Experiencing multiple stressors triggered by the COVID-19 pandemic are directly linked to rising acute stress and depressive symptoms

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Experiencing multiple stressors triggered by the COVID-19 pandemic – such as unemployment – and COVID-19-related media consumption are directly linked to rising acute stress and depressive symptoms across the U.S., according to a groundbreaking University of California, Irvine study.

The report appears in Science Advances.

“The pandemic is not hitting all communities equally,” said lead author E. Alison Holman, UCI professor of nursing. “People have lost wages, jobs and loved ones with record speed.

Individuals living with chronic mental and physical illness are struggling; young people are struggling; poor communities are struggling. Mental health services need to be tailored to those most in need right now.”

In addition, the research highlights the connection between mental health and exposure to media coverage of the COVID-19 pandemic, suggesting the need to step away from the television, computer or smartphone to protect psychological well-being.

“The media is a critical source of information for people when they’re faced with ambiguous, ongoing disasters,” said Roxane Cohen Silver, professor of psychological science and one of the study’s principal investigators.

“But too much exposure can be overwhelming and lead to more stress, worry and perceived risks.”

With funding from a National Science Foundation RAPID grant, Holman, Silver, and co-investigators Dana Rose Garfin and Rebecca R. Thompson conducted a national survey of more than 6,500 U.S. residents in March and April 2020, as illness and deaths were rising around the country.

Using the NORC AmeriSpeak panel, the study was the first of its kind to examine early predictors of rising mental health problems across the nation. The design let researchers evaluate the effects of the pandemic as it was unfolding in real time.

“Over the course of the study, the size of the pandemic shifted dramatically,” Holman said. Accordingly, people surveyed later in the study period reported the highest rate of acute stress and depressive symptoms.

The UCI team’s findings offer insights into priorities for building community resilience in the face of the COVID-19 pandemic:

  • Those with pre-existing mental and physical conditions are more likely to show both acute stress and depressive symptoms.
  • Secondary stressors – job and wage loss, a shortage of necessities – are also strong predictors in the development of these symptoms.
  • Extensive exposure to pandemic-related news and conflicting information in the news are among the strongest predictors of pandemic-specific acute stress.

“It’s critical that we prioritize providing resources to communities most in need of support right now – the unemployed, poor or chronically ill people, and young people,” Holman said.

“We also encourage the public to limit exposure to media as an important public health intervention. It can prevent mental and physical health symptoms and promote resilience.”


The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 (1,2).

To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24–30, 2020.

Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%).

The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers (21.7%).

Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys†† administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research.

Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses.

Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶

 Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale††† (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§

Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey.

Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (α = 0.005 to account for multiple comparisons).

Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted†††† odds ratios (ORs), 95% CI, and p-values (α = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.

Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1).

At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.

Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age.

Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents.

Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not.

Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.

Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019).

CharacteristicAll respondents who completed surveys during June 24–30, 2020 weighted* no. (%)Weighted %*
ConditionsStarted or increased substance use to cope with pandemic-related stress or emotionsSeriously considered suicide in past 30 days≥1 adverse mental or behavioral health symptom
Anxiety disorderDepressive disorderAnxiety or depressive disorderCOVID-19–related TSRD§
All respondents5,470 (100)25.524.330.926.313.310.740.9
Gender
Female2,784 (50.9)26.323.931.524.712.28.941.4
Male2,676 (48.9)24.724.830.427.914.412.640.5
Other10 (0.2)20.030.030.030.010.00.030.0
Age group (yrs)
18–24731 (13.4)49.152.362.946.024.725.574.9
25–441,911 (34.9)35.332.540.436.019.516.051.9
45–641,895 (34.6)16.114.420.317.27.73.829.5
≥65933 (17.1)6.25.88.19.23.02.015.1
Race/Ethnicity
White, non-Hispanic3,453 (63.1)24.022.929.223.310.67.937.8
Black, non-Hispanic663 (12.1)23.424.630.230.418.415.144.2
Asian, non-Hispanic256 (4.7)14.114.218.022.16.76.631.9
Other race or multiple races, non-Hispanic**164 (3.0)27.829.333.228.311.09.843.8
Hispanic, any race(s)885 (16.2)35.531.340.835.121.918.652.1
Unknown50 (0.9)38.034.044.034.018.026.048.0
2019 Household income (USD)
<25,000741 (13.6)30.630.836.629.912.59.945.4
25,000–49,9991,123 (20.5)26.025.633.227.213.510.143.9
50,999–99,9991,775 (32.5)27.124.831.626.412.611.440.3
100,999–199,9991,301 (23.8)23.120.827.724.215.511.737.8
≥200,000282 (5.2)17.417.020.623.114.811.635.1
Unknown247 (4.5)19.623.127.224.96.23.941.5
Education
Less than high school diploma78 (1.4)44.551.457.544.522.130.066.2
High school diploma943 (17.2)31.532.838.432.115.313.148.0
Some college1,455 (26.6)25.223.431.722.810.98.639.9
Bachelor’s degree1,888 (34.5)24.722.528.726.414.210.740.6
Professional degree1,074 (19.6)20.919.525.424.512.610.035.2
Unknown33 (0.6)25.223.228.223.210.55.528.2
Employment status††
Employed3,431 (62.7)30.129.136.432.117.915.047.8
Essential1,785 (32.6)35.533.642.438.524.721.754.0
Nonessential1,646 (30.1)24.124.129.925.210.57.841.0
Unemployed761 (13.9)32.029.437.825.07.74.745.9
Retired1,278 (23.4)9.68.712.111.34.22.519.6
Unpaid adult caregiver status§§
Yes1,435 (26.2)47.645.256.148.432.930.766.6
No4,035 (73.8)17.716.922.018.46.33.631.8
Region¶¶
Northeast1,193 (21.8)23.923.929.922.812.810.237.1
Midwest1,015 (18.6)22.721.127.524.49.07.536.1
South1,921 (35.1)27.926.533.429.115.412.544.4
West1,340 (24.5)25.824.230.926.714.010.943.0
Rural-urban classification***
Rural599 (10.9)26.022.529.325.411.510.238.3
Urban4,871 (89.1)25.524.631.126.413.510.741.2
Know someone who had positive test results for SARS-CoV-2
Yes1,109 (20.3)23.821.929.621.512.97.539.2
No4,361 (79.7)26.025.031.327.513.411.541.3
Knew someone who died from COVID-19
Yes428 (7.8)25.820.630.628.111.37.640.1
No5,042 (92.2)25.524.731.0.26.113.410.941.0
Receiving treatment for previously diagnosed condition
Anxiety
Yes536 (9.8)59.652.066.051.926.623.672.7
No4,934 (90.2)21.821.327.123.511.89.337.5
Depression
Yes540 (9.9)52.550.660.845.525.222.168.8
No4,930 (90.1)22.621.527.724.212.09.437.9
Posttraumatic stress disorder
Yes251 (4.6)72.369.178.769.443.844.888.0
No5,219 (95.4)23.322.228.624.211.89.038.7

Abbreviations: COVID-19 = coronavirus disease 2019; TSRD = trauma- and stressor-related disorder.
* Survey weighting was employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census with respondents in which gender, age, and race/ethnicity were reported. Respondents who reported a gender of “Other” or who did not report race/ethnicity were assigned a weight of one.
 Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for each disorder, respectively.
§ Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored ≥1.75 out of 4 were considered symptomatic.
 104 respondents selected “Prefer not to answer.”
** The Other race or multiple races, non-Hispanic category includes respondents who identified as not being Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or “Other.”
†† Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential vs. nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.
§§ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing.
¶¶ Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions of the United States. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdfpdf iconexternal icon.
*** Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.htmlexternal icon.

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CharacteristicPrevalence ratio (95% CI)
Symptoms of anxiety disorder or depressive disorderSymptoms of a TSRD related to COVID-19§Started or increased substance use to cope with stress or emotions related to COVID-19Serious consideration of suicide in past 30 days
Gender
Female vs. male1.04 (0.96–1.12)0.88 (0.81–0.97)0.85 (0.75–0.98)0.70 (0.60–0.82)**
Age group (yrs)
18–24 vs. 25–441.56 (1.44–1.68)**1.28 (1.16–1.41)**1.31 (1.12–1.53)**1.59 (1.35–1.87)**
18–24 vs. 45–643.10 (2.79–3.44)**2.67 (2.35–3.03)**3.35 (2.75–4.10)**6.66 (5.15–8.61)**
18–24 vs. ≥657.73 (6.19–9.66)**5.01 (4.04–6.22)**8.77 (5.95–12.93)**12.51 (7.88–19.86)**
25–44 vs. 45–641.99 (1.79–2.21)**2.09 (1.86–2.35)**2.56 (2.14–3.07)**4.18 (3.26–5.36)**
25–44 vs. ≥654.96 (3.97–6.20)**3.93 (3.18–4.85)**6.70 (4.59–9.78)**7.86 (4.98–12.41)**
45–64 vs. ≥652.49 (1.98–3.15)**1.88 (1.50–2.35)**2.62 (1.76–3.9)**1.88 (1.14–3.10)
Race/Ethnicity††
Hispanic vs. non-Hispanic black1.35 (1.18–1.56)**1.15 (1.00–1.33)1.19 (0.97–1.46)1.23 (0.98–1.55)
Hispanic vs. non-Hispanic Asian2.27 (1.73–2.98)**1.59 (1.24–2.04)**3.29 (2.05–5.28)**2.82 (1.74–4.57)**
Hispanic vs. non-Hispanic other race or multiple races1.23 (0.98–1.55)1.24 (0.96–1.61)1.99 (1.27–3.13)**1.89 (1.16–3.06)
Hispanic vs. non-Hispanic white1.40 (1.27–1.54)**1.50 (1.35–1.68)**2.09 (1.79–2.45)**2.35 (1.96–2.80)**
Non-Hispanic black vs. non-Hispanic Asian1.68 (1.26–2.23)**1.38 (1.07–1.78)2.75 (1.70–4.47)**2.29 (1.39–3.76)**
Non-Hispanic black vs. non-Hispanic other race or multiple races0.91 (0.71–1.16)1.08 (0.82–1.41)1.67 (1.05–2.65)1.53 (0.93–2.52)
Non-Hispanic black vs. non-Hispanic white1.03 (0.91–1.17)1.30 (1.14–1.48)**1.75 (1.45–2.11)**1.90 (1.54–2.36)**
Non-Hispanic Asian vs. non-Hispanic other race or multiple races0.54 (0.39–0.76)**0.78 (0.56–1.09)0.61 (0.32–1.14)0.67 (0.35–1.29)
Non-Hispanic Asian vs. non-Hispanic white0.62 (0.47–0.80)**0.95 (0.74–1.20)0.64 (0.40–1.02)0.83 (0.52–1.34)
Non-Hispanic other race or multiple races vs. non-Hispanic white1.14 (0.91–1.42)1.21 (0.94–1.56)1.05 (0.67–1.64)1.24 (0.77–2)
Employment status
Employed vs. unemployed0.96 (0.87–1.07)1.28 (1.12–1.46)**2.30 (1.78–2.98)**3.21 (2.31–4.47)**
Employed vs. retired3.01 (2.58–3.51)**2.84 (2.42–3.34)**4.30 (3.28–5.63)**5.97 (4.20–8.47)**
Unemployed vs. retired3.12 (2.63–3.71)**2.21 (1.82–2.69)**1.87 (1.30–2.67)**1.86 (1.16–2.96)
Essential vs. nonessential worker§§1.42 (1.30–1.56)**1.52 (1.38–1.69)**2.36 (2.00–2.77)**2.76 (2.29–3.33)**
Unpaid caregiver for adults vs. not¶¶`2.55 (2.37–2.75)**2.63 (2.42–2.86)**5.28 (4.59–6.07)**8.64 (7.23–10.33)**
Rural vs. urban residence***0.94 (0.82–1.07)0.96 (0.83–1.11)0.84 (0.67–1.06)0.95 (0.74–1.22)
Knows someone with positive SARS-CoV-2 test result vs. not0.95 (0.86–1.05)0.78 (0.69–0.88)**0.96 (0.81–1.14)0.65 (0.52–0.81)**
Knew someone who died from COVID-19 vs. not0.99 (0.85–1.15)1.08 (0.92–1.26)0.84 (0.64–1.11)0.69 (0.49–0.97)
Receiving treatment for anxiety vs. not2.43 (2.26–2.63)**2.21 (2.01–2.43)**2.27 (1.94–2.66)**2.54 (2.13–3.03)**
Receiving treatment for depression vs. not2.20 (2.03–2.39)**1.88 (1.70–2.09)**2.13 (1.81–2.51)**2.35 (1.96–2.82)**
Receiving treatment for PTSD vs. not2.75 (2.55–2.97)**2.87 (2.61–3.16)**3.78 (3.23–4.42)**4.95 (4.21–5.83)**

Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019; PTSD = posttraumatic stress disorder; TSRD = trauma- and stressor-related disorder.
* Number of respondents for characteristics: gender (female = 2,784, male = 2,676), age group in years (18–24 = 731; 25–44 = 1,911; 45–64 = 1,895; ≥65 = 933), race/ethnicity (non-Hispanic white = 3453, non-Hispanic black = 663, non-Hispanic Asian = 256, non-Hispanic other race or multiple races = 164, Hispanic = 885).
 Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered to have symptoms of these disorders.
§ Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include PTSD, acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Persons who scored ≥1.75 out of 4 were considered to be symptomatic.
 Comparisons within subgroups were evaluated on weighted responses via Poisson regressions used to calculate a prevalence ratio, 95% CI, and p-value (not shown). Statistical significance was evaluated at a threshold of α = 0.005 to account for multiple comparisons. In the calculation of prevalence ratios for started or increased substance use, respondents who selected “Prefer not to answer” (n = 104) were excluded.
** P-value is statistically significant (p<0.005).
†† Respondents identified as a single race unless otherwise specified. The non-Hispanic, other race or multiple races category includes respondents who identified as not Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or ‘Other’.
§§ Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential vs. nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.
¶¶ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing.
*** Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.htmlexternal icon.

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Symptom or behaviorEssential worker vs. all other employment statuses (nonessential worker, unemployed, retired)Unpaid caregiver for adults§ vs. not unpaid caregiver
UnadjustedAdjustedUnadjustedAdjusted**
OR (95% CI)††p-value††OR (95% CI)††p-value††OR (95% CI)††p-value††OR (95% CI)††p-value††
Symptoms of anxiety disorder§§1.92 (1.29–2.87)0.0011.63 (0.99–2.69)0.0561.97 (1.25–3.11)0.0041.81 (1.14–2.87)0.012
Symptoms of depressive disorder§§1.49 (1.00–2.22)0.0521.13 (0.70–1.82)0.6062.29 (1.50–3.50)<0.0012.22 (1.45–3.41)<0.001
Symptoms of anxiety disorder or depressive disorder§§1.67 (1.14–2.46)0.0081.26 (0.79–2.00)0.3261.84 (1.19–2.85)0.0061.73 (1.11–2.70)0.015
Symptoms of a TSRD related to
COVID–19¶¶
1.55 (0.86–2.81)0.1461.27 (0.63–2.56)0.5121.88 (0.99–3.56)0.0541.79 (0.94–3.42)0.076
Started or increased substance use to cope with stress or emotions related to COVID–192.36 (1.26–4.42)0.0072.04 (0.92–4.48)0.0783.51 (1.86–6.61)<0.0013.33 (1.75–6.31)<0.001
Serious consideration of suicide in previous 30 days0.93 (0.31–2.78)0.8950.53 (0.16–1.70)0.2853.00 (1.20–7.52)0.0193.03 (1.20–7.63)0.019

Abbreviations: CI = confidence interval, COVID–19 = coronavirus disease 2019, OR = odds ratio, TSRD = trauma– and stressor–related disorder.
* For outcomes assessed via the four-item Patient Health Questionnaire (PHQ–4), odds of incidence were marked by the presence of symptoms during May 5–12 or June 24–30, 2020, after the absence of symptoms during April 2–8, 2020. Respondent pools for prospective analysis of odds of incidence (did not screen positive for symptoms during April 2–8): anxiety disorder (n = 1,236), depressive disorder (n = 1,301) and anxiety disorder or depressive disorder (n = 1,190). For symptoms of a TSRD precipitated by COVID–19, started or increased substance use to cope with stress or emotions related to COVID–19, and serious suicidal ideation in the previous 30 days, odds of incidence were marked by the presence of an outcome during June 24–30, 2020, after the absence of that outcome during May 5–12, 2020. Respondent pools for prospective analysis of odds of incidence (did not report symptoms or behavior during May 5–12): symptoms of a TSRD (n = 1,206), started or increased substance use (n = 1,408), and suicidal ideation (n = 1,456).
 Essential worker status was self–reported. For Table 3, essential worker status was determined by identification as an essential worker during the June 24–30 survey. Essential workers were compared with all other respondents, not just employed respondents (i.e., essential workers vs. all other employment statuses (nonessential worker, unemployed, and retired), not essential vs. nonessential workers).
§ Unpaid adult caregiver status was self–reported. The definition of an unpaid caregiver for adults was having provided unpaid care to a relative or friend 18 years or older to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing.
 Adjusted for gender, employment status, and unpaid adult caregiver status.
** Adjusted for gender, employment status, and essential worker status.
†† Respondents who completed surveys from all three waves (April, May, June) were eligible to be included in an unweighted longitudinal analysis. Comparisons within subgroups were evaluated via logit–linked Binomial regressions used to calculate unadjusted and adjusted odds ratios, 95% confidence intervals, and p–values. Statistical significance was evaluated at a threshold of α = 0.05. In the calculation of odds ratios for started or increased substance use, respondents who selected “Prefer not to answer” (n = 11) were excluded.
§§ Symptoms of anxiety disorder and depressive disorder were assessed via the PHQ–4. Those who scored ≥3 out of 6 on the two–item Generalized Anxiety Disorder (GAD–2) and two-item Patient Health Questionnaire (PHQ–2) subscales were considered symptomatic for each disorder, respectively.
¶¶ Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others. Symptoms of a TSRD precipitated by the COVID–19 pandemic were assessed via the six–item Impact of Event Scale (IES–6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID–19 pandemic was specified as the traumatic exposure to record peri– and posttraumatic symptoms associated with the range of potential stressors introduced by the COVID–19 pandemic. Those who scored ≥1.75 out of 4 were considered symptomatic.


https://www.medrxiv.org/content/10.1101/2020.04.22.20076141v1external icon.

 Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others.

§ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing.

 Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential versus nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.

** A minimum age of 18 years and residence within the United States as of April 2–8, 2020, were required for eligibility for the longitudinal cohort to complete a survey during June 24–30, 2020. Residence was reassessed during June 24–30, 2020, and one respondent who had moved from the United States was excluded from the analysis. A minimum age of 18 years and residence within the United States were required for eligibility for newly recruited respondents included in the cross-sectional analysis. For both the longitudinal cohort and newly recruited respondents, respondents were required to provide informed consent before enrollment into the study. All surveys underwent data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Respondents who failed an attention or speed check, along with any responses identified by the data-scrubbing algorithms, were excluded from analysis.

†† The surveys contained 101 items for first-time respondents and 86 items for respondents who also participated in later surveys, with the 15 additional items for first-time respondents consisting of questions on demographics. The survey instruments included a combination of individual questions, validated questionnaires, and COVID-19-specific questionnaires, which were used to assess respondent attitudes, behaviors, and beliefs related to COVID-19 and its mitigation, as well as the social and behavioral health impacts of the COVID-19 pandemic.

§§ https://www.qualtrics.com/external icon.

¶¶ Survey weighting was implemented according to the 2010 U.S. Census with respondents who reported gender, age, and race/ethnicity. Respondents who reported a gender of “Other,” or who did not report race/ethnicity were assigned a weight of one.

*** Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for these respective disorders. This instrument was included in the April, May, and June surveys.

††† Symptoms of a TSRD attributed to the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored ≥1.75 out of 4 were considered symptomatic. This instrument was included in the May and June surveys only.

§§§ For this survey, substance use was defined as use of “alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.” Questions regarding substance use and suicidal ideation were included in the May and June surveys only. Participants were informed that responses were deidentified and that direct support could not be provided to those who reported substance use behavior or suicidal ideation. Regarding substance use, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the Substance Abuse and Mental Health Services Administration National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889. This is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for persons and family members facing mental and/or substance use disorders.” Regarding suicidal ideation, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the National Suicide Prevention Lifeline, 1-800-273-TALK (8255, or chat line) for help for themselves or others.”

¶¶¶ Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.htmlexternal icon.

**** Odds of incidence was defined as the odds of the presence of an adverse mental or behavioral health outcome reported during a later survey after previously having reported the absence of that outcome (e.g., having reported symptoms of anxiety disorder during June 24–30, 2020, after not having reported symptoms of anxiety disorder during April 2–8, 2020).

†††† Adjusted for gender, employment status, and essential worker status or unpaid adult caregiver status.

§§§§ Disaster Distress Helpline (https://www.samhsa.gov/disaster-preparednessexternal icon): 1-800-985-5990 (press 2 for Spanish), or text TalkWithUs for English or Hablanos for Spanish to 66746. Spanish speakers from Puerto Rico can text Hablanos to 1-787-339-2663.

¶¶¶¶ Substance Abuse and Mental Health Services Administration National Helpline (also known as the Treatment Referral Routing Service) for persons and families facing mental disorders, substance use disorders, or both: https://www.samhsa.gov/find-help/national-helplineexternal icon, 1-800-662-HELP, or TTY 1-800-487-4889.

***** National Suicide Prevention Lifeline (https://suicidepreventionlifeline.org/external icon): 1-800-273-TALK for English, 1-888-628-9454 for Spanish, or Lifeline Crisis Chat (https://suicidepreventionlifeline.org/chat/external icon).

References

  1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
  2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdfpdf icon
  3. Czeisler MÉ, Tynan MA, Howard ME, et al. Public attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance—United States, New York City, and Los Angeles, May 5–12, 2020. MMWR Morb Mortal Wkly Rep 2020;69:751–8. CrossRefexternal icon PubMedexternal icon
  4. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. CrossRefexternal icon PubMedexternal icon
  5. Hosey MM, Leoutsakos JS, Li X, et al. Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019;23:276. CrossRefexternal icon PubMedexternal icon
  6. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdfpdf iconexternal icon
  7. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: call to close critical gaps and adapt to new realities. Psychol Trauma 2020;12:331–5. CrossRefexternal icon PubMedexternal icon
  8. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008;53:769–78. CrossRefexternal icon PubMedexternal icon
  9. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdfpdf icon

More information: The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health in the U.S. Science Advances (2020). DOI: 10.1126/sciadv.abd5390 , advances.sciencemag.org/conten … 09/18/sciadv.abd5390

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