Purpose <p>Return to work (RTW) is a key outcome of occupational rehabilitation for working-age stroke survivors, yet marked individual differences exist in RTW success and timing. This study aimed to identify longitudinal trajectories of psychosocial adaptation among young and middle-aged patients with stroke and to examine their bidirectional associations with RTW outcomes during the first year after discharge.</p> Methods <p>In this prospective longitudinal cohort study, 237 stroke survivors aged 18–59&#xa0;years were assessed at discharge and at 3-, 6-, and 12-month post-discharge. Psychosocial adaptation was measured using the Psychosocial Adaptation to Illness Scale–Self-Report (PAIS-SR). Latent class growth modeling identified distinct adaptation trajectories among patients who had not returned to work at 3 and 6&#xa0;months (<i>n</i> = 189). Logistic regression and generalized estimating equations examined associations between adaptation trajectories and RTW status and timing.</p> Results <p>Three psychosocial adaptation trajectories were identified: a High Adaptation-Enhanced group (24.87%); a Medium Adaptation group (40.74%); and a Persistently Low Adaptation group (34.39%). RTW rates at 12&#xa0;months differed significantly across trajectories (46.81%, 22.08%, and 24.62%, respectively; <i>P</i> = 0.008). Compared with the Persistently Low Adaptation group, patients in the High Adaptation-Enhanced group had higher odds of RTW (OR = 2.70, 95% CI 1.21–6.02). In the full cohort, earlier RTW was associated with significantly better psychosocial adaptation at 12&#xa0;months.</p> Conclusion <p>Psychosocial adaptation trajectories are a key determinant of successful return to work after stroke, while earlier RTW is associated with better subsequent adaptation. Early identification of patients at risk of poor adaptation and implementation of supported RTW strategies may enhance occupational rehabilitation outcomes.</p>