Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults

Abstract

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 U.S. 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.

Funding: CLIMB Time 1 was sponsored by the Rockefeller Foundation-Boston University 3-D Commission. CLIMB Time 2 was sponsored by the de Beaumont Foundation.

Keywords: Depression; Economic inequities; Low-income; Mental Health; Stressors; Wealth.

Figure 1

Distribution of depressive symptoms scores before the COVID-19 pandemic (2017-2018), at the start of COVID-19 (March-April 2020), and one year into the COVID-19 pandemic (March-April 2021). Note: Depression symptoms measured using the Patient Health Questionnaire–9 (PHQ-9). Source: CLIMB: COVID19 and Life Stressors Impact on Mental Health and Well-being study. 2020 data: Time 1 collected from March 31, 2020, to April 13, 2020. 2021 data: Time 2 collected from March 24, 2021 to April 19, 2021. 2017-2018 data: National Health and Nutrition Examination Survey (NHANES). Relevant survey weights used to calculate percentages.

Figure 2

Prevalence of elevated depressive symptoms across time by exposure to COVID-19 related stressors in Spring 2021. Note: (a) T2 survey weights used to calculate percentages. (b) Low stressor count (0-1), Medium stressor count (2-3), High stressor count (4 or more) defined by presence of: seeing family in person less, travel restrictions, death of someone close to you due to COVID-19, family or relationship problems, challenges finding childcare for your kids, feeling alone, not being able to get food due to shortages, not being able to get supplies due to shortages, losing a job, member of household losing a job, having financial problems, having difficulty paying rent, and being forced to leave campus. (c) Elevated depressive symptoms defined by Patient Health Questionnaire–9 (PHQ-9) score of 10 or greater. (d) Data source: COVID-19 and Life Stressors Impact on Mental Health and Well-being study. Time 1 collected from March 31, 2020, to April 13, 2020. Time 2 collected from March 24, 2021 to April 19, 2021.