To the Editor:
COVID-19 disproportionately affected individuals from Black, Asian, and Minority Ethnic (BAME) backgrounds, with increased infection rates, higher illness severity, and mortality. Research before the COVID-19 pandemic also highlighted increased mental health needs and other significant health inequalities, complex comorbidities, and socioeconomic inequities within BAME populations.1 , 2 It is therefore imperative to understand the impact of COVID-19 on mental health for older BAME populations, who have been woefully underrepresented in studies examining the effects of the pandemic. We report findings from a cross-sectional study investigating loneliness, depression, anxiety, and key mediating factors across ethnic populations in the United Kingdom during the COVID-19 pandemic.
The data were collected as part of the E-BAME longitudinal online questionnaire study, launched October 2020. The cohort included healthy adults aged 40 or older across different ethnic groups. The data reported demographics and health outcomes (depression, anxiety, and loneliness) using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and the UCLA 3-item loneliness scale,3, 4, 5 using the Mann-Whitney and linear regression analysis.
The cohort included 191 individuals from Afro-Caribbean (24%), Asian (31%), Mixed (27%), and White (18%) backgrounds, with mean age 62 (SD 12.99, range 41–98), including 71% female participants. The number of people reporting loneliness (P < .001) and depression (P = .008) was significantly higher among BAME cohorts, as compared with Whites, and there was a nonsignificant increase in the frequency of anxiety in the BAME participants (P = .055). Loneliness was a key factor predicting depression (P = .008) (See Table 1).
Table 1.
Loneliness, Depression, and Anxiety Across Various Ethnic Groups With Mann-Whitney
| Ethnicity, n (%) | |||||||
|---|---|---|---|---|---|---|---|
| Afro-Caribbean | Asian | Mixed | BAME Overall | White | Prob > |z| | ||
| UCLA Score (Loneliness) | |||||||
| Hardly as Ever | 25 (55.56) | 28 (47.46) | 26 (50.00) | 79 (50.64) | 27 (77.14) | ||
| Sometimes | 14 (31.11) | 19 (32.20) | 19 (36.24) | 52 (33.33) | 8 (22.86) | P < .001 | |
| Often | 6 (13.33) | 12 (20.34) | 7 (13.46) | 25 (16.03) | 0 (0) | ||
| PHQ-9 Severity (Depression) | |||||||
| Minimum | 27 (60) | 37 (62.71) | 30 (57.69) | 94 (76.42) | 29 (82.86) | P = .008 | |
| Mild | 8 (17.78) | 7 (11.86) | 10 (19.23) | 25 (86.21) | 4 (11.43) | ||
| Moderate | 5 (11.11) | 8 (13.56) | 8 (15.38) | 21 (95.45) | 1 (2.86) | ||
| Moderate/Severe | 3 (6.67) | 3 (5.08) | 3 (5.77) | 9 (90) | 1 (2.86) | ||
| Severe | 2 (4.44) | 4 (6.78) | 1 (1.92) | 7 (100) | 0 (0) | ||
| GAD-7 Severity (Anxiety) | |||||||
| Minimum | 30 (66.67) | 39 (66.10) | 38 (73.08) | 107 (68.59) | 30 (85.71) | ||
| Mild | 8 (17.78) | 9 (15.25) | 10 (19.23) | 27 (17.31) | 2 (5.71) | P = .055 | |
| Moderate | 5 (11.11) | 6 (10.17) | 3 (5.77) | 14 (8.97) | 2 (5.71) | ||
| Severe | 2 (4.44) | 5 (8.47) | 1 (1.92) | 8 (5.13) | 1 (2.86) | ||
Mann-Whitney U test was chosen to investigate the difference between 2 groups: BAME and Whites in relation to anxiety, depression, and loneliness.
There were significantly higher levels of depression and loneliness reported by older people from Afro-Caribbean and Asian communities as compared with White individuals. Loneliness was found to be a key predictor of depression. Combating loneliness can be a key mediator in addressing the levels of depression in older adults from BAME communities, providing a vital opportunity for intervention development.
The BAME populations are one of the fastest aging communities in the United Kingdom,6 with increased risk of developing mental health challenges.7 , 8 COVID-19 has exacerbated these health inequalities more than ever before and highlighted the role of loneliness and limited access to appropriate support that can overcome specific communication barriers, cultural beliefs, and preferences. Individuals from BAME groups must cope with existing systemic inequalities, more frequent and severe encounters with COVID-19–related stressors, and mistrust in support services and practitioners.9 Individuals from BAME backgrounds may often feel less able to access community activities and support, with current support mechanisms as less suited to specific cultural and communication needs. Language barriers play a key role in building social connections, patient access, journey, and continuity of care. Other important facets such as stigma within these communities, could also affect levels of loneliness and access to help in these populations. Improving awareness around these key issues can be an essential guiding point for planning further interventions to better address the needs of individuals from underrepresented populations.
Although, current findings are limited to cross-sectional data, longitudinal data will help to identify the long-term effects of COVID-19, in addition to identifying key determinants of mental health in individuals from different ethnic communities. Ethnicity is a salient social identifier and there may be sensitive, yet important differences in key risk factors affecting mental health. Individuals from BAME populations are underrepresented in research and service use. Comprehensive, good-quality data are essential for enabling researchers, health professionals, and policymakers to identify and address the specific needs of different ethnic groups. Services can apply the knowledge gained to provide more nuanced care, educating on signs, symptoms, and support available, while increasing engagement and connection.10
Footnotes
This represents independent research sponsored by King's College London, originally funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. We acknowledge our research participants and community group leads, especially the 60-up community group for supporting our research.
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