Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic

United States, June 24-30, 2020

Mark É. Czeisler; Rashon I. Lane MA; Emiko Petrosky, MD; Joshua F. Wiley, PhD; Aleta Christensen, MPH; Rashid Njai, PhD; Matthew D. Weaver, PhD; Rebecca Robbins, PhD; Elise R. Facer-Childs, PhD; Laura K. Barger, PhD; Charles A. Czeisler, MD, PhD; Mark E. Howard, MBBS, PhD; Shantha M.W. Rajaratnam, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(32):1049-1057. 

In This Article

Abstract and Introduction

Introduction

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.

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.

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).

*https://www.medrxiv.org/content/10.1101/2020.04.22.20076141v1.
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.
§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.
Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential versus nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.
**A minimum age of 18 years and residence within the United States as of April 2–8, 2020, were required for eligibility for the longitudinal cohort to complete a survey during June 24–30, 2020. Residence was reassessed during June 24–30, 2020, and one respondent who had moved from the United States was excluded from the analysis. A minimum age of 18 years and residence within the United States were required for eligibility for newly recruited respondents included in the cross-sectional analysis. For both the longitudinal cohort and newly recruited respondents, respondents were required to provide informed consent before enrollment into the study. All surveys underwent data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Respondents who failed an attention or speed check, along with any responses identified by the data-scrubbing algorithms, were excluded from analysis.
††The surveys contained 101 items for first-time respondents and 86 items for respondents who also participated in later surveys, with the 15 additional items for first-time respondents consisting of questions on demographics. The survey instruments included a combination of individual questions, validated questionnaires, and COVID-19-specific questionnaires, which were used to assess respondent attitudes, behaviors, and beliefs related to COVID-19 and its mitigation, as well as the social and behavioral health impacts of the COVID-19 pandemic.
§§ https://www.qualtrics.com/.
¶¶Survey weighting was implemented according to the 2010 U.S. Census with respondents who reported gender, age, and race/ethnicity. 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 these respective disorders. This instrument was included in the April, May, and June surveys.
†††Symptoms of a TSRD attributed to 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. This instrument was included in the May and June surveys only.
§§§For this survey, substance use was defined as use of "alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor." Questions regarding substance use and suicidal ideation were included in the May and June surveys only. Participants were informed that responses were deidentified and that direct support could not be provided to those who reported substance use behavior or suicidal ideation. Regarding substance use, respondents were provided the following: "This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the Substance Abuse and Mental Health Services Administration National Helpline, 1–800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1–800-487-4889. This is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for persons and family members facing mental and/or substance use disorders." Regarding suicidal ideation, respondents were provided the following: "This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the National Suicide Prevention Lifeline, 1-800-273-TALK (8255, or chat line) for help for themselves or others."
¶¶¶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.
****Odds of incidence was defined as the odds of the presence of an adverse mental or behavioral health outcome reported during a later survey after previously having reported the absence of that outcome (e.g., having reported symptoms of anxiety disorder during June 24–30, 2020, after not having reported symptoms of anxiety disorder during April 2–8, 2020).
††††Adjusted for gender, employment status, and essential worker status or unpaid adult caregiver status.

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