Almost a third (32.8%) of US adults experienced elevated depressive symptoms in 2021, compared to 27.8% at the start of the pandemic in 2020, and 8.5% before the pandemic, found a nationally representative longitudinal study in The Lancet Regional Health – Americas.
The study, by the Boston University School of Public Health, found that the main drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during pandemic. The findings underscore the inextricable link between the pandemic and its short and long-term impact on population mental health, write the authors.
“The sustained high prevalence of depression does not follow patterns after previous traumatic events like Hurricane Ike and the Ebola outbreak,” said study senior author Sandro Galea, dean, and Professor Robert Knox. “Typically, we would expect depression to peak after the traumatic event, and then lower over time. Instead, we found that 12 months into the pandemic, levels of depression remained high.”
The study is the first nationally-representative study in the US to examine the change in depression prevalence before and during COVID, using the Patient Health Questionnaire-9 (PHQ 9), the leading self-administered depression screening tool.
The researchers used data from 5,065 respondents to the 2017-2018 National Health and Nutrition Examination Survey (NHANES), as well as from respondents to two COVID-19 Life Stressors Impact on Mental Health and Well-Being (CLIMB) surveys. The first survey included 1,441 respondents and was conducted from 31 March to 13 April 2020, when most of the US population was under stay-at-home advisories. The second survey took place with the same group one year later, from 23 March to 19 April 2021, and included 1,161 respondents.
Both surveys used the PHQ 9 to assess depression symptoms and gathered the same demographic data, and the CLIMB surveys also gathered data on COVID-related stressors such as job loss, the death of a loved one due to COVID, financial problems, feeling alone, and a lack of childcare.
The survey responses suggested that the burden of depression intensified over the pandemic and disproportionately affected adults with lower incomes. When adjusting for other demographics, people making less than $20,000 in spring 2020 were 2.3 times more likely to experience elevated depressive symptoms, compared with people making $75,000 or more; by spring 2021, low-income adults were more than seven times as likely to experience these symptoms.
Although population-level stressors decreased overall during the first year of the pandemic, people with four or more stressors were more likely to also experience elevated depressive symptoms, and least likely to overcome those.
“The sustained and increasing prevalence of elevated depressive symptoms suggests that the burden of the pandemic on mental health has been ongoing—and that it has been unequal,” said study lead author Catherine Ettman, doctoral candidate at Brown University School of Public Health and chief of staff and director of strategic initiatives in the Office of the Dean. She added that economic relief and the development of COVID-19 vaccines might have prevented even worse depression outcomes.
“Low-income populations have been disproportionately affected by the pandemic and efforts should keep this population in mind. Addressing stressors like job loss, challenges accessing childcare, and difficulties paying rent, will help to improve population mental health and reduce inequities that have deepened during the pandemic.”
Study details
Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of US adults
Catherine Ettman, Gregory Cohen, Salma Abdalla, Laura Sampson, Ludovic Trinquart, Brian Castrucci, Rachel Bork, Melissa Clark, Ira Wilson, Patrick Vivier, Sandro Galea.
Published in The Lancet Regional Health – Americas on 4 October 2021
Summary
Background
The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms.
Methods
Longitudinal panel study of a nationally representative group of U.S. adults ages 18 years and older surveyed in March-April 2020 (Time 1; N=1441) and March-April 2021 (Time 2; N=1161) in the COVID-19 and Life Stressors Impact on Mental Health and Well-being study (CLIMB). The Patient Health Questionnaire-9 (PHQ-9) was used to define elevated depressive symptoms (cut-off ≥10) and depressive symptoms score (0-27).
Findings
The prevalence of elevated depressive symptoms persisted from 27.8% in 2020 (95% CI: 24.9, 30.9) to 32.8% in 2021 (95% CI: 29.1, 36.8). Over time, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low income relative to high-income persons increased from 2.3 (95% CI: 1.2, 4.2) in 2020 to 7.0 (95% CI: 3.7, 13.3) in 2021. Fewer people reported experiencing 4 or more COVID-19 stressors in 2021 than in 2020 (47.5% in 2020 vs 37.1% in 2021), but the odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 (95% CI: 1.2, 3.1) in 2020 to 5.4 (95% CI: 3.2, 9.2) in 2021.
Interpretation
The burden of depressive symptoms in the US adult population increased over the course of the COVID-19 pandemic. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic.
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