Introduction

Since the start of the COVID-19 pandemic, there have been more than 6.9 million fatalities worldwide [1], with the United States and Canada experiencing more than 1.1 million and 52,000 deaths, respectively [1, 2]. In response to the pandemic, governments enacted public health measures to mitigate the spread of the virus, such as stay-at-home orders and non-essential business closures. The resulting increases in social isolation and economic precarity, combined with reduced access to health and mental health resources have contributed to declines in physical and mental wellbeing [3, 4] and increases in the prevalence of depression and anxiety in the general population [5, 6].

One particular subpopulation known to have elevated depression prior to the COVID-19 pandemic is individuals with peptic ulcer disease (PUD) [7–9]. PUD is a painful condition in which open gastric sores or ulcers develop in the lining of the stomach or the upper portion of the small intestine. The leading causes of PUD are Helicobacter pylori (H. pylori) infection and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen [10, 11]. Psychological stress is also a major factor contributing to the onset of PUD, as well as the severity of its course [12, 13]. The lifetime prevalence of PUD in the general population is an estimated 5–10% [14]. PUD symptoms, such as bleeding and chronic pain, often disrupt usual activities in daily life, and can result in a dramatically lower quality of life for these individuals [15, 16]. While previous studies have established that depression is associated with an increased risk of developing PUD [8, 9], emerging research suggests that this relationship may be bidirectional, and that those with PUD also face a heightened risk of developing depression [7]. A recent longitudinal study examined the relationship between PUD and depression, and found that individuals with PUD had an adjusted hazard ratio for depression that was 1.68-fold higher than the control group without PUD, even when their demographic factors and other medical history were matched [7].

To date, there has not been a large longitudinal study examining the impact of the COVID-19 pandemic on the mental health of individuals with PUD. While the COVID-19 pandemic exacerbated many risk factors for depression in the general population, there were particular stressors for those with chronic health conditions, who often faced disruptions to their usual healthcare access and increased stress over the risk of COVID-19 [17, 18]. This likely impacted individuals with PUD. Additionally, research conducted prior to the pandemic has attributed the elevated risk of depression among those with PUD to the presence of pain, reduced quality of life, and high levels of stress [7, 19], many of which were likely exacerbated due to the pandemic. Stay-at-home orders and physical distancing limitations had many unintended consequences, such as increases in loneliness and social isolation. It is also possible that the stress of the COVID-19 pandemic led to worsening PUD symptoms, which in turn can lead to worsening mental health outcomes among this population [19]. Collectively, these factors highlight the potentially detrimental impact of the pandemic on the mental health of individuals with PUD.

When considering the high comorbidity between PUD and depression prior to the pandemic, combined with the unprecedented stressors of the COVID-19 pandemic, it is evident that there is a need for longitudinal research to examine the relationship between PUD and the occurrence or recurrence of depression during the pandemic. The current study addresses this gap by using a large Canadian longitudinal panel study of older adults to achieve the following objectives: (1) in a sample of older adults with PUD without a history of depression, to determine the factors associated with developing incident depression during the COVID-19 pandemic; (2) in a sample of older adults with PUD and a history of depression, to identify factors associated with the recurrence of depression during the pandemic.

Materials and methods

Results

Table 1 presents the sample characteristics of individuals with PUD by pre-pandemic depression status (estimated using CES-D-10 score and self-reported clinical depression diagnosis). A larger proportion of female respondents had a pre-pandemic history of depression than male respondents. A higher proportion of separated/divorced/widowed respondents and single respondents had a pre-pandemic history of depression than those who were married or living common-law. Sociodemographic and health-related variables were different between those who were free of pre-pandemic depression and those who had a history of depression. Respondents who had no history of pre-pandemic depression had a higher household income, owned their house without mortgage, had more savings, had enough income to satisfy needs, were under or normal weight, free of chronic pain, and had no multimorbidity when compared to those who had a history of pre-pandemic depression. A higher proportion of respondents who had a history of pre-pandemic depression felt a lack of companionship, felt left out, felt isolated from others, felt lonely during the pandemic, had functional limitations, and experienced COVID-related stressors.

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Table 1. Characteristics of CLSA respondents with PUD (n = 1,140).

https://doi.org/10.1371/journal.pone.0289932.t001

Table 2 displays the characteristics of older adults with PUD with and without a history of depression who did not develop depression and who developed depression. Among older adults with PUD and no pre-pandemic history of depression, 13.0% developed depression during the pandemic. Among older adults with PUD with a history of depression, nearly half (46.6%) were depressed during the pandemic. More than 7 in 10 older adults with PUD (71.2%) who screened positive for depression based on CES-D-10 scores at both the Baseline and Follow-up 1 waves were depressed in the Autumn 2020 wave, compared to half of those (50.0%) who screened positive for depression based on CES-D-10 scores at Follow-up 1 wave, but not at Baseline, and 44.1% of those whose CES-D-10 scores indicated depression at Baseline, but not at Follow-up 1. In contrast, 29.0% of those who screened negative for depression on the CES-D-10 scores at both Baseline and Follow-up 1 waves, but who reported that they had been diagnosed by a health professional at some point in their life, developed depression during the pandemic.

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Table 2. Cumulative incidence of depression by CLSA Autumn 2020 among older adults with PUD.

https://doi.org/10.1371/journal.pone.0289932.t002

We conducted a sensitivity analysis to compare these findings on incident and recurrent depression among older adults with PUD during the COVID-19 pandemic to pre-pandemic patterns from the Baseline to the Follow-up 1 wave. Among those who reported they had no history of depression and a CES-D-10 score less than 10 at Baseline, the incidence of new depression at Follow-up 1 according to the CES-D-10 was 7.5% (95% CI: 5.4%, 9.6%). Among those who had a CES-D-10 score of 10 or more and/or a self-reported history of a medical diagnosis of depression at Baseline, the prevalence of depression at Follow-up 1 was 37.9% (95% CI: 32.4%, 43.5%). As reported above, the COVID-19 incidence and recurrence rates of depression were substantially higher than pre-pandemic rates.

Table 3 presents the multivariate logistic regression model on incident depression status during Autumn 2020 for older adults with PUD and no history of depression. Female respondents had substantially higher odds of incident depression than male respondents during the COVID-19 pandemic (OR = 2.03, 95% CI [1.13; 3.69], p = 0.021). Older adults with PUD who felt lonely occasionally/all of the time during the first few months of the pandemic had a significantly higher prevalence of depression by Autumn 2020 compared to those who felt lonely rarely or never/some of the time (OR = 5.99, 95% CI [2.87, 12.48], p < 0.001). Respondents living in apartments were more likely to report depression during the pandemic than those who lived in houses (OR = 2.55, 95% CI [1.24; 5.24], p = 0.011). Respondents with functional limitations also reported higher odds of incident depression compared to those without (OR = 2.69, 95% CI [1.43; 5.05], p = 0.002). Experiencing COVID-19-related health stressors, such as becoming ill or having a loved one become ill or die, was significantly associated with higher odds ratio of developing incident depression (OR = 3.72, 95% CI [2.12; 6.55], p <0.001). Moreover, older adults with PUD who had increased verbal or physical conflict in the family during the COVID-19 pandemic had a higher odds ratio of developing incident depression (OR = 3.30, 95% CI [1.47; 7.43], p = 0.004). Respondents who were unable to access usual healthcare had higher odds for depression (OR = 1.91, 95% CI [1.04; 3.50], p = 0.037) compared to those who were able to access usual health care.

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Table 3. Logistic regression results for incident depression among older adults with PUD with no history of depression (n = 689).

https://doi.org/10.1371/journal.pone.0289932.t003

Table 4 presents the estimated parameters derived from the relative risk model, focusing on the depression status of older adults with a history of depression prior to the pandemic, specifically during CLSA Autumn 2020. Individuals who experienced loneliness occasionally/ all of the time during the initial months of the COVID-19 pandemic exhibited an elevated risk of developing depression by Autumn 2020, with a relative risk (RR) of 1.30 (95% CI [1.03; 1.63], p = 0.013). Older adults with functional limitations had a higher likelihood of experiencing depression compared to their counterparts without such limitations, with an RR of 1.50 (95% CI [1.17; 1.90], p<0.001). Moreover, respondents who reported increased levels of family conflict demonstrated a heightened probability of developing depression, with an RR of 1.52 (95% CI [1.17; 1.97], p<0.001). Additionally, individuals who encountered other family-related issues such as separation from family members and/or increased caregiving responsibilities had a 1.45 times higher risk of depression (RR = 1.45, 95% CI [1.05; 1.99], p = 0.001) compared to those who did not face such issues.

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Table 4. Relative risk regression results for depression among older adults with PUD with a history of depression (n = 451).

https://doi.org/10.1371/journal.pone.0289932.t004

Discussion

This longitudinal study revealed that approximately 13% of older Canadians with PUD who had no previous history of depression developed depression for the first time during the COVID-19 pandemic. Among those with a lifetime history of depression, approximately 47% experienced a recurrence of depression symptoms during the pandemic. For comparison, sensitivity analyses were conducted to examine the incidence and recurrence of depression among older adults with PUD during the pre-pandemic period between the Baseline (2011–2015) and Follow-up 1 (2015–2018). Our results indicate that the incidence and recurrence of depression pre-pandemic wave were 7.5% and 37.9%, respectively, which was substantially lower than the incidence and recurrence of depression during the pandemic. The findings of this study emphasize the importance of supporting the mental health of older adults with PUD during the COVID-19 pandemic. There were several factors that were associated with incident and recurrent depression, highlighting subpopulations of older adults with PUD who may be more vulnerable to adverse mental health outcomes.

Older women with PUD were approximately twice as likely to develop incident depression as their male counterparts. The high vulnerability to depression among older women has been previously identified in studies both before (e.g., [27]) and during the pandemic (e.g., [6]). The higher risk of depression identified in the current study may be partly due to declines in social interaction during the pandemic [28]. Although older women tend to have higher levels of social support than older men, a review on sex differences in depression among older adults hypothesized that older women may be more vulnerable to the absence of social support than their male counterparts [29]. Similarly, a study by Carayanni and colleagues [30] found that social support factors, such as regularly engaging in outings and excursions, were protective against depression for older women, but not for older men. It is possible that disruptions to socializing due to extended lockdowns disproportionately harmed older women. This is supported by the emerging research that has found higher levels of loneliness among older women compared to older men during the pandemic [31].

Among older adults with PUD, experiencing loneliness during the first few months of the pandemic was associated with a six-fold risk for incident depression and a more than two-fold risk for recurrent depression. There is a well-established link between loneliness and depression in middle-aged and older adults [27, 32]. Prior to the COVID-19 pandemic, loneliness and social isolation had already been identified as a major public health concern compromising the physical and mental health of older adults [33], and emerging research suggests that levels of loneliness among older adults have increased during the pandemic [34]. Increases in loneliness and time spent isolated are particularly concerning for older adults with PUD, as social isolation is associated with PUD recurrence in older adults with depression [35], emphasizing the reciprocal relationship between physical and mental health outcomes in older adults with PUD.

Among those with no history of depression, individuals who had trouble financially meeting their basic needs before the pandemic had more than triple the risk of developing depression for the first time during the pandemic. The COVID-19 pandemic created unprecedented economic challenges for vulnerable groups, particularly for those who live at the intersection of different vulnerabilities, such as low-income older adults with chronic illness [36]. Although older adults often have sources of income that would not have been affected by the pandemic, such as pensions and social security, many low-income older adults maintain employment into later life to meet their financial needs. Older adults are frequently employed in industries that were disproportionately impacted by periods of lockdown, such as retail stores, which may have resulted in layoffs and reductions in scheduling [36].

Among those with PUD, functional limitations were associated with an approximately three-fold risk for both incident and recurrent depression, while chronic pain was associated with a 63% higher risk of recurrent depression only. Functional limitations and chronic pain have important implications for the mental health of older adults. There is a high comorbidity between chronic pain and depression [37]. Both conditions are highly intertwined, whereby both physical and psychological pain exacerbate the other condition [37]. These findings of the current study are consistent with other research on the effects of chronic pain on depression, which indicate that high levels of pain can lead to depressive symptoms, potentially due to pain’s impact on physical functioning and fatigue [38]. Declines in physical functioning that lead to increased dependency have also been found to predict depression [39]. A longitudinal analysis of community-dwelling and institutionalized older adults found that those with limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) had significantly higher depression scores than those with no limitations [39]. Functional limitations and chronic pain often disrupt usual role activities, which is associated with lower quality of life among those with PUD [15, 16].

Older adults with PUD who reported increases in family conflict during the pandemic, such as verbal or physical conflict and/or marital breakdown, were three times more likely to develop incident depression and four times more likely to develop recurrent depression. Emerging research indicates substantial deterioration in family functioning during the pandemic [40]. COVID-19 has severely impacted many domains of life that may increase stressors among families, such as employment instability and economic precarity. When combined with increased time spent together at home in conjunction with disruptions to coping mechanisms that may reduce familial conflict, such as social support from loved ones, it is unsurprising that there may have been increases in interpersonal conflict [41]. Previous research has identified interpersonal conflict as a risk factor for depression in older adulthood [42].

There were several other COVID-19-related factors that were associated with incident and recurrent depression among older adults with PUD. Health stressors, such as being ill or having a loved one become ill during the pandemic, and/or experiencing the death of a loved one were associated with double the risk of incident depression only. Additionally, experiencing disruptions to regular health care access during COVID-19 was also associated with approximately double the risk of incident depression only. Finally, experiencing disruptions to medication access during COVID-19 was associated with a five-fold risk of recurrent depression only. The identified association between pandemic-related health stressors and depression supports other research that has found a high comorbidity between early COVID-19 infection and/or infection of a loved one and depressive symptoms [43, 44]. Additionally, the finding that disruptions to healthcare access and medication access were associated with depression reinforces issues with healthcare equity during COVID-19. There are ongoing concerns that reductions in healthcare access and shifts to telemedicine will create difficulties for managing chronic illness, particularly for older adults who may have challenges adapting to changing patterns of care [45]. Other studies have identified numerous medication-related problems for people with chronic illness during the pandemic, such as difficulty accessing medication due to doctor office closures, medication shortages, and fear of COVID-19 exposure in pharmacies or doctor’s offices, ultimately causing individuals to neglect obtaining their required medication [46]. It is essential to understand and address these issues in healthcare equity to support the mental health of older adults with PUD beyond the pandemic.

Acknowledgments

This research was made possible using the data collected by the Canadian Longitudinal Study on Aging (CLSA). This research has been conducted using the CLSA Baseline Comprehensive Dataset version 6.0, Baseline Tracking Dataset version 3.7, Follow-up 1 Comprehensive Dataset version 3.0 and Follow-up 1 Tracking Dataset version 2.2, COVID-19 Questionnaire Study Dataset version 1.0 under Application ID 2104024. The CLSA is led by Drs. Parminder Raina, Christina Wolfson and Susan Kirkland. The opinions expressed in this manuscript are the author’s own and do not reflect the views of the Canadian Longitudinal Study on Aging

Funding for the CLSA is provided by the Government of Canada through the Canadian Institutes of Health Research (CIHR) under grant reference: LSA 94473 and the Canada Foundation for Innovation, as well as the following provinces, Newfoundland, Nova Scotia, Quebec, Ontario, Manitoba, Alberta, and British Columbia. Funding for support of the CLSA COVID-19 questionnaire-based study is provided by the Juravinski Research Institute, Faculty of Health Sciences, McMaster University, the Provost Fund from McMaster University, the McMaster Institute for Research on Aging, the Public Health Agency of Canada/CIHR grant reference CMO 174125 and the government of Nova Scotia