Depression following stroke and myocardial infarction: effective strategies and evidence gaps. A systematic review

At least a quarter of acute stroke and myocardial infarction (MI) survivors experience subsequent major depressive disorder, which adversely impacts adherence to secondary prevention strategies and is associated with a reduced quality of life and increased risk of recurrence of cardiovascular event and mortality.

To provide a comprehensive review of evidence from randomised controlled trials (RCTs) evaluating pharmacological and non-pharmacological interventions to help mitigate depression after non-fatal stroke or MI.

PubMed database was searched on 17th April 2025 for all trials evaluating the efficacy of interventions to help treat depression amongst those with recent stroke or MI and have reported effects on depressive symptoms (as a primary outcome) using validated tools. Studies were included if RCT design and if intervention duration were 4 weeks or longer, compared against routine care/no active treatment, and published since 1st January 2000. Risk of bias was assessed using Cochrane Risk of Bias tool.

53 RCTs were included. 44 studies were in post-stroke patients, and 9 were in post-MI patients. 16 evaluated pharmacological and 37 evaluated non-pharmacological (sub-divided into 8 types) interventions. The findings suggest that some selective serotonin reuptake inhibitors (escitalopram) and serotonin-norepinephrine reuptake inhibitors (duloxetine, milnacipran) are effective in reducing severity of depression amongst stroke survivors. Non-pharmacological interventions such as psychological interventions (e.g. behavioural therapies), device-based stimulation (vagus nerve, transcranial), and some physical activity/exercise interventions appear efficacious in those with recent stroke but there is a substantial evidence gap for the efficacy of these interventions amongst MI survivors.

A holistic, multidisciplinary, and tailored approach encompassing pharmacological treatments together with non-pharmacological interventions (psychological therapy, device-based stimulation, and physical activity/exercise) is beneficial in reducing depression severity or risk amongst those with recent stroke, but there is a lack evidence for the long-term efficacy amongst those with recent MI.