Seungju Kim
Relationship between lifestyle changes due to the COVID-19 pandemic and depression: Nationwide population-based research using Community Health Survey data in South Korea
COVID-19,Depression,Chronic diseases,Hypertension,Diabetes
Aims This study evaluated the association between depression and lifestyle changes due to the COVID-19 pandemic and evaluated this association in patients with chronic diseases. Methods Data were obtained from the 2020 Community Health Survey in South Korea. This study included 212,806 participants and perceived changes in life patterns (sleep, food, and exercise) after the COVID-19 outbreak were measured. People with hypertension or diabetes were categorized as patients with chronic diseases and depression was defined as a score of ≥10 on the Patient Health Questionnaire-9. Results Compared with before the COVID-19 pandemic, increased or decreased sleep, the consumption of instant food, and decreased physical activity were associated with increased depression. Compared with the general population, patients with chronic diseases showed increased depression, with or without medication. Additionally, among patients with chronic diseases not taking medication, increased physical activity was associated with reduced depression, whereas reduced physical activity was associated with increased depression in both younger and older groups. Conclusions This study found that unhealthy lifestyle changes during the COVID-19 pandemic were associated with increased depression. Maintaining a certain lifestyle is important for mental health. Chronic disease patients need appropriate disease management, including physical activity.
Relationship between lifestyle changes due to the COVID-19 pandemic and depression: Nationwide population-based research using Community Health Survey data in South Korea

This study evaluated the association between depression and lifestyle changes due to the COVID-19 pandemic and evaluated this association in patients with chronic diseases.

Data were obtained from the 2020 Community Health Survey in South Korea. This study included 212,806 participants and perceived changes in life patterns (sleep, food, and exercise) after the COVID-19 outbreak were measured. People with hypertension or diabetes were categorized as patients with chronic diseases and depression was defined as a score of ≥10 on the Patient Health Questionnaire-9.

Compared with before the COVID-19 pandemic, increased or decreased sleep, the consumption of instant food, and decreased physical activity were associated with increased depression. Compared with the general population, patients with chronic diseases showed increased depression, with or without medication. Additionally, among patients with chronic diseases not taking medication, increased physical activity was associated with reduced depression, whereas reduced physical activity was associated with increased depression in both younger and older groups.

This study found that unhealthy lifestyle changes during the COVID-19 pandemic were associated with increased depression. Maintaining a certain lifestyle is important for mental health. Chronic disease patients need appropriate disease management, including physical activity.

Since the coronavirus disease 2019 (COVID-19) outbreak, an end to this new infectious disease has not yet been declared in any part of the world [1], [2]. The COVID-19 pandemic has changed people’s lives, affecting their living environments and individual life patterns markedly [3]. Various government regulations to prevent the spread of the disease have also changed individuals’ behavioral patterns, leading to unhealthy lifestyles such as reduced physical activity and the increased consumption of unhealthy foods [3], [4]. In particular, concerns about infection and social isolation can have negative psychological effects, thus worsening the mental health of vulnerable individuals [5]. One study on mental health after the onset of COVID-19 found that people with a weaker sense of coherence had worse mental health [6]. An Australian study showed that negative changes in physical activity, sleep, smoking, and alcohol consumption were associated with increased symptoms of depression, anxiety, and stress [7]. In particular, decreased social and physical activity, poor sleep quality, and unhealthy food consumption were associated with poor mental health and depression [4], [8]. Depressive symptoms increased in the United States compared with the pre-COVID-19 period, and people with low social resources and those exposed to stress were more likely to experience depressive symptoms [9]. Anxious individuals displayed increased addictive behaviors such as alcohol consumption and smoking [10]. These findings suggest that changes in life patterns after the COVID-19 outbreak may differ depending on individual characteristics and that the impact of these changes on mental health may also vary depending on individual vulnerability. Patients with chronic diseases are a vulnerable group, and the COVID-19 pandemic may have affected not only chronic disease management, but also mental health. Since the COVID-19 outbreak, hospitalizations for all patients have decreased, except for acute disease recovery, while hospitalizations for chronic diseases have remained low, suggesting the need for appropriate interventions for patients with unmanaged chronic diseases [11]. A lack of access to treatment and delayed treatment due to concerns about infection are associated with increased anxiety and depression in patients with chronic diseases, such as oncological patients [12] and cardiovascular patients [13]. Previous studies have presented the various changes in life patterns due to the COVID-19 pandemic and effects of these changes on depression; however, most studies have included only a small number of participants. In addition, few studies have considered lifestyle changes and hospitalizations due to the COVID-19 pandemic, and since most studies were conducted on Westerners, data from studies on Asians are lacking. If appropriate interventions are not provided for vulnerable individuals, the burden of disease caused by the COVID-19 pandemic will gradually increase. To reduce this burden, appropriate management is required, which demands clear evidence of which factors affect mental health. This study aimed to evaluate the relationship between lifestyle changes caused by the COVID-19 pandemic and depression. First, the relationships among individuals’ perceived changes in life patterns, lifestyle changes, chronic diseases, and depression were evaluated. Next, since lifestyle changes caused by the COVID-19 pandemic may appear differently in patients with chronic diseases, the relationship between lifestyle changes and depression was evaluated in patients with hypertension or diabetes. Finally, a subgroup analysis by age evaluated the association between lifestyle changes caused by COVID-19 and depression.

This study used data from the 2020 Community Health Survey administered by the Korea Centers for Disease Control and Prevention, which has been conducted since 2008 by survey teams jointly formed with universities and public health centers in the community in accordance with the Community Health Act [14]. This survey is conducted at the household level, and a surveyor conducts one-on-one visits and interviews adults aged ≥19 years. The data included factors such as health behaviors, quality of life, socio-environmental factors, and healthcare utilization. In 2020, from August 16 to October 31, trained investigators visited the households selected as the sample and conducted one-on-one interview surveys; 229,269 people were included. Among them, those over 80 years of age were excluded, and subjects who answered “do not know” or “refused to answer” to the items set as variables, such as depressive symptoms and changes in life patterns after the COVID-19 outbreak, were excluded. A total of 212,806 participants were included in this study.

The variables of interest were changes in life patterns after the COVID-19 outbreak and chronic disease. Changes in life patterns due to the COVID-19 pandemic were evaluated in two respects: self-awareness and type. First, self-awareness of changes in life patterns due to the COVID-19 pandemic was evaluated using the following questions: “If your state of life before the COVID-19 pandemic is represented by 100 points and complete disruption of your daily life by 0 points, what is your current state?” The score was measured in units of 10 points, and the closer the score was to 100, the less change there was. Second, changes in life patterns after the COVID-19 outbreak were evaluated with the question “What types of changes have there been in your daily life compared with before the COVID-19 pandemic?” Responses to these questions were “decreased,” “similar,” and “increased,” and included physical activity (including indoor and outdoor walking exercise), amount of sleep, consumption of instant food and carbonated beverages, consumption of delivery food, consumption of alcohol, and smoking. Patients with chronic diseases were those diagnosed with hypertension or diabetes, and it was considered that the effects of the COVID-19 pandemic may appear differently for patients receiving and not receiving drug treatment. Chronic diseases were evaluated based on the questions “Have you ever been diagnosed with hypertension (or diabetes)?” and “What treatment are you currently receiving to manage your blood sugar (or blood pressure)?” Based on these questions, the participants were classified as patients receiving drug treatment (hypertensive drugs, oral hypoglycemic agents, and insulin injections), those not receiving drug treatment (exercise, diet, and nothing), and non-patients. The dependent variable was depression, which was evaluated using the Patient Health Questionnaire-9 (PHQ-9) [15]. The PHQ-9 asks, “Over the last two weeks, how often have you been bothered by this problem?” The scores to its nine questions range from 0 points (no depressive symptoms) to 27 points (all symptoms occurring daily), with each item being scored from 0 points (not at all) to 3 points (nearly every day). In a previous study, a score of 10 or more showed a sensitivity and specificity of 88 % in diagnosing major depression or clinically relevant depression [16], while a score of 10 or more on the PHQ-9 has also been suggested as a screening criterion for depressive disorders among South Koreans [17], [18]. In this study, as in previous studies, a score of 10 or higher was defined as depression. Additionally, experiences of hospitalization or isolation due to the COVID-19 pandemic were included (yes or no), and basic patient characteristics such as sex (male and female), occupation (office worker, professional/manager, sales and service worker, agriculture, forestry and fisheries, other, and not working), age (19–34, 35–49, 50–64, and 65–80 years), education level (elementary school, middle school, high school, and college), and marital status (single, separation/divorce/bereavement, and married) were included.

Categorical variables were analyzed using χ2 tests and presented as frequencies and percentages. In this study, weights were assigned to the sample results to indicate the representativeness of the entire country. For the continuous variables, t-tests were used to compare the group means. Multiple logistic regression analysis with the questionnaire weight applied was performed to evaluate the association between changes in life patterns due to the COVID-19 pandemic and depression. All the variables were added into the fully adjusted model simultaneously. Next, this study evaluated the relationship between lifestyle changes and depression following the COVID-19 pandemic in patients with hypertension or diabetes. Finally, a subgroup analysis was conducted on the association between lifestyle changes due to COVID-19 and depression according to age. All the statistical analyses were performed using SAS statistical software version 9.4. The statistical significance was set at P < 0.05.

Table 1 shows the general characteristics of the study population. Of the 212,806 participants included in the study, 2.8 % (n = 5557) were classified as having depression (PHQ-9 score of 10 or higher). As for changes in life patterns due to the COVID-19 pandemic, participants with depression scored 48.5 points and participants without depression scored 55.0 points, indicating that such changes were significantly higher in participants with depression (p < 0.0001). Of all the participants, 50 % responded that their physical activity had decreased. Individual lifestyle changes and depression tended to be higher as physical activity decreased (n = 2957, 3.5 %), amount of sleep decreased (n = 1372, n = 7.7 %), and instant food intake increased (n = 1153, 4.4 %). Regarding lifestyle changes, depression was higher in the group with increased alcohol consumption (n = 449, 6.7 %) and smoking (n = 330, 9.9 %) compared with before the COVID-19 outbreak. Among the patients with hypertension or diabetes, 3.2 % of those receiving drug treatment and 5.5 % of those not receiving drug treatment had depression. Table 2 shows the results of the logistic regression analysis on the relationship between lifestyle changes and depression due to the COVID-19 pandemic. The participants who felt fewer changes in their lives due to the COVID-19 pandemic were associated with decreased depression (odds ratio [OR]: 0.992; 95 % confidence interval [CI]: 0.990–0.993), and decreased physical activity was associated with increased depression (OR: 1.097, 95 % CI: 1.020–1.180). A decrease (OR: 2.973, 95 % CI: 2.720–3.251) or increase (OR: 1.329, 95 % CI: 1.199–1.472) in the amount of sleep and a decrease (OR: 1.194, 95 % CI: 1.046–1.364) or increase (OR: 1.469, 95 % CI: 1.323–1.631) in instant food intake were all associated with increased depression. Compared with individuals without hypertension or diabetes, patients taking medication (OR: 1.298, 95 % CI: 1.189–1.416) and those not taking medication (OR: 2.300, 95 % CI: 1.844–2.868) reported increased depression. Fig. 1 shows the association between lifestyle changes and depression in patients with hypertension or diabetes. Among patients taking medication, increased (OR: 2.414, 95 % CI: 2.059–2.829) or decreased (OR: 1.446, 95 % CI: 1.183–1.766) sleep, the increased consumption of instant food (OR: 1.310, 95 % CI: 1.001–1.715), increased alcohol consumption (OR: 1.825, 95 % CI: 1.289–2.584), and increased smoking (OR: 2.375, 95 % CI: 1.653–3.413) were associated with increased depression. Changes in the amount of sleep, increased alcohol consumption (OR: 1.780, 95 % CI: 1.309–2.418), and increased smoking (OR: 1.982, 95 % CI: 1.324–2.965) were associated with increased depression in patients not taking medication. In addition, among non-drug taking patients, increased physical activity compared with before COVID-19 was associated with reduced depression (OR: 0.257, 95 % CI: 0.088–0.754). Table 3 shows the relationship between lifestyle changes and depression according to age. A decrease in physical activity compared with before COVID-19 was significantly associated with increased depression in those under 34 years (OR: 1.283, 95 % CI: 1.106–1.488) and over 65 years (OR: 1.157, 95 % CI: 1.011–1.325). A decrease or increase in the amount of sleep was associated with an increase in depression in all age groups and the magnitude of the relationship between decreased sleep and depression was greatest in those under 34 years (OR: 3.090, 95 % CI: 2.570–3.717).

This study found that fewer lifestyle changes due to the COVID-19 pandemic were less associated with depression, and that unhealthy changes in life patterns, such as reduced physical activity and changes in the amount of sleep, were associated with increased depression. In addition, lifestyle changes were associated with depression in patients with hypertension or diabetes who were taking medication and in those not receiving medication, while increased physical activity is associated with reduced depression in chronic patients who do not take drugs. These results show that changes in individuals’ lives caused by a pandemic can affect their mental health. Previous studies have suggested that lifestyle factors are associated with mental health [19] and that decreased physical activity may increase depressive symptoms in active young adults [20]. Further, eating healthy food is associated with happiness and food intake has a close association with disease treatment [21]. In particular, poor sleep quality is associated with poor mental health [22]. Lockdowns due to COVID-19 may have affected individuals’ sleep patterns, and this may have had more of an impact on depression than other lifestyle changes [23]. Therefore, appropriate interventions are necessary to care for mental health during a pandemic such as COVID-19 [24]. This finding supports the results of previous studies suggesting that individuals changing their lifestyles may be more vulnerable to depression and need appropriate management. Therefore, it is necessary to educate the public that rapid lifestyle changes can be related to negative mental health and make them aware of the importance of maintaining a healthy lifestyle. In addition, this study showed that patients with hypertension or diabetes reported increased depression compared with the general population. These findings are similar to the findings of increased depression and anxiety among adult patients diagnosed with chronic conditions during the COVID-19 pandemic in Brazil [25]. However, in a Greek study, anxiety and depression during the COVID-19 quarantine period were not significantly different from those of the general population [26]. A plausible explanation for these findings could be related to access to care for patients with chronic diseases. According to previous studies, the limitations of treatment due to the COVID-19 pandemic have increased non-face-to-face treatments such as via apps and phone consultations, and most patients with chronic diseases experience depression [27]. The concentration of healthcare services on infectious diseases would impact the access to care of patients with chronic diseases who were receiving routine treatment and this restriction of access would have had a negative impact on mental health. In addition, lifestyle changes in hypertension or diabetes patients may have a different relationship with depression depending on whether they are treated with medication. To examine these effects, the relationship between lifestyle changes and depression in patients with chronic diseases was evaluated and changes in the amount of sleep or an increase in alcohol consumption and smoking were found to be associated with an increase in depression. Overall, the association between unhealthy lifestyle changes and depression in patients with chronic diseases was similar to the main findings; in particular, an increase in physical activity in patients with chronic diseases who did not receive drug treatment was associated with a decrease in depression. Exercise is an important disease management method for patients with chronic diseases who do not use drugs, as it can alleviate depression [28]. Therefore, it is important to educate patients with chronic diseases about the necessity of continuous exercise and various exercise methods that can be performed at home during a pandemic such as COVID-19. The results of the subgroup analysis showed that the relationship between certain lifestyle changes and depression was significant in the younger and older populations. A decrease in physical activity was associated with depression among those under 34 and over 65 years, while a decrease in the amount of sleep due to the COVID-19 pandemic was associated with an increase in depression in all age groups, but the size of the effect was larger in the younger age group. Previous research has also shown that the impact of lifestyle changes due to the COVID-19 pandemic may be greater in younger age groups [29] and that physical activity in older adults may have a protective effect on worsening mental health [30]. These results show that the relationship between changes in sleep and physical activity and mental health may differ according to age, suggesting that the appropriate management of sleep and physical activity is necessary to manage mental health. Finally, in this study, the prevalence of depression was relatively low (3 % of the participants). Previous studies have reported depression rates between 3 % and 13 % during the COVID-19 period [31], with some finding rates above 30 % [32]. These differences may be due to the definition of depression and influenced by the infectious disease control policies of the country in which the study was conducted. In previous studies in South Korea, the depression rate has been found to be low, as in our study [33]. In 2020, when the data were collected, South Korea had a low prevalence of COVID-19 and some degree of social isolation; however, as industry shutdowns were less severe than those in other countries, the sense of social isolation may have been low [33]. This difference could explain the low depression rate. Nonetheless, 2022 was the year with the highest prevalence of COVID-19 in South Korea. Hence, further research on depression using data collected in 2022 is needed. This study has several strengths. First, although there are many studies on mental health after the COVID-19 outbreak, most have included small samples; by contrast, the data used in this study are representative and the results are robust and reliable. Second, this study evaluated the relationship between changes in life patterns and depression among those with chronic diseases and presented evidence of the need for appropriate management for vulnerable individuals. Nevertheless, this study has several limitations. Only hypertension and diabetes were defined as chronic diseases and patients with other unmeasured chronic diseases were not evaluated. Therefore, further research considering various chronic diseases is needed. In addition, this study could not exclude participants who were previously diagnosed with mental illness due to data limitations, and additional research will be needed because it cannot present a causal relationship between lifestyle changes and depression.

This study shows that changes in individuals’ lifestyles due to COVID-19 are associated with negative mental health. During this pandemic, the importance of the proper management of individuals’ mental health increased and the early detection or appropriate management of vulnerable individuals may have reduced the burden of disease. Therefore, even in the COVID-19 era, it is necessary to educate both the public on the importance of maintaining daily life patterns and vulnerable individuals, especially those with chronic diseases, on the importance of steady physical activity.

This study used secondary data, which are public data. No ethical approval was required.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors declare that they have no conflict of interest.