Mental Distress in the United States at the Beginning of the COVID-19 Pandemic

Calliope Holingue, PhD, MPH; Luther G. Kalb, PhD; Kira E. Riehm, MSc; Daniel Bennett, PhD; Arie Kapteyn, PhD; Cindy B. Veldhuis, PhD; Renee M. Johnson, PhD, MPH; M. Daniele Fallin, PhD; Frauke Kreuter, PhD; Elizabeth A. Stuart, PhD; Johannes Thrul, PhD


Am J Public Health. 2020;110(11):1628-1634. 

In This Article

Abstract and Introduction


Objectives: To assess the impact of the COVID-19 pandemic on mental distress in US adults.

Methods: Participants were 5065 adults from the Understanding America Study, a probability-based Internet panel representative of the US adult population. The main exposure was survey completion date (March 10–16, 2020). The outcome was mental distress measured via the 4-item version of the Patient Health Questionnaire.

Results: Among states with 50 or more COVID-19 cases as of March 10, each additional day was significantly associated with an 11% increase in the odds of moving up a category of distress (odds ratio = 1.11; 95% confidence interval = 1.01, 1.21; P = .02). Perceptions about the likelihood of getting infected, death from the virus, and steps taken to avoid infecting others were associated with increased mental distress in the model that included all states. Individuals with higher consumption of alcohol or cannabis or with history of depressive symptoms were at significantly higher risk for mental distress.

Conclusions: These data suggest that as the COVID-19 pandemic continues, mental distress may continue to increase and should be regularly monitored. Specific populations are at high risk for mental distress, particularly those with preexisting depressive symptoms.


The United States has entered a new historical phase with the rapid spread of the novel coronavirus SARS-CoV-2 and deaths from COVID-19. Data from China suggest that the mental health impacts of COVID-19 are severe.[1] Thus far, there are little data on the mental health impact of the pandemic in the United States. This information is critical, as there is a robust literature on how public health crises, such as SARS or natural disasters, can lead to mental health challenges, including symptoms of acute stress, loneliness, anxiety, and depression.[2] Social distancing recommendations may further increase the likelihood of mental health symptoms, because isolation is known to have detrimental mental health effects.[3]

Early findings from China indicate the serious mental health impact of the COVID-19 pandemic. In one survey with 1210 participants conducted in January and February 2020, 54% rated the psychological impact of the COVID-19 pandemic as moderate to severe, 29% reported moderate-to-severe anxiety symptoms, 17% reported moderate-to-severe depressive symptoms, and 8% reported moderate-to-severe stress levels.[1] Another survey with 52 730 respondents in January and February 2020 reported that almost 35% of the sample experienced psychological distress.[4] This study also found regional differences in psychological distress, with respondents from Hubei province, the epicenter of the COVID-19 pandemic, reporting significantly higher distress. Moreover, people with preexisting mental disorders could be more heavily affected by the COVID-19 pandemic, including possible relapse or exacerbation of psychiatric conditions.[5]

There are marked mental health disparities in the United States that are likely to be exacerbated by this pandemic. For example, serious mental distress is more common in women and in those who are uninsured and is often comorbid with chronic somatic conditions.[6] In addition, those in higher income brackets have lower rates of serious mental distress.[6] Existing research has linked economic hardship with the incidence[7] and progression[8] of mental disorders. Difficulty with finances not only contributes to stress but also is a leading barrier to receiving mental health and substance use disorder treatment.[9] The COVID-19 pandemic has become intertwined with an economic crisis and has resulted in widespread job loss and economic downturn.[10] Information is needed to understand how shifting labor market outcomes, secondary to the COVID-19 pandemic, are potentially exacerbating mental health disparities across the United States. Research from China has already demonstrated that college students whose families had less stable incomes were at increased risk of mental distress because of COVID-19.[11]

The social isolation, financial hardship, and fear associated with COVID-19 could present a perfect storm for public mental health in the United States. Data are needed to track the impact of the COVID-19 pandemic on mental health, including identifying those in greatest need, to serve as evidence-based information for the public and to marshal resources across local, state, and federal agencies. The current study addresses this need by examining predictors of mental distress in a nationally representative household panel during a period of rapid spread of COVID-19 in the United States.