Poststroke psychosis: a systematic review

A preregistered systematic review of poststroke psychosis examining clinical characteristics, prevalence, diagnostic procedures, lesion location, treatments, risk factors and outcome. Neuropsychiatric outcomes following stroke are common and severely impact quality of life. No previous reviews have focused on poststroke psychosis despite clear clinical need. CINAHL, MEDLINE and PsychINFO were searched for studies on poststroke psychosis published between 1975 and 2016. Reviewers independently selected studies for inclusion, extracted data and rated study quality. Out of 2442 references, 76 met inclusion criteria. Average age for poststroke psychosis was 66.6 years with slightly more males than females affected. Delayed onset was common. Neurological presentation was typical for stroke, but a significant minority had otherwise ‘silent strokes’. The most common psychosis was delusional disorder, followed by schizophrenia-like psychosis and mood disorder with psychotic features. Estimated delusion prevalence was 4.67% (95% CI 2.30% to 7.79%) and hallucinations 5.05% (95% CI 1.84% to 9.65%). Twelve-year incidence was 6.7%. No systematic treatment studies were found. Case studies frequently report symptom remission after antipsychotics, but serious concerns about under-representation of poor outcome remain. Lesions were typically right hemisphere, particularly frontal, temporal and parietal regions, and the right caudate nucleus. In general, poststroke psychosis was associated with poor functional outcomes and high mortality. Poor methodological quality of studies was a significant limitation. Psychosis considerably adds to illness burden of stroke. Delayed onset suggests a window for early intervention. Studies on the safety and efficacy of antipsychotics in this population are urgently needed.