Stroke survivors are often affected by psychological distress and neuropsychiatric disturbances. About one-third of stroke survivors experience depression, anxiety or apathy, which are the most common neuropsychiatric sequelae of stroke. Neuropsychiatric sequelae are disabling, and can have a negative influence on recovery, reduce quality of life and lead to exhaustion of the caregiver. Despite the availability of screening instruments and effective treatments, neuropsychiatric disturbances attributed to stroke are currently underdiagnosed and undertreated. Stroke severity, stroke-related disabilities, cerebral small vessel disease, previous psychiatric disease, poor coping strategies and unfavourable psychosocial environment influence the presence and severity of the psychiatric sequelae of stroke. Although consistent associations between psychiatric disturbances and specific stroke locations have yet to be confirmed, functional MRI studies are beginning to unveil the anatomical networks that are disrupted in stroke-associated psychiatric disorders. Evidence regarding biochemical and genetic biomarkers for stroke-associated psychiatric disorders is still limited, and better understanding of the biological determinants and pathophysiology of these disorders is needed. Investigation into the management of these conditions must be continued, and should include pilot studies to assess the benefits of innovative behavioural interventions and large-scale cooperative randomized controlled pharmacological trials of drugs that are safe to use in patients with stroke.

Stroke is a major cause of death and disability worldwide¹. In developed countries, the acute treatment of stroke has improved substantially in the past two decades with the implementation of stroke units and the use of thrombolysis and/or thrombectomy. As a consequence, the mortality associated with acute stroke has decreased and the proportion of survivors with mild to moderate disability has increased². Traditionally, research into the functional impairments following stroke and care of stroke sequelae has focused on motor and sensory deficits, language disorders, visuospatial neglect, and impairment of daily living. However, long term follow-up of stroke survivors by multidisciplinary teams shows that a substantial proportion of these individuals are also affected by psychological distress and numerous psychiatric disorders³. These disabling psychiatric outcomes markedly reduce the quality of life after stroke; they are a major source of burden, stress and exhaustion for the caregiver, and often precipitate institutionalization of the patient.

The psychiatric complications of stroke are under-recognized and undertreated, despite growing evidence for the beneficial effects of available pharmacological and behavioural interventions. Health-care professionals are becoming more aware of the prevalence and relevance of neuropsychiatric disorders in patients with stroke. Unfortunately, physicians, nurses and physiotherapists rarely receive formal training in the screening and management of emotional and behavioural disorders.

This Review provides medical practitioners, including neurologists, psychiatrists, neurosurgeons, emergency and internal medicine physicians, family physicians, nurses and rehabilitation specialists, with an update on the acute and long-term psychiatric consequences of stroke, with an emphasis on the clinical aspects, biological and psychosocial determinants, and management of stroke-related psychiatric symptoms. We focus on disorders that are the most common, that are preventable and treatable (such as mood and anxiety disorders), and/or for which scientific advances have accumulated in recent years (for example, post-traumatic stress disorder and personality changes) (Table 1). Stroke-associated acute psychiatric disorders (delirium, acute stress disorders, acute psychosis, hallucinations and delusions) and chronic neurocognitive disorders (vascular cognitive impairment and dementia) will not be covered here. Disorders with predominantly somatic manifestations (disorders of sleep, eating and sexual function) are also not included because of the confounding effect of other comorbidities with similar symptoms that are common in elderly stroke survivors. Finally, fatigue, pain and disorders that affect the control of expression of emotions will not be covered in this Review, because they are not included as psychiatric disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)⁴. The reader is referred to other excellent reviews^3, 5 and books⁶ on the neuropsychiatric manifestations of cerebrovascular diseases that are not covered here.