9%) included language indicating virtual visits benefitted family and childcare situations. Thirteen (18.8%) respondents expressed a preference for in-person visits, commented only on benefits of in-person visits, or commented only on drawbacks to virtual visits. Their comments included language on the benefits of personal and emotional interactions, the ability to read body language, and the capacity to comfort and express care. The remaining 24 (34.8%) respondents did not express a preference, commented on benefits/drawbacks of both options, or did not provide a clear or relevant response.

Our results indicate that a great deal of benefit can come from telepsychiatric care. These findings corroborate those of other groups.

 Conceivably, increased convenience coupled with comparable quality would predict a significant preference toward virtual visits. However, the actual trend observed was modest. This may be explained by the heterogeneous nature of our patient population. For example, differences in access to technology, technological proficiency, access to transportation, travel time, availability, and personal finances are just a few variables that account for differences in preferences and opinions.

Even differences in diagnoses play a role. Within free-response answers, many patients indicated that they felt more comfortable attending virtual visits given their struggles with agoraphobia. It is worthy to note, however, that this “benefit” may not be in some patients’ best interest. For example, some providers may feel that exposure to places and situations that cause discomfort is necessary for recovery.

There were some important limitations to this initiative. Results may have been influenced by selection and non-response bias. For example, given that the survey was administered via email, it stands to reason that patients who are more comfortable using computer technology may have been more likely to respond. Also, demographic data show that 60.5% of responders reported attainment of a bachelor’s degree or higher, and 28.6% reported having attended some college or obtaining an associate’s degree. As such, results largely reflect the opinions and preferences of more highly educated patients and, therefore, do not accurately represent those of our patient population as a whole. Other types of bias that may be at play include recall, acquiescence, and question order bias.

The best way to meet diverse needs is to offer diverse options. Telepsychiatry represents an option that may be well suited to some and not as well suited to others. To test for associations between patient opinions and factors such as demographics, baseline clinical characteristics, and diagnoses, formal research is required. Telepsychiatry is a branch of health care delivery still in its infancy, and there is much to be discovered. Future research will inform on optimal ways to provide individualized psychiatric care.

is a psychiatrist at LifeStance Health, Upper Arlington, Ohio.

is a health scientist in the Department of Health Sciences at Cleveland Clinic Akron General, Akron, Ohio; she is also an assistant professor of psychiatry and a clinical assistant professor of obstetrics and gynecology at Northeast Ohio Medical University, Rootstown, Ohio.

is professor and chairman, Department of Psychiatry, Creighton University School of Medicine, Omaha, Nebraska, and chairman, Catholic Health Initiatives (CHI) Health Behavioral Health Services, Omaha, Nebraska.

1. Hubley S, Lynch SB, Schneck C, et al. 

A comparison of electronically-delivered and face to face cognitive behavioural therapies in depressive disorders: a systematic review and meta-analysis

 [published correction appears in EClinicalMedicine. 2021 Nov 02;41:101182]. 

Covid-19 and health care’s digital revolution

COVID-19 and telepsychiatry: early outpatient experiences and implications for the future

5. Yellowlees P, Nakagawa K, Pakyurek M, et al. 

Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19

Patient attitudes toward telepsychiatry during the COVID-19 pandemic: a nationwide, multisite survey

7. Ramaswamy A, Yu M, Drangsholt S, et al. 

Patient satisfaction with telemedicine during the COVID-19 pandemic: retrospective cohort study

8. Serhal E, Kirvan A, Sanches M, et al. 

Client satisfaction and experience with telepsychiatry: development and validation of a survey using clinical quality domains

A review of patient and provider satisfaction with telemedicine

Articles

COVID-19 has prompted an unprecedented shift toward virtual psychiatric health care—but how do patients and providers really feel about it?

Telepsychiatry: Diverse Needs Require Diverse Options

The goals for this activity are to understand the epidemiology and neurobiology of poststroke depression, to learn how to complete an appropriate assessment, and to be able to provide comprehensive treatment for these individuals.

1. To discuss the epidemiology of poststroke depression

2. To describe the risk factors for poststroke depression

3. To elaborate on the assessment of individuals with poststroke depression

4. To enumerate the treatments for poststroke depression

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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It is estimated that in the United States alone, approximately 795,000 individuals have a stroke annually. The prevalence of stroke is greater among men than women, but the stroke incidence doubles among postmenopausal women. Furthermore, 

 was rated as the third most common cause of disability adjusted life-years worldwide in 2010.

 In the United States, stroke has been established as the most burdensome of all neurological disorders.

 found that among the long-term (15 year) survivors of stroke, 33.8% have mild disability, 14.3% have moderate disability, and 15.0% have severe disability (

). The prevalence of disability increased with time, but 10% of these individuals had lived with moderate-severe disability since their stroke.

Available evidence indicates that there are a multitude of neuropsychiatric syndromes that occur after a stroke (

 Poststroke bipolar disorder, mania, and psychotic symptoms are rare sequelae to stroke. Cognitive impairment occurs in approximately one-third of individuals post stroke.

 often impede the recovery of motor functioning, reduce social functioning, and decrease the overall quality of life.

A recent meta-analysis found that the prevalence of any depressive disorder post stroke is approximately 33.5%.6 In this study, the point prevalence of major depression was 17.7% with the prevalence for minor depression being 

.1%. Prevalence of dysthymia and adjustment disorder was 3.1% and 6.9%, respectively. An earlier meta-analysis found that the frequency of poststroke depression was approximately 31%.7 The proportion of those with depression between 1 and 5 years after stroke was 25%, and the proportion of those with depression at 5 years after stroke was 23%.

Figure 1. Disability Among Long-Term Survivors of Stroke

Figure 2. Neuropsychiatric Symptoms Occurring After a Stroke

In the DSM-5, poststroke depression (PSD) is classified under the criteria for “

Depressive Disorder Due to Another Medical Condition

). To meet the DSM-5 criteria, individuals should present with a prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all or almost all activities. The history, physical examination, or laboratory findings should show that the depressive symptoms are due to the direct pathophysiological consequence of a stroke. Furthermore, the presence of depressive symptoms should not be better explained by another mental disorder, including an adjustment disorder, nor should the depressive symptoms occur exclusively during the course of a 

. In addition, these symptoms should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Figure 3. Prevalence of Depressive Disorders After a Stroke

PSD symptoms can be further subclassified as presenting with (1) depressive features when all criteria for a major depressive episode are not met, (2) a major depressive-like episode when the criteria for a major depressive episode are met, and (3) mixed features when symptoms of mania or hypomania are also present but do not predominate in the clinical presentation.

PSD phenomenology is similar to, but not the same as, that described by other individuals with depression.

 For example, individuals with PSD are less likely to report “inability to feel” or “disturbed sleep.” In addition, individuals with PSD may be less likely to report anhedonia and apathy when compared with other individuals who have 

. In one study, researchers compared symptoms in (1) poststroke patients with and without depression, (2) individuals who were being seen in general practice, and (3) patients with symptomatic atherosclerotic diseases.

 They found that although the 3 cohorts demonstrated broadly similar symptom profiles, as well as comparable levels of individual symptom prevalence, the individuals with PSD had more severe symptoms than individuals in the other 2 groups.

A recent meta-analysis by Shi et al indicated that a history of mental illness (depression/anxiety) was the highest-ranking risk factor for PSD (odds ratio [OR] 2.93).

 Other risk factors for PSD were family history of mental illness (OR = 1.95), age (< 70 years, OR = 1.94), female sex (OR = 1.77), level of handicap (OR = 1.52), severity of stroke (OR = 1.12), and neuroticism (OR = 1.08). The investigators also found that education (> 8 years) and social support (OR = 0.93) were protective factors for PSD. Brain damage in the left frontal lobe and left basal ganglia was associated with PSD, and specified levels (< 10.2 ng/ml) of brain-derived neurotrophic factor and leptin (> 20.7 ng/ml) were risk factors for PSD. Biochemical factors, including interleukin-1b (IL-1b) and intercellular cell adhesion molecule-1 (ICAM-1), hypertension, 

 mellitus, hyperlipidemia, atrial fibrillation, and myocardial infarction were not found to be associated with PSD.

In a prospective observational study of individuals who were post stroke and in the emergency department or admitted to acute care in designated stroke centers, individuals with PSD had more severe strokes, greater functional handicap, and longer hospital stays and were less likely to be discharged home following acute hospitalization (all P < .001) than patients without PSD.

 One systematic review indicated that individuals with PSD tend to experience a moderate increase in the risk of poor functional outcome (OR = 2.16) when compared with stroke patients without depression.13 This association did not seem to be caused by poor rehabilitation and functional improvement among individuals with PSD.

 is also a consequence of PSD. A meta-analysis by Bartoli et al found the pooled proportion of suicidal ideation among stroke survivors was 11.8%.

 Current (OR = 11.50; P < .001) and past (OR = 6.96; P < .001) depression, recurrent stroke (OR = 1.77; P < .001), disability (P = .01), and cognitive impairment (P = .03) were all associated with

. Suicidal ideation was less likely to occur in stroke survivors who were married (OR = 0.63; P < .001), employed (OR = 0.57; P = .02), and had higher education levels (OR = 0.55; P = .002). A meta-analysis by Cai et al found that PSD was associated with significantly increased risk for mortality among stroke survivors (HR = 1.59).

The pathogenesis of PSD involves complex interactions between neuroanatomical and neurochemical factors.

 It is thought that the processes involved in development of PSD include reduced levels of monoamines, abnormal neurotrophic response to the occurrence of stroke, increased 

 in the brain, dysregulation of hypothalamic-pituitary-adrenal (HPA) axis, and glutamate-mediated excitotoxicity.

 Available studies indicate that large lesions in critical areas of the brain, including the left frontal lobe and basal ganglia or the accumulation of silent cerebral lesions beyond a critical threshold, may interrupt the pathways of monoamine neurotransmitters or pathways that control mood regulation.

 Cytokines that are produced post stroke increase glutamate-induced excitotoxicity, resulting in neuronal death in critical areas of the brain. This may also lead to the enlargement of cerebral infarctions. This process, coupled with hypercortisolism induced by stress or inflammation after the stroke, may reduce intracellular serotonin transporters, resulting in depression. Additionally, hippocampal neurogenesis may be inhibited by the interaction among cytokines, glucocorticoid, and neurotrophin. Available evidence indicates that these neurobiological processes, seen among individuals who develop PSD, may differ from individuals who do not develop depression after a stroke, but the details regarding these complex mechanisms are only emerging.

Although fairly common, PSD is often underdiagnosed.

 Differential diagnosis is difficult, as many of these individuals who are post stroke may present with cognitive impairment and may not be able to report their symptoms accurately (

). In addition, some symptoms of stroke and depression (eg, loss of appetite, difficulty concentrating, and 

) may be indistinguishable from one another. In these situations, the presence of nonsomatic symptoms including guilt, depressed mood, hopelessness, or worthlessness is more suggestive of PSD.

In one study, PSD was diagnosed in only 4.8% of the patients, and only 6.7% of these individuals were treated with a new antidepressant.

 However, compared with patients admitted to standard units, individuals admitted to specialized stroke units were more likely to be diagnosed with depression (5.2% vs 4.0%, P < .014) and were more likely to receive a new prescription for an antidepressant (7.8% vs 4.5%, P < .001). These results indicate that there should be routine screening post stroke for PSD. Additionally, specialized stroke unit care may improve the detection and treatment of PSD.

A number of tools may be helpful in identifying PSD. One meta-analysis found that the Center of Epidemiological Studies-Depression Scale (CES-D) (sensitivity, 0.75 and specificity, 0.88), the Hamilton Depression Rating Scale (HDRS) (sensitivity, 0.84 and specificity, 0.83), and the Patient Health Questionnaire (PHQ)-9 (sensitivity, 0.86 and specificity, 0.79) were optimal screening tools.21 The PHQ-2 performed less well than other measures. However, the investigators found that the clinical utility of these tools was modest for case-finding. They cautioned that these screening tools should not be used in 

; a more detailed clinical assessment to detect PSD should also be used.

A meta-analysis by Hackett et al evaluated interventions for preventing PSD. The investigators included data from 10 pharmaceutical trials (12 comparisons) and 4 psychotherapy trials. 

 Most of the participants were recruited within 1 month of acute stroke, and the duration of treatment ranged from 2 weeks to 1 year. The proportion of participants meeting the study criteria for depression was lower in the antidepressant‐treated group; however, meta‐analysis was not performed, as the study methods and end point measured varied among studies. There was no evidence of benefit of 

 on the mean depression scores at the end of treatment or change in mean scores from baseline. Additionally, there was no evidence of 

 improving cognitive function or activities of daily living (ADL) or reducing disability. There was no clear evidence of harm demonstrated in the analysis of adverse events. The investigators noted benefit of psychotherapy in the pooled proportion of participants who met the study criteria for depression at the end of treatment (OR = 0.64) and a reduction in psychological distress scores from baseline on the 28-item General Health Questionnaire (mean difference [MD] = ‐1.37). There was no evidence of benefit or harm either in ADL or social activities. There were also fewer adverse events noted in the intervention group (OR = 3.73).

In a meta-analysis that included data from 10 randomized placebo-controlled trials (RCTs) that evaluated the prophylactic effects of antidepressants in nondepressed individuals with stroke to prevent PSD, Chen et al found the pooled occurrence rates of newly developed PSD cases in the intervention and control groups were 12.54% (41 of 327 participants) and 29.17% (91 of 312 participants), respectively.

 (SSRIs) and tricyclic antidepressants (TCAs) were associated with reductions in the incidence of PSD. The reductions in the incidence of PSD were not related to the interval between stroke onset and the administration of an antidepressant (P = .47), and the prophylactic effects of antidepressants were not related to duration of their use (P = .11).

In a recent meta-analysis, Gu et al included data from 12 studies that evaluated the use of prophylactic antidepressants to prevent the occurrence of PSD.

 The investigators found antidepressants following acute stroke reduced PSD incidence (relative risk [RR] = 0.33, P < .001). There were no differences detected in efficacy noted between the SSRIs, TCAs, and serotonin norepinephrine reuptake inhibitors (SNRIs) in the subgroup analysis. When compared with the control group, the RR of PSD recurrence during the follow-up period in the treatment group was 0.51 (P < .001). The pooled mean difference in reduction of depression severity on the HDRS between the antidepressant and control groups was 5.73 (P < .001). Additionally, there were improvements in the motor function (weighted mean difference [WMD] = 12.56, P < .001) and neurological function (WMD = 1.13, P < .001) between the antidepressant and the control groups. There were no differences between the 2 groups with regard to mortality rates (RR = 1.63, P = .377) or incidence of adverse events (RR = 0.93, P = .806).

In a cross-sectional study of data from the National Ambulatory Medical Care Survey and its outpatient department, Bhattacharjee and colleagues found that only 47.32% of the participants with PSD received treatment, which was mainly driven by the use of antidepressant alone. In this study, men were approximately 3 times more likely to receive depression treatment compared with women.

 Additionally, individuals who were Caucasian were almost 4 times more likely to receive depression treatment compared with other races or ethnicities. This study also found that an increase in number of chronic diseases was associated with a lower likelihood of receiving any 

In a meta-analysis of 28 RCTs that evaluated cognitive behavioral therapy (CBT) for PSD, the investigators found that CBT had positive effects on PSD when compared with control groups (P < .001).

 Both CBT alone (P = .001) and CBT in combination with antidepressants (P < .00001) improved depressive symptoms in PSD. CBT resulted in significantly higher remission rates (P < .00001) and response rates (P < .00001), improving anxiety, neurological functional deficits, and ADL. Data from 8 studies showed no significant relationship between CBT effects and the mean duration after stroke (P > .05).

In a network meta-analysis of 23 RCTs that evaluated 

 PSD treatment interventions, the investigators found that SNRIs were associated with the highest reduction in the depression scores, followed by TCAs, psychotherapy plus antidepressant, and SSRI antidepressants.

 In a second network meta-analysis, the investigators included data from 15 RCTs in which 13 antidepressant drugs were considered.

 The investigators found that for efficacy, paroxetine was ranked the best antidepressant for reduction in depression scores at the end of treatment, followed by imipramine, reboxetine, nortriptyline, citalopram, and fluoxetine. They also found that duloxetine ranked the best for the reduction in depression scores at durations of 4 weeks and 8 weeks. For tolerability, paroxetine was ranked the best, but there was no significant difference noted between any of the comparisons. In a third network meta-analysis of 14 RCTs with 9 different antidepressant treatments, the investigators found that doxepin, paroxetine, and nortriptyline were significantly more effective than placebo (standardized mean differences: -1.93, -1.39, and -1.25, respectively) in the treatment of PSD.

In a study that evaluated transcranial direct current stimulation (tDCS) for PSD, the investigators randomized 48 antidepressant-free individuals with PSD into 2 groups: active and sham tDCS.30 Participants received twelve 30-minute sessions of left/cathodal right dorsolateral prefrontal tDCS over a 6-week period: once daily on weekdays for 2 weeks, then 1 session every other week. The primary outcome was a change in the 17-item HDRS at 6 weeks. The investigators found that active tDCS was superior to sham at the end point (P < .001). The response and remission rates were also significantly higher in the active treatment group (37.5% and 20.8%, respectively) when compared with the sham treatment group (4.1% and 0%, respectively). The number-needed-to-treat for response and remission were 3 and 5, respectively. There were no changes in cognitive performance due to tDCS, and the frequency of adverse events was not significantly different between the active and sham groups at all time points. Additionally, no serious adverse events were reported.

 The investigators did not identify any potential predictors of response including depression onset after stroke, duration of the 

A systematic review and meta-analysis of 22 RCTs evaluated the effect of 

repetitive transcranial magnetic stimulation

 (rTMS) on PSD.31 The primary outcome was severity of depression as measured by the HDRS. The secondary outcomes were response rates, remission rates, stroke severity, and ability to perform daily activities. The investigators found that rTMS was beneficial for PSD on all of the following: HDRS (P < .001); response rates (OR = 3.46, P < .00001); remission rates (OR = 0.99, P < .00001); National Institutes of Health Stroke Scale (P < .001); ADL (P < .001); and Montgomery-Asberg Depression Scale (P = .0001). A total of 15 (1.7%) participants in the active treatment group and 6 (0.7%) participants in the control group experienced headache; 2 (0.2%) participants in the active treatment group and 9 (1.0%) participants in the control group developed gastrointestinal reactions; 3 (0.3%) participants in the active treatment group and 7 (0.8%) participants in the control group had dry mouth; 1 (0.1%) participant in the active treatment group suffered from tinnitus; 1 (0.1%) participant in the active treatment group felt weak; and 6 (0.7%) participants in the control group experienced other adverse events. The investigators did not find any statistically significant differences in withdrawals due to adverse events between the 2 groups; 0.2% (2 of 881) of patients in the control group withdrew due to gastrointestinal effects. Because of the significant heterogeneity between the different studies, the effect of frequency of treatment, site, duration of illness, type of basic treatment, type of control intervention, and total session on outcomes could not be evaluated.

PSD is a common sequela of stroke. The pathogenesis of PSD involves complex interactions between both neuroanatomical and neurochemical factors. PSD is associated with more severe strokes, greater functional handicap, longer hospital stays, lower likelihood of discharge to home following acute hospitalization, and a greater risk for mortality. Common risk factors for PSD include a history of mental illness (depression/anxiety), a family history of mental illness, age (< 70 years), female sex, level of handicap, severity of stroke, and neuroticism.

Although fairly common, PSD often remains underrecognized and poorly treated. Available evidence indicates efficacy of both nonpharmacological and pharmacological treatment strategies for the prevention of PSD. Early identification and appropriate management of PSD will reduce the morbidity and mortality due to this condition. Future research should investigate the pathophysiological underpinnings of PSD, so that more effective preventative and treatment strategies can be developed.

is professor and chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General and Chief, Section for Geriatric Psychiatry, Department of Psychiatry and Psychology, Cleveland Clinic. 

 is a research coordinator, Department of Research at Cleveland Clinic Akron General and clinical assistant professor of Obstetrics and Gynecology, Northeast Ohio Medical University.

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https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm04

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10. de Man-van Ginkel JM, Hafsteinsdóttir TB, Lindeman E, et al. Clinical manifestation of depression after stroke: is it different from depression in other patient populations? 

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14. Bartoli F, Pompili M, Lillia N, et al. Rates and correlates of suicidal ideation among stroke survivors: a meta-analysis. 

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21. Meader N, Moe-Byrne T, Llewellyn A, Mitchell AJ. Screening for poststroke major depression: a meta-analysis of diagnostic validity studies. 

22. Hackett ML, Anderson CS, House A, Halteh C. Interventions for preventing depression after stroke. 

23. Chen Y, Patel NC, Guo JJ, Zhan S. Antidepressant prophylaxis for poststroke depression: a meta-analysis. 

24. Gu J, Huang H, Chen K, et al. Are they necessary? preventive therapies for post-stroke depression: a meta-analysis of RCTs. 

25. Bhattacharjee S, Axon DR, Goldstone L, Lee JK. Patterns and predictors of depression treatment among stroke survivors with depression in ambulatory settings in the United States. 

26. Wang SB, Wang YY, Zhang QE, et al. Cognitive behavioral therapy for post-stroke depression: a meta-analysis. 

27. Deng L, Sun X, Qiu S, et al. Interventions for management of post-stroke depression: a Bayesian network meta-analysis of 23 randomized controlled trials.

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29. Qin B, Chen H, Gao W, et al. Efficacy, acceptability, and tolerability of antidepressant treatments for patients with post-stroke depression: a network meta-analysis. 

30. Valiengo LC, Goulart AC, de Oliveira JF, et al. Transcranial direct current stimulation for the treatment of post-stroke depression: results from a randomised, sham-controlled, double-blinded trial. 

31. Shen X, Liu M, Cheng Y, et al. Repetitive transcranial magnetic stimulation for the treatment of post-stroke depression: a systematic review and meta-analysis of randomized controlled clinical trials. 

Available evidence indicates that there are a multitude of neuropsychiatric syndromes that occur after a stroke. Cognitive impairment occurs in approximately one-third of patients. These neuropsychiatric manifestations often impede the recovery of motor functioning, reduce social functioning, and decrease the overall quality of life.

Estee George, PhD

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