[version 1; peer review: 1 approved, 1 approved with reservations]
People who have had a stroke or a Transient Ischaemic Attack (TIA) can experience psychological and/or cognitive difficulties. The body of research for psychological and neuropsychological interventions after stroke is growing, however, published systematic reviews vary in scope and methodology, with different types and severity of strokes included, and at times, diverse conclusions drawn about the effectiveness of the interventions evaluated. In this umbrella review, we aim to systematically summarise the existing systematic reviews evaluating psychological interventions for mood and cognition post-stroke/TIA.
We will conduct this umbrella review according to the JBI Manual for Evidence Synthesis. The following databases will be searched from inception: Cochrane Database of Systematic Reviews, Database of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Epistemonikos. Systematic reviews with or without meta-analysis published until the search date will be included. Reviews including psychological interventions addressing mood and/or cognition outcomes for any stroke type or severity will be screened for eligibility. A narrative synthesis, including content analysis, will be used. Each stage of the review will be processed by two independent reviewers and a third reviewer will be considered to resolve disagreements. The methodological quality of the included reviews will be assessed using AMSTAR 2.
Existing systematic reviews provide varied evidence on the effectiveness of psychological interventions post-stroke/TIA. This umbrella review aims to summarise knowledge and evidence on different types of psychological and neuropsychological interventions targeting mood and cognition. Findings will highlight important knowledge gaps and help prioritise future research questions.
This protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on November 15, 2022; PROSPERO
Canadian Agency for Drugs and Technology in Health
Database of Reviews of Effects
Joanna Briggs Institute
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols
Randomised Controlled Trial
Systematic Review
Transient Ischaemic Attack
Virtual Reality
Mood (e.g., depression, anxiety)
The body of research for psychological interventions after stroke is growing, and our initial scoping search in the Cochrane Database of Systematic Reviews suggested that there were at least seven published Cochrane systematic reviews on the effectiveness of interventions for depression,
This umbrella review aims to summarise and synthesise the published evidence on psychological interventions for neuropsychological (specifically mood and cognition) difficulties after stroke/TIA. Furthermore, when information is available in the identified systematic reviews, we will attempt to systematically evaluate the quality of the evidence and the extent of potential methodological limitations on this topic.
In the present protocol, we describe how this review will aim to address the following questions:
What are the available psychological interventions for addressing difficulties with mood (depression and anxiety) and cognition (all cognitive domains including language) after stroke/TIA? Which of these interventions, if any, are effective for which stroke survivors (stroke type, severity) and for which outcome measures (mood, individual cognitive domains, quality of life)?
The protocol is based on the guidelines provided by the JBI (Joanna Briggs Institute) Manual for Evidence Synthesis
The following databases will be searched from inception until the search date: Cochrane Database of Systematic Reviews, Database of Reviews of Effects (DARE), Ovid MEDLINE, Ovid Embase, CINAHL, Ovid PsycINFO, and Epistemonikos.
Our search algorithm will be developed, peer-reviewed and undertaken by two Information Specialists (FS, NT). We will use the Canadian Agency for Drugs and Technology in Health (CADTH) (
The search terms will include the following themes, with synonyms to describe each: psychotherapies, depression, anxiety, cognition, and stroke. Full details and search strategies can be found in
Psychological interventions with a variety of theoretical underpinnings will be considered. The main types of psychological interventions that will be identified for inclusion in our umbrella review will be
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| Study type | Systematic reviews with or without a meta-analysis that include randomised controlled trial (RCT) designs and quasi-RCT designs |
| Population | Participants with a confirmed diagnosis of stroke and/or TIA |
| Mixed population systematic reviews with stroke participants totalling at least 70% of the population | |
| Condition | Any type and severity of stroke including TIA |
| Reviews with mixed stroke subtypes | |
| Intervention | Neuropsychological (psychological and cognitive) interventions focusing on addressing mood and/or cognition |
| Psychological (psychotherapy/talking therapy) interventions designed to improve mood and/or cognition | |
| Cognitive rehabilitation therapies designed to improve cognitive functioning using a range of restorative or compensatory strategies | |
| Interventions providing advice, support or education designed to address mood and/or cognition that are based on psychological principles and specify the theoretical model (e.g., Cognitive Behavioural Therapy) | |
| Reviews including music therapy, mental imagery meditation, relaxation, tai-chi, or yoga, will be included if delivered within a psychological intervention (e.g., Compassionate Focused Therapy or Mindfulness-based Therapies) | |
| Family/carer interventions (e.g., dyadic) if outcomes are reported separately for stroke participants | |
| Mixed intervention reviews will be included if at least 50% of the interventions are psychologically based and are separately reported | |
| Comparison | Any type of control/comparison (usual care, no intervention, waiting list, or attention control) |
| Context | Any healthcare or community settings |
| Interventions delivered remotely | |
| Outcome | Mood (e.g., depression, low mood, anxiety, stress) |
| Cognition (e.g., memory, attention, executive function) | |
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| Study type | Lack of quality appraisal in methodology |
| Population | Focus on subarachnoid haemorrhage only |
| Intervention | Music therapy, mental imagery meditation, relaxation, tai-chi, or yoga as a standalone intervention |
| Computerised-cognitive rehabilitation interventions (e.g., computer games, virtual reality, or technology-based interventions) | |
| Non-invasive brain stimulation interventions (e.g., electroconvulsive therapy, transcranial magnetic stimulation) | |
| Psychological interventions combined with another component (e.g., a pharmacological intervention) | |
| Those focused on prevention, not treatment | |
We will consider the consensus definition of a systematic review used in overviews of systematic reviews.
Two authors will screen the titles and abstracts (EK, FS), and full-text papers, with discrepancies being resolved through either consensus or with a third author (NC, MW). Two authors (NC, MW) will independently extract relevant characteristics of the reviews, including title, author, year of publication, databases searched, years searched, inclusion criteria, intervention details, outcomes assessed, type of data synthesis performed, results from methodological quality assessments, quantitative and descriptive results relating to the outcome measures. Any disagreement will be resolved after consulting with a third author (EK). Data extraction will be conducted using a bespoke data extraction form (
Two authors will independently assess the methodological quality of the included reviews using the AMSTAR 2
A narrative synthesis will be performed to look systematically at the data and to describe each review. Patterns in the data will be identified through tabulation and visual representation of the results. The commonality in results between the reviews will be identified using content analysis based on an inductive approach (deriving concepts from the data). We will investigate reasons for differences in the magnitude of each outcome measure through investigating within-review differences, e.g., psychological therapy versus cognitive rehabilitation. A summary of findings table will be created to provide an overview of the findings from the reviews, which will comprise the intervention, relevant reviews and outcome measure using a ‘stop-light’ indicator, where green indicates the intervention is beneficial, amber is no differences, and red suggests the intervention is detrimental. It is anticipated that there will be discordant/inconsistent findings between included systematic reviews on the same research topic. In these instances, this will be clearly reported and the assignment of the ‘stop-light’ indicator will be fully described.
In the synthesis stage, we will describe and explain any overlap from the same primary studies reported across the included systematic reviews. We will attempt to visually present the amount of overlap using a table or a matrix. As there is currently no standard methodological approach recommended for managing overlap, we will choose an appropriate method based on the number of included reviews and their primary studies.
Subgroup analysis will be used, if possible, to investigate whether there are differences in the effectiveness of the psychological interventions by population (stroke versus TIA/minor stroke).
A complete list of the different types of psychological interventions included will be considered when presenting the findings of our review. Reasons for excluding any reviews based on our eligibility criteria will be reported.
Considering the high prevalence of psychological and cognitive difficulties reported in the stroke literature and the varied evidence on the effectiveness of available interventions, this umbrella review aims to summarise the current state of the evidence on psychological interventions for people with stroke/TIA. It will attempt to identify what the different types of psychological interventions are for addressing the most common neuropsychological difficulties (primarily mood and cognition) following a diagnosis of stroke/TIA. The quality of the included systematic reviews will be discussed, and recommendations for future research will be provided. Finally, the findings from this review will be used to inform the development and evaluation of a psychological care pathway for people experiencing less severe strokes.
Ongoing. At the time of submission, the umbrella review will be progressing at data extraction stage.
No data are associated with this article.
Data are available under the terms of the
This paper describes a protocol for an umbrella review of psychological interventions for cognition and mood after stroke in order to harmonize the increasing amount of research focused on this topic. In general, the protocol is clear, and I mainly have suggestions to strengthen the potential quality of the umbrella review.
The search terms seem largely appropriate; given the second research question of the protocol focus on which outcome measures demonstrate benefit for stroke/TIA survivors, will the authors consider reviews which focus on interventions to improve quality of life post-stroke? How will the authors consider the role of time post-stroke in their umbrella review – some interventions may be delivered very early on in stroke or in chronic stages and this could impact interpretation of results Why are the authors including articles where 70% of the sample in included reviews has a stroke – this seems like a large number given that many neuropsychological rehabilitation reviews focus on acquired brain injury more generally and might exclude potentially useful information about neuropsychological interventions. Further, given that mixed health care services exist that work with stroke and other acquired brain injury survivors the potential overlap does not seem irrelevant in the context of this review, which aims to describe mood and cognitive interventions in a broad sense.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Reviewer Expertise:
stroke, mental health, cognition, mood disorders, clinical trials, neuropsychological rehabilitation,
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
We are grateful to the expert reviewer for their interest in this topic and for taking the time to review our manuscript. We appreciate their helpful and thorough comments. A revised version was submitted and a detailed response to each comment.
This paper provides a protocol for an umbrella review of psychological interventions for mood and cognition after stroke and transient ischaemic attack. They propose conducting an umbrella review (along established guidelines) to help syntheses the existing systematic reviews, evaluating psychological interventions for mood and cognition. They present a robust methodology, searching a range of relevant databases, using clear eligibility criteria and search terms. Quality assessment will be conducted using AMSTAR 2, to establish quality of the included systematic reviews. A narrative synthesis will be used to collate findings, establishing commonality between findings and to investigate any potential differences in the effectiveness of interventions.
This is a relevant and useful paper for this field. The importance of psychological and mood interventions has been frequently highlighted by stroke survivors, their families and health care professionals as a major concern post stroke. Currently there is little consensus or structured recommendation on what interventions/approaches are most appropriate to this population. There is some published findings in the area but its lacking in agreement and this is needed to help drive this clinical area forward. This paper provides an opportunity to address some of these gaps.
Abstract is appropriately detailed, covering all main areas. Background is sufficiently detailed, provides a rationale for the study, identifying the need for this study (and using this methodology). Methods; Good level of detail, sufficient for replication. Clear thought has been applied to use of the research team, with good use of double screening, extraction etc. Good explanation and description of data extraction and quality assessment procedures.
Supplementary material- clear, useful and appropriate.
Major Points
No major points.
Minor Points
The research questions in the paper differ slightly from those stated in PROSPERO I suggest editing these (on properso) to ensure consistency. Quasi-RC isn’t defined or further detail on what may fall under this category, isn't provided which may be useful (especially for replication). Could you provide a justification for exclusion of Computerised-cognitive rehabilitation interventions? A line or two of additional detail on how ” using content analysis based on an inductive approach” will be implemented would be helpful for the reader. No participant details such as average age, gender are being recorded in the data extraction form, I find this unusual especially if one of the aims is to look at potential subgroups analysis. I believe these details should be extracted.
I recommended some minor comments.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Yes
Reviewer Expertise:
Stroke, Neurorehabilitation, Psychology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
We thank the reviewer for spending time on our review and for providing helpful comments. We have made minor amendments to the manuscript addressing their recommendations.