Pandemic stressors and mental health indicators in eight countries

PURPOSE

The Covid-19 pandemic has exacted a significant physical, financial, social, and emotional toll on populations throughout the world. This study aimed to document the association between pandemic stressors and mental health during the pandemic across countries that differ in cultural, geographic, economic, and demographic factors.

METHODS

We administered an online survey randomly in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States from September 2020 to November 2020. This survey included questions on Covid-19-related stressors as well as the Patient Health Questionnaire-2 and the Primary Care PTSD Checklist to screen for depression and post-traumatic stress disorder (PTSD) symptoms, respectively. We performed bivariable and multivariable regression analyses to assess the prevalence and odds ratios of overall depression symptoms and probable PTSD and in relation to stressors across countries.

RESULTS

Among 8754 respondents, 28.9% (95% CI 27.5-30.0%) experienced depression symptoms, and 5.1% (95% CI 4.5-6.0%) experienced probable PTSD. The highest prevalence of depression symptoms was in Egypt (41.3%, 95% CI 37.6-45.0%) and lowest in the United States (24.9%, 95% CI 22.3-27.7%). The highest prevalence of probable PTSD was in Brazil (7.3%, 95% CI 5.6-9.4%) and the lowest in China (1.2%, 95% CI 0.7-2.0%). Overall, experiencing six or more Covid-19-related stressors was associated with both depression symptoms (OR 1.90, 95% CI 1.46-2.48) and probable PTSD (OR 13.8, 95% CI 9.66-19.6).

CONCLUSION

The association between pandemic related stressors and the burden of adverse mental health indicators early in the Covid-19 pandemic transcended geographic, economic, cultural, and demographic differences between countries. The short-term and long-term impacts of the pandemic on mental health should be incorporated in efforts to tackle the consequences of Covid-19.

Assets and depression in U.S. adults during the COVID-19 pandemic: a systematic review

PURPOSE

Mental health is shaped by social and economic contexts, which were altered during the COVID-19 pandemic. No study has systematically reviewed the literature on the relation between different assets and depression during the COVID-19 pandemic.

METHODS

We conducted a systematic review of the literature on financial (e.g. income/savings), physical (e.g., home ownership), and social (e.g., marital status, educational attainment) assets and depression in U.S. adults. For each asset type, we created binary comparisons to report on the direction of the relationship and described if each study reported insignificant, positive, negative, or mixed associations.

RESULTS

Among the 41 articles identified, we found that income was the most studied asset (n=34), followed by education (n=25), marital status (n=18), home ownership (n=5), and savings (n=4). 88%, 100%, and 100% of articles reported a significant association of higher income, home ownership, and higher savings, respectively, with less depression. The association between marital status and education with depression was more nuanced: 72% (13 of 18) studies showed that unmarried persons had greater risk of depression than married or cohabitating persons and 52% (13 of 25) of studies reported no significant difference in depression across educational groups.

CONCLUSION

This work adds to the literature a deeper understanding of how different assets relate to depression. In the context of largescale traumatic events, policies that maintain and protect access to social, physical, and financial assets may help to protect mental health.

Trends in Telepsychiatry and In-Person Psychiatric Care for Depression in an Academic Health System, 2017-2022

OBJECTIVE

The authors aimed to assess differences in appointment completion rates between telepsychiatry and in-person outpatient psychiatric care for patients with depression in an academic health system.

METHODS

Electronic health records of encounters for patients (ages ≥10) with a depression diagnosis and at least one scheduled outpatient psychiatric appointment (N=586,266 appointments; November 2017-October 2022) were assessed for appointment volume and completion of telepsychiatry versus in-person sessions.

RESULTS

Telepsychiatry became the dominant care modality after the onset of the COVID-19 pandemic, although the number of telepsychiatry and in-person appointments nearly converged by October 2022. Logistic regression showed that telepsychiatry appointments (July 2020-October 2022) were more likely (OR=1.30, 95% CI=1.27-1.34) to be completed than in-person appointments.

CONCLUSIONS

Telepsychiatry appointments were less likely to be canceled or missed than in-person appointments, suggesting that telepsychiatry improved efficiency and continuity of care. As in-person operations resume following the pandemic, maintaining telepsychiatry services may optimize hospital-level and patient outcomes.

Risk factors for increased alcohol consumption among young adults during COVID-19

Objective: This study explored correlates of increased alcohol use among a predominantly low-socioeconomic status student population at two time points during the COVID-19 pandemic. Participants: Participants were students enrolled in at least one course at a City University of New York (CUNY) campus. Methods: Demographic characteristics, stressor endorsements, probable diagnoses, and alcohol use endorsement, were collected via self-report surveys in April and July 2020. Frequencies and multivariable logistic regressions were computed to assess for prevalence and odds of increased alcohol consumption. Results: High cumulative stress was significantly related to increased alcohol use in both April and July 2020. A greater number of specific stressors was associated with increased alcohol use in April as compared to July. Probable diagnoses of depression and anxiety were associated with higher odds of alcohol consumption at both time points. Conclusion: Findings highlight the importance of stress and mental health on increases in alcohol use for public university students.

Symptoms of Posttraumatic Stress During the COVID-19 Pandemic in the Governmental Public Health Workforce and General Population

We aimed to estimate the prevalence of COVID-19-related posttraumatic stress symptoms (PTSS) in the governmental public health workforce and in US adults, assess differences in reporting PTSS within subgroups, and evaluate whether frontline workers reported higher levels of PTSS than persons in other jobs. We used data from 2 nationally representative studies: the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) and the COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) study. Our study found that the state and local governmental public health workforce was more likely to report PTSS than the general adult population. Almost a quarter of public health agency employees (24.7%) and 21.1% of adults reported at least 3 symptoms of posttraumatic stress. Differences in levels of PTSS appeared within demographic groups for both samples. Personal care and service frontline workers had 4.3 times the odds of reporting symptoms of posttraumatic stress than non-frontline workers.

Education is protective against depressive symptoms in the context of COVID-19

OBJECTIVE

This study assessed current education stage (ie, undergraduate, graduate) as protective against depressive symptoms among a low socioeconomic status (SES) student population in a public university, in the context of COVID-19-related stressors.

PARTICIPANTS

Participants were students at The City University of New York (CUNY) during the Spring 2020.

METHODS

Demographic data, symptom severity, and current educational stage were collected via an online university-wide survey between April 8, 2020 and May 2, 2020.

RESULTS

The prevalence of probable depression was lower amongst persons who reported being currently in a more advanced educational stage compared to people currently in a lower educational stage. COVID-19-related stressor exposure was the largest predictor of depressive symptoms, followed by demographics and current education stage.

CONCLUSIONS

Current education stage is related to depressive symptoms during COVID-19. Pandemic-related educational disruptions and shifts to remote learning may limit educational achievement for low-SES student populations creating further threats to these students' health.

Evolution of Depression and Anxiety During the COVID-19 Pandemic and Across Demographic Groups in a Large Sample of U.S. Adults

Introduction

This study aimed to document the trends of feelings of depression and anxiety over the course of the COVID-19 pandemic within and across age, gender, education, and employment groups.

Methods

Using a large, national, serial cross-sectional sample of adults in the U.S. collected through the COVID-19 Trends and Impact Survey conducted in partnership with Facebook, we examined trends in feelings of depression and anxiety from April 2020 through June 2022 (N=21,359,165).

Results

Over time, differences in feelings of anxiety and depression widened for educational attainment, stayed consistent between employment groups, and narrowed for female versus male and age groups. The odds of frequent feelings of anxiety or depression were significantly lower in the studied final quarter (April-June 2022) than in the studied first quarter (October-December 2020) for the overall population (p<0.001). In April-June 2022, younger persons reported 6-7 times the odds (AOR for depression=6.07; 95% CI=5.72, 6.43 and AOR for anxiety=6.69; 95% CI=6.33, 7.07), nonbinary persons reported 5 times the odds (AOR for depression=5.35, 95% CI=4.89, 5.86 and AOR for anxiety=5.35, 95% CI=4.9, 5.85), persons with a high school degree reported 2 times the odds (AOR for depression=2.07, 95% CI=1.92, 2.22 and AOR for anxiety=1.68, 95% CI=1.57, 1.8), and persons who were not employed reported 1.3-1.5 times the odds (AOR for depression=1.46, 95% CI=1.42, 1.51 and AOR for anxiety=1.34, 95% CI=1.3, 1.38) of frequent feelings depression and anxiety, respectively, than counterparts who were older, were male, had graduate degrees, or were employed.

Conclusions

The risk factors most highly associated with poor mental health 2 years into the pandemic were young age, nonbinary gender, and low educational attainment.

The Potential Influence of AI on Population Mental Health

The integration of artificial intelligence (AI) into everyday life has galvanized a global conversation on the possibilities and perils of AI on human health. In particular, there is a growing need to anticipate and address the potential impact of widely accessible, enhanced, and conversational AI on mental health. We propose 3 considerations to frame how AI may influence population mental health: through the advancement of mental health care; by altering social and economic contexts; and through the policies that shape the adoption, use, and potential abuse of AI-enhanced tools.

Depression and PTSD among Houston Residents who Experienced Hurricane Harvey and COVID-19: Implications for Urban Areas Affected by Multiple Disasters

Little is known about the combined impact of the COVID-19 pandemic and other major disasters on mental health. Hurricane Harvey hit the Gulf Coast in 2017, resulting in substantial costs, significant levels of displacement, and approximately 100 deaths, and was followed in 2020 by the COVID-19 pandemic. We randomly sampled 1167 Houstonians from 88 designated super-neighborhoods and surveyed them about their demographics, event-specific traumas and stressors, and symptoms of current depression and post-traumatic stress disorder (PTSD). We estimated the prevalence of depression (5.8%) and PTSD (12.6%) more than three years after Hurricane Harvey, and assessed the relative influence of event-specific stressors and traumas on current mental health. Overall, we observed evidence for two key findings that are salient for residents of urban environments in the context of multiple disasters. First, stressors were primary influences on depression, whereas both stressors and traumas influenced PTSD. Second, the influences of stressors and traumas on depression and PTSD symptoms faded with time.

Correlates of long-COVID-19: the role of demographics, chronic illness, and psychiatric diagnosis in an urban sample

Long-COVID-19 symptoms are an emerging public health issue. This study sought to investigate demographics, chronic illness, and probable psychiatric diagnoses as correlates for long-COVID-19 in an urban adult sample. Self-report Qualtrics surveys were sent to students across City University of New York (CUNY) campuses in New York City in Winter 2021-2022. Binary logistic regressions were used to assess the relation of a range of factors with endorsement of long-COVID-19. Results demonstrated that Latinx participants endorsed higher odds of long-COVID-19, as compared to non-Latinx white participants. Participants who endorsed having a prior chronic illness and those who met the cut-off for probable psychiatric diagnoses all endorsed higher odds of long-COVID-19. Long-COVID-19 may be more likely among specific subpopulations and among persons with other ongoing physical and mental illness.

Financial strain and depression in the U.S.: a scoping review

While the association between assets and depression has been established, less is known about the link between financial strain and depression. Given rising financial strain and economic inequity due to the COVID-19 pandemic, understanding the role that financial strain plays in shaping population depression in the United States is particularly salient. We conducted a scoping review of the peer-reviewed literature on financial strain and depression published from inception through January 19, 2023, in Embase, Medline via PubMed, and PsycINFO, PsycArticles, SocINDEX, and EconLit via Ebsco. We searched, reviewed, and synthesized the literature on longitudinal studies on financial strain and depression conducted in the United States. Four thousand and four unique citations were screened for eligibility. Fifty-eight longitudinal, quantitative articles on adults in the United States were included in the review. Eighty-three percent of articles (n = 48) reported a significant, positive association between financial strain and depression. Eight articles reported mixed results, featuring non-significant associations for some sub-groups and significant associations for others, one article was unclear, and one article reported no significant association between financial strain and depression. Five articles featured interventions to reduce depressive symptoms. Effective interventions included coping mechanisms to improve one's financial situation (e.g., mechanisms to assist in finding employment), to modify cognitive behavior (e.g., reframing mindset), and to engage support (e.g., engaging social and community support). Successful interventions were tailored to participants, were group-based (e.g., they included family members or other job seekers), and occurred over multiple sessions. While depression was defined consistently, financial strain was defined variably. Gaps in the literature included studies featuring Asian populations in the United States and interventions to reduce financial strain. There is a consistent, positive association between financial strain and depression in the United States. More research is needed to identify and test interventions that mitigate the ill effects of financial strain on population's mental health.

Global Health Equity Requires Global Equity

Many global health challenges are characterized by the inequitable patterning of their health and economic consequences, which are etched along the lines of pre-existing inequalities in resources, power, and opportunity. These links require us to reconsider how we define global health equity, and what we consider as most consequential in its pursuit. In this article, we discuss the extent to which improving underlying global equity is an essential prerequisite to global health equity. We conclude that if we are to improve global health equity, there is a need to focus more on foundational—rather than proximal—causes of ill health and propose ways in which this can be achieved.

Understanding the Mental Health Impact of the COVID-19 Pandemic Among Individuals With Chronic Illness

People with chronic illnesses are vulnerable to stress and psychopathology during population-level disasters, as a subset of individuals with disabilities. We aimed to examine the relationships between chronic illness, cumulative and specific stressors, and probable depression, probable anxiety, and post-traumatic stress in an under-resourced urban population in New York City during the COVID-19 pandemic. Using cross-sectional survey data collected in April 2020, we utilized bivariate chi-square analyses and multivariable logistic regression models to estimate differences in and adjusted odds of stressor endorsement and diagnostic prevalence between people with and without chronic illness. We also assessed effect modification of the relationship between stressor exposure and psychopathology by chronic illness status. Compared to people without chronic illness, those who reported having a chronic illness experienced increased odds of probable depression, probable anxiety, and post-traumatic stress. They were also more likely to report high cumulative COVID-19-related stress exposure, death of someone close to them due to coronavirus or COVID-19, family problems, feeling alone, supply shortages, and financial problems. Chronic illness was found to be an effect modifier in the relationship between the death of someone close due to coronavirus or COVID-19 and probable depression and between household job loss and probable anxiety.

Examining the role of material and social assets on mental health in the context of COVID-19 among an urban public university sample

OBJECTIVE

Material and social stressors are both well-documented contributors to the onset of psychiatric symptoms. This relationship has not yet been investigated within the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic, and within low-income and racially/ethnically diverse urban student populations, who are facing increased stress.

METHOD

Via an online survey, this study assessed material and social stressors and symptom endorsements for depression, anxiety, and posttraumatic stress (PTS), within a public university student sample at two time points, April 8 through May 2, 2020; n = 2,925; and July 9 through July 31, 2020; n = 1,073; during the pandemic.

RESULTS

Multivariate regression analyses assessed the relationship between each diagnostic symptom category and stressor category scores. Analyses yielded stronger associations for total social stressor score and probable anxiety (β = .695, SE = .046, p < .001 in April, β = .730, SE = .085, p < .001 in July), probable depression (β = .655, SE = .045, p < .001 in April, β = .676, SE = .080, p < .001 in July) and probable PTS (β = .587, SE = .045, p < .001 in April, β = .687, SE = .083, p < .001 in July), compared with total material stressor scores, total material and social stressor scores.

CONCLUSION

Such findings highlight the burden of both stressor types, but particularly social stress, on psychological health for underresourced students, and emphasize the need for targeted interventions that increase social assets. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prevalence of depressive symptoms in U.S. adults during the COVID-19 pandemic: A systematic review

The COVID-19 pandemic has led to a worsening of mental health among U.S. adults. However, no review to date has synthesized the overall prevalence of population depressive symptoms in the U.S. over the COVID-19 pandemic. We aimed to document the population prevalence of depressive symptoms and psychological distress across time since the start of the COVID-19 pandemic, both to identify patterns that emerged in the literature and to assess the data sources, methods, sampling, and measurement used to examine population mental health during the pandemic. In a systematic review of the peer review literature, we identified 49 articles reporting 88 prevalence points of depressive symptoms and related constructs in nationally representative samples of U.S. adults from March 2020 to June 2021. First, we found that the average prevalence of poor mental health across studies was 12.9% for severe depression, 26.0% for at least moderate depression, and 36.0% for at least mild depression. Second, we found that women reported significantly higher prevalence of probable depression than men in 63% of studies that reported depression levels by gender and that results on statistically significant differences between racial and ethnic groups were mixed. Third, we found that the 49 articles published were based on 12 studies; the most common sources were the Household Pulse Survey (n = 15, 31%), the AmeriSpeak panel (n = 8, 16%), the Qualtrics panel (n = 8, 16%), and the Understanding America Study (n = 5, 10%). Prevalence estimates varied based on mental health screening instruments and cutoffs used. The most commonly used instruments were the Patient Health Questionnaire (PHQ) (n = 36, 73%) and the Kessler (n = 8, 16%) series. While the prevalence of population depression varied over time depending on the survey instruments, severity, and constructs reported, the overall prevalence of depression remained high from March 2020 through June 2021 across instruments and severity. Understanding the scope of population mental health can help policymakers and providers address and prepare to meet the ongoing and future mental health needs of U.S. adults in the post-COVID-19 context and beyond.

The capacity to adapt: Documenting the relationship between stressors and probable depression, anxiety, and posttraumatic stress at two time points during the COVID-19 pandemic

BACKGROUND

Psychological adaptability, or the reduction of psychiatric symptoms in the context of ongoing stressors, is well-documented. The present study assessed relationships between COVID-19 related stressors and depression, anxiety, and post-traumatic stress (PTS) during April and July 2020.

METHODS

Prevalence of, and changes in, symptom severity levels in April vs. July were measured with ANOVA F-tests. Logistic regressions were used to assess the odds of probable diagnosis.

RESULTS

Symptom distributions skewed lower in July, as compared to April for all three diagnostic categories. From April to July, prevalence of probable anxiety and depression decreased across all levels of stress, prevalence of PTS increased for high stress, and decreased for medium and low stress levels. In July, only high stress related to higher odds of probable diagnoses, as compared to April when both medium and high stress did.

LIMITATIONS

Due to use of cross-sectional self-report data, the present findings could not establish causality between variables, and provide probable, rather than clinical, diagnoses.

CONCLUSION

Findings emphasize adaptability phenomena during COVID-19 and highlight the nuanced impact of ongoing stress.

Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

The US population faced stressors associated with suicide brought on by the COVID-19 pandemic. Understanding the relationship between stressors and suicidal ideation in the context of the pandemic may inform policies and programs to prevent suicidality and suicide. We compared suicidal ideation between two cross-sectional, nationally representative surveys of adults in the United States: the 2017-2018 National Health and Nutrition Examination Survey (NHANES) and the 2020 COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) study (conducted March 31 to April 13). We estimated the association between stressors and suicidal ideation in bivariable and multivariable Poisson regression models with robust variance to generate unadjusted and adjusted prevalence ratios (PR and aPR). Suicidal ideation increased from 3.4% in the 2017-2018 NHANES to 16.3% in the 2020 CLIMB survey, and from 5.8% to 26.4% among participants in low-income households. In the multivariable model, difficulty paying rent (aPR: 1.5, 95% CI: 1.2-2.1) and feeling alone (aPR: 1.9, 95% CI: 1.5-2.4) were associated with suicidal ideation but job loss was not (aPR: 0.9, 95% CI: 0.6 to 1.2). Suicidal ideation increased by 12.9 percentage points and was almost 4.8 times higher during the COVID-19 pandemic. Suicidal ideation was more prevalent among people facing difficulty paying rent (31.5%), job loss (24.1%), and loneliness (25.1%), with each stressor associated with suicidal ideation in bivariable models. Difficulty paying rent and loneliness were most associated with suicidal ideation. Policies and programs to support people experiencing economic precarity and loneliness may contribute to suicide prevention.

Long-COVID and comorbid depression and anxiety two years into the COVID-19 pandemic

Long-COVID, or the persistence of COVID-19 symptoms for months after initial infection, has been shown to impact the lives of those affected. The current study sought to investigate the relationships between long-COVID, COVID-19 related stress, depression, anxiety, and comorbid depression and anxiety outcomes. Data were collected in Winter 2021-2022 from a population of adults enrolled in at least one course across multiple City University of New York (CUNY) campuses. Frequencies and chi-square tests were computed to assess for demographics and relationships to probable diagnoses of depression and anxiety, and binary logistic regressions were computed to assess for the odds of probable comorbid depression and anxiety based on demographics, stressors, and long-COVID. Women participants reported higher odds of probable depression outcomes, and stressor levels were significant correlates of probable anxiety outcomes. Women participants, 3.2 [1.5-6.9], as compared to men, lower-SES participants, 2.16 [1.1-4.2], as compared to higher-SES participants, participants with higher COVID-19 related stress levels, 4.8 [2.0-12.0], as compared to those with low levels, and participants with long-COVID, 3.7 [1.9-7.0], as compared to those without, all had higher odds of probable comorbid depression and anxiety. Findings highlight the importance of social location, stress, and long-COVID, in tandem, as correlates of psychological health during the shifting pandemic.

Suicidal ideation during COVID-19: The contribution of unique and cumulative stressors

The link between large-scale disasters and population-level risk of suicide remains unclear. The present study sought to investigate suicidal ideation (SI) in relation to COVID-19 related stress, including material and social stress, in a predominantly low-SES ethno-racially diverse sample in New York City during a peak in COVID-19 cases in April 2020. Using binary logistic regressions of data collected with self-report surveys, we found that individuals who identified as Asian, as well as those with high total, material, and social stress levels, and persons without access to primary care providers had significantly higher adjusted odds of SI. These results indicate the specific burden faced by Asian participants due to increases in targeted racism, the importance of cumulative stress and specific stressor type, as well as the role of healthcare access on SI during the pandemic. Such findings suggest the need for specific interventions that target individuals who may be at higher risk of suicide after large-scale traumatic events and during the ongoing pandemic.

A multilevel approach to social support as a determinant of mental health during COVID-19

The COVID-19 pandemic has detrimentally affected the mental health of lower income communities. We sought to investigate the relationship among multilevel social support, specifically individual-, network-, and neighborhood-level social supports, COVID-19-related stressors, and probable diagnoses of depression, anxiety, and posttraumatic stress (PTS), within a racially diverse and predominantly low-socioeconomic status population. We used multiple logistic regressions to assess the odds of diagnosis for high versus low social support and stressor levels. Participants who endorsed high levels of stress had significantly higher odds of probable diagnoses. Participants who endorsed low individual-level social support had higher odds of probable depression and anxiety. Those who endorsed low neighborhood-level social support had higher odds of probable depression and probable PTS. Network-level social support was not significantly associated with the health indicators of interest. Results indicate the importance of both individual- and neighborhood-level support to protect mental health during COVID-19.

Assets, stressors, and symptoms of persistent depression over the first year of the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by an increase in depression in U.S. adults. Previous literature suggests that having assets may protect against depression. Using a nationally representative longitudinal panel survey of U.S. adults studied in March and April 2020 and in March and April 2021, we found that (i) 20.3% of U.S. adults reported symptoms of persistent depression in Spring 2020 and Spring 2021, (ii) having more assets was associated with lower symptoms of persistent depression, with financial assets-household income and savings-most strongly associated, and (iii) while having assets appeared to protect persons-in particular those without stressors-from symptoms of persistent depression over the COVID-19 pandemic, having assets did not appear to reduce the effects of job loss, financial difficulties, or relationship stress on symptoms of persistent depression. Efforts to reduce population depression should consider the role played by assets in shaping risk of symptoms of persistent depression.

Wealth and depression: A scoping review

INTRODUCTION

The inverse relation between income and depression is well established. Less is understood about the relation between wealth and depression. We therefore conducted a scoping review to answer the question: What is known from the existing literature about the relation between wealth and depression?

METHODS

We searched for studies and articles in Medline (via PubMed), Embase, PsycINFO, PsycArticles, EconLit, and SocINDEX from inception through July 19, 2020. Ninety-six articles were included in our review. Key article characteristics were year of publication, sample size, country, study design, definition of depression, definition of wealth, and association between wealth and depression. Thirty-two longitudinal articles were included in a detailed charted review.

RESULTS

Depression was defined in a relatively standard manner across articles. In contrast, definitions and measurements of wealth varied greatly. The majority of studies in the full review (n = 56, 58%) and half of the studies in the longitudinal charted review (n = 16, 50%) reported an inverse relation between wealth and depression. The longitudinal charted review showed that (1) macro-economic events influenced depression, (2) wealth status influenced depression across the lifecourse, (3) wealth protected against depression in the face of stressors such as job loss, (4) subjective or psychosocial factors such as perception of wealth, relative comparison, and social status modified the relation between wealth and depression, and (5) savings interventions were successful in reducing depression and varied by context.

CONCLUSION

These findings suggest that wealth should be included in our consideration of the forces that shape mental health.

Trends of depression and anxiety during massive civil unrest and COVID-19 in Hong Kong, 2019-2020

Both COVID-19 and unrest are posing a significant threat to population mental health across the globe. This study examined trends of probable depression and anxiety during a time of civil unrest and concurrent COVID-19 in Hong Kong. Four random digit dialing telephone surveys were conducted in July 2019 (n = 1112), February-March 2020 (n = 2003), April-May 2020 (n = 2008), and July-August 2020 (n = 2034). The prevalence of probable depression increased from 25.7% (95% CI: 23.2-28.3) in July 2019 to 28.2% (95% CI: 26.2-30.1) in February-March 2020, and then decreased to 15.3% (95% CI: 14.0-17.0) in April-May 2020 and 13.7% (95% CI: 12.2-15.2) in July-August 2020. The prevalence of probable anxiety was 19.2% (95% CI: 17.5-20.9) in February-March 2020 and then stabilized in April-May 2020 and July-August 2020 (14.1%, 95% CI: 12.0-15.8). Probable depression and anxiety were more prevalent among persons with high relative to low daily routine disruptions. Combined high unrest-COVID-19 stress was associated with probable depression and anxiety across all persons; high unrest stress alone was associated with probable mental disorders at high daily routine disruptions. Civil unrest and COVID-19 are jointly associated with depression and anxiety among Hong Kong citizens. While population mental health improved, daily routine disruptions is a risk factor of mental disorders at every time-point.

Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults

BACKGROUND

The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms.

METHODS

Longitudinal panel study of a nationally representative group of U.S. adults ages 18 years and older surveyed in March-April 2020 (Time 1; N=1441) and March-April 2021 (Time 2; N=1161) in the COVID-19 and Life Stressors Impact on Mental Health and Well-being study (CLIMB). The Patient Health Questionnaire-9 (PHQ-9) was used to define elevated depressive symptoms (cut-off ≥10) and depressive symptoms score (0-27).

FINDINGS

The prevalence of elevated depressive symptoms persisted from 27.8% in 2020 (95% CI: 24.9, 30.9) to 32.8% in 2021 (95% CI: 29.1, 36.8). Over time, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low income relative to high income persons increased from 2.3 (95% CI: 1.2, 4.2) in 2020 to 7.0 (95% CI: 3.7, 13.3) in 2021. Fewer people reported experiencing 4 or more COVID-19 stressors in 2021 than in 2020 (47.5% in 2020 vs 37.1% in 2021), but the odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 (95% CI: 1.2, 3.1) in 2020 to 5.4 (95% CI: 3.2, 9.2) in 2021.

INTERPRETATION

The burden of depressive symptoms in the U.S. adult population increased over the course of the COVID-19 pandemic. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic.

FUNDING

CLIMB Time 1 was sponsored by the Rockefeller Foundation-Boston University 3-D Commission. CLIMB Time 2 was sponsored by the de Beaumont Foundation.

Mental health consequences of COVID-19: a nationally representative cross-sectional study of pandemic-related stressors and anxiety disorders in the USA

OBJECTIVE

To document the prevalence of anxiety disorders in the USA during the COVID-19 pandemic.

DESIGN

A cross-sectional analysis.

SETTING

A nationally representative sample in the USA between 31 March and 13 April 2020.

PARTICIPANTS

1450 English-speaking adult participants in the AmeriSpeak Panel. AmeriSpeak is a probability-based panel designed to be representative of households in the USA.

MAIN OUTCOME MEASURES

Prevalence of probable generalised anxiety disorder (GAD) using the GAD-7 and post-traumatic stress symptoms (PTSS) using the four-item PTSD (post-traumatic stress disorder) checklist. Both outcomes were stratified by demographics and COVID-19-related stressors.

RESULTS

The majority of participants were female (51.8%), non-Hispanic white (62.9%) and reported a household saving of $5000 or more. Those between 18 and 29 years old were the largest age group (38.1%) compared with 40-59 years (32.0%) and 60 years or more (29.9%). The prevalence of probable GAD was 10.9% (95% CI 9.1% to 13.2%) and the prevalence of PTSS was 21.7% (95% CI 19.1% to 24.6%). Among participants reporting five or more COVID-19-related stressors, the prevalence of probable GAD was 20.5% (95% CI 16.1% to 25.8%) and the prevalence of PTSS was 35.7% (95% CI 30.2% to 41.6%). Experiencing five or more COVID-19-related stressors was a predictor of both probable GAD (OR=4.5, 95% CI 2.3 to 8.8) and PTSS (OR=3.3, 95% CI 2.1 to 5.1).

CONCLUSIONS

The prevalence of probable anxiety disorders in the USA, as the COVID-19 pandemic and policies implemented to tackle it unfolded, is higher than estimates reported prior to the pandemic and estimates reported following other mass traumatic events. Exposure to COVID-19-related stressors is associated with higher prevalence of both probable GAD and PTSS, highlighting the role these stressors play in increasing the risk of developing anxiety disorders in the USA. Mitigation and recovery policies should take into account the mental health toll the pandemic had on the USA population.

Data, Social Determinants, and Better Decision-making for Health: the 3-D Commission

More than a decade after the World Health Organization Commission on the Social Determinants of Health (SDoH), it is becoming widely accepted that social and economic factors, including but not limited to education, energy, income, race, ethnicity, and housing, are important drivers of health in populations. Despite this understanding, in most contexts, social determinants are not central to local, national, or global decision-making. Greater clarity in conceptualizing social determinants, and more specificity in measuring them, can move us forward towards better incorporating social determinants in decision-making for health. In this paper, first, we summarize the evolution of the social framing of health. Second, we describe how the social determinants are conceptualized and contextualized differently at the global, national, and local levels. With this, we seek to demonstrate the importance of analyzing and understanding SDoH relative to the contexts in which they are experienced. Third, we problematize the gap in data across contexts on different dimensions of social determinants and describe data that could be curated to better understand the influence of social determinants at the local and national levels. Fourth, we describe the necessity of using data to understand social determinants and inform decision-making to improve health. Our overall goal is to provide a path for our collective understanding of the foundational causes of health, facilitated by advances in data access and quality, and realized through improved decision-making.

Housing as a Social Determinant of Health: Evidence from Singapore, the UK, and Kenya: the 3-D Commission

Housing is a paradigmatic example of a social determinant of health, as it influences and is influenced by structural determinants, such as social, macroeconomic, and public policies, politics, education, income, and ethnicity/race, all intersecting to shaping the health and well-being of populations. It can therefore be argued that housing policy is critically linked to health policy. However, the extent to which this linkage is understood and addressed in public policies is limited and highly diverse across and within countries. This analysis seeks to describe the linkages between housing policies and health and well-being using examples from three countries at different levels of the wealth spectrum: Singapore, the UK, and Kenya.We conducted a comparative policy analysis across three country contexts (Singapore, the UK, and Kenya) to document the extent to which housing policies address health and well-being, highlighting commonalities and differences among them. To guide our analysis, we used the United Nations (UN) definition of adequate housing as it offers a broad framework to analyze the impact of housing on health and well-being.The anatomy of housing policies has a strong correlation to the provision of adequate housing across Singapore, the UK, and Kenya, especially for vulnerable groups. The paper demonstrates that contextual factors including population composition (i.e., aging versus youthful), political ideologies, legal frameworks (i.e., welfare versus market-based provision of housing), and presence (or absence) of adequate, quality, timely, reliable, robust data systems for decision-making, which are taken up by stakeholders/state, have strong implications of the type of housing policies developed and implemented, in turn directly and indirectly impacting the overall health and well-being of populations.This analysis demonstrates the value of viewing housing policies as public health policies that could significantly impact the health and well-being of populations, especially vulnerable groups. Moreover, the findings highlight the importance of the Health in All Policies approach to facilitate integrated policy responses to address social determinants of health such as housing. This is more critical than ever, given the context of the global pandemic that has led to worsening overall health and well-being.

Taking the Long View: COVID-19 Priorities for the Biden Administration

The COVID-19 pandemic transformed the American political landscape, influencing the course of the 2020 election and creating an urgent policy priority for the new administration. The Biden-Harris plan for beating COVID-19 represents a practicable, technically competent plan to contain the pandemic, one that will serve the country well in the months ahead. The authors suggest that the United States would also benefit from an even bolder set of aspirations-reframing the national conversation on COVID-19, embedding equity in all health decision making, strengthening the social safety net, and changing how we talk about health-as part of the national response to COVID-19. This would represent a genuine step forward in the US approach to health, informed by the systemic flaws COVID-19 exposed, and would realize benefits from the pandemic moment that in turn would propel national health forward for the rest of the century.

Savings, home ownership, and depression in low-income US adults

PURPOSE

While the association between income and depression is well established, less explored is the relation between wealth and depression, particularly among low-income adults. We studied the relation between two types of assets-savings and home ownership-and probable depression to understand how access to different assets may shape depression among low-income US adults.

METHODS

Study sample We conducted a serial cross-sectional, observational study with 12,019 adults with low-income in the United States using National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2016. Measures We measured probable major depressive disorder (MDD) with impairment using the Patient Health Questionnaire-9. Low savings was defined as having $5000 or less in family savings. Statistical analysis We estimated adjusted and unadjusted prevalence, odds ratios, and predicted probability of probable MDD across asset groups.

RESULTS

Of low-income US adults, 5.4% had probable MDD with impairment, 85.9% had low savings, and 54.9% rented their home. Persons with low savings had 2.34 (95% CI 1.44-3.79) times the odds of having probable MDD relative to those with high savings. Home owners had 2.14 (95% CI 1.20-3.86) and home renters had 3.65 (95% CI 1.45-9.20) times the odds of having probable MDD if they had low savings relative to high savings.

CONCLUSION

Family savings and home ownership are associated with lower burden of depression among low-income adults in the US.

Depression and Anxiety During the COVID-19 Pandemic in an Urban, Low-Income Public University Sample

Mental health disparities in the aftermath of national disasters and the protective role of socioeconomic status are both well documented. We assessed the prevalence of depression and anxiety symptoms among underresourced public university students during the COVID-19 pandemic in New York City. Between April 8, 2020, and May 2, 2020, adult students (N = 1,821) across the CUNY system completed an online survey examining COVID-19-related stressors and mental health and sociodemographic factors. Using multivariable logistical regression to assess the association between COVID-19-related stressors and depression and anxiety symptoms, we found a high prevalence and severity of depression and anxiety symptoms. We also observed that more exposure to COVID-19-related stressors was associated with increased depressive (27.0%, 41.4%, and 63.1% for low-, medium-, and high-level stressors, respectively) and anxiety symptoms (19.3%, 34.6%, 52.2%). In addition, the degree of exposure to COVID-19-related stressors served as an important predictor of depression and anxiety symptoms. Compared to high levels of stressors, the odds of depression were 0.2, 95% CI [0.2, 0.3] for low- and 0.4, 95% CI [0.3, 0.5] for medium-level stressors; for anxiety, the odds were 0.2, 95% CI [0.2, 0.3] for low and 0.05, 95% CI [0.4, 0.6] for medium stressors. Finally, household savings of less than $5,000 increased the risk of anxiety but not depression symptoms, OR = 1.3, 95% CI [1.0,1.6]. Together, these findings tell a devastating story of psychological distress among students from lower socioeconomic groups living in the COVID-19 epicenter of the U.S. pandemic.

Financial hardship and health risk behavior during COVID-19 in a large US national sample of women

COVID-19 has caused over 300,000 US deaths thus far, but its long-term health consequences are not clear. Policies to contain the pandemic have led to widespread economic problems, which likely increase stress and resulting health risk behaviors, particularly among women, who have been hardest hit both by job loss and caregiving responsibilities. Further, women with pre-existing disadvantage (e.g., those without health insurance) may be most at risk for stress and consequent health risk behavior. Our objective was to estimate the associations between financial stressors from COVID-19 and health risk behavior changes since COVID-19, with potential effect modification by insurance status. We used multilevel logistic regression to assess the relationships between COVID-19-related financial stressors (job loss, decreases in pay, trouble paying bills) and changes in health risk behavior (less exercise, sleep, and healthy eating; more smoking/vaping and drinking alcohol), controlling for both individual-level and zip code-level confounders, among 90,971 US women who completed an online survey in March–April 2020. Almost 40% of women reported one or more COVID-19-related financial stressors. Each financial stressor was significantly associated with higher odds of each type of health risk behavior change. Overall, reporting one or more financial stressors was associated with 56% higher odds (OR = 1.56; 95% CI: 1.51, 1.60) of reporting two or more health risk behavior changes. This association was even stronger among women with no health insurance (OR = 2.46; 95% CI: 1.97, 3.07). COVID-19-related economic stress is thus linked to shifts in health risk behaviors among women, which may have physical health consequences for years to come. Further, the relationship between financial hardship and health risk behavior among women may be modified by health insurance status, as a marker for broader socioeconomic context and resources. The most socioeconomically vulnerable women are likely at highest risk for long-term health effects of COVID-19 financial consequences.

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Over 1/3 of women in this study reported COVID-19-related financial stress.

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Financial stress was associated with higher odds of health risk behavior changes.

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This relationship was modified by health insurance status among women.

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These behavior changes may eventually lead to cardiovascular disease.

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Women who are already more vulnerable are likely at even higher risk.

Civil unrest, COVID-19 stressors, anxiety, and depression in the acute phase of the pandemic: a population-based study in Hong Kong

PURPOSE

To examine the joint associations of civil unrest and COVID-19 with probable anxiety and depression during the first half of 2020 in Hong Kong. Associations were compared between persons with low or high assets.

METHODS

A population-representative sample of 4011 Hong Kong Chinese residents aged 15 years or older were recruited between February and May 2020. Respondents reported current anxiety and depressive symptoms, unrest stress, COVID-19 stress, assets (savings and home ownership), and demographics.

RESULTS

Stress due to unrest and COVID-19 was associated with higher prevalence of probable anxiety and depression; persons with both stressors had higher prevalence. This pattern was consistent among persons with low or high assets, but the probabilities of mental disorder were substantially higher among persons with fewer assets.

CONCLUSIONS

The effect of stressors on probable anxiety and depression are cumulative: persons with stress due to civil unrest and to COVID-19 reported more mental disorders than persons with stress due to only one, or none of these factors. Overall high assets appear to buffer the consequences of stressors, lowering the risk of mental disorder.

Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults

BACKGROUND

COVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic.

METHODS

Between 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups.

RESULTS

We found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression.

CONCLUSION

Populations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Invited Commentary: Reckoning With the Relationship Between Stressors and Suicide Attempts in a Time of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic presents a unique set of risk exposures for populations, which might lead to an increase in suicide. While large-scale traumatic events are known to increase psychological disorders, thus far the science has not shown a clear link between these events and suicide. In this issue of the Journal, Elbogen et al. (Am J Epidemiol. 2020;189(11):1266-1274) used representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to show that 4 dimensions of financial strain-financial debt/crisis, unemployment, past homelessness, and lower income-are associated with subsequent suicide attempts. There are 3 main lessons we can take from Elbogen et al.: First, with populations facing record-breaking unemployment, economic recession, and reduced wages, we can anticipate an increase in suicide in the wake of the COVID-19 pandemic. Second, these data show the centrality of financial stressors, marking the current moment as distinct from other disasters or large-scale trauma. Third, the data teach us that financial stressors are linked and cumulative. In this way, Elbogen et al. provide a sobering harbinger of the potential effects on suicide of the collective stressors borne by the COVID-19 pandemic and other mass traumatic events that are accompanied by substantial financial stressors.

Do assets explain the relation between race/ethnicity and probable depression in U.S. adults?

Depression is a leading cause of disability in the U.S. across all race/ethnicity groups. While non-Hispanic Black and Hispanic persons have worse physical health on most indicators than non-Hispanic White persons, the literature on the association between race/ethnicity and rates of depression is mixed. Given unequal distribution of assets across racial/ethnic groups, it is possible that social and economic differences may explain differential rates of depression across race/ethnicity groups. Using National Health and Nutrition Examination Survey (NHANES) data from 2007–2016, we constructed a nationally representative sample of 26,382 adults over 18 years old (11,072 non-Hispanic White, 5,610 non-Hispanic Black, 6,981 Hispanic, and 2,719 Other race). We measured symptoms of depression using the Patient Health Questionnaire-9 (PHQ-9), with a score of 10 or more indicating probable depression. We identified three kinds of assets: financial assets (income), physical assets (home ownership), and social assets (marital status and education). We estimated the weighted prevalence of probable depression across race/ethnicity groups, odds ratios controlling for assets, and predicted probabilities of probable depression across race/ethnicity and asset groups. Three results contribute to our understanding of the differences in probable depression rates between race/ethnicity groups: 1) Non-Hispanic Black and Hispanic persons had a higher weighted prevalence of probable depression in the U.S. than non-Hispanic White persons. In models unadjusted for assets, non-Hispanic Black and Hispanic persons had 1.3 greater odds of probable depression than non-Hispanic White persons (p<0.01). 2) We found an inverse relation between assets and probable depression across all race-ethnicity groups. Also, non-Hispanic Black and Hispanic persons had fewer assets than non-Hispanic Whites. 3) When we controlled for assets, non-Hispanic Black and Hispanic persons had 0.8 times lower odds of probable depression than non-Hispanic White persons (p<0.05). Thus, when holding assets constant, minorities had better mental health than non-Hispanic White persons in the U.S. These three findings help to reconcile findings in the literature on race/ethnicity and depression. Given vastly unequal distribution of wealth in the U.S., it is not surprising that racial minorities, who hold fewer assets, would have an overall larger prevalence of mental illness, as seen in unadjusted estimates. Once assets are taken into account, Black and Hispanic persons appear to have better mental health than non-Hispanic White persons. Assets may explain much of the relation between race/ethnicity group and depression in the U.S. Future research should consider the role of assets in protecting against mental illness.

Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms.

OBJECTIVE

To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020.

EXPOSURES

The COVID-19 pandemic and outcomes associated with the measures to mitigate it.

MAIN OUTCOMES AND MEASURES

Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20).

RESULTS

A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]).

CONCLUSIONS AND RELEVANCE

These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

Is wealth associated with depressive symptoms in the United States?

PURPOSE

The aim of the study was to assess the relation between family wealth and depression in U.S. adults.

METHODS

Participants were 5134 members of the 2015-2016 National Health and Nutrition Examination Survey who were aged 18 years or older and completed the depression screener. Using the Patient Health Questionnaire and household demographics interview data, we calculate the adjusted odds of depressive symptoms for persons with low relative to high family savings, using multivariable logistic regression. We estimate predicted probabilities of having depressive symptoms for low and high family savings groups at low, middle, and high family income categories.

RESULTS

Overall, 57.4% of the total weighted population had low family savings (below $20,000), and 23.7% of the weighted population had depressive symptoms. Persons with low family savings had 1.49 times higher odds (95% confidence interval, 1.01-2.21) of having depressive symptoms than persons with high family savings, controlling for gender, age, race, education, marital status, family size, and family income. Predicted probabilities of depressive symptoms were higher for low family savings groups than high family savings groups at every income level.

CONCLUSIONS

Family wealth is associated with lower prevalence of current depressive symptoms in U.S. adults. Wealth may be an important determinant of population mental health, separate and independent from income.