1
Mental health outcomes and associations during the coronavirus disease 2019 pandemic: A
cross-sectional survey of the US general population
Bella Nichole Kantor;
1
Jonathan Kantor, MD, MSCE, MA
2,3,4,5*
1. Harvard Extension School, Harvard University, Cambridge, MA, 02138 USA
2. Center for Global Health, University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, 19104 USA
3. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School
of Medicine, Philadelphia, PA, 19104 USA
4. Department of Dermatology, University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, 19104 USA
5. Florida Center for Dermatology, P.A., St Augustine, FL, 32080 USA
Abstract
Pandemic coronavirus disease 2019 (COVID-19) may lead to significant mental health stresses,
potentially with modifiable risk factors. To determine the presence of and magnitude of
associations between baseline associations and anxiety and depression in the US general
population, we performed an internet-based cross-sectional survey of an age-, sex-, and race-
stratified representative sample from the US general population. Degrees of anxiety,
depression, and loneliness were assessed using the 7-item Generalized Anxiety Disorder scale
(GAD-7), the 9-item Patient Health Questionnaire (PHQ-9), and the 8-item UCLA Loneliness
Scale, respectively. Unadjusted and multivariable logistic regression analyses were performed
to determine associations with baseline demographic characteristics. A total of 1,005 finished
surveys were returned of the 1,020 started, yielding a completion rate of 98.5% in the survey
panel. The mean (SD) age of respondents was 45 (16), and 494 (48.8%) were male. Baseline
demographic data were similar between those that were (n=663, 66.2%) and were not (n=339,
33.8%) under a shelter in place/ stay at home order, with the exception of sex and geographic
location. Overall, 264 subjects (26.8%) met criteria for an anxiety disorder based on a GAD-7
cutoff of 10; a cutoff of 7 yielded 416 subjects (41.4%) meeting clinical criteria for anxiety. On
multivariable analysis, male sex (OR 0.65, 95% CI [0.49, 0.87]) and living in a larger home (OR
0.46, 95% CI [0.24, 0.88]) were associated with a decreased odds of meeting anxiety criteria.
Rural location (OR 1.39, 95% CI [1.03, 1.89]), loneliness (OR 4.92, 95% CI [3.18, 7.62]), and
history of hospitalization (OR 2.04, 95% CI [1.38, 3.03]), were associated with increased odds of
meeting anxiety criteria. 232 subjects (23.6%) met criteria for clinical depression. On
multivariable analysis, male sex (OR 0.71, 95% CI [0.53, 0.95]), increased time outdoors (OR
0.51, 95% CI [0.29, 0.92]), and living in a larger home (OR 0.35, 95% CI [0.18, 0.69]), were
associated with decreased odds of meeting depression criteria. Having lost a job (OR 1.64, 95%
CI [1.05, 2.54]), loneliness (OR 10.42, 95% CI [6.26, 17.36]), and history of hospitalization (OR
2.42, 95% CI [1.62, 3.62]), were associated with an increased odds of meeting depression
criteria. Income, media consumption, and religiosity were not associated with mental health
outcomes. Anxiety and depression are common in the US general population in the context of
the COVID-19 pandemic, and are associated with potentially modifiable factors.
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NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
2
Mental health outcomes and associations during the coronavirus disease 2019 pandemic: A
cross-sectional survey of the US general population
The Coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented levels of
movement restriction, job losses, and economic uncertainty in the United States and around
the world.
1
Concerns regarding illness, death, and the death of loved ones may be compounded
by financial uncertainty, as reports of mass unemployment with variable international
governmental responses circulate.
2
Mental health outcomes have been associated with pandemics in the past.
3-5
While there has
been a rapid response to the COVID-19 pandemic in terms of nonpharmaceutical interventions,
vaccine development, and medical support, little comprehensive planning has been performed
to predict and respond to the possible mental health crisis that could emerge from the
pandemic, and the only data available on general public responses to the pandemic are in
Chinese populations.
6,7
These data are echoed by recent research that has suggested that
healthcare workers have a significant burden of mental health challenges in the face of COVID-
19.
8
Moreover, pandemics and other natural disasters may disproportionately affect those with
underlying mental illness.
9
We therefore sought to investigate the prevalence of anxiety and depression in the general US
population in the context of the early COVID-19 pandemic, and explore associations of these
mental health outcomes with loneliness (of particular concern given enhanced social distancing
and isolation), health status, socioeconomic status, residence size, time spent outdoors, and
other baseline demographic characteristics. A better understanding of the prevalence of these
mental health outcomes and their putative risk factors may help guide public policy in
establishing improved guidelines for those required to stay at home.
Methods
Study Design
This study is a cross-sectional, internet-based survey performed via age, sex, and race
stratification, conducted between March 29, 2020 and March 31, 2020. Responses to all survey
questions were recorded (Supplemental file). This study was deemed exempt by the Ascension
Health institutional review board.
We developed an online survey using the Qualtrics platform (Qualtrics Corp, Provo, Utah) after
iterative online pilot testing. The survey was distributed to a representative sample of the US
population using Prolific Academic (Oxford, United Kingdom), an established platform for
academic survey research.
10
Respondents were rewarded with a small payment (<US$1).
Participants provided consent and were permitted to terminate the survey at any time. All
surveys were anonymous and confidential, with linkages between data performed using a 24-
character alphanumeric code. The investigators had no access to identifying information at any
time.
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 28, 2020. ; https://doi.org/10.1101/2020.05.26.20114140doi: medRxiv preprint
3
Participants
This internet-based survey was stratified by age, sex, and race to reflect the makeup of the
general US population. Sample size calculations were conducted for the primary endpoint of
detecting a 10% difference in the Generalized Anxiety Disorder-7 scale (GAD-7) between those
that were and were not under a stay at home order at the time of survey completion. 682
subjects (341 per group) would be adequate to detect a 10% change in GAD-7 with 80% power
and with an alpha of 0.05, assuming a baseline GAD-7 mean of 11.6 with a standard deviation
of 5.4 and assuming equal group sizes.
11
We inflated our sample size to 1,000 given that
approximately 2/3 of the US was under stay at home orders at the time of survey initiation and
given uncertainty regarding changes in those orders over the duration of the survey, as well as
to permit subgroup analyses.
Outcome Measures
Demographic information was self-reported by respondents. Responses to a battery of
questions regarding attitudes to the COVID-19 pandemic, were collected using Likert scales.
For our main outcome measures, anxiety and depression, validated scales were used. Anxiety
was assessed using the GAD-7, a validated self-report scale for anxiety, with scores ranging
from 0 (no anxiety) to 21 (extreme anxiety). Prior psychometric research suggested cutoffs as 0-
4 (no anxiety); 5-9 (mild anxiety); 10-14 (moderate anxiety); and 15-21 (severe anxiety).
8,11
Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9), a validated measure
for clinical depression.
12
Scores range from 0 (no depression) to 27 (severe depression). Prior
psychometric research has suggested cutoffs as 0-4 (no depression); 5-9 (mild depression); 10-
14 (moderate depression); and 15-27 (severe depression).
8,13
Loneliness was quantified with the UCLA short-form loneliness scale (ULS-8), a validated
measure of loneliness.
14
Scores range from 8 (no loneliness) to 32 (extreme loneliness); no
clinically meaningful cutoffs have been established psychometrically.
Statistics
Normally distributed baseline demographic data are presented as mean values with 95%
confidence intervals (CI). Outcomes that were not normally distributed are presented as
medians with interquartile ranges (IQR). T-tests and chi-squared tests were used as appropriate
for baseline continuous and categorical variables. Subgroup comparisons of non-normally
distributed data were performed using the Kruskal Wallis test. Unadjusted and multivariable
(adjusting for age and sex, which are not modifiable confounders) logistic regression odds ratios
of association were assessed between the dependent variables of anxiety or depression,
presented as dichotomous outcomes using the established cutoffs of 10 for both the GAD-7 and
PHQ-9, and putative risk factors.
All statistical analyses were performed using Stata 13 for Mac (Stata Corporation, College
Station, Texas).
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 28, 2020. ; https://doi.org/10.1101/2020.05.26.20114140doi: medRxiv preprint
4
Results
Baseline Characteristics
Of the 1,020 subjects who were recruited, 1,005 finished the survey, yielding a completion rate
of 98.5%. The mean (SD) age of respondents was 45 (16), and 494 (48.8%) of the respondents
were male; baseline respondent characteristics are outlined in Table 1. Baseline demographic
data were similar between those that were (n=663, 66.2%) and were not (n=339, 33.8%) under
a shelter in place or stay at home order, with the exception of sex and geographic location
(urban versus rural status). The median (IQR) ULS-8 score for loneliness was 16 (8), similar to
baseline estimates from previous studies.
14-16
Anxiety
The median (IQR) GAD-7 score was 5 (9), and 513 subjects (52.1%) of subjects had at least mild
anxiety. Overall, 264 subjects (26.8%) met criteria for an anxiety disorder based on a GAD-7
cutoff of 10 (Table 2). Adopting a more liberal GAD-7 cutoff of 7, as used in a recent study on
healthcare worker anxiety in the COVID-19 context,
8
would yield 416 subjects (41.4%) meeting
clinical criteria for anxiety. Women (p=0.002) and those living in rural areas (p=0.041), reported
more severe anxiety than men and those in urban areas, respectively.
Unadjusted logistic regression analysis demonstrated that men were less likely to meet criteria
for anxiety (OR 0.67, 95% CI [0.51, 0.89]) while those who lost their job (OR 1.61, 95% CI [1.45,
2.45]), had been hospitalized within the past 2 years (OR 1.86, 95% CI [1.27, 2.73]), or were in
the most lonely quartile (OR 5.39, 95% CI [3.53, 8.24]), were more likely to meet criteria for
anxiety. On multivariable analysis controlling for age and sex as confounders, male sex (OR
0.65, 95% CI [0.49, 0.87]), and living in a larger home (OR 0.46, 95% CI [0.24, 0.88]) were
associated with a decreased odds of meeting anxiety criteria. Rural location (OR 1.39, 95% CI
[1.03, 1.89]), loneliness (OR 4.92, 95% CI [3.18, 7.62]), and history of hospitalization within the
past 2 years (OR 2.04, 95% CI [1.38, 3.03]), were independent risk factors for meeting anxiety
criteria (Table 3).
Depression
The median (IQR) PHQ-9 score was 4 (8), and 465 (47.3%) of subjects reported at least mild
depression by screening (Table 2). A total of 232 subjects (23.6%) met criteria for clinical
depression. Women (p=0.008) and unmarried subjects (p<0.0001) reported more severe
depression than men and those who are married, respectively.
Unadjusted logistic regression analysis demonstrated that men were less likely to meet criteria
for depression (OR 0.73, 95% CI [0.55, 0.98]), while those who lost their job (OR 1.74, 95% CI
[1.13, 2.67]), had been hospitalized within the past 2 years (OR 2.16, 95% CI [1.47, 3.17]), or
were in the most lonely quartile (OR 11.90, 95% CI [7.21, 19.65]), were more likely to meet
criteria for depression. On multivariable analysis controlling for age and sex as confounders,
male sex (OR 0.71, 95% CI [0.53, 0.95]), increased time outdoors (OR 0.51, 95% CI [0.29, 0.92]),
and living in a larger home (OR 0.35, 95% CI [0.18, 0.69]) were associated with a decreased odds
of meeting depression criteria. Having lost a job (OR 1.64, 95% CI [1.05, 2.54]), loneliness (OR
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 28, 2020. ; https://doi.org/10.1101/2020.05.26.20114140doi: medRxiv preprint
5
10.42, 95% CI [6.26, 17.36]), and history of hospitalization within the past 2 years (OR 2.42, 95%
CI [1.62, 3.62]), were associated with meeting depression criteria (Table 3).
Discussion
In this first study of general US population mental health during the COVID-19 pandemic, we
found high baseline levels of both anxiety and depression, independent of living under a shelter
in place or stay at home order. More than half (52.1%) of respondents had at least mild anxiety,
and 47.3% of subjects had at least mild depressive symptoms. Adopting the cutoff of 7 on the
GAD-7 score for anxiety, as used in a recent study on COVID-19, would yield 416 subjects
(41.4%) meeting clinical criteria for anxiety. This high burden of mental health concerns in the
general population in the pandemic context suggests the need for further study and
consideration for intervention.
Living in a larger home was associated with a reduced risk of both anxiety and depression; this
effect was seen despite the lack of any association between anxiety or depression and
household income and persisted when including income and number of household members
into a multivariable model. Similarly, we found that increased time spent outdoors correlated
with a reduction in depression (but not anxiety) risk, and those that spent more than an hour a
day outdoors had approximately half the risk of depression as those that spent no time
outdoors. This association of depression with time outdoors echoes prior research on access to
green space access and its impact on mental health.
17
Our finding that both larger living space
and increased time spent outdoors correlate with a reduction in mental health burden may
have actionable implications for public health initiatives and decisions regarding access to
outdoor recreation areas during stay at home or shelter in place orders.
History of hospitalization, a rough measure of overall health status, was associated with an
increased risk of both anxiety and depression. This effect persisted even when controlling for
age and history of anxiety and depression, respectively, suggesting that those with a poorer
health status may be at increased risk of adverse mental health outcomes in the context of the
COVID-19 pandemic.
Media consumption, measured by the number of hours spent watching or reading about the
pandemic, was not associated with the presence of anxiety or depression. Similarly, we did not
detect significant associations between likelihood of meeting criteria for anxiety or depression
and household income or religiosity on adjusted multivariable analyses.
Notably, we found that less than half of respondents had no anxiety; that is, more than half of
subjects reported a level of anxiety that would at least be classified as mild. Conversely, 13.4%
of subjects demonstrated severe anxiety, a higher proportion than has been reported even in
healthcare workers responding to pandemic COVID-19.
8
Loneliness is an established risk factor for both anxiety and depression,
15,18
and we found an
approximately 5- to 10-fold increase in odds of anxiety and depression, respectively, with being
in the highest loneliness quartile. As with those living in smaller homes with minimal access to
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 28, 2020. ; https://doi.org/10.1101/2020.05.26.20114140doi: medRxiv preprint
