Among older Canadians with a history of stroke, 1 in 7 experienced depression for the first time during the COVID-19 pandemic, while 1 in 2 with a lifetime history of depression experienced a recurrence or persistence of depression during the pandemic

A new longitudinal study from the University of Toronto highlights the substantial mental health toll of the COVID-19 pandemic on older adults with a history of stroke.

Researchers examined a sample of over 500 older adults with a history of stroke from the Canadian Longitudinal Study on Aging, a large dataset of older Canadians. Their findings indicated high levels of depression in this population during the COVID-19 pandemic.

“People who have experienced a stroke are already highly vulnerable to adverse mental health outcomes, such as depression,” said lead author Andie MacNeil, a research assistant at the University of Toronto’s Factor-Inwentash Faculty of Social Work (FIFSW). “Unfortunately, the pandemic caused so many disruptions to care for stroke patients, which has major implications for the physical and mental well-being of this population.”

Using longitudinal data, the researchers were able to separate respondents with a history of depression from those who had never experienced depression prior to the pandemic. They found that 1 in 7 older adults with stroke history experienced depression for the first time during the pandemic. When the analysis was restricted to those with a history of depression, the prevalence was much higher, with 1 in 2 of these individuals experiencing a recurrence or persistence of depression during the pandemic.

“Our findings highlight that many stroke survivors were struggling during the lockdown period, even among those who were mentally healthy up until the pandemic,” said co-author Grace Li, PhD candidate in the Sociology Department at the University of Victoria. “These findings emphasize the importance of screening for depressive symptoms in older adults with stroke history, even among those with no lifetime history of depression.”

The researchers also examined risk factors for both first onset and recurrent depression. Among respondents with a history of depression, functional impairment was associated with approximately double the risk of depression during the pandemic.

“Older adults who have a lifetime history of both stroke and depression are unsurprisingly a population that was at particularly high-risk for experiencing depression during the pandemic. Functional status may play an important role in this relationship,” said co-author Aneisha Taunque, research assistant at the Institute for Life Course and Aging, University of Toronto. “A large body of research has demonstrated that post-stroke impairment greatly increases the risk of depression. Unfortunately, the pandemic caused many disruptions to rehabilitation services, potentially contributing to worsening functional status among this population.”

Respondents who had difficulty accessing their usual healthcare services had more than triple the risk of experiencing incident depression.

“In addition to disruptions to rehabilitation services, the pandemic caused other stressors for stroke patients, such as delayed follow-up appointments and intravenous thrombolysis,” reported co-author Ishnaa Gulati, a Master of Public Health Student at the University of Toronto’s Dalla Lana School of Public Health. “Experiencing challenges with healthcare access can be extremely stressful, particularly for individuals with complex health needs. Our findings underscore the impact that healthcare continuity can have on mental health.”

Older adults with a history of stroke who frequently felt lonely at the beginning of the pandemic were more likely to experience new onset depression than their peers who did not feel lonely often. “There is a robust literature showing loneliness is a major risk factors for depression. Due to the elevated risk of serious COVID-19 outcomes, it is possible that those with stroke may have been more vigilant in adhering to physical distancing recommendations and limiting social interaction, potentially increasing feelings of loneliness and social isolation,” said senior author Esme Fuller-Thomson, a professor at FIFSW and director of the Institute for Life Course & Aging.

Among respondents with no history of depression, immigrant status was also found to approximately triple the risk of incident depression.

“Early in the pandemic, Canadian communities with a large proportion of immigrants were observed to have a disproportionately high risk of COVID-19-related morbidity and mortality, likely increasing psychological stress among individuals in these communities,” stated Ying Jiang, Senior Epidemiologist at the Public Health Agency of Canada.

Family stressors, such as separation from family and caregiving challenges, were found to increase the risk of both incident and recurrent depression.

“People who have experienced a stroke may rely on support from loved ones to aid their recovery. For many families, the pandemic created significant caregiving challenges or situations where loved ones were separated due to illness or concern of contracting COVID,” said

Margaret de Groh, Scientific Manager at the Public Health Agency of Canada. “We found that this greatly increased the risk of depression for this population.”

The researchers also conducted a sensitivity analysis to examine the prevalence of incident and recurrent depression among people with a history of stroke between two earlier intervals before the pandemic. They found that the prevalence of depression was significantly lower in the pre-pandemic period, emphasizing the unique impact of COVID-19 on the mental health status of this population.

“Our research helps inform clinicians on some of the important risk factors for depression among those with a history of stroke,” said Fuller-Thomson. “We hope these results can help inform targeted screening and intervention, and in turn support the mental health of this population.”