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.
TABLE 1
Respondent characteristics and prevalence of adverse mental health outcomes, increased
substance use to cope with stress or emotions related to COVID-19 pandemic, and suicidal
ideation — United States, June 24–30, 2020
Characteristic
All respondents who completed surveys during June 24–30, 2020 weighted* no. (%)
Weighted %*
Conditions
Started or increased substance use to cope with pandemic-related stress or emotions¶
Seriously considered suicide in past 30 days
≥1 adverse mental or behavioral health symptom
Anxiety disorder†
Depressive disorder†
Anxiety or depressive disorder†
COVID-19–related TSRD§
All respondents
5,470 (100)
25.5
24.3
30.9
26.3
13.3
10.7
40.9
Gender
Female
2,784 (50.9)
26.3
23.9
31.5
24.7
12.2
8.9
41.4
Male
2,676 (48.9)
24.7
24.8
30.4
27.9
14.4
12.6
40.5
Other
10 (0.2)
20.0
30.0
30.0
30.0
10.0
0.0
30.0
Age group (yrs)
18–24
731 (13.4)
49.1
52.3
62.9
46.0
24.7
25.5
74.9
25–44
1,911 (34.9)
35.3
32.5
40.4
36.0
19.5
16.0
51.9
45–64
1,895 (34.6)
16.1
14.4
20.3
17.2
7.7
3.8
29.5
≥65
933 (17.1)
6.2
5.8
8.1
9.2
3.0
2.0
15.1
Race/Ethnicity
White, non-Hispanic
3,453 (63.1)
24.0
22.9
29.2
23.3
10.6
7.9
37.8
Black, non-Hispanic
663 (12.1)
23.4
24.6
30.2
30.4
18.4
15.1
44.2
Asian, non-Hispanic
256 (4.7)
14.1
14.2
18.0
22.1
6.7
6.6
31.9
Other race or multiple races, non-Hispanic**
164 (3.0)
27.8
29.3
33.2
28.3
11.0
9.8
43.8
Hispanic, any race(s)
885 (16.2)
35.5
31.3
40.8
35.1
21.9
18.6
52.1
Unknown
50 (0.9)
38.0
34.0
44.0
34.0
18.0
26.0
48.0
2019 Household income (USD)
<25,000
741 (13.6)
30.6
30.8
36.6
29.9
12.5
9.9
45.4
25,000–49,999
1,123 (20.5)
26.0
25.6
33.2
27.2
13.5
10.1
43.9
50,999–99,999
1,775 (32.5)
27.1
24.8
31.6
26.4
12.6
11.4
40.3
100,999–199,999
1,301 (23.8)
23.1
20.8
27.7
24.2
15.5
11.7
37.8
≥200,000
282 (5.2)
17.4
17.0
20.6
23.1
14.8
11.6
35.1
Unknown
247 (4.5)
19.6
23.1
27.2
24.9
6.2
3.9
41.5
Education
Less than high school diploma
78 (1.4)
44.5
51.4
57.5
44.5
22.1
30.0
66.2
High school diploma
943 (17.2)
31.5
32.8
38.4
32.1
15.3
13.1
48.0
Some college
1,455 (26.6)
25.2
23.4
31.7
22.8
10.9
8.6
39.9
Bachelor's degree
1,888 (34.5)
24.7
22.5
28.7
26.4
14.2
10.7
40.6
Professional degree
1,074 (19.6)
20.9
19.5
25.4
24.5
12.6
10.0
35.2
Unknown
33 (0.6)
25.2
23.2
28.2
23.2
10.5
5.5
28.2
Employment status††
Employed
3,431 (62.7)
30.1
29.1
36.4
32.1
17.9
15.0
47.8
Essential
1,785 (32.6)
35.5
33.6
42.4
38.5
24.7
21.7
54.0
Nonessential
1,646 (30.1)
24.1
24.1
29.9
25.2
10.5
7.8
41.0
Unemployed
761 (13.9)
32.0
29.4
37.8
25.0
7.7
4.7
45.9
Retired
1,278 (23.4)
9.6
8.7
12.1
11.3
4.2
2.5
19.6
Unpaid adult caregiver status§§
Yes
1,435 (26.2)
47.6
45.2
56.1
48.4
32.9
30.7
66.6
No
4,035 (73.8)
17.7
16.9
22.0
18.4
6.3
3.6
31.8
Region
¶¶
Northeast
1,193 (21.8)
23.9
23.9
29.9
22.8
12.8
10.2
37.1
Midwest
1,015 (18.6)
22.7
21.1
27.5
24.4
9.0
7.5
36.1
South
1,921 (35.1)
27.9
26.5
33.4
29.1
15.4
12.5
44.4
West
1,340 (24.5)
25.8
24.2
30.9
26.7
14.0
10.9
43.0
Rural-urban classification***
Rural
599 (10.9)
26.0
22.5
29.3
25.4
11.5
10.2
38.3
Urban
4,871 (89.1)
25.5
24.6
31.1
26.4
13.5
10.7
41.2
Know someone who had positive test results for SARS-CoV-2
Yes
1,109 (20.3)
23.8
21.9
29.6
21.5
12.9
7.5
39.2
No
4,361 (79.7)
26.0
25.0
31.3
27.5
13.4
11.5
41.3
Knew someone who died from COVID-19
Yes
428 (7.8)
25.8
20.6
30.6
28.1
11.3
7.6
40.1
No
5,042 (92.2)
25.5
24.7
31.0.
26.1
13.4
10.9
41.0
Receiving treatment for previously diagnosed condition
Anxiety
Yes
536 (9.8)
59.6
52.0
66.0
51.9
26.6
23.6
72.7
No
4,934 (90.2)
21.8
21.3
27.1
23.5
11.8
9.3
37.5
Depression
Yes
540 (9.9)
52.5
50.6
60.8
45.5
25.2
22.1
68.8
No
4,930 (90.1)
22.6
21.5
27.7
24.2
12.0
9.4
37.9
Posttraumatic stress disorder
Yes
251 (4.6)
72.3
69.1
78.7
69.4
43.8
44.8
88.0
No
5,219 (95.4)
23.3
22.2
28.6
24.2
11.8
9.0
38.7
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.pdf.
*** 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.html.
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.
TABLE 2
Comparison of symptoms of adverse mental health outcomes among all respondents who
completed surveys (N = 5,470), by respondent characteristic* — United States, June
24–30, 2020
Characteristic
Prevalence ratio
¶
(95% CI¶)
Symptoms of anxiety disorder or depressive disorder
†
Symptoms of a TSRD related to COVID-19
§
Started or increased substance use to cope with stress or emotions related to COVID-19
Serious consideration of suicide in past 30 days
Gender
Female vs. male
1.04 (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. 25–44
1.56 (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. 45–64
3.10 (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. ≥65
7.73 (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. 45–64
1.99 (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. ≥65
4.96 (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. ≥65
2.49 (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 black
1.35 (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 Asian
2.27 (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 races
1.23 (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 white
1.40 (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 Asian
1.68 (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 races
0.91 (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 white
1.03 (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 races
0.54 (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 white
0.62 (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 white
1.14 (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. unemployed
0.96 (0.87–1.07)
1.28 (1.12–1.46)**
2.30 (1.78–2.98)**
3.21 (2.31–4.47)**
Employed vs. retired
3.01 (2.58–3.51)**
2.84 (2.42–3.34)**
4.30 (3.28–5.63)**
5.97 (4.20–8.47)**
Unemployed vs. retired
3.12 (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. not
0.95 (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. not
0.99 (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. not
2.43 (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. not
2.20 (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. not
2.75 (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.html.
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).
TABLE 3
Odds of incidence* of symptoms of adverse mental health, substance use to cope with
stress or emotions related to COVID–19 pandemic, and suicidal ideation in the third
survey wave, by essential worker status and unpaid adult caregiver status among respondents
who completed monthly surveys from April through June (N = 1,497) — United States,
April 2–8, May 5–12, and June 24–30, 2020
Symptom or behavior
Essential worker† vs. all other employment statuses (nonessential worker, unemployed,
retired)
Unpaid caregiver for adults§ vs. not unpaid caregiver
Unadjusted
Adjusted¶
Unadjusted
Adjusted**
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)
0.001
1.63 (0.99–2.69)
0.056
1.97 (1.25–3.11)
0.004
1.81 (1.14–2.87)
0.012
Symptoms of depressive disorder§§
1.49 (1.00–2.22)
0.052
1.13 (0.70–1.82)
0.606
2.29 (1.50–3.50)
<0.001
2.22 (1.45–3.41)
<0.001
Symptoms of anxiety disorder or depressive disorder§§
1.67 (1.14–2.46)
0.008
1.26 (0.79–2.00)
0.326
1.84 (1.19–2.85)
0.006
1.73 (1.11–2.70)
0.015
Symptoms of a TSRD related to
COVID–19¶¶
1.55 (0.86–2.81)
0.146
1.27 (0.63–2.56)
0.512
1.88 (0.99–3.56)
0.054
1.79 (0.94–3.42)
0.076
Started or increased substance use to cope with stress or emotions related to COVID–19
2.36 (1.26–4.42)
0.007
2.04 (0.92–4.48)
0.078
3.51 (1.86–6.61)
<0.001
3.33 (1.75–6.31)
<0.001
Serious consideration of suicide in previous 30 days
0.93 (0.31–2.78)
0.895
0.53 (0.16–1.70)
0.285
3.00 (1.20–7.52)
0.019
3.03 (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.
Discussion
Elevated levels of adverse mental health conditions, substance use, and suicidal ideation
were reported by adults in the United States in June 2020. The prevalence of symptoms
of anxiety disorder was approximately three times those reported in the second quarter
of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately
four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (
2
). However, given the methodological differences and potential unknown biases in survey
designs, this analysis might not be directly comparable with data reported on anxiety
and depression disorders in 2019 (
2
). Approximately one quarter of respondents reported symptoms of a TSRD related to
the pandemic, and approximately one in 10 reported that they started or increased
substance use because of COVID-19. Suicidal ideation was also elevated; approximately
twice as many respondents reported serious consideration of suicide in the previous
30 days than did adults in the United States in 2018, referring to the previous 12
months (10.7% versus 4.3%) (
6
).
Mental health conditions are disproportionately affecting specific populations, especially
young adults, Hispanic persons, black persons, essential workers, unpaid caregivers
for adults, and those receiving treatment for preexisting psychiatric conditions.
Unpaid caregivers for adults, many of whom are currently providing critical aid to
persons at increased risk for severe illness from COVID-19, had a higher incidence
of adverse mental and behavioral health conditions compared with others. Although
unpaid caregivers of children were not evaluated in this study, approximately 39%
of unpaid caregivers for adults shared a household with children (compared with 27%
of other respondents). Caregiver workload, especially in multigenerational caregivers,
should be considered for future assessment of mental health, given the findings of
this report and hardships potentially faced by caregivers.
The findings in this report are subject to at least four limitations. First, a diagnostic
evaluation for anxiety disorder or depressive disorder was not conducted; however,
clinically validated screening instruments were used to assess symptoms. Second, the
trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding
distinction among them; however, the findings highlight the importance of including
COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts
of the COVID-19 pandemic (
7
). Third, substance use behavior was self-reported; therefore, responses might be
subject to recall, response, and social desirability biases. Finally, given that the
web-based survey might not be fully representative of the United States population,
findings might have limited generalizability. However, standardized quality and data
inclusion screening procedures, including algorithmic analysis of click-through behavior,
removal of duplicate responses and scrubbing methods for web-based panel quality were
applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder
were largely consistent with findings from the Household Pulse Survey during June
(
1
).
Markedly elevated prevalences of reported adverse mental and behavioral health conditions
associated with the COVID-19 pandemic highlight the broad impact of the pandemic and
the need to prevent and treat these conditions. Identification of populations at increased
risk for psychological distress and unhealthy coping can inform policies to address
health inequity, including increasing access to resources for clinical diagnoses and
treatment options. Expanded use of telehealth, an effective means of delivering treatment
for mental health conditions, including depression, substance use disorder, and suicidal
ideation (
8
), might reduce COVID-19-related mental health consequences. Future studies should
identify drivers of adverse mental and behavioral health during the COVID-19 pandemic
and whether factors such as social isolation, absence of school structure, unemployment
and other financial worries, and various forms of violence (e.g., physical, emotional,
mental, or sexual abuse) serve as additional stressors. Community-level intervention
and prevention efforts should include strengthening economic supports to reduce financial
strain, addressing stress from experienced racial discrimination, promoting social
connectedness, and supporting persons at risk for suicide (
9
). Communication strategies should focus on promotion of health services
§§§§
,
¶¶¶¶
,
***** and culturally and linguistically tailored prevention messaging regarding practices
to improve emotional well-being. Development and implementation of COVID-19–specific
screening instruments for early identification of COVID-19–related TSRD symptoms would
allow for early clinical interventions that might prevent progression from acute to
chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19,
resources, including social support, comprehensive treatment options, and harm reduction
services, are essential and should remain accessible. Periodic assessment of mental
health, substance use, and suicidal ideation should evaluate the prevalence of psychological
distress over time. Addressing mental health disparities and preparing support systems
to mitigate mental health consequences as the pandemic evolves will continue to be
needed urgently.
Summary
What is already known about this topic?
Communities have faced mental health challenges related to COVID-19–associated morbidity,
mortality, and mitigation activities.
What is added by this report?
During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental
health conditions associated with COVID-19. Younger adults, racial/ethnic minorities,
essential workers, and unpaid adult caregivers reported having experienced disproportionately
worse mental health outcomes, increased substance use, and elevated suicidal ideation.
What are the implications for public health practice?
The public health response to the COVID-19 pandemic should increase intervention and
prevention efforts to address associated mental health conditions. Community-level
efforts, including health communication strategies, should prioritize young adults,
racial/ethnic minorities, essential workers, and unpaid adult caregivers.