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Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations
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Author(s):
Amy Tausch , MPH,
Renato Oliveira e Souza , MD, MSc,
Carmen Martinez Viciana , MPH, MSc,
Claudina Cayetano , MD, MPH,
Jarbas Barbosa , MD, PhD,
Anselm JM Hennis , MD, PhD
*
Publication date (Electronic):
15 November 2021
Journal:
Lancet Regional Health. Americas
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Abstract
The COVID-19 pandemic is having a major impact on the mental health of populations in the Americas. Studies show high rates of depression and anxiety, among other psychological symptoms, particularly among women, young people, those with pre-existing mental health conditions, health workers, and persons living in vulnerable conditions. Mental health systems and services have also been severely disrupted. A lack of financial and human resource investments in mental health services, limited implementation of the decentralized community-based care approach and policies to address the mental health gap prior to the pandemic, have all contributed to the current crisis. Countries must urgently strengthen their mental health responses to COVID-19 by taking actions to scale up mental health and psychosocial support services for all, reach marginalized and at-risk populations, and build back better mental health systems and services for the future.
Editorial Disclaimer : This translation in Spanish was submitted by the authors and we reproduce it as supplied. It has not been peer-reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as a reference for this manuscript. Disclaimer: The Authors hold sole responsibility for the views expressed in this article, which may not necessarily reflect the opinion or policy of the Pan American Health Organization/World Health Organization.
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Most cited references32
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Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020
Mark Czeisler, Rashon Lane, Emiko Petrosky … (2020)
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.
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6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records
Maxime Taquet, John R Geddes, Masud Husain … (2021)
Background Neurological and psychiatric sequelae of COVID-19 have been reported, but more data are needed to adequately assess the effects of COVID-19 on brain health. We aimed to provide robust estimates of incidence rates and relative risks of neurological and psychiatric diagnoses in patients in the 6 months following a COVID-19 diagnosis. Methods For this retrospective cohort study and time-to-event analysis, we used data obtained from the TriNetX electronic health records network (with over 81 million patients). Our primary cohort comprised patients who had a COVID-19 diagnosis; one matched control cohort included patients diagnosed with influenza, and the other matched control cohort included patients diagnosed with any respiratory tract infection including influenza in the same period. Patients with a diagnosis of COVID-19 or a positive test for SARS-CoV-2 were excluded from the control cohorts. All cohorts included patients older than 10 years who had an index event on or after Jan 20, 2020, and who were still alive on Dec 13, 2020. We estimated the incidence of 14 neurological and psychiatric outcomes in the 6 months after a confirmed diagnosis of COVID-19: intracranial haemorrhage; ischaemic stroke; parkinsonism; Guillain-Barré syndrome; nerve, nerve root, and plexus disorders; myoneural junction and muscle disease; encephalitis; dementia; psychotic, mood, and anxiety disorders (grouped and separately); substance use disorder; and insomnia. Using a Cox model, we compared incidences with those in propensity score-matched cohorts of patients with influenza or other respiratory tract infections. We investigated how these estimates were affected by COVID-19 severity, as proxied by hospitalisation, intensive therapy unit (ITU) admission, and encephalopathy (delirium and related disorders). We assessed the robustness of the differences in outcomes between cohorts by repeating the analysis in different scenarios. To provide benchmarking for the incidence and risk of neurological and psychiatric sequelae, we compared our primary cohort with four cohorts of patients diagnosed in the same period with additional index events: skin infection, urolithiasis, fracture of a large bone, and pulmonary embolism. Findings Among 236 379 patients diagnosed with COVID-19, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 33·62% (95% CI 33·17–34·07), with 12·84% (12·36–13·33) receiving their first such diagnosis. For patients who had been admitted to an ITU, the estimated incidence of a diagnosis was 46·42% (44·78–48·09) and for a first diagnosis was 25·79% (23·50–28·25). Regarding individual diagnoses of the study outcomes, the whole COVID-19 cohort had estimated incidences of 0·56% (0·50–0·63) for intracranial haemorrhage, 2·10% (1·97–2·23) for ischaemic stroke, 0·11% (0·08–0·14) for parkinsonism, 0·67% (0·59–0·75) for dementia, 17·39% (17·04–17·74) for anxiety disorder, and 1·40% (1·30–1·51) for psychotic disorder, among others. In the group with ITU admission, estimated incidences were 2·66% (2·24–3·16) for intracranial haemorrhage, 6·92% (6·17–7·76) for ischaemic stroke, 0·26% (0·15–0·45) for parkinsonism, 1·74% (1·31–2·30) for dementia, 19·15% (17·90–20·48) for anxiety disorder, and 2·77% (2·31–3·33) for psychotic disorder. Most diagnostic categories were more common in patients who had COVID-19 than in those who had influenza (hazard ratio [HR] 1·44, 95% CI 1·40–1·47, for any diagnosis; 1·78, 1·68–1·89, for any first diagnosis) and those who had other respiratory tract infections (1·16, 1·14–1·17, for any diagnosis; 1·32, 1·27–1·36, for any first diagnosis). As with incidences, HRs were higher in patients who had more severe COVID-19 (eg, those admitted to ITU compared with those who were not: 1·58, 1·50–1·67, for any diagnosis; 2·87, 2·45–3·35, for any first diagnosis). Results were robust to various sensitivity analyses and benchmarking against the four additional index health events. Interpretation Our study provides evidence for substantial neurological and psychiatric morbidity in the 6 months after COVID-19 infection. Risks were greatest in, but not limited to, patients who had severe COVID-19. This information could help in service planning and identification of research priorities. Complementary study designs, including prospective cohorts, are needed to corroborate and explain these findings. Funding National Institute for Health Research (NIHR) Oxford Health Biomedical Research Centre.
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Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA
Maxime Taquet, Sierra Luciano, John R Geddes … (2020)
Background Adverse mental health consequences of COVID-19, including anxiety and depression, have been widely predicted but not yet accurately measured. There are a range of physical health risk factors for COVID-19, but it is not known if there are also psychiatric risk factors. In this electronic health record network cohort study using data from 69 million individuals, 62 354 of whom had a diagnosis of COVID-19, we assessed whether a diagnosis of COVID-19 (compared with other health events) was associated with increased rates of subsequent psychiatric diagnoses, and whether patients with a history of psychiatric illness are at a higher risk of being diagnosed with COVID-19. Methods We used the TriNetX Analytics Network, a global federated network that captures anonymised data from electronic health records in 54 health-care organisations in the USA, totalling 69·8 million patients. TriNetX included 62 354 patients diagnosed with COVID-19 between Jan 20, and Aug 1, 2020. We created cohorts of patients who had been diagnosed with COVID-19 or a range of other health events. We used propensity score matching to control for confounding by risk factors for COVID-19 and for severity of illness. We measured the incidence of and hazard ratios (HRs) for psychiatric disorders, dementia, and insomnia, during the first 14 to 90 days after a diagnosis of COVID-19. Findings In patients with no previous psychiatric history, a diagnosis of COVID-19 was associated with increased incidence of a first psychiatric diagnosis in the following 14 to 90 days compared with six other health events (HR 2·1, 95% CI 1·8–2·5 vs influenza; 1·7, 1·5–1·9 vs other respiratory tract infections; 1·6, 1·4–1·9 vs skin infection; 1·6, 1·3–1·9 vs cholelithiasis; 2·2, 1·9–2·6 vs urolithiasis, and 2·1, 1·9–2·5 vs fracture of a large bone; all p<0·0001). The HR was greatest for anxiety disorders, insomnia, and dementia. We observed similar findings, although with smaller HRs, when relapses and new diagnoses were measured. The incidence of any psychiatric diagnosis in the 14 to 90 days after COVID-19 diagnosis was 18·1% (95% CI 17·6–18·6), including 5·8% (5·2–6·4) that were a first diagnosis. The incidence of a first diagnosis of dementia in the 14 to 90 days after COVID-19 diagnosis was 1·6% (95% CI 1·2–2·1) in people older than 65 years. A psychiatric diagnosis in the previous year was associated with a higher incidence of COVID-19 diagnosis (relative risk 1·65, 95% CI 1·59–1·71; p<0·0001). This risk was independent of known physical health risk factors for COVID-19, but we cannot exclude possible residual confounding by socioeconomic factors. Interpretation Survivors of COVID-19 appear to be at increased risk of psychiatric sequelae, and a psychiatric diagnosis might be an independent risk factor for COVID-19. Although preliminary, our findings have implications for clinical services, and prospective cohort studies are warranted. Funding National Institute for Health Research.
Author and article information
Journal
Journal ID (nlm-ta): Lancet Reg Health Am
Journal ID (iso-abbrev): Lancet Reg Health Am
Title:
Lancet Regional Health. Americas
Publisher:
The Pan American Health Organization. Published by Elsevier Ltd.
ISSN
(Electronic):
2667-193X
Publication date PMC-release: 15
November
2021
Publication date
(Print):
January
2022
Publication date
(Electronic):
15
November
2021
Volume: 5
Page: 100118
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Author notes
Article
Publisher Item ID: S2667-193X(21)00114-9 Publisher ID: 100118DOI: 10.1016/j.lana.2021.100118
PMC ID: 8782269
PubMed ID: 35098200
SO-VID: 099d6d67-272b-4f53-a98f-bd3c24c90318
Copyright © © 2021 The Pan American Health Organization
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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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Health Policy
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