Pandemic Tied to Depression Risk in Patients With Stroke

Older adults in Canada with a stroke history were at high risk for depression during the first year of the COVID-19 pandemic, researchers suggested.

An analysis of 577 patients with stroke history found that approximately one in seven developed depression for the first time during the first year of the COVID‐19 pandemic. About half of patients with a history of stroke and depression had a recurrence of depression.

In addition, the risk of developing depressive symptoms was significantly higher among immigrants than patients who were born in Canada.

“We had anticipated that those with stroke might be more vulnerable to depression because research conducted prior to the COVID‐19 pandemic indicates that people with stroke history are already highly vulnerable to adverse mental health outcomes such as depression, which affects an estimated 30% of stroke patients,” study author Esme Fuller-Thomson, PhD, director of the Institute for Life Course and Aging at the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News.

“We were surprised to discover that among individuals with stroke who had no prepandemic history of depression, immigrant status tripled the risk of new-onset depression,” she said. “Immigrants often live in intergenerational households, and many immigrants work in essential services, so older immigrants with a history of stroke may have experienced greater worry about their high risk of exposure to COVID-19.”

The article was published online on February 21 in the International Journal of Geriatric Psychiatry.

Pandemic-Related Stressors

Researchers analyzed data from four waves of the Canadian Longitudinal Study on Aging (CLSA) comprehensive cohort, which included 577 individuals with a stroke history. The population’s mean age was about 75 years. About 46% of participants were women, and 20.8% were immigrants. Participants were recruited in the Baseline (2011-2015), Follow‐up 1 (2015-2018), COVID Spring 2020 (April‐May 2020), and COVID Autumn 2020 (September‐December 2020) waves.

Self-reported stroke was defined by a yes or no response to the question, “Has a doctor ever told you that you have experienced a stroke or cerebrovascular accident?”

The primary outcome was a positive screen for depression, based on the Center for Epidemiologic Studies Short Scale of Depression (CES‐D‐10). A score of 10 or greater during the 2020 CLSA COVID autumn questionnaire identified participants with depression.

Approximately 15% of participants with a stroke history developed depression for the first time during the COVID‐19 pandemic. Among those with a stroke history and a history of depression, 49.5% had a depression recurrence during the pandemic.

In contrast, between the Baseline and Follow‐up 1 waves, the incidence and recurrence of depression were lower, at about 9.5% and 41.2%, respectively.

Overall, the risk for depression was higher among immigrants, participants who were lonely, those with functional limitations, and those who experienced COVID‐19-related stressors, such as increased family issues, difficulty accessing healthcare, and becoming sick or having a loved one become sick or die during the pandemic.

Specifically, during the pandemic, immigrants had higher odds of incident depressive symptoms than those who were born in Canada (odds ratio [OR], 2.94). Older adults with stroke who felt lonely occasionally or all the time had higher odds of developing depressive symptoms than those who felt lonely some of the time, rarely, or never (OR, 4.33).

Targeted Screening Proposed

Participants with COVID‐19-related health stressors had significantly higher odds of depression than those without (OR, 2.13), and respondents with stroke and functional limitations had a higher risk for depressive symptoms than those without such limitations (OR, 2.28).

Furthermore, respondents with caregiving responsibilities or family problems during the pandemic were 2.23 times more likely to have depression than those without.

In addition, participants with a stroke history who could not access their usual healthcare during the pandemic had 3.38 times higher odds of depressive symptoms than those who were able to access their usual healthcare.

“Doctors and other healthcare providers should be attuned to the possible long‐term mental health repercussions of COVID‐19 among individuals who have experienced a stroke,” said Fuller-Thomson. “Clinicians may want to consider targeted screening and referral for their stroke patients who are experiencing depression. Cognitive behavioral therapy is a very effective and relatively brief form of talk therapy that can be provided in one-on-one sessions, in group therapy, or online.”

The study has limitations, however. Although the CES‐D‐10 is a valid measure of depression among patients with stroke history, a clinical assessment or chart review would have been preferable to a self‐report measure, according to the researchers. The study also relied on a self‐report of a stroke diagnosis and did not have information on stroke severity or the type of stroke that individuals had. Furthermore, a self-report measure of functional impairment was used.

Adults who were living in long‐term care homes at baseline were not included in the study, which may have resulted in an underrepresentation of older adults with depression.

‘Not Just Stroke’

Brian Buck, MD, an associate professor of neurology at the University of Alberta in Edmonton, commented on the study for Medscape Medical News. He noted that the study looked only at depression during COVID-19 among older individuals with a prior history of stroke, but not in comparison with other individuals with other illnesses.

“The article does not suggest at all that individuals with stroke were more at risk of depression than, for example, similarly aged adults with other chronic illnesses,” he said. “Not surprisingly, the depression risk was highest in immigrants and those who were lonely, those with functional limitations, and those who experienced COVID‐19-related stressors, such as increased family issues, difficulty accessing healthcare, and becoming ill or having a loved one become ill or die during the pandemic.”

“This finding highlights the importance of factors that protect against depression among individuals with prior stroke, such as access to family, community, and social supports,” he said. These factors were disrupted during the early part of the pandemic. “The study findings would likely apply to all elderly individuals with preexisting illnesses, not just stroke.”

This research was supported in part by a Canadian Institutes of Health Research grant to Fuller-Thomson. The lead author received funding from the Public Health Agency of Canada to support this research activity. Fuller-Thomson and Buck reported no relevant financial conflicts.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.