More than one-half of stroke survivors experience ongoing psychological difficulties such as stress, fatigue, anxiety, and depression (1, 2). These ongoing issues create barriers to stroke recovery and rehabilitation. Post-stroke fatigue and depression are associated with increased mortality (3, 4), decreased quality-of-life (5) and poorer functional outcome (6, 7). Similarly, perceived stress is associated with long-term poorer functional outcome (8, 9). Despite being important determinants of stroke outcome and recovery, stress and fatigue are often not specifically addressed as part of stroke rehabilitation programmes. There are limited evidence-based programmes that have been designed to empower and enable stroke survivors to manage these conditions. Likewise, post-stroke depression remains largely underdiagnosed and untreated (10). This may be due to the fact that unlike physical disabilities, these psychological difficulties are “invisible.” This Research Topic was dedicated to this healthcare gap in stroke rehabilitation and the articles published in this issue showcases the clear need to tackle these invisible obstacles.

There is the lack of consensus regarding the nature and type of support that people with stroke might need to manage their fatigue. This issue contains a qualitative study by Bicknell et al. who describe the experience of post-stroke fatigue during outpatient rehabilitation from the perspective of people with stroke and their carers. Six major themes were identified. The findings suggested that most stroke survivors had to find their own solutions to manage their post-stroke fatigue, and support from care-givers, can lead to both positive and negative experiences. The authors concluded that post-stroke fatigue should be routinely screened, and appropriate support and education should be provided during rehabilitation.

The paper by Kliem et al., included in this issue, focused on characterizing the inter-relationships between fatigue, sleep, cognitive functioning and mood. They found that poorer cognition and lower mood at 3 months post-ischemic stroke predicted worse fatigue and daytime sleep at 12 months, controlling for stroke severity, age, sex, and difficulties sleeping at night. As highlighted by the authors, this suggests that interventions addressing both cognition and mood, such as Cognitive Behavior Therapy, may be a promising approach to treating fatigue and sleep difficulties (11, 12).

Perceptual disorders are not uncommon after stroke (13). In this Research Topic, Chen et al. investigated whether perceived limb heaviness can affect engagement in rehabilitation after stroke. By retrospectively reviewing 108 participants data, they found 37% reported limb heaviness and this, along with strength, appeared to influence engagement in rehabilitation. Solutions targeting altered body perceptions might have a role in promoting better stroke recovery.

Repetitive transcranial magnetic stimulation (rTMS) is a treatment for depression that has shown promise, however relatively few studies have explored its use in post-stroke depression. It is thought that stimulation of the left dorsolateral prefrontal cortex might initiate early stages of synaptic plasticity, supporting improvements in mood. However, it is unclear whether damage to this brain region due to stroke influences efficacy of this treatment. In a case study published in the current issue, Hordacre et al. applied rTMS as a treatment for post-stroke depression in a patient with ischemic damage to the left middle frontal gyrus. Comprising an acute, daily treatment schedule, followed by weekly maintenance, depression scores were meaningfully reduced, with benefits persisting well beyond completion of the treatment. rTMS appears worthy of further investigation as a treatment for post-stroke depression.

A growing body of evidence has indicated that higher measures of resilience are associated with the lower levels of perceived stress and recovery after stroke (8). However, the study of Norvang et al., included in this issue, did not find an association of early measurement of resilience obtained within 2 weeks after stroke with activities of daily living at 3 months post-stroke. The authors suggested that the impact of resilience might not apply to physical adversity as compared to psychosocial adversity.

Preliminary evidence suggests that traditional Chinese medicines may also have a role in reducing post-stroke depression. Although not clear, preliminary work suggests acupuncture might evoke similar changes in neurotransmitter activity and brain connectivity as pharmacological management of depression (14, 15). In this issue, Luo et al. proposed a protocol for a randomized controlled trial to evaluate efficacy and safety of optimized acupuncture and moxibustion as a treatment for post-stroke depression. The trial will aim to recruit 134 patients, randomized 1:1 to intervention or control. Treatments will be delivered five times per week for 4 weeks.

Racial disparities exist in stroke treatment and care (16). In this issue, Love et al. provided a protocol that aim to understand if resilience could buffer the effect of racism and psychological stress on quality of life among black stroke survivors in USA.

Taken together, the articles in this special edition provide interesting insights that build our understanding of the invisible obstacles to stroke recovery and rehabilitation including stress, depression, mood, and fatigue. Several articles suggested potential interventions and trial protocols to mitigate these invisible obstacles, including Cognitive Behavior Therapy, resilience building programs, acupuncture and repetitive transcranial magnetic stimulation. Future studies are needed to better understand the prevalence, pathophysiology, inter-relationships, mechanisms, impacts and trajectory of these issues and more rigorous clinical trials are warranted to investigate the feasibility and efficacy of potential therapeutic interventions. We hope that this Research Topic provides a springboard to encourage more work in this important area.