The Impact of the COVID-19 Pandemic and Associated Control Measures on the Mental Health of the General Population : A Systematic Review and Dose-Response Meta-analysis

Abstract

Background: To what extent the COVID-19 pandemic and its containment measures influenced mental health in the general population is still unclear.

Purpose: To assess the trajectory of mental health symptoms during the first year of the pandemic and examine dose-response relations with characteristics of the pandemic and its containment.

Data sources: Relevant articles were identified from the living evidence database of the COVID-19 Open Access Project, which indexes COVID-19-related publications from MEDLINE via PubMed, Embase via Ovid, and PsycInfo. Preprint publications were not considered.

Study selection: Longitudinal studies that reported data on the general population's mental health using validated scales and that were published before 31 March 2021 were eligible.

Data extraction: An international crowd of 109 trained reviewers screened references and extracted study characteristics, participant characteristics, and symptom scores at each timepoint. Data were also included for the following country-specific variables: days since the first case of SARS-CoV-2 infection, the stringency of governmental containment measures, and the cumulative numbers of cases and deaths.

Data synthesis: In a total of 43 studies (331 628 participants), changes in symptoms of psychological distress, sleep disturbances, and mental well-being varied substantially across studies. On average, depression and anxiety symptoms worsened in the first 2 months of the pandemic (standardized mean difference at 60 days, -0.39 [95% credible interval, -0.76 to -0.03]); thereafter, the trajectories were heterogeneous. There was a linear association of worsening depression and anxiety with increasing numbers of reported cases of SARS-CoV-2 infection and increasing stringency in governmental measures. Gender, age, country, deprivation, inequalities, risk of bias, and study design did not modify these associations.

Limitations: The certainty of the evidence was low because of the high risk of bias in included studies and the large amount of heterogeneity. Stringency measures and surges in cases were strongly correlated and changed over time. The observed associations should not be interpreted as causal relationships.

Conclusion: Although an initial increase in average symptoms of depression and anxiety and an association between higher numbers of reported cases and more stringent measures were found, changes in mental health symptoms varied substantially across studies after the first 2 months of the pandemic. This suggests that different populations responded differently to the psychological stress generated by the pandemic and its containment measures.

Primary funding source: Swiss National Science Foundation. (PROSPERO: CRD42020180049).

Appendix Figure.. Study flow diagram.

Figure 1.. Forest plot of SMDs of symptoms during the pandemic minus before the pandemic for anxiety and depression (A) and for other conditions, mental well-being, and life satisfaction (B).

Studies are ordered by days since the first recorded infection. CrI = credible interval; SMD = standardized mean difference; τ = heterogeneity SD.

Figure 1.. Continued

Figure 2.. Dose–response meta-analysis plots of SMDs for symptoms of anxiety and depression as a function of days since the first case in the study country (A), the stringency index (B), cumulative number of cases (C), and cumulative number of deaths (D).

Dark green shading indicates credible regions, and light green shading indicates prediction regions. SMD < 0 means that the symptoms worsen over time. SMD = standardized mean difference.