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      COVID-19 and Social Control

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          Abstract

          The COVID-19 pandemic has once again brought into relief and tension the delicate balancing act modern governments must strike in assuring individual liberties of its citizens, while at the same time dealing with infectious diseases and other public health risks. It is not clear how best to strike this balance, or how to judge which countries are doing an adequate job and which others are failing (on either or both fronts). What is clear, however, is that by virtue of it being available to the state, public health is based not merely on medical expertise but also on power, insofar as it part of the regulative apparatus of the administrative state which can be implemented by decree at the behest of the executive.

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          Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 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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            Retraction—Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis

            After publication of our Lancet Article, 1 several concerns were raised with respect to the veracity of the data and analyses conducted by Surgisphere Corporation and its founder and our co-author, Sapan Desai, in our publication. We launched an independent third-party peer review of Surgisphere with the consent of Sapan Desai to evaluate the origination of the database elements, to confirm the completeness of the database, and to replicate the analyses presented in the paper. Our independent peer reviewers informed us that Surgisphere would not transfer the full dataset, client contracts, and the full ISO audit report to their servers for analysis as such transfer would violate client agreements and confidentiality requirements. As such, our reviewers were not able to conduct an independent and private peer review and therefore notified us of their withdrawal from the peer-review process. We always aspire to perform our research in accordance with the highest ethical and professional guidelines. We can never forget the responsibility we have as researchers to scrupulously ensure that we rely on data sources that adhere to our high standards. Based on this development, we can no longer vouch for the veracity of the primary data sources. Due to this unfortunate development, the authors request that the paper be retracted. We all entered this collaboration to contribute in good faith and at a time of great need during the COVID-19 pandemic. We deeply apologise to you, the editors, and the journal readership for any embarrassment or inconvenience that this may have caused.
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              Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality

              The unprecedented global social and economic crisis triggered by the COVID-19 pandemic poses grave risks to the nutritional status and survival of young children in low-income and middle-income countries (LMICs). Of particular concern is an expected increase in child malnutrition, including wasting, due to steep declines in household incomes, changes in the availability and affordability of nutritious foods, and interruptions to health, nutrition, and social protection services. 1 One in ten deaths among children younger than 5 years in LMICs is attributable to severe wasting because wasted children are at increased risk of mortality from infectious diseases. 2 Before the COVID-19 pandemic, an estimated 47 million children younger than 5 years were moderately or severely wasted, most living in sub-Saharan Africa and south Asia. 3 The economic, food, and health systems disruptions resulting from the COVID-19 pandemic are expected to continue to exacerbate all forms of malnutrition. Estimates from the International Food Policy Research Institute suggest that because of the pandemic an additional 140 million people will be thrown into living in extreme poverty on less than US$1·90 per day in 2020. 4 According to the World Food Programme, the number of people in LMICs facing acute food insecurity will nearly double to 265 million by the end of 2020. 5 Sharp declines are expected in access to child health and nutrition services, similar to those seen during the 2014–16 outbreak of Ebola virus disease in sub-Saharan Africa. 6 Early in the COVID-19 pandemic, UNICEF estimated a 30% overall reduction in essential nutrition services coverage, reaching 75–100% in lockdown contexts, including in fragile countries where there are humanitarian crises. 7 The accompanying call to action on child malnutrition and COVID-19 from leaders of four UN agencies 8 in The Lancet is an important first step for the international community. Alongside these efforts, the Standing Together for Nutrition consortium, a multidisciplinary consortium of nutrition, economics, food, and health systems researchers, is working to estimate the scale and reach of nutrition challenges related to COVID-19. These efforts link three approaches to model the combined economic and health systems impacts from COVID-19 on malnutrition and mortality: MIRAGRODEP's macroeconomic projections of impacts on per capita gross national income (GNI); 4 microeconomic estimates of how predicted GNI shocks impact child wasting using data on 1·26 million children from 177 Demographic Health Surveys (DHS) conducted in 52 LMICs between 1990–2018; 9 and the Lives Saved Tool (LiST), which links country-specific health services disruptions and predicted increases in wasting to child mortality. 10 What do our initial analyses and estimates suggest? First, the MIRAGRODEP projections suggest that even fairly short lockdown measures, combined with severe mobility disruptions and comparatively moderate food systems disruptions, result in most LMICs having an estimated average 7·9% (SD 2·4%) decrease in GNI per capita relative to pre-COVID-19 projections. 4 Second, the microeconomic model projections indicate that decreases in GNI per capita are associated with large increases in child wasting. 9 Our own analyses, based on these estimates applied to 118 LMICs, suggest there could be a 14·3% increase in the prevalence of moderate or severe wasting among children younger than 5 years due to COVID-19-related predicted country-specific losses in GNI per capita. We estimate this would translate to an additional estimated 6·7 million children with wasting in 2020 compared with projections for 2020 without COVID-19; an estimated 57·6% of these children are in south Asia and an estimated 21·8% in sub-Saharan Africa. © 2020 Reuters/Jorge Cabrera 2020 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. Third, when the projected increase in wasting in each country is combined with a projected year average of 25% reduction in coverage of nutrition and health services, we estimate there would be 128 605 (ranging from 111 193 to 178 510 for best and worst case scenarios) additional deaths in children younger than 5 years during 2020, with an estimated 52% of these deaths in sub-Saharan Africa. The range reflects coverage scenarios, as previously described by Roberton and colleagues, 10 using a low of 15% and high of 50% disruption in vitamin A supplementation, treatment of severe wasting, promotion of improved young child feeding, and provision of micronutrient supplements to pregnant women. Our projections emphasise the crucial need for the actions to protect child nutrition that are urged by the UN leaders in the accompanying Comment. 8 These actions require rapid mobilisation of domestic and donor resources at a time when most national economies are reeling from COVID-19-related losses. In 2017, the Word Bank estimated that $7 billion per year over 10 years is needed to reach the global Sustainable Development Goal nutrition targets. 11 These estimates need to be revised upwards to overcome COVID-19-related setbacks. The COVID-19 pandemic is expected to increase the risk of all forms of malnutrition. The wasting-focused estimates we present here are likely to be conservative, given that the duration of this crisis is unknown, and its full impacts on food, health, and social protection systems are yet to be realised. The disruption of other health services during lockdowns will further compromise maternal and child health and mortality, 10 and with the deepening of economic and food systems crises, other forms of malnutrition, including child stunting, micronutrient malnutrition, and maternal nutrition, are expected to increase. 1 Without adequate action, the profound impact of the COVID-19 pandemic on early life nutrition could have intergenerational consequences for child growth and development and life-long impacts on education, chronic disease risks, and overall human capital formation. 12 Forthcoming analyses by this consortium will examine a range of diet and nutrition outcomes in women and young children and provide consensus advice on multisectoral actions and resources needed to recover and support optimal nutrition now and into the future.
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                Author and article information

                Contributors
                (View ORCID Profile)
                Journal
                Academicus International Scientific Journal
                Academicus Journal
                20793715
                23091088
                January 2021
                January 2021
                : 23
                : 21-40
                Affiliations
                [1 ]Department of Sociology and Criminology, Cleveland State University, Ohio, USA
                Article
                10.7336/academicus.2021.23.02
                e8d697e8-c1f2-43a4-bec3-90a8cc8d30a0
                © 2021

                https://creativecommons.org/licenses/by-nc-nd/4.0/

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