A hidden pandemic? An umbrella review of global evidence on mental health in the time of COVID-19

Abstract

Background: The mental health impacts of the COVID-19 pandemic remain a public health concern. High quality synthesis of extensive global literature is needed to quantify this impact and identify factors associated with adverse outcomes.

Methods: We conducted a rigorous umbrella review with meta-review and present (a) pooled prevalence of probable depression, anxiety, stress, psychological distress, and post-traumatic stress, (b) standardised mean difference in probable depression and anxiety pre-versus-during the pandemic period, and (c) comprehensive narrative synthesis of factors associated with poorer outcomes. Databases searched included Scopus, Embase, PsycINFO, and MEDLINE dated to March 2022. Eligibility criteria included systematic reviews and/or meta-analyses, published post-November 2019, reporting data in English on mental health outcomes during the COVID-19 pandemic.

Findings: Three hundred and thirty-eight systematic reviews were included, 158 of which incorporated meta-analyses. Meta-review prevalence of anxiety symptoms ranged from 24.4% (95%CI: 18-31%, I ²: 99.98%) for general populations to 41.1% (95%CI: 23-61%, I ²: 99.65%) in vulnerable populations. Prevalence of depressive symptoms ranged from 22.9% (95%CI: 17-30%, I ²: 99.99%) for general populations to 32.5% (95%CI: 17-52%, I ²: 99.35) in vulnerable populations. Prevalence of stress, psychological distress and PTSD/PTSS symptoms were 39.1% (95%CI: 34-44%; I ²: 99.91%), 44.2% (95%CI: 32-58%; I ²: 99.95%), and 18.8% (95%CI: 15-23%; I ²: 99.87%), respectively. Meta-review comparing pre-COVID-19 to during COVID-19 prevalence of probable depression and probable anxiety revealed standard mean differences of 0.20 (95%CI = 0.07-0.33) and 0.29 (95%CI = 0.12-0.45), respectively.

Conclusion: This is the first meta-review to synthesise the longitudinal mental health impacts of the pandemic. Findings show that probable depression and anxiety were significantly higher than pre-COVID-19, and provide some evidence that that adolescents, pregnant and postpartum people, and those hospitalised with COVID-19 experienced heightened adverse mental health. Policymakers can modify future pandemic responses accordingly to mitigate the impact of such measures on public mental health.

Keywords: COVID-19; epidemiology; mental health; meta-review; psychopathology; public mental health; review; umbrella review.

Figure 1

PRISMA diagram. PRISMA flow diagram outlining the progression of the 5-phase systematic search undertaken to retrieve articles examining the impact of COVID-19 on mental health outcomes. Phase 1: The initial search across four databases (Scopus, Embase, PsycINFO, MEDLINE) yielded 6,029 records, of which 1,888 articles were identified as duplicates, and removed before screening commenced. Phase 2: The titles and abstracts of 4,141 records were screened for relevance, which led to 3,361 records being excluded. Phase 3: Subsequently, 780 articles underwent full-text screening, with 442 records removed prior to quality appraisal. Phase 4: Of the 338 reviews assessed for quality using the AMSTAR-2 critical appraisal tool, 313 records were excluded from the narrative synthesis, and 255 records were excluded from the meta-review. Phase 5: Twenty-five records were included in the narrative synthesis, comprising 14 systematic reviews, 8 combined systematic reviews and meta-analyses, and 3 meta-analyses. There were 84 records included in the meta-review consisting of 67 combined systematic reviews and meta-analyses and 16 meta-analyses. n, number of records; SR, systematic review; MA, meta-analysis; SR + MA, systematic review and meta-analysis; AMSTAR-2, Assessment of Multiple Systematic Reviews Revised; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Meta-review of pooled prevalence of depression. Displays the forest plots of probable depression prevalence (and 95% CIs) across all subgroups.

Figure 3

Meta-review of pooled prevalence of anxiety. The forest plots of probable anxiety prevalence (with 95% CIs) across all subgroups.

Figure 4

Meta-reviews of pooled prevalence of stress and psychological distress. The forest plots of the pooled prevalence (and 95% CIs) for stress across the general population, healthcare workers (HCW), pregnant and postpartum people, and young people (above) and psychological distress amongst the general population, HCW, and pregnant and postpartum people (below).

Figure 5

Meta-review of pooled prevalence of PTSD/PTSS. The forest plots of the prevalence (and 95% CIs) of probable post-traumatic stress disorder (PTSD) combined with post-traumatic stress symptoms (PTSS) (PTSD/PTSS) across all subgroups.

Figure 6

Meta-review of pooled standardised mean difference comparing COVID-19 to pre-COVID-19 levels. The forest plots of pooled standardised mean difference (SMD) comparing COVID-19 levels to pre-COVID-19 levels for probable depression, anxiety, and other mental disorders across all subgroups. The 95%CI is indicated by the rightmost, and leftmost points of the diamond.

Figure 7

Diagrammatic representation of factors associated with adverse mental health outcomes during the COVID-19 period, as identified through narrative synthesis. A diagrammatic representation of the factors associated with adverse mental health in the COVID-19 period, as identified through narrative synthesis. The key has color coding for population group in which the association was investigated. The stars show the level of confidence in the findings, based off the Synthesis Without Meta-analysis (SWiM) method, in addition to the AMSTAR-2 quality appraisal.