549
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          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.

          Related collections

          Most cited references 3

          • Record: found
          • Abstract: found
          • Article: not found

          Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities.

          Coronavirus-19 (COVID-19) is transforming every aspect of our lives. Identified in late 2019, COVID-19 quickly became characterized as a global pandemic by March of 2020. Given the rapid acceleration of transmission, and the lack of preparedness to prevent and treat this virus, the negative impacts of COVID-19 are rippling through every facet of society. Although large numbers of people throughout the world will show resilience to the profound loss, stress, and fear associated with COVID-19, the virus will likely exacerbate existing mental health disorders and contribute to the onset of new stress-related disorders for many.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            Public Attitudes, Behaviors, and Beliefs Related to COVID-19, Stay-at-Home Orders, Nonessential Business Closures, and Public Health Guidance — United States, New York City, and Los Angeles, May 5–12, 2020

            SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to be transmitted mainly by person-to-person contact ( 1 ). Implementation of nationwide public health orders to limit person-to-person interaction and of guidance on personal protective practices can slow transmission ( 2 , 3 ). Such strategies can include stay-at-home orders, business closures, prohibitions against mass gatherings, use of cloth face coverings, and maintenance of a physical distance between persons ( 2 , 3 ). To assess and understand public attitudes, behaviors, and beliefs related to this guidance and COVID-19, representative panel surveys were conducted among adults aged ≥18 years in New York City (NYC) and Los Angeles, and broadly across the United States during May 5–12, 2020. Most respondents in the three cohorts supported stay-at-home orders and nonessential business closures* (United States, 79.5%; New York City, 86.7%; and Los Angeles, 81.5%), reported always or often wearing cloth face coverings in public areas (United States, 74.1%, New York City, 89.6%; and Los Angeles 89.8%), and believed that their state’s restrictions were the right balance or not restrictive enough (United States, 84.3%; New York City, 89.7%; and Los Angeles, 79.7%). Periodic assessments of public attitudes, behaviors, and beliefs can guide evidence-based public health decision-making and related prevention messaging about mitigation strategies needed as the COVID-19 pandemic evolves. During May 5–12, 2020, a total of 4,042 adults aged ≥18 years in the United States were invited to complete a web-based survey administered by Qualtrics, LLC. † Surveys were conducted among residents of NYC and Los Angeles to enable comparison of the two most populous cities in the United States with each other and with the nationwide cohort ( 4 ). The nationwide survey did not exclude respondents from NYC and Los Angeles, but no respondent was counted in more than one cohort. Invited participants were recruited using methods to create panels representative of the 2010 U.S. Census by age, gender, race, and ethnicity ( 5 ). Overall, 2,402 respondents completed surveys (response rate = 59.4%); of these, 2,221 (92.5%) (United States cohort = 1,676, NYC cohort = 286, and Los Angeles cohort = 259) passed quality screening procedures § ( 5 ); sample sizes provided a margin of error at 95% confidence levels of 2.4%, 5.7%, and 5.9%, respectively. Questions about the effects of the COVID-19 pandemic focused on public attitudes, behaviors, and beliefs regarding stay-at-home orders, nonessential business closures, and public health guidance. Chi-squared statistics (threshold of α = 0.05) were calculated to examine differences between the survey cohorts and to examine potential associations between reported characteristics (gender, age, race, ethnicity, employment status, essential worker status, rural-urban residence, knowing someone with COVID-19, and knowing someone who had died from COVID-19). Jupyter Notebook (version 6.0.0; Project Jupyter) was used to conduct statistical analyses. Among respondents in the U.S. cohort (1,676), 16.8% knew someone who had positive test results for COVID-19, compared with 42.0% of respondents in NYC and 10.8% in Los Angeles (Table 1); 5.9% of respondents in the U.S. survey cohort knew someone who had died from COVID-19, compared with 23.1% in NYC and 7.3% in Los Angeles. TABLE 1 Self-reported characteristics of invited participants and survey respondents — United States, New York City, and Los Angeles,* May 5–12, 2020 Characteristic %† United States New York City Los Angeles Invited Responded Invited Responded Invited Responded (N = 3,010) (N = 1,676) (N = 507) (N = 286) (N = 525) (N = 259) Gender Female 55.9 56.1 52.9 55.2 52.4 52.9 Male 44.0 43.9 47.1 44.8 47.6 47.1 Other 0.1 0.0 0.0 0.0 0.0 0.0 Age group (yrs) 18–24 11.4 3.9 11.2 4.2 11.0 5.8 25–34 14.8 8.5 18.5 11.5 18.1 10.4 35–44 17.6 15.0 15.6 14.0 17.5 12.4 45–54 17.6 19.0 15.0 13.6 16.4 18.5 55–64 18.0 23.4 19.3 26.9 17.1 22.0 ≥65 20.6 30.2 20.3 29.7 19.8 30.9 Race White 78.4 84.7 72.6 82.5 74.3 80.7 Black or African American 9.2 5.0 11.2 4.5 9.1 4.6 Asian 5.7 6.2 6.1 7.3 5.7 7.3 Multiple Race/other § 6.7 4.2 10.1 5.6 10.9 7.3 Ethnicity Hispanic or Latino 8.8 5.9 13.6 8.0 17.1 10.8 Not Hispanic or Latino 91.2 94.1 86.4 92.0 82.9 89.2 Rural-urban residence classification¶ Rural 15.3 15.5 0.8 1.4 0.8 0.4 Urban 84.7 84.5 99.2 98.6 99.2 99.6 Employment status** Employed †† 62.9 49.6 71.2 58.7 68.6 52.5    Essential — 23.4 — 16.1 — 23.2    Nonessential — 26.2 — 42.7 — 29.3 Retired 24.4 34.9 19.9 29.4 21.0 32.8 Unemployed 12.8 15.5 8.9 11.9 10.5 14.7 Know someone with positive test results for COVID-19 — 16.8 — 42.0 — 10.8 Know someone who died from COVID-19 — 5.9 — 23.1 — 7.3 Abbreviation: COVID-19 = coronavirus disease 2019. * The U.S. survey group did not exclude respondents from New York City and Los Angeles. † Totals might not all sum to 100 because of rounding. § The multiple race/other category includes respondents who self-reported as a race with 87% in each area) and limiting gatherings to fewer than 10 persons (>82% in each area). At the time of the survey, most also agreed that dining inside restaurants should not be allowed, with agreement higher in NYC (81.5%) than in Los Angeles (71.8%) and in the United States overall (66.6%). TABLE 2 Attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance — United States (U.S.),* New York City (NYC), and Los Angeles (LA), May 5–12, 2020 Attitudes, behaviors, and beliefs U.S. NYC LA p-value† p-value† p-value† (N = 1,676) (N = 286) (N = 259) U.S. versus NYC U.S. versus LA NYC versus LA Attitudes, no. of respondents (%) Support stay-at-home order and nonessential business closures Yes 1,332 (79.5) 248 (86.7) 211 (81.5) 85% of adults in the three cohorts. Approximately 90% of respondents reported having been in a public area during the preceding week; among those, 74.1% nationwide reported always or often wearing cloth face coverings when in public, with higher percentages reporting this behavior in NYC (89.6%) and Los Angeles (89.8%). Overall, 84.3% of adults in the U.S. survey cohort believed their state’s COVID-19 community mitigation strategies were the right balance or not restrictive enough, compared with 89.7% in NYC and 79.7% in Los Angeles. As well, 74.3% of respondents in the United States reported they would not feel safe if these restrictions were lifted nationwide at the time the survey was conducted, compared with 81.5% in NYC and 73.4% in Los Angeles. In addition, among those who reported that they would not feel safe, some indicated that they would nonetheless want community mitigation strategies lifted and would accept associated risks (17.1%, 12.6%, and 12.7%, respectively). Reported prevalence of self-isolation and feeling safe if community mitigation strategies were lifted differed significantly by age, employment status, and essential worker status among adults in the U.S. survey cohort (Table 3). The percentage of respondents who reported that they were in self-isolation was highest among persons aged 18–24 years (92.3%) and lowest among those aged 45–54 years (71.5%). The percentage who reported that they would feel safe if community mitigation strategies were lifted was approximately twice as high among persons aged 18–24 as it was among those aged ≥65 years (43.1% versus 19.2%). Respondents who reported that they were essential workers** accounted for 47.2% of employed respondents in the U.S. cohort and were significantly less likely than were nonessential workers to report self-isolating (63.1% versus 80.6%). Essential workers were also significantly more likely than were nonessential workers to report that they would feel safe if COVID-19 community mitigation strategies were lifted (37.7% versus 23.7%). TABLE 3 Attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance, by respondent characteristics* — United States, May 5–12, 2020 By gender, age group, and ethnicity, % Attitudes, behaviors and, beliefs Gender Age group (yrs) Ethnicity Male Female 18–24 25–34 35–44 45–54 55–64 ≥65 Hispanic Non- Hispanic Attitudes Support stay-at-home orders and nonessential business closures Yes 76.3 81.9 84.6 85.2 83.7 75.2 76.0 80.4 83.8 79.2 p-value† 0.0521 0.1803 1.0 Nonessential workers should stay home Agree 64.9 69.2 55.4 76.8 72.2 62.7 62.0 70.8 72.7 67.0 Disagree 17.8 14.2 13.8 7.7 11.5 20.7 19.6 14.4 11.1 16.1 p-value† 0.9043 <0.05§ 1.0 Persons should always keep ≥6-ft of physical distance Agree 86.5 88.6 73.8 82.4 86.9 85.0 91.1 90.5 77.8 88.3 Disagree 4.8 4.7 4.6 5.6 2.8 7.2 4.8 3.8 6.1 4.6 p-value† 1.0 <0.05§ <0.05§ Groups of 10 or more persons should not be allowed Agree 80.4 84.0 70.8 80.3 83.7 76.8 82.9 87.0 80.8 82.5 Disagree 9.9 7.0 10.8 8.5 6.0 11.9 9.2 6.1 5.1 8.5 p-value† 0.7238 <0.05§ 1.0 Dining inside restaurants should not be allowed Agree 62.2 70.1 67.7 72.5 68.3 60.8 65.6 68.6 66.7 66.6 Disagree 21.8 16.5 9.2 12.0 15.9 23.8 23.2 16.8 14.1 19.1 p-value† <0.05§ <0.05§ 1.0 Behaviors In self-isolation Yes 75.8 78.5 92.3 81.7 77.8 71.5 72.7 81.2 87.9 76.7 p-value† 1.0 <0.05§ 0.1246 Keep ≥6 ft apart from others Always 54.6 61.0 29.2 56.3 60.3 55.2 56.4 64.6 54.5 58.4 Often 22.6 20.3 30.8 23.2 18.3 21.6 23.5 19.2 18.2 21.5 Sometimes 9.0 7.7 26.2 7.0 9.1 9.1 7.7 5.7 14.1 7.9 Rarely 5.0 3.4 9.2 5.6 2.8 4.4 4.6 3.2 7.1 3.9 Never 8.8 7.7 4.6 7.7 9.5 9.7 7.9 7.3 6.1 8.3 p-value† 0.7508 <0.05§ 0.8299 Avoid groups of 10 or more persons Always 72.5 77.2 52.3 68.3 74.2 73.4 73.7 82.6 63.6 75.8 Often 12.2 9.7 15.4 18.3 11.9 8.8 12.0 7.9 14.1 10.6 Sometimes 3.9 3.2 15.4 2.1 4.4 4.4 3.1 1.8 6.1 3.4 Rarely 2.4 2.2 15.4 2.8 0.4 2.2 2.0 1.8 6.1 2.1 Never 8.8 7.8 1.5 8.5 9.1 11.3 9.2 5.9 10.1 8.1 p-value† 1.0 <0.05§ 0.1843 Been to a public area in the preceding week Yes 94.7 88.9 96.9 88.0 92.5 90.6 94.4 89.5 90.9 91.5 p-value† <0.05§ 0.3145 1.0 Wear cloth face covering when in public¶ Always 54.6 65.1 44.4 59.2 57.9 56.1 55.1 71.1 57.8 60.5 Often 14.9 12.9 15.9 16.0 12.9 13.1 17.6 10.8 13.3 13.9 Sometimes 10.1 7.6 15.9 8.8 8.6 8.7 10.3 6.6 13.3 8.5 Rarely 4.6 3.7 12.7 4.0 4.7 4.5 3.5 2.9 4.4 4.1 Never 15.8 10.6 11.1 12.0 15.9 17.6 13.5 8.6 11.1 13.1 p-value† <0.05§ <0.05§ 1.0 Beliefs State restrictions are The right balance 64.5 67.8 61.5 57.0 65.1 63.3 67.3 71.3 60.6 66.7 Not restrictive enough 18.0 18.1 21.5 31.7 19.0 16.9 16.1 15.4 26.3 17.5 p-value† 1.0 <0.05§ 0.7720 Would feel safe if restrictions were lifted nationwide at the time the survey was conducted Yes 28.8 23.3 43.1 26.8 27.4 30.1 26.3 19.2 25.3 25.7 p-value† 0.1019 <0.05§ 1.0 By race, employment status, and essential worker status, % Attitudes, behaviors, and beliefs Race** Employment status Essential worker†† White Black Asian Multiple race/Other Unemployed Retired Employed Yes No Attitudes Support stay-at-home orders and nonessential business closures Yes 77.9 89.2 90.4 84.3 81.9 80.0 78.4 75.6 80.9 p-value† <0.05§ 1.0 0.6953 Nonessential workers should stay home Agree 66.4 63.9 78.8 72.9 68.3 69.9 65.1 58.3 71.3 Disagree 16.8 16.9 4.8 11.4 13.9 14.9 17.1 19.6 14.8 p-value† 0.4225 1.0 <0.05§ Persons should always keep ≥6-ft of physical distance Agree 88.2 81.9 89.4 81.4 83.0 92.5 85.8 81.7 89.5 Disagree 4.9 6.0 1.9 4.3 8.1 2.1 5.5 7.1 4.1 p-value† 1.0 <0.05§ <0.05§ Groups of 10 or more persons should not be allowed Agree 82.0 84.3 89.4 78.6 79.5 87.5 79.7 74.8 84.1 Disagree 8.9 7.2 1.9 7.1 9.7 5.8 9.6 10.7 8.7 p-value† 1.0 <0.05§ <0.05§ Dining inside restaurants should not be allowed Agree 65.8 75.9 72.1 64.3 66.0 69.6 64.8 59.5 69.5 Disagree 20.5 7.2 6.7 15.7 19.3 16.9 20.0 22.4 17.8 p-value† <0.05§ 1.0 0.0899 Behaviors In self-isolation Yes 77.2 78.3 73.1 84.3 81.1 82.7 72.4 63.1 80.6 p-value† 1.0 <0.05§ <0.05§ Keep ≥6 ft apart from others Always 58.2 48.2 67.3 55.7 58.3 65.8 52.8 44.8 59.9 Often 21.6 20.5 17.3 21.4 21.6 19.0 22.8 26.0 20.0 Sometimes 8.0 14.5 4.8 11.4 5.8 5.5 10.9 13.0 9.1 Rarely 3.9 9.6 1.0 5.7 5.4 2.9 4.6 6.6 2.7 Never 8.2 7.2 9.6 5.7 8.9 6.8 8.9 9.7 8.2 p-value† 0.5507 <0.05§ <0.05§ Avoid groups of 10 or more persons Always 76.2 56.6 77.9 71.4 73.0 81.2 71.5 65.6 76.8 Often 10.8 15.7 6.7 11.4 10.8 8.2 12.6 16.0 9.6 Sometimes 3.0 12.0 1.9 5.7 4.2 2.2 4.2 5.6 3.0 Rarely 2.0 8.4 1.9 2.9 2.3 2.1 2.5 4.1 1.1 Never 8.0 7.2 11.5 8.6 9.7 6.3 9.1 8.7 9.6 p-value† <0.05§ 0.1179 <0.05§ Been to a public area in the preceding week Yes 91.8 91.6 87.5 91.4 88.4 89.1 94.1 97.5 91.1 p-value† 1.0 <0.05§ <0.05§ Wear cloth face covering when in public¶ Always 60.1 55.3 71.4 54.7 58.5 70.4 54.2 49.3 58.8 Often 13.7 19.7 9.9 14.1 10.0 11.1 16.7 20.4 13.3 Sometimes 8.4 13.2 8.8 10.9 10.5 5.6 10.3 9.7 11.0 Rarely 3.8 7.9 3.3 7.8 2.2 3.1 5.4 6.5 4.3 Never 14.0 3.9 6.6 12.5 18.8 9.8 13.4 14.1 12.8 p-value† 0.3708 <0.05§ 0.1843 Beliefs State restrictions are The right balance 66.7 65.1 67.3 60.0 67.6 68.7 64.3 64.9 63.8 Not restrictive enough 16.7 28.9 22.1 25.7 18.5 17.4 18.3 14.5 21.6 p-value† 0.0523 1.0 0.0563 Would feel safe if restrictions were lifted nationwide at the time the survey was conducted Yes 25.8 37.3 15.4 25.7 22.4 20.7 30.3 37.7 23.7 p-value† 0.0765 <0.05§ <0.05§ * Nationwide cohort (n = 1,676) only unless otherwise specified. The six respondent characteristic categories shown in the table (gender, age, ethnicity, race, employment status, and essential worker status) account for 32 of 34 significant associations among the 108 potential interactions evaluated. Responses and p-values values for significant associations with characteristics not presented in the table that are associated with the attitudes, behaviors, and beliefs include the following: Use of cloth face coverings when in public × Rural-urban classification, (p-value = 0.0324); Rural: Always = 51.4%, Often = 15.5%, Sometimes = 10.2%, Rarely = 7.8%, Never = 15.1%; Urban: Always = 62.0%, Often = 13.5%, Sometimes = 8.5%, Rarely = 3.4%, Never = 12.6%; attitude that dining inside restaurants should not be allowed × Know someone with COVID-19 (p-value = 0.0243), Know someone: Agree = 75.1%, Disagree = 12.5%; Do not know someone: Agree = 64.9%, Disagree = 20.1%. † Calculated with Chi-squared test of independence. § P-value is statistically significant. ¶ Of respondents who reported having been in a public area in the preceding week. ** The multiple race/other category includes respondents who self-reported as a race with <2.5% of respondents in any cohort (e.g., American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or more than one race). †† Of 832 employed respondents in the U.S. cohort. Reported prevalences of always or often wearing a cloth face covering in public and maintaining ≥6 feet of physical distance also varied significantly across respondent demographics and characteristics. Respondents who were male, employed, or essential workers were significantly more likely to report having been in public areas in the past week. Among respondents who had been in public areas during the preceding week, significantly higher percentages of women, adults aged ≥65 years, retired persons, and those living in urban areas reported wearing cloth face coverings. A significantly higher percentage of adults aged ≥65 years and nonessential workers reported maintaining 6 feet of physical distance between themselves and others and abiding by the recommendation to avoid gatherings of 10 or more persons than did others. Adherence to recommendations to maintain 6 feet of physical distance and limit gatherings to fewer than 10 persons also differed significantly by employment status and race, respectively, with employed persons less likely than were retired persons to have maintained 6 feet of distance and black persons less likely than were white or Asian persons to have limited gatherings to fewer than 10 persons. Discussion There was broad support for stay-at-home orders, nonessential business closures, and adherence to public health recommendations to mitigate the spread of COVID-19 in early- to mid-May 2020. Most adults reported they would not feel safe if government-ordered community mitigation strategies such as stay-at-home orders and nonessential business closures were lifted nationwide at the time the survey was conducted, although a minority of these adults who did not feel safe wanted these restrictions lifted despite the risks. There was a significant association between age and feeling safe without community mitigation strategies, with younger adults feeling safer than those aged ≥65 years, which might relate to perceived risk for infection and severe disease. As of May 16, adults aged ≥65 years accounted for approximately 80% of reported COVID-19–associated deaths, compared with those aged 15–24 years, who accounted for 0.1% of such deaths ( 6 ). Identifying variations in public attitudes, behaviors, and beliefs by respondent characteristics can inform tailored messaging and targeted nonpharmacological interventions that might help to reduce the spread of COVID-19. Other variations in attitudes, behaviors, and beliefs by respondent characteristics have implications for implementation of COVID-19 mitigation strategies and related prevention messaging. For example, a lower percentage of respondents in the U.S. survey cohort reported wearing cloth face coverings and self-isolating than did those in NYC and Los Angeles. However, although use of cloth face coverings in NYC and Los Angeles were similar, NYC experienced substantially higher COVID-19-related mortality during the initial months of the pandemic than did Los Angeles ( 4 ). Nationwide, higher percentages of respondents from urban areas reported use of cloth face coverings than did rural area respondents. Because outbreaks have been reported in rural communities and among certain populations since March 2020 ( 7 , 8 ), these data suggest a need for additional and culturally effective messaging around the benefits of cloth face coverings targeting these areas. Essential workers also reported lower adherence to recommendations for self-isolation, 6 feet of physical distancing, and limiting gatherings to fewer than 10 persons. These behaviors might be related to job requirements and other factors that could limit the ability to effectively adhere to these recommendations. Nevertheless, the high rate of person-to-person contact associated with these behaviors increases the risk for widespread transmission of SARS-CoV-2 and underscores the potential value of tailored and targeted public health interventions. The findings in this report are subject to at least four limitations. First, behaviors and adherence to recommendations were self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Second, responses were cross-sectional, precluding inferences about causality. Third, respondents were not necessarily representative among all groups; notably a lower percentage of African Americans responded than is representative of the U.S. population. In addition, participation might have been higher among persons who knew someone who had tested positive or had died from COVID-19, which could have affected support for and adherence to mitigation efforts. Finally, given that the web-based survey does not recruit participants using population-based probability sampling and respondents might not be fully representative of the U.S. population, findings might have limited generalizability. However, this survey did apply screening procedures to address issues related to web-based panel quality. Widespread support for community mitigation strategies and commitment to COVID-19 public health recommendations indicate that protecting health and controlling disease are public priorities amid this pandemic, despite daily-life disruption and adverse economic impacts ( 5 , 9 ). These findings of high public support might inform reopening policies and the timelines and restriction levels of these mitigation strategies as understanding of public support for and adherence to these policies evolves. Absent a vaccine, controlling COVID-19 depends on community mitigation strategies that require public support to be effective. As the pandemic progresses and mitigation strategies evolve, understanding public attitudes, behaviors, and beliefs is critical. Adherence to recommendations to wear cloth face coverings and physical distancing guidelines are of public health importance. Strong public support for these behaviors suggests an opportunity to normalize safe practices and promote continued use of these and other recommended personal protective behaviors to minimize further spread of COVID-19 as jurisdictions reopen. These findings and periodic assessments of public attitudes, behaviors, and beliefs can also inform future planning if subsequent outbreak waves occur, and if additional periods of expanded mitigation efforts are necessary to prevent the spread of COVID-19 and save lives. Summary What is already known about this topic? Stay-at-home orders and recommended personal protective practices were disseminated to mitigate the spread of COVID-19 in the United States. What is added by this report? During May 5–12, 2020, a survey among adults in New York City and Los Angeles and broadly across the United States found widespread support of stay-at-home orders and nonessential business closures and high degree of adherence to COVID-19 mitigation guidelines. Most respondents reported that they would feel unsafe if restrictions were lifted at the time of the survey. What are the implications for public health practice? Routine assessment of public priorities can guide public health decisions requiring collective action. Current levels of public support for restrictions and adherence to mitigation strategies can inform decisions about reopening and balancing duration and intensity of restrictions.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6)

              Background Posttraumatic stress disorder (PTSD) symptoms are common in acute respiratory distress syndrome (ARDS) survivors. Brief screening instruments are needed for clinical and research purposes. We evaluated internal consistency, external construct, and criterion validity of the Impact of Event Scale-6 (IES-6; 6 items) compared to the original Impact of Event Scale—Revised (IES-R; 22 items) and to the Clinician Administered PTSD Scale (CAPS) reference standard evaluation in ARDS survivors. Methods This study is a secondary analysis from two independent multi-site, prospective studies of ARDS survivors. Measures of internal consistency, and external construct and criterion validity were evaluated. Results A total of 1001 ARDS survivors (51% female, 76% white, mean (SD) age 49 (14) years) were evaluated. The IES-6 demonstrated internal consistency over multiple time points up to 5 years after ARDS (Cronbach’s alpha = 0.96; 95% confidence interval (CI) 0.94 to 0.97). The IES-6 demonstrated stronger correlations with related constructs (e.g., anxiety and depression; |r| = 0.32 to 0.52) and weaker correlations with unrelated constructs (e.g., physical function and healthcare utilization measures (|r| = 0.02 to 0.27). Criterion validity evaluation with the CAPS diagnosis of PTSD in a subsample of 60 participants yielded an area under receiver operating characteristic curve (95% CI) of 0.93 (0.86, 1.00), with an IES-6 cutoff score of 1.75 yielding 0.88 sensitivity and 0.85 specificity. Conclusions The IES-6 is reliable and valid for screening for PTSD in ARDS survivors and may be useful in clinical and research settings.
                Bookmark

                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                14 August 2020
                14 August 2020
                : 69
                : 32
                : 1049-1057
                Affiliations
                Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia; Austin Health, Melbourne, Australia; CDC COVID-19 Response Team; Brigham and Women’s Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; University of Melbourne, Melbourne, Australia.
                Author notes
                Corresponding author: Rashon Lane for the CDC COVID-19 Response Team, Rlane@ 123456cdc.gov .
                Article
                mm6932a1
                10.15585/mmwr.mm6932a1
                7440121
                32790653

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

                Categories
                Full Report

                Comments

                Comment on this article