Mental Health Symptom Changes by Sex or Gender Before and During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Gabriel Chun Yin Sung; Yin Wu; Suiqiong Fan; Tiffany Dal Santo; Nadia P González-Domínguez; Ying Sun; Letong Li; Kexin Li; Xiaowen Jiang; Amina Tasleem; Yutong Wang; Jill T Boruff; Palak Desai; Brienne Tougas; Monica D’Onofrio; Ankur Krishnan; Claire Adams; Chen He; Richard S Henry; Afra Alkan; Danielle B Rice; Sarah Markham; Marleine Azar; Elsa-Lynn Nassar; Sophie Hu; Mara Cañedo-Ayala; Dipika Neupane; Andrea Benedetti; Brett D Thombs

doi:10.1001/jamanetworkopen.2026.27595

. 2026 Aug 6;9(8):e2627595. doi: 10.1001/jamanetworkopen.2026.27595

Mental Health Symptom Changes by Sex or Gender Before and During the COVID-19 Pandemic

A Systematic Review and Meta-Analysis

Gabriel Chun Yin Sung ¹, Yin Wu ^1,², Suiqiong Fan ¹, Tiffany Dal Santo ^1,³, Nadia P González-Domínguez ¹, Ying Sun ¹, Letong Li ¹, Kexin Li ¹, Xiaowen Jiang ¹, Amina Tasleem ¹, Yutong Wang ^1,⁴, Jill T Boruff ⁵, Palak Desai ¹, Brienne Tougas ¹, Monica D’Onofrio ^1,⁴, Ankur Krishnan ¹, Claire Adams ^1,³, Chen He ¹, Richard S Henry ^1,³, Afra Alkan ^1,⁴, Danielle B Rice ^6,⁷, Sarah Markham ⁸, Marleine Azar ¹, Elsa-Lynn Nassar ^1,⁹, Sophie Hu ^1,⁴, Mara Cañedo-Ayala ¹, Dipika Neupane ¹, Andrea Benedetti ^3,^10,¹¹, Brett D Thombs ^1,^3,^4,^11,^✉

¹Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada

²School of Public Health, Shanghai Jiao Tong University, Shanghai, China

³Department of Psychiatry, McGill University, Montreal, Quebec, Canada

⁴Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

⁵Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, Quebec, Canada

⁶Department of Psychology, St Joseph’s Healthcare, Hamilton, Ontario, Canada

⁷Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada

⁸Department of Biostatistics and Health Informatics, King’s College London, London, United Kingdom

⁹Department of Psychology, McGill University, Montreal, Quebec, Canada

¹⁰Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Quebec, Canada

¹¹Department of Medicine, McGill University, Montreal, Quebec, Canada

Accepted for Publication: June 15, 2026.

Published: August 6, 2026. doi:10.1001/jamanetworkopen.2026.27595

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License, which does not permit alteration or commercial use, including those for text and data mining, AI training, and similar technologies. © 2026 Sung GCY et al. JAMA Network Open.

^✉

Corresponding Author: Brett D. Thombs, PhD, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Cote Ste-Catherine, Pavilion H4.83, Montreal, QC H3T 1E2, Canada (brett.thombs@mcgill.ca).

Author Contributions: Drs Wu and Thombs had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Sung and Dr Wu were co–first authors. Drs Benedetti and Thombs were co–senior authors.

Concept and design: Wu, Sun, Benedetti, Thombs.

Acquisition, analysis, or interpretation of data: Sung, Wu, Fan, Dal Santo, González-Domínguez, L. Li, K. Li, Jiang, Tasleem, Wang, Boruff, Desai, Tougas, D’Onofrio, Krishnan, Adams, He, Henry, Alkan, Rice, Markham, Azar, Nassar, Hu, Cañedo-Ayala, Neupane, Benedetti, Thombs.

Drafting of the manuscript: Sung, Wu, Fan, Dal Santo, K. Li, Thombs.

Critical review of the manuscript for important intellectual content: Sung, Wu, Fan, Dal Santo, González-Domínguez, Sun, L. Li, Jiang, Tasleem, Wang, Boruff, Desai, Tougas, D’Onofrio, Krishnan, Adams, He, Henry, Alkan, Rice, Markham, Azar, Nassar, Hu, Cañedo-Ayala, Neupane, Benedetti, Thombs.

Statistical analysis: Sung, Wu, Fan, Dal Santo, González-Domínguez, K. Li, Markham, Thombs.

Obtained funding: Benedetti, Thombs.

Administrative, technical, or material support: He.

Supervision: Wu, Benedetti, Thombs.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by grants PJT-195921, CMS-171703, MS1-173070, GA4-177758, and WI2-179944 from the Canadian Institutes of Health Research (CIHR) and R2-42 from the McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund. Dr Wu reported receiving support from a Fonds de recherche du Québec–Santé (FRQS) Postdoctoral Training Fellowship. Ms Dal Santo reported receiving an FRQS Master’s Training Scholarship. Dr Adams reported receiving a CIHR Banting Postdoctoral Fellowship. Dr Henry reported receiving a CIHR Postdoctoral Fellowship. Ms Nassar reported receiving an FRQS Doctoral Research Award. Ms Hu reported receiving a CIHR Canada Graduate Scholarship Masters Award. Dr Thombs reported receiving a Tier 1 Canada Research Chair.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Information: A protocol for this study was posted online at https://osf.io/96csg/overview prior to initiating searches.

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Corresponding author.

PMCID: PMC13448792 PMID: 42560673

Key Points

Question

Did changes in mental health symptoms from before the COVID-19 pandemic to during the pandemic differ by sex or gender?

Findings

In this systematic review and meta-analysis study of findings from 27 unique cohorts, changes from before to during the COVID-19 pandemic in mental health symptoms, including general mental health, anxiety, depression, and stress, were not statistically significantly different by sex or gender. Substantial heterogeneity, high risk of bias, or both were present across all analyses.

Meaning

This study did not find sex and gender differences in mental health symptom changes from before to during the COVID-19 pandemic; however, the findings should be interpreted cautiously and may not apply to all populations due to methodological limitations of included studies and high heterogeneity across analyses.

This systematic review and meta-analysis assesses changes in mental health symptoms from before to during the COVID-19 pandemic by sex and gender.

Abstract

Importance

A previous systematic review reported that general mental health and anxiety symptoms, but not depression or stress, worsened more for females or women than for males or men from before to during the COVID-19 pandemic based on 12 studies published up to August 2021.

Objective

To update a systematic review on sex or gender differences in mental health symptom changes from before to during the COVID-19 pandemic.

Data Sources

Medline, PsycINFO, CINAHL, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv, and Open Science Framework Preprints were searched from December 31, 2019, to August 31, 2023.

Study Selection

Eligible studies included data to calculate changes in general mental health, anxiety symptoms, depression symptoms, or stress from before to during the COVID-19 pandemic by sex or gender.

Data Extraction and Synthesis

Standardized mean differences (SMDs) for continuous changes and proportions for dichotomous changes were used. Two independent reviewers extracted data and evaluated risk of bias. Data were pooled via random-effects models on March 21, 2024.

Main Outcomes and Measures

The main outcome was the differences in SMD changes and proportions between women or females and men or males of mental health symptoms from before the COVID-19 pandemic to during the COVID-19 pandemic.

Results

The study included 27 unique cohorts from 14 countries (n = 102-18 127; 31 155 women or females and 30 737 men or males). Differences in SMD change between men and women were minimal and not statistically significant for continuous outcomes of general mental health (0.01 [95% CI, −0.07 to 0.10 and 95% prediction interval (PI), −0.23 to 0.25]; 8 cohorts; 21 762 participants; heterogeneity [I²] = 81.4%), anxiety (0.09 [95% CI, −0.04 to 0.22 and 95% PI, −0.27 to 0.45]; 7 cohorts; 6039 participants; I² = 68.7%), depression (0.10 [95% CI, −0.00 to 0.20 and 95% PI, −0.23 to 0.43]; 12 cohorts; 9750 participants; I² = 65.4%), and stress (−0.08 [95% CI, −0.16 to 0.01 and 95% PI, −0.18 to 0.02]; 8 cohorts; 2994 participants; I² = 0%). Substantial heterogeneity, high risk of bias, or both were present across analyses. No studies reported changes for gender minority groups (eg, transgender, nonbinary).

Conclusion and Relevance

In this systematic review and meta-analysis of sex or gender differences in mental health changes from before to during the COVID-19 pandemic, no significant differences were found. However, findings should be interpreted cautiously and may not apply in all settings due to heterogeneity and methodological limitations of included studies.

Introduction

There are concerns that COVID-19 may have affected mental health among certain groups, including women and gender-diverse individuals (transgender, nonbinary), disproportionately.^1,2,3 The most comprehensive systematic review that compared mental health symptom changes from before the COVID-19 pandemic to during the pandemic found that changes overall and by subgroups were small (standardized mean differences [SMDs] = 0.05-0.22). Females and women were the only group with statistically significant declines across all 3 mental health categories evaluated, including general mental health (6 cohorts; 10 329 participants; SMD = 0.22 [95% CI, 0.08-0.35]), anxiety symptoms (5 cohorts; 3500 participants; SMD = 0.20 [95% CI, 0.12-0.29]), and depression symptoms (7 cohorts; 3851 participants; SMD = 0.22 [95% CI, 0.05-0.40]).¹ Changes were evaluated separately for women and men but not directly compared since most change estimates for each sex or gender group came from different studies.

A substudy of that systematic review evaluated studies with data that allowed direct comparisons of differences in SMD changes among women vs men and found significantly greater worsening for women in general mental health (3 cohorts; 15 692 participants; SMD = 0.15 [95% CI, 0.12 to 0.18]) and anxiety symptoms (4 cohorts; 4344 participants; SMD = 0.15 [95% CI, 0.07 to 0.22]) but not depression symptoms (4 cohorts; 4475 participants; SMD = 0.12 [95% CI, −0.09 to 0.33]) or stress (4 cohorts; 1533 participants; SMD = −0.10 [95% CI, −0.21 to 0.01]). That analysis, however, included only evidence from searches up to August 30, 2021, and no analysis included more than 4 cohorts.² We did not identify any other studies that directly compared changes by sex or gender. Objectives were to update our substudy and compare changes by sex or gender from before to during the COVID-19 pandemic on continuously measured scale scores and proportions above cutoffs for general mental health, anxiety symptoms, depression symptoms, and stress.

Methods

The main systematic review was registered with PROSPERO (CRD42020179703), and a protocol was posted prior to initiating searches (see Additional Information). The present systematic review and meta-analysis is a substudy.¹ Results are reported per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Methods were adopted from the main systematic review¹ and from a study by investigators from our team of a previous sex or gender comparison.² Thus, we followed Text Recycling Research Project reporting guidance.⁴ Research ethics approval was not required since the study evaluated previously published summary statistics.

Eligibility Criteria

The main review included studies on any population that compared pre–COVID-19 mental health outcomes, with at least 80% of participants assessed from January 1, 2018, to December 31, 2019, with outcomes collected on January 1, 2020, or later. Studies had to report data from at least 90% of the same participants between pre–COVID-19 and COVID-19 periods or statistically account for missing data. Studies with fewer than 100 participants were excluded. For the present substudy, studies had to report mental health outcomes separately by sex (assignment based on external genitalia, usually at birth; eg, female, male, or intersex persons) or gender (socially constructed characteristics of roles and behaviors; eg, woman, man, transgender woman, transgender man, or nonbinary person).⁵

Search Strategy

We searched Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), Embase (Ovid), Web of Science Core Collection: Citation Indexes, China National Knowledge Infrastructure, Wanfang, medRxiv, and Open Science Framework Preprints with a strategy designed by an experienced health sciences librarian (J.T.B.). Chinese databases were searched using terms based on our English-language strategy. COVID-19 terms were developed in collaboration with other librarians working on the topic and updated as COVID-19–specific subject headings became available (eMethods 1 in Supplement 1). The initial search was conducted from December 31, 2019, to April 13, 2020, with daily updates thereafter and then weekly updates beginning December 28, 2020, with the final search on August 31, 2023.

Selection of Eligible Studies

Search results were imported into DistillerSR (Evidence Partners), and duplicates were removed. Two independent reviewers evaluated titles and abstracts in random order. If either deemed a study potentially eligible, a full-text review was completed by 2 independent reviewers, with discrepancies resolved through consensus, consulting a third reviewer as necessary. See eMethods 2 in Supplement 1 for the inclusion and exclusion coding guide.

Data Extraction and Adequacy Assessment

For each eligible study, data were extracted in DistillerSR by a single reviewer, with validation by a second reviewer, and discrepancies resolved by consensus with a third reviewer consulted if necessary. Reviewers extracted (1) publication characteristics (eg, first author, year, and journal); (2) eligibility criteria, recruitment method, number of participants, assessment timing, and age; (3) mental health outcomes including general mental health, anxiety symptoms, depression symptoms, and stress; (4) whether studies reported outcomes by sex or gender or used these terms inconsistently; and (5) sex or gender categories.

Adequacy of methods and reporting was assessed using an adapted version of the Joanna Briggs Institute Checklist for Prevalence Studies, which assesses sampling-frame appropriateness for the target population, recruiting methods, sample size, setting and participant descriptions, participation rate, outcome assessment methods, assessment standardization across participants, statistical analysis, and follow-up.⁶ Items were coded as yes for meeting criteria, no for not meeting criteria, or unclear if incomplete reporting did not allow a judgment to be made (eMethods 3 in Supplement 1).

Statistical Analyses

For continuous outcomes, separately by sex or gender group, we extracted SMDs for change from before the COVID-19 pandemic to during the COVID-19 pandemic with 95% CIs. If not provided, we extracted pre–COVID-19 and during COVID-19 means and SDs and calculated SMD for change using Hedges g for each group,^7,8 Raw change scores were presented in scale units and direction, whereas SMD change scores were presented as positive when associated with worsened mental health and negative when associated with improved mental health. We then calculated Hedges g for differences in change between sex or gender groups with 95% CIs. Positive numbers represented greater negative change (associated with improvement) in females or women compared with males or men.

For publications that reported proportions of participants above a scale cutoff, for pre–COVID-19 and COVID-19 proportions, if a 95% CI was not provided, we calculated a 95% CI using the Agresti and Coull approximate method for binomial proportions.⁹ We then extracted or calculated the proportion change in participants above the cutoff, along with 95% CI, for each sex or gender group. Proportion changes were presented as positive when associated with worsened mental health from before the COVID-19 pandemic to during the COVID-19 pandemic and negative when associated with improved mental health. If 95% CIs for proportion change were not reported, we generated them using the Newcombe method for differences between binomial proportions based on paired data.¹⁰ This method requires the number of cases at both assessments, which was not available in some studies. We assumed that 50% of pre–COVID-19 cases continued to be cases during COVID-19 and confirmed that results did not differ substantively if we used values from 30% to 70% (all 95% CI end points were within 0.05 except in women from 1 cohort¹¹) (eTable 1 in Supplement 1).¹² In addition, we calculated a difference of the proportion change between sex or gender groups with 95% CI. Positive numbers were associated with greater improvement or less worsening in females or women compared with males or men.

Meta-analyses were done to synthesize differences between sex or gender groups in SMD change for continuous outcomes and proportion change for dichotomous outcomes, both with 95% CIs and 95% prediction intervals (PIs), via a restricted maximum-likelihood random-effects meta-analysis. Heterogeneity was assessed with I². Multiple outcomes of studies assessing the same cohort were integrated to give the results for the cohort, and studies with more than 1 measurement for a continuous outcome category were pooled within the study. Meta-analyses were performed in R, version 4.3.1 (RStudio, version 2023.06.2), using the metacont and metagen functions in the meta package (R Project for Statistical Computing).¹³ Forest plots were generated using the forest function in R’s meta, version 5.0-0. Two-sided α < .05 was used for statistical significance. All analyses were conducted March 21, 2024.

Results

Search Results and Selection of Eligible Studies

As of our final search on August 31, 2023, there were 149 026 unique references identified and screened for potential eligibility, of which 145 463 were excluded after title and abstract review and 2092 after full-text review. Of 661 articles with longitudinal data collection, 632 did not have eligible sex or gender data and were excluded. Thus, results from 27 unique cohorts (29 publications) were included,^{11,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41} in which 4 included cohorts published sex or gender change comparisons. The other 23 cohorts did not compare changes but published data that allowed us to calculate changes. The eFigure in Supplement 1 shows the article flow.

Characteristics of Included Studies

Table 1 shows study characteristics, including participant ages and countries. The 27 cohorts were from 14 countries and included 31 155 women or females and 30 737 men or males. There were 3 adult national cohorts (5 publications)^{28,29,38,39,41} from China (n = 18 127),⁴¹ the Netherlands (n = 3983-4064 depending on outcome),^38,39 and the UK (n = 10 918-15 376).^28,29 Three cohorts^14,23,25 reported on adult community samples from Spain (n = 102),²⁵ the Netherlands (n = 183),²³ or the US (n = 325),¹⁴ and 1 reported on an adult clinic-based sample from the US (n = 967).³⁶ Two cohorts^31,35 reported on young adult samples, 1 on young adult twins from the UK (n = 3563-3694)³¹ and another on young adults from Switzerland (n = 786).³⁵ Seven cohorts^{15,19,21,24,27,30,40} assessed adolescents from Australia (n = 248),²⁴ China (n = 831-1780),^19,21,40 Italy (n = 153-813),^15,30 or Portugal (n = 1099).²⁷ Three cohorts^17,33,34 assessed undergraduate students from China (n = 4085-4341),¹⁷ India (n = 217),³³ or the UK (n = 214).³⁴ Two cohorts^20,22 assessed patients from the US with systemic lupus erythematosus (n = 316)²² or with traumatic brain injury (n = 365-694).²⁰ Two cohorts^26,37 assessed employees from China (n = 2999)²⁶ and Iran (n = 850).³⁷ Five cohorts^{14,16,18,23,32} assessed parents from Hong Kong (n = 428),¹⁶ the Netherlands (n = 183),²³ Norway (n = 309),³² or the US (n = 180-325).^14,18 One cohort assessed teachers from Iceland (n = 920).¹¹

Table 1. Characteristics of Included Studies (N = 29).

Source	Outcome domains				Description of study design and participants	Country	Pre–COVID-19 and post–COVID-19 dates of data collection	Females or women/girls, No. (%) or range (%)	Males or men/boys, No. (%) or range (%)	Mean (SD) or range (%)
Source	Anxiety symptoms	Depression symptoms	General mental health	Stress	Description of study design and participants	Country	Pre–COVID-19 and post–COVID-19 dates of data collection	Females or women/girls, No. (%) or range (%)	Males or men/boys, No. (%) or range (%)	Participant age, y	Females or women/girls by age, y	Males or men/boys by age, y
Adesogan et al,¹⁴ 2022	NA	CES-D	NA	NA	Two-parent African American families from the Protecting Strong African American Families project	US	Month NR in 2018-March 2020^a June-September 2020	Women: 187 (57.5)	Men: 138 (42.5)	43 (8)	Women: 43 (8)	Men: 47 (10)
Cerniglia et al,¹⁵ 2023	NA	NA	YSR Anxiety-Depression YSR Internalizing Symptoms	NA	Adolescents aged 14-15 y	Italy	October 2019 April 2020	Females/girls: 415 (51.0)^b	Males/boys: 398 (49.0)^b	14 (1)	NR	NR
Cheung et al,¹⁶ 2022	NA	PHQ-9	NA	NA	Mothers and fathers of preschool-aged children from 5 Hong Kong kindergartens	Hong Kong	March-June 2019 October 2020-May 2021	Women: 216 (50.5)	Men: 212 (49.5)	38 (5)^c	Women: 36 (4)	Men: 40 (6)
Dong,¹⁷ 2020^d	NA	NA	SCL-90-R	NA	First-year undergraduates from 1 university recruited online	China	September 2019 Before November 2020^e	Women: 3162-3277 (75.5-77.4)	Men: 923-1064 (22.6-24.5)	19 (1)	NR	NR
Frank et al,¹⁸ 2021	NA	PHQ-9	NA	NA	Physician parents enrolled in the Intern Health Study	US	August 2018 August 2020	Women: 95 (52.8)	Men: 85 (47.20)	40 (4)	Women: 40 (3)	Men: 40 (4)
He et al,¹⁹ 2022	NA	CES-DC	NA	NA	Seventh-grade students from a middle school in Huaibei City, Anhui Province	China	October 2019 October 2020	Females/girls: 668 (39.6)^b	Males/boys: 1019 (60.4)^b	12 (0)	NR	NR
Kumar et al,²⁰ 2022	GAD-7	NA	NA	NA	Participants with moderate-to-severe traumatic brain injury from the TBIMS national database	US	November 2018-December 2019 April 2020-January 2021	Females: 100-175 (25-27)	Males: 265-519 (73-75)	47 (20)	NR	NR
Li et al,²¹ 2021	SAS	BDI-II	NA	NA	Students aged 14 to 19 y from 3 public commuter secondary vocational schools in Southern China	China	December 2019 March 2020	Females/women: 503-601 (58.9-60.5)^b	Males/men: 328-419 (39.5-41.1)^b	16 (1)	NR	NR
Lim et al,²² 2020^d	PROMIS Anxiety	PROMIS Depression	NA	PSS	Patients with systemic lupus erythematosus from the Georgians Organized Against Lupus Cohort	US	Month NR in 2018-2019 March-April 2020	Females: 295 (93.4)	Males: 21 (6.6)	47 (13)	NR	NR
Lucassen et al,²³ 2021	NA	NA	NA	PSS	Parents with a child aged 3 y and having a Dutch native background	The Netherlands	May 2018-January 2020 April 2020	Females/women: 94 (51.4)^b	Males/men: 89 (48.6)^b	NR	NR	NR
Magson et al,²⁴ 2021^d	SCAS-C	SMFQ-C	NA	NA	Annually assessed adolescents aged 13 to 16 y from an ongoing longitudinal cohort	Australia	Month NR in 2019 May 2020	Females/girls: 126 (50.8)^b	Males/boys: 122 (49.2)^b	14 (1)	NR	NR
Megías-Robles et al,²⁵ 2022^d	NA	NA	PANAS-NA	NA	Community sample aged 19 to 67 y	Spain	November 2019 April 2020	Women: 67 (65.7)	Men: 35 (34.3)	30 (13)	NR	NR
Mei et al,²⁶ 2024	NA	NA	GHQ-12	NA	Employees from 14 petrochemical corporations	China	May 2019 May 2020	Females/Women: 710 (23.7)^b	Males/Men: 2289 (76.3)^b	20-65^f	NR	NR
Meireles et al,²⁷ 2022	NA	NA	BLSS KIDSCREEN	NA	Students aged 12 to 16 y in North Portugal	Portugal	April-July 2019 May-June 2020	Girls: 582 (47.0)	Boys: 517 (53.0)	13 (1)	Girls: 13 (1)	Boys: 13 (1)
Pierce et al,²⁸ 2020^d Daly et al,²⁹ 2021^d	NA	NA	GHQ-12	NA	National probability-based sample of adults aged ≥18 y who were part of the UK Household Longitudinal Study	UK	Pre–COVID-19 waves^g April-September 2020	Women: 7181 (46.7)^h Females/women: 6380 (58.4)^b	Men: 8195 (53.3)^h Males/men: 4538 (41.6)^b	18-34 (11.5)ⁱ 35-49 (22.4)ⁱ 50-64 (34.5)ⁱ ≥65 (31.6)ⁱ	NR	NR
Pedrini et al,³⁰ 2022	SCARED	PHQ-9	NA	ASQ	Students from 8 classes belonging to 3 high schools in Brescia, Northern Italy	Italy	November 2019-January 2020 April-May 2021	Females/women: 110 (71.9)	Males/men: 43 (28.3)	16 (0)	NR	NR
Rimfeld et al,³¹ 2021^d	GAD-7	SMFQ	NA	NA	Adult twins born from 1994 to 1996, who, at age 18 mo, were enrolled in the Twins Early Development Study	UK	Month NR in 2018 April-May 2020	Females/women: 2513-2578 (69.8-70.5)^j	Males/men: 1050-1116 (29.5-30.2)^j	24-26 (100.0)	NR	NR
Rohde et al,³² 2022	NA	NA	RAND-36 Mental Health RAND-36-MCS	PSQ	Parents of adolescents	Norway	November 2018-April 2019 January-February 2021	Women: 252 (81.6)	Men: 57 (18.4)	46 (5)	Women: 45 (5)	Men: 47 (5)
Saraswathi et al,³³ 2020^d	DASS-21 Anxiety	DASS-21 Depression	NA	DASS-21 Stress	Convenience sample of undergraduate university medical students	India	December 2019 June 2020	Females/women: 139 (64.1)^b	Males/men: 78 (35.9)^b	20 (2)	NR	NR
Savage et al,³⁴ 2020^d	NA	NA	WEMWBS	PSS	Email-recruited undergraduate students from 1 university who completed ≥3 assessments for the Student Health Study	UK	October 2019 April 2020	Females/women: 154 (72.0)^b	Males/men: 60 (28.0)^b	18-21 (64.5) 22-25 (22.0) 26-35 (7.5) >35 (6.1)	NR	NR
Shanahan et al,³⁵ 2022^d	NA	NA	NA	PSS	Young adults who completed 9 assessments since 2004 from the Zurich Project on the Social Development From Childhood to Adulthood	Switzerland	Month NR in 2018 April 2020	Females: 378 (48.1)	Males: 408 (51.9)	22 (0)	NR	NR
Shuval et al,³⁶ 2022	NA	CES-D	NA	NA	Community-dwelling adults who attended a preventive medicine clinic visit	US	March 2018-December 2019 March-December 2020	Females/Women: 212 (21.9)^b	Males/Men: 755 (78.1)^b	52 (8)	Females/Women: 51 (8)^b	Males/Men: 52 (8)^b
Sigursteinsdottir et al,¹¹ 2022	NA	NA	NA	PSS	Primary school teachers in 12 municipalities in Iceland	Iceland	Month NR in 2019 Month NR in 2021	Females/Women: 759 (82.5)^b	Males/Men: 161 (17.5)^b	<30 (4.9) 31-40 (23.0) 41-50 (36.0) 51-60 (23.0) ≥61 (11.1)	NR	NR
Soltanzadeh et al,³⁷ 2021	NA	NA	GHQ-28	NA	Employees of 3 oil refineries in southern Iran with at least 1 y of work experience	Iran	November 2019 July 2020	Females/Women: 161 (81.0)^b	Males/Men: 689 (19.0)^b	35 (13)	NR	NR
van der Velden et al,³⁸ 2020^d van der Velden et al,³⁹ 2022^d	NA	NA	MHI-5	NA	National probability-based sample of adults from the Longitudinal Internet Studies for the Social Sciences	The Netherlands	March 2019 November-December 2019 March 2020 November-December 2020	Women: 2020 (50.7) Females: 2062 (50.7)	Men: 1963 (49.3) Males: 2002 (49.3)	18-34 (24.9)^k 35-49 (22.9)^k 50-64 (26.1)^k ≥65(26.1)^k	NR	NR
Yu,⁴⁰ 2021	NA	NA	SCL-90	NA	Students from the first and second year of a secondary vocational school	China	September 2019 April 2020	Women: 743 (41.7)	Men: 1037 (58.3)	15-18^f	NR	NR
Zhang et al,⁴¹ 2023	NA	CES-D	NA	NA	National probability-based sample of families enrolled in the China Family Panel Studies	China	Month NR in 2018 July-December 2020	Women: 8918 (49.2)^c	Men: 9209 (50.8)^c	<18 (11.0) 18-39 (29.7) 40-65 (48.3) ≥66 (11.0)	NR	NR

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Abbreviations: ASQ, Ask Suicide-Screening Questions; BDI-II, Beck Depression Inventory Second Edition; BLSS, Brief Life Satisfaction Scale; CES-D, Centre for Epidemiologic Studies Depression Scale; CES-DC, CES-D for Children; DASS-21 Anxiety, Depression, Anxiety, and Stress Scale–Anxiety subscale; DASS-21 Depression, DASS-21–Depression subscale; DASS-21 Stress, DASS-21–Stress subscale; GAD-7, Generalized Anxiety Disorder-7; GHQ-12, General Health Questionnaire-12; GHQ-28, GHQ-28; MHI-5, Mental Health Index-5; NA, not applicable; NR, not reported; PANAS-NA, Positive and Negative Affect Schedule–Negative Affect subscale; PHQ-9, Patient Health Questionnaire-9; PROMIS Anxiety, Patient-Reported Outcomes Measurement Information System–Anxiety subscale; PROMIS Depression, PROMIS–Depression subscale; PSQ, Personality Structure Questionnaire; PSS, Perceived Stress Scale; RAND-36 Mental Health, RAND 36-Item Health Survey–Mental Health subscale; RAND-36-MCS, RAND 36–Mental Component Summary; SAS, Zung Self-Rating Anxiety Scale; SCARED, Screen for Child Anxiety Related Disorders; SCAS-C, Spence Children’s Anxiety Scale-Child; SCL-90, Symptom Check List-90; SCL-90-R, SCL-90 Revised; SMFQ, Short Mood and Feelings Questionnaire; SMFQ-C, SMFQ–Child Version; TBIMS, Traumatic Brain Injury Model Systems; WEMWBS, Warwick Edinburgh Mental Well-Being Scale; YSR, Achenbach Youth Self-Report.

^{^a}

Over 90% of pre–COVID-19 data collected before January 1, 2020.

^{^b}

Sex and gender terms were used inconsistently within studies (eg, females and males, which are sex terms, were used interchangeably with women or girls and men or boys, which are gender terms).

^{^c}

Number of participants was calculated from percentages.

^{^d}

Authors did not provide dates of data collection. The article was identified in a November 9, 2020, search.

^{^e}

Results included in the previous study (Dal Santo et al²).

^{^f}

Only range is provided.

^{^g}

Analyses compared COVID-19 symptom levels with preceding trends across multiple assessments.

^{^h}

Number included in fixed effects regression analysis, in which the majority of data were extracted.

^ⁱ

Age groups reported for Pierce et al²⁸ and for Daly et al²⁹: 16 to 24 years = 8.8%, 25 to 34 years = 11.2%, 35 to 44 years = 16.0%, 45 to 54 years = 20.1%, 55 to 69 years = 28.9%, and 70 or more years = 15.1%.

^{^j}

Number of participants differed by outcome.

^{^k}

Based on van der Velden et al.³⁹

Twelve unique cohorts (14 publications) assessed general mental health symptoms,^{15,16,17,25,26,27,28,29,32,34,37,38,39,40} 7 assessed anxiety symptoms,^{20,21,22,24,30,31,33} 12 assessed depression symptoms,^{14,16,18,19,21,22,24,30,31,33,36,41} and 8 assessed stress.^{11,22,23,30,32,33,34,35} All cohorts compared women with men or females with males; none included other sex or gender groups. Use of sex and gender terms, however, was inconsistent in 14 of 29 included publications (48%; eg, results were assessed by gender but were reported using sex terms).^{11,15,19,21,23,24,26,29,30,31,33,34,36,37} Among the 27 cohorts, most (22 [81%]) reported outcome data from 2020^{14,15,17,18,19,21,22,23,24,25,26,27,28,29,31,33,34,35,36,37,38,39,40,41}; 2 (7%) from 2020 to 2021,^16,20 and 3 (11%) from 2021.^11,30,32

Adequacy of Study Methods and Reporting

Among included studies, 2 publications on the same cohort were rated as yes for adequacy for all items.^38,39 Other publications were rated no for 1 to 3 items (plus 0-3 unclear ratings),^{11,14,15,16,17,18,19,20,21,23,24,25,26,27,29,30,32,33,34,35,36,37,40,41} or no on none but unclear on 2 to 4 items.^22,28,31 Overall, 22 of 29 reports (76%) were rated no or unclear for appropriate sampling frame, 23 (79%) for adequate response rate and coverage, and 22 (76%) for appropriate participant recruitment (eTable 2 in Supplement 1).

Mental Health Symptom Changes

There were 35 total comparisons of continuous score changes and 9 of proportion changes, as shown in Table 2. Forest plots are shown in Figure 1 and Figure 2. Estimates of differences in SMD change between women and men were close to 0 and not statistically significant for continuously measured outcomes, including general mental health (Figure 1A) (0.01 [95% CI, −0.07 to 0.10 and 95% PI, −0.23 to 0.25]; 8 cohorts^{15,25,26,27,28,32,34,37}; 21 762 participants; I² = 81.4%), anxiety symptoms (Figure 1B) (0.09 [95% CI, −0.04 to 0.22 and 95% PI, −0.27 to 0.45]; 7 cohorts^{20,21,22,24,30,31,33}; 6039 participants; I² = 68.7%), depression symptoms (Figure 1C) (0.10 [95% CI, −0.00 to 0.20 and 95% PI, −0.23 to 0.43]; 12 cohorts^{14,16,18,19,20,21,22,24,30,31,33,36}; 9750 participants; I² = 65.4%), and stress (Figure 1D) (−0.08 [95% CI, −0.16 to 0.01 and 95% PI, −0.18 to 0.02]; 8 cohorts^{11,22,23,30,32,33,34,35}; 2994 participants; I² = 0%). No dichotomous changes between women and men were statistically significant: general mental health (Figure 2A) (proportion change = −0.03 [95% CI, −0.08 to 0.03 and 95% PI, −0.20 to 0.15]; 4 cohorts^17,29,39,40; 20 765 participants; I² = 91.7%), anxiety symptoms (Figure 2B) (proportion change = −0.05 [95% CI, −0.20 to 0.11]; 1 cohort³³; 217 participants), depression symptoms (Figure 2C) (proportion change = −0.13 [95% CI, −0.81 to 0.55 and 95% PI, −7.09 to 6.82]; 2 cohorts^33,41; 18 344 participants; I² = 68.5%), and stress (Figure 2D) (proportion change = 0.03 [95% CI, −0.10 to 0.17 and 95% PI, −0.85 to 0.92]; 2 cohorts^11,33; 1033 participants; I² = 0%).

Table 2. Outcomes From Included Studies by Sex or Gender^a.

Source	Pre–COVID-19 and post–COVID-19 data collection	Sex or gender	No. or range	Continuous outcome measure	Mean (SD)			Hedges g, SMD (95% CI)	Dichotomous outcome measure	% (95% CI)		Change, % (95%CI)
Source	Pre–COVID-19 and post–COVID-19 data collection	Sex or gender	No. or range	Continuous outcome measure	Before COVID-19	After COVID-19	Change	Hedges g, SMD (95% CI)	Dichotomous outcome measure	Before COVID-19	After COVID-19	Change, % (95%CI)
General mental health
Cerniglia et al,¹⁵ 2023	October 2019 April 2020	Women	398	YSR Anxiety-Depression^b	8.03 (2.45)	13.53 (4.43)	5.50 (3.58)	1.53 (1.38 to 1.69)	NA	NA	NA	NA
		Men	415	YSR Anxiety-Depression^b	7.57 (1.22)	9.72 (1.65)	2.15 (1.45)	1.48 (1.33 to 1.63)	NA	NA	NA	NA
		Females/girls	398	YSR Internalizing symptoms^b	17.23 (3.15)	27.21 (2.41)	9.98 (2.80)	3.55 (3.33 to 3.78)	NA	NA	NA	NA
		Males/boys	415	YSR Internalizing symptoms^b	15.18 (4.25)	22.45 (3.55)	7.27 (3.92)	1.85 (1.69 to 2.02)	NA	NA	NA	NA
Dong,¹⁷ 2020^c	September 2019 Before November 2020^d	Women	3162-3277	NA	NA	NA	NA	NA	SCL-90-R ≥ 160	19.7 (18.4 to 21.1)	27.9 (26.4 to 29.5)	8.2 (6.3 to 10.0)
Dong,¹⁷ 2020^c	September 2019 Before November 2020^d	Men	923-1064	NA	NA	NA	NA	NA	SCL-90-R ≥ 160	14.3 (12.3 to 16.5)	21.2 (18.7 to 24.0)	6.9 (4.0 to 9.9)
Megías-Robles et al,²⁵ 2022^c	November 2019 April 2020	Women	67	PANAS-NA	1.93 (0.65)	2.28 (0.79)	0.34 (0.86)	0.46 (0.12 to 0.81)	NA-	NA	NA	NA
Megías-Robles et al,²⁵ 2022^c	November 2019 April 2020	Men	35	PANAS-NA	1.88 (0.67)	2.11 (0.66)	0.23 (0.66)	0.34 (−0.14 to 0.82)	NA	NA	NA	NA
Mei et al,²⁶ 2024	May 2019 May 2020	Females/women	710	GHQ-12	1.36 (2.20)	1.44 (2.50)	0.08 (2.35)	0.03 (−0.07 to 0.14)	NA-	NA	NA	NA
Mei et al,²⁶ 2024	May 2019 May 2020	Males/men	2289	GHQ-12	1.84 (2.74)	1.99 (3.02)	0.15 (2.88)	0.05 (−0.01 to 0.11)	NA	NA	NA	NA
Meireles et al,²⁷ 2022	April-July 2019 May-June 2020	Females/women	582	BLSS^b	4.78 (0.94)	4.99 (0.76)	0.21 (0.85)	0.25 (0.13 to 0.36)	NA-	NA	NA	NA
		Males/men	517	BLSS^b	4.58 (1.02)	5.08 (0.74)	0.50 (0.89)	0.56 (0.44 to 0.68)	NA	NA	NA	NA
		Females/women	582	KIDSCREEN^b	3.75 (0.61)	3.73 (0.55)	−0.02 (0.58)	−0.03 (−0.15 to 0.08)	NA	NA	NA	NA
		Males/men	517	KIDSCREEN^b	3.69 (0.61)	3.88 (0.56)	0.19 (0.59)	0.32 (0.20 to 0.45)	NA	NA	NA	NA
Pierce et al,²⁸ 2020^c^,^d Daly et al,²⁹ 2021^c^,^d	Pre–COVID-19 waves April 2020 September 2020	Women	7181²⁵^,^e 6380²³	GHQ-12	12.00 (5.91)	13.60 (7.14)	1.60 (6.55)^f 0.88 (NR)^g	0.24 (0.21 to 0.28) 0.13 (0.10 to 0.17)	GHQ-12 ≥4^h	24.5 (22.5 to 26.4)^h 24.5 (22.5 to 26.4)^h	36.8 (34.8 to 38.9)^h 25.0 (23.3 to 26.8)^h	12.4 (9.9 to 14.9)^h 0.5 (−1.8 to 2.9)^h
Pierce et al,²⁸ 2020^c^,^d Daly et al,²⁹ 2021^c^,^d	Pre–COVID-19 waves April 2020 September 2020	Men	8195²⁵ 4538²³	GHQ-12	10.80 (4.99)	11.50 (5.75)	0.70 (5.38)^f 0.03 (NR)^g	0.13 (0.10 to 0.16) 0.01 (−0.03 to 0.04)	GHQ-12 ≥4^h	16.7 (14.6 to 18.7)^h 16.7 (14.6 to 18.7)^h	21.1 (19.0 to 23.3)^h 16.0 (14.0 to 17.9)^h	4.5 (2.0 to 7.0)^h −0.7 (−2.9 to 1.5)^h
Rohde et al,³² 2022	November 2018-April 2019 January-February 2021	Women	252	RAND-36 Mental Health^b	80.40 (12.60)	79.00 (14.80)	−1.40 (13.74)	−0.10 (−0.28 to 0.07)	NA-	NA	NA	NA
		Men	57	RAND-36 Mental Health^b	82.70 (9.50)	82.00 (9.70)	−2.70 (9.60)	−0.28 (−0.65 to 0.09)	NA	NA	NA	NA
		Women	252	RAND-36-MCS^b	51.80 (8.50)	50.30 (10.20)	−1.50 (9.40)	−0.16 (−0.33 to 0.02)	NA-	NA	NA	NA
		Men	57	RAND-36-MCS^b	54.20 (6.50)	53.90 (6.60)	−0.30 (6.60)	−0.05 (−0.42 to 0.33)	NA	NA	NA	NA
Savage et al,³⁴ 2020^c	October 2019 April 2020	Females/women	154	WEMWBSⁱ	43.00 (9.00)	40.00 (10.00)	−3.00 (9.51)	0.31 (0.09 to 0.54)	NA-	NA	NA	NA
Savage et al,³⁴ 2020^c	October 2019 April 2020	Males/men	60	WEMWBSⁱ	47.00 (9.00)	44.00 (10.00)	−3.00 (9.51)	0.31 (−0.05 to 0.67)	NA	NA	NA	NA
Soltanzadeh et al,³⁷ 2021	November 2019 July 2020	Females/women	161	GHQ-28	45.11 (12.07)	50.91 (12.69)	5.80 (12.38)	0.47 (0.24 to 0.69)	NA	NA	NA	NA
Soltanzadeh et al,³⁷ 2021	November 2019 July 2020	Males/men	689	GHQ-28	46.12 (11.36)	51.38 (12.34)	5.26 (11.90)	0 (−0.11 to 0.11)	NA	NA	NA	NA
van der Velden et al,³⁸ 2020^c^,^d van der Velden et al,³⁹ 2022^c^,^d	March 2019 November-December 2019 March 2020 November-December 2020	Women	2020 2062	NA	NA	NA	NA	NA	MHI-5 ≤59	18.9 (17.3 to 20.7) 19.1 (17.4 to 20.8)	18.3 (16.7 to 20.1) 17.8 (16.2 to 19.5)	−0.6 (−2.5 to 1.3) −1.3 (−3.1 to 0.6)
		Men	1962-1963 2002	NA	NA	NA	NA	NA	MHI-5 ≤59	14.6 (13.1 to 16.3) 14.7 (13.2 to 16.3)	15.6 (14.1 to 17.3) 15.9 (14.4 to 17.6)	1.0 (−0.8 to 2.7) 1.2 (−0.5 to 3.0)
Yu,⁴⁰ 2021	September 2019 April 2020	Women	743	NA	NA	NA	NA	NA	SCL-90 ≥160	28.3 (25.1 to 31.6)	33.8 (30.5 to 37.3)	5.5 (1.5 to 9.5)
Yu,⁴⁰ 2021	September 2019 April 2020	Men	1037	NA	NA	NA	NA	NA	SCL-90 ≥160	23.1 (20.6 to 25.7)	30.9 (28.1 to 33.7)	7.8 (4.7 to 10.9)
Anxiety symptoms
Kumar et al,²⁰ 2022	November 2018-December 2019 April 2020-January 2021	Females	178	GAD-7	3.91 (4.83)	4.82 (5.39)	0.91 (5.12)	0.18 (−0.03 to 0.39)	NA	NA	NA	NA
Kumar et al,²⁰ 2022	November 2018-December 2019 April 2020-January 2021	Males	533	GAD-7	4.07 (5.40)	4.05 (4.97)	−0.02 (5.19)	0 (−0.12 to 0.12)	NA	NA	NA	NA
Li et al,²¹ 2021	December 2019 March 2020	Females/women	328	SAS	47.50 (9.06)	45.70 (9.42)	−1.80 (9.24)	0.19 (−0.35 to −0.04)	NA	NA	NA	NA
Li et al,²¹ 2021	December 2019 March 2020	Males/men	503	SAS	44.70 (13.23)	44.80 (13.91)	0.1 (13.57)	0.01 (−0.12 to 0.13)	NA	NA	NA	NA
Lim et al,²² 2020^b	Month NR in 2018-2019	Females	295	PROMIS Anxiety	50.20 (11.50)	50.40 (11.10)	0.20 (10.10)	0.02 (−0.14 to 0.18)	NA	NA	NA	NA
Lim et al,²² 2020^b	March-April 2020	Males	21	PROMIS Anxiety	50.50 (9.90)	48.60 (11.00)	−1.90 (12.10)	−0.17 (−0.80 to 0.45)	NA	NA	NA	NA
Magson et al,²⁴ 2021^c	Month NR in 2019 May 2020	Females/girls	126	SCAS-C	5.55 (4.05)	6.52 (4.31)	0.97 (4.18)	0.23 (−0.02 to 0.48)	NA	NA	NA	NA
Magson et al,²⁴ 2021^c	Month NR in 2019 May 2020	Males/boys	122	SCAS-C	3.63 (3.13)	3.64 (3.16)	0.01 (3.15)	0 (−0.25 to 0.26)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Females/women	110	SCARED	67.79 (12.48)	70.21 (12.71)	2.42 (12.60)	0.19 (−0.08 to 0.46)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Males/men	43	SCARED	58.51 (9.16)	59.47 (9.09)	0.96 (9.13)	0.10 (−0.32 to 0.53)	NA	NA	NA	NA
Rimfeld et al,³¹ 2021^c	Month NR in 2018 April-May 2020	Females/women	2513	GAD-7	8.15 (7.53)	9.69 (7.69)	1.54 (7.61)	0.20 (0.15 to 0.26)	NA	NA	NA	NA
Rimfeld et al,³¹ 2021^c	Month NR in 2018 April-May 2020	Males/men	1050	GAD-7	5.88 (6.66)	6.30 (6.58)	0.42 (6.62)	0.06 (−0.02 to 0.15)	NA	NA	NA	NA
Saraswathi et al,³³ 2020^c	December 2019 June 2020	Females/women	139	DASS-21 Anxiety	4.59 (6.29)	5.94 (6.93)	1.35 (6.62)	0.20 (−0.03 to 0.44)	DASS-21 Anxiety >7	18.7 (13.1 to 26.0)	32.4 (25.2 to 40.5)	13.7 (4.4 to 22.7)
Saraswathi et al,³³ 2020^c	December 2019 June 2020	Males/men	78	DASS-21 Anxiety	4.62 (6.04)	6.41 (7.50)	1.79 (6.81)	0.26 (−0.06 to 0.58)	DASS-21 Anxiety >7	25.6 (17.3 to 36.3)	34.6 (25.0 to 45.7)	9.0 (−4.0 to 21.5)
Depression symptoms
Adesogan et al,¹⁴ 2022	Month NR in 2018-March 2020 June-September 2020	Women	188	CES-D	6.82 (4.70)	9.23 (5.77)	2.41 (5.26)	0.46 (0.25 to 0.66)	NA	NA	NA	NA
Adesogan et al,¹⁴ 2022	Month NR in 2018-March 2020 June-September 2020	Men	137	CES-D	6.20 (3.46)	6.86 (5.17)	0.66 (4.4)	0.15 (−0.09 to 0.39)	NA	NA	NA	NA
Cheung et al,¹⁶ 2022	March-June 2019 October 2020-May 2021	Women	216	PHQ-9	3.49 (4.01)	3.40 (4.25)	−0.09 (4.13)	−0.02 (−0.21 to 0.17)	NA	NA	NA	NA
Cheung et al,¹⁶ 2022	March-June 2019 October 2020-May 2021	Men	212	PHQ-9	3.26 (3.48)	3.51 (4.52)	0.25 (3.76)	0.07 (−0.12 to 0.26)	NA	NA	NA	NA
Frank et al,¹⁸ 2021	August 2018 August 2020	Women	95	PHQ-9	3.69 (5.26)	5.05 (6.64)	1.36 (5.99)	−0.01 (−0.30 to 0.27)	NA	NA	NA	NA
Frank et al,¹⁸ 2021	August 2018 August 2020	Men	85	PHQ-9	3.60 (6.30)	3.52 (5.75)	−0.08 (6.03)	0.86 (0.55 to 1.18)	NA	NA	NA	NA
He et al,¹⁹ 2022	August 2018 August 2020	Females/women	668	CES-DC	22.36 (11.16)	20.97 (12.77)	−1.39 (11.99)	−0.12 (−0.22 to −0.01)	NA	NA	NA	NA
He et al,¹⁹ 2022	August 2018 August 2020	Males/men	1019	CES-DC	20.06 (9.80)	17.35 (11.03)	−2.71 (10.43)	−0.26 (−0.35 to −0.17)	NA	NA	NA	NA
Lim et al,²² 2020^c	Month NR in 2018-2019	Females/girls	295	PROMIS Depression	50.80 (10.70)	49.30 (9.80)	−1.50 (9.30)	−0.15 (−0.31 to 0.02)	NA	NA	NA	NA
Lim et al,²² 2020^c	March-April 2020	Males/boys	21	PROMIS Depression	50.70 (8.60)	49.90 (9.70)	−0.80 (8.20)	−0.08 (−0.70 to 0.54)	NA	NA	NA	NA
Magson et al,²⁴ 2021^c	Month NR in 2019 May 2020	Females/girls	126	SMFQ-C	4.77 (5.00)	8.16 (6.46)	3.39 (5.78)	0.58 (0.33 to 0.84)	NA	NA	NA	NA
Magson et al,²⁴ 2021^c	Month NR in 2019 May 2020	Males/boys	122	SMFQ-C	2.81 (3.18)	4.02 (4.76)	1.21 (4.05)	0.30 (0.04 to 0.55)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Females/women	110	PHQ-9	8.59 (4.80)	8.73 (4.76)	0.14 (4.78)	0.03 (−0.24 to 0.29)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Males/men	43	PHQ-9	5.86 (3.85)	7.30 (4.65)	1.44 (4.27)	0.33 (−0.10 to 0.76)	NA	NA	NA	NA
Rimfeld et al,³¹ 2021^c	Month NR in 2018 April-May 2020	Females/women	2578	SMFQ	4.65 (4.20)	4.81 (4.07)	0.16 (4.14)	0.04 (−0.02 to 0.09)	NA	NA	NA	NA
Rimfeld et al,³¹ 2021^c	Month NR in 2018 April-May 2020	Males/men	1116	SMFQ	3.71 (3.70)	3.33 (3.40)	−0.38 (3.55)	−0.11 (−0.19 to −0.02)	NA	NA	NA	NA
Saraswathi et al,³³ 2020^c	December 2019 June 2020	Females/women	139	DASS-21 Depression	7.71 (7.57)	7.94 (8.77)	0.23 (8.19)	0.03 (−0.21 to 0.26)	DASS-21 Depression >9	36.7 (29.1 to 45.0)	34.5 (27.1 to 42.8)	−2.2 (−11.7 to 7.4)
Saraswathi et al,³³ 2020^c	December 2019 June 2020	Males/men	78	DASS-21 Depression	7.28 (8.40)	8.54 (9.17)	1.26 (8.79)	0.14 (−0.17 to 0.45)	DASS-21 Depression >9	26.9 (18.3 to 37.7)	37.2 (27.3 to 48.3)	10.3 (−2.9 to 22.9)
Shuval et al,³⁶ 2022^c	March 2018-December 2019 March-December 2020	Females/women	212	CES-D	2.90 (3.10)	3.60 (3.40)	0.70 (3.25)	0.21 (0.02 to 0.41)	NA	NA	NA	NA
Shuval et al,³⁶ 2022^c	March 2018-December 2019 March-December 2020	Males/men	755	CES-D	2.80 (3.10)	2.90 (3.20)	0.10 (3.15)	0.03 (−0.07 to 0.13)	NA	NA	NA	NA
Zhang et al,⁴¹ 2023^c	Month NR in 2018 July-December 2020	Women	8918	NA	NA	NA	NA	NA	CES-D ≥12	7.5 (6.9 to 8.0)	8.4 (7.8 to 9.0)	0.9 (0.3 to 1.5)
Zhang et al,⁴¹ 2023^c	Month NR in 2018 July-December 2020	Men	9209	NA	NA	NA	NA	NA	CES-D ≥12	5.2 (4.7 to 5.7)	6.7 (6.2 to 7.2)	1.5 (1.0 to 2.0)
Stress
Lim et al,²² 2020^c	Month NR in 2018-2019	Females	295	PSS	17.50 (8.00)	16.40 (8.20)	−1.10 (6.60)	−0.14 (−0.30 to 0.03)	NA	NA	NA	NA
Lim et al,²² 2020^c	March-April 2020	Males	21	PSS	17.70 (6.60)	18.10 (6.80)	0.40 (8.00)	0.06 (−0.56 to 0.68)	NA	NA	NA	NA
Lucassen et al,²³ 2021	May 2018-January 2020 April 2020	Females/women	94	PSS	36.22 (7.68)	37.90 (7.93)	1.68 (7.81)	0.21 (−0.07 to 0.50)	NA	NA	NA	NA
Lucassen et al,²³ 2021	May 2018-January 2020 April 2020	Males/men	89	PSS	34.50 (7.20)	36.19 (8.12)	1.69 (7.67)	0.22 (−0.08 to 0.51)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Females/women	110	ASQ	78.46 (18.58)	71.05 (16.15)	−7.41 (17.41)	−0.42 (−0.69 to −0.15)	NA	NA	NA	NA
Pedrini et al,³⁰ 2022	November 2019-January 2020 April-May 2021	Males/men	43	ASQ	69.79 (17.76)	65.67 (15.67)	−4.12 (16.75)	−0.24 (−0.67 to 0.19)	NA	NA	NA	NA
Rohde et al,³² 2022	November 2018-April 2019 January 2021-February 2021	Women	252	PSQ	0.29 (0.16)	0.28 (0.16)	−0.01 (0.16)	−0.06 (−0.24 to 0.11)	NA	NA	NA	NA
Rohde et al,³² 2022	November 2018-April 2019 January 2021-February 2021	Men	57	PSQ	0.24 (0.14)	0.24 (0.49)	0 (0.20)	0 (−0.37 to 0.37)	NA	NA	NA	NA
Saraswathi et al,³³2020^c	December 2019 June 2020	Females/women	139	DASS-21 Stress	6.95 (7.22)	8.88 (7.99)	1.93 (7.61)	0.25 (0.02 to 0.49)	DASS-21 Stress >14	19.4 (13.7 to 26.8)	22.3 (16.2 to 29.9)	2.9 (−4.9 to 10.6)
Saraswathi et al,³³2020^c	December 2019 June 2020	Males/men	78	DASS-21 Stress	7.95 (7.54)	10.08 (8.50)	2.13 (8.03)	0.26 (−0.05 to 0.58)	DASS-21 Stress >14	23.1 (15.1 to 33.6)	29.5 (20.5 to 40.4)	6.4 (−5.6 to 18.2)
Savage et al,³⁴ 2020^c	October 2019 April 2020	Females/women	154	PSS	21.00 (7.00)	24.00 (7.00)	3.00 (7.00)	0.43 (0.20 to 0.65)	NA	NA	NA	NA
Savage et al,³⁴ 2020^c	October 2019 April 2020	Males/men	60	PSS	17.00 (6.00)	21.00 (7.00)	4.00 (6.52)	0.61 (0.24 to 0.97)	NA	NA	NA	NA
Shanahan et al,³⁵ 2022^c	Month NR in 2018 April 2020	Females	378	PSS	3.02 (0.98)	3.10 (0.94)	0.08 (0.96)	0.08 (−0.06 to 0.23)	NA	NA	NA	NA
Shanahan et al,³⁵ 2022^c	Month NR in 2018 April 2020	Males	408	PSS	2.57 (0.86)	2.74 (0.86)	0.17 (0.86)	0.20 (0.06 to 0.34)	NA	NA	NA	NA
Sigursteinsdottir et al,¹¹ 2022	Month NR in 2019 Month NR in 2021	Females/women	759	PSS	13.74 (6.34)	15.63 (6.77)	1.89 (6.56)	0.29 (0.18 to 0.40)	PSS ≥20	19.9 (17.1 to 23.1)	28.9 (25.6 to 32.5)	9.0 (5.3 to 12.6)
Sigursteinsdottir et al,¹¹ 2022	Month NR in 2019 Month NR in 2021	Males/men	161	PSS	12.27 (6.54)	14.34 (6.20)	2.07 (6.37)	0.32 (0.09 to 0.55)	PSS ≥20	13.8 (9.1 to 20.3)	23.5 (17.4 to 31.0)	10.2 (3.4 to 17.2)

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Abbreviations: ASQ, Ask Suicide-Screening Questions; BLSS, Brief Life Satisfaction Scale; CES-D, Centre for Epidemiologic Studies Depression Scale; CES-DC, CES-D for Children; DASS-21 Anxiety, Depression, Anxiety, and Stress Scale–Anxiety subscale; DASS-21 Depression, DASS-21–Depression subscale; DASS-21 Stress, DASS-21–Stress subscale; GAD-7, Generalized Anxiety Disorder-7; GHQ-12, General Health Questionnaire-12; GHQ-28, GHQ-28; MHI-5, Mental Health Index-5; NA, not applicable; NR, not reported; PANAS-NA, Positive and Negative Affect Schedule–Negative Affect subscale; PHQ-9, Patient Health Questionnaire-9; PROMIS Anxiety, Patient-Reported Outcomes Measurement Information System–Anxiety subscale; PROMIS Depression, PROMIS–Depression subscale; PSQ, Personality Structure Questionnaire; PSS, Perceived Stress Scale; RAND-36 Mental Health, RAND 36-Item Health Survey–Mental Health subscale; RAND-36-MCS, RAND 36–Mental Component Summary; SAS, Zung Self-Rating Anxiety Scale; SCARED, Screen for Child Anxiety Related Disorders; SCAS-C, Spence Children’s Anxiety Scale-Child; SCL-90, Symptom Check List-90; SCL-90-R, SCL-90 Revised; SMD, standardized mean difference; SMFQ, Short Mood and Feelings Questionnaire; SMFQ-C, SMFQ–Child Version; WEMWBS, Warwick Edinburgh Mental Well-Being Scale; YSR, Achenbach Youth Self-Report.

^{^a}

Positive Hedges g sizes and increases in proportions above a threshold indicate worse mental health during COVID-19 compared with before COVID-19. Effects for measures in which high scores equal positive outcomes were reversed to reflect this.

^{^b}

Hedges g sizes pooled within the study before meta-analysis for outcomes with multiple measurements.

^{^c}

Results included in the previous review (Dal Santo et al²).

^{^d}

Number included in fixed effects regression analysis in which the majority of data were extracted.

^{^e}

Hedges g effect sizes pooled before meta-analysis for studies assessing the same cohort.

^{^f}

Based on difference between 2020 and 2019 outcomes.

^{^g}

Based on estimate from the fixed effects regression model that estimates within-person change accounting for pre–COVID-19 trends.

^{^h}

Only Daly et al²⁹ reported proportion outcomes and they reported for 2 time points

^ⁱ

Higher scale scores reflect better mental health; thus, the direction of effect sizes was reversed.

Graph with four forest plot panels comparing sex groups across mental health outcomes. Four stacked panels labeled A, B, C, and D, each pairing a study table on the left with a forest plot on the right. Each table lists Study, Females or women slash girls with Total and Mean change with S D, Males or men slash boys with Total and Mean change with S D, and Standardized mean difference with 95 percent C I. Each forest plot has a horizontal axis labeled Standardized mean difference with 95 percent C I, with tick marks spanning approximately minus zero point six to zero point eight in panels A and B, minus zero point eight to zero point eight in panel C, and minus zero point eight to zero point six in panel D. A vertical dotted line marks zero, and a vertical dashed line marks the pooled estimate. Individual studies appear as dark teal squares with horizontal confidence interval lines; square size varies by weight. A diamond at the bottom of each panel marks the random effects model estimate, and an orange horizontal bar beneath the diamond marks the prediction interval. Text above the forest plots reads Lower likelihood on the left and Higher likelihood on the right. Panel A title: Continuous general mental health. Random effects model total females 9505 and males 12257; pooled standardized mean difference zero point zero one with 95 percent C I minus zero point zero seven to zero point one zero; prediction interval minus zero point two three to zero point two five; heterogeneity I 2 equals 81 point 4 percent. Panel B title: Continuous anxiety symptoms. Random effects model total females 3689 and males 2350; pooled standardized mean difference zero point zero nine with 95 percent C I minus zero point zero four to zero point two two; prediction interval minus zero point two seven to zero point four five; heterogeneity I 2 equals 68 point 7 percent. Panel C title: Continuous depression symptoms. Random effects model total females 5130 and males 4620; pooled standardized mean difference zero point one zero with 95 percent C I zero point zero zero to zero point two zero; prediction interval minus zero point two three to zero point four three; heterogeneity I 2 equals 65 point 4 percent. Panel D title: Continuous stress symptoms. Random effects model total females 2091 and males 903; pooled standardized mean difference minus zero point zero eight with 95 percent C I minus zero point one six to zero point zero one; prediction interval minus zero point one eight to zero point zero two; heterogeneity I 2 equals zero percent. — ^aResults included in the previous study (Dal Santo et al²).

Data figure with four forest plots comparing sex differences in symptom change. Four stacked panels labeled A through D, each combining a left table and a right forest plot. Each panel table columns read: Study; Females or women slash girls, No.; Percentage change; Males or men slash boys, No.; Percentage change; Difference with 95 percent confidence interval. Each forest plot has a vertical dotted reference line at zero and a horizontal axis labeled Difference with 95 percent C I; left side labeled Lower likelihood and right side labeled Higher likelihood. Panel A title: Dichotomous general mental health. Rows: Daly et al 2021, females 6380, percentage change 12.4; males 4538, percentage change 4.5; difference minus zero point zero eight with 95 percent C I minus zero point one zero to minus zero point zero six. Dong et al 2020, females 3162, 8.2; males 923, 6.9; difference minus zero point zero one, minus zero point zero five to zero point zero two. van der Velden et al 2022, females 2020, minus zero point six; males 1962, 1.0; difference zero point zero two, minus zero point zero one to zero point zero four. Yu 2021, females 743, 5.5; males 1037, 7.8; difference minus two point three zero, minus seven point three six to two point seven six. Random effects model totals females 12,305 and males 8460; pooled difference minus zero point zero three, minus zero point zero eight to zero point zero three, diamond marker; prediction interval minus zero point two zero to zero point one five as an orange horizontal line; heterogeneity I squared 91.7 percent. Panel B title: Dichotomous anxiety symptoms. Saraswathi et al 2020, females 139, 13.7; males 78, 9.0; difference minus zero point zero five, minus zero point two zero to zero point one one; axis from minus zero point two to zero point two. Panel C title: Dichotomous depression symptoms. Saraswathi et al 2020, females 139, minus two point two; males 78, 10.3; difference zero point one two, minus zero point zero three to zero point two eight. Zhang et al 2023, females 8918, 0.9; males 9209, 1.5; difference minus zero point six zero, minus one point three eight to zero point one eight. Random effects model totals females 9057 and males 9287; pooled difference minus zero point one three, minus zero point eight one to zero point five five, diamond; prediction interval minus seven point zero nine to six point eight two as an orange line; heterogeneity I squared 68.5 percent; axis from minus eight to eight. Panel D title: Dichotomous stress symptoms. Saraswathi et al 2020, females 139, 2.9; males 78, 6.4; difference zero point zero four, minus zero point one zero to zero point one seven. Sigursteinsdottir et al 2022, females 669, 9.0; males 147, 10.2; difference minus one point two zero, minus nine point zero one to six point six one. Random effects model totals females 808 and males 225; pooled difference zero point zero three, minus zero point one zero to zero point one seven, diamond; prediction interval minus zero point eight five to zero point zero two as an orange line; heterogeneity I squared zero percent; axis from minus ten to ten. — ^aResults included in the previous study (Dal Santo et al²).

^bPooled value with Pierce et al,²⁸ which examined the same cohort.

^cPooled value with van der Velden et al,³⁸ which examined the same cohort.

Discussion

In this systematic review and meta-analysis, we reviewed evidence from 27 cohorts that reported changes in mental health symptoms from before to during the COVID-19 pandemic by sex or gender. We found data to compare females or women with males or men but no other sex or gender groups. We did not find substantive or statistically significant differences. The methodological quality of most studies, however, was low, and heterogeneity was substantial in all analyses. These factors reduced confidence in estimates and the degree that they can be applied accurately to individual settings, as illustrated by the wide PIs estimated for each analysis.

Earlier in the pandemic, women or females were anticipated to experience greater worsening in mental health as compared with men or males due to factors including pregnancy status, domestic violence, heavier household and childcare burdens, and worsened socioeconomic environment.^{42,43,44,45,46,47} To our knowledge, 3 systematic reviews and meta-analyses compared data before and during the pandemic, 2 reported significant differences in mental health changes across sex or gender for depression and anxiety disorders as well as psychological distress,^48,49 while 1 found no gender differences in suicide rates.⁵⁰ Both reviews with significant differences, however, relied primarily on cross-sectional studies but very few longitudinal studies. The first review analyzed 48 population surveys reporting prevalences of major depressive and anxiety disorders and estimated change in prevalence by logistic meta-regression. The study found females to be associated with a higher percentage increase than males for both depression (29.8% [95% CI, 27.3%-32.5%] vs 24.0% [95% CI, 21.5%-26.7%]) and anxiety (27.9% [95% CI, 25.6%-30.4%] vs 21.7% [95% CI, 19.3%-24.1%]).⁴⁸ The other meta-analysis analyzed 21 studies estimating the prevalence of psychological distress associated with the COVID-19 pandemic with the psychological distress impact tool and concluded that overall pooled prevalence of distress was significantly higher in females (53.0%) than in males (39.0%).⁴⁹

In our study, we did not find consistent patterns of differences by sex or gender as reported in previous studies, although confidence in our findings was low due to study quality and heterogeneity. The difference between our estimates and those of previous studies may be associated with the use of cross-sectional vs longitudinal data.¹ Measured cross-sectionally, women or females consistently report higher mental health symptom levels than males or men.^51,52 Cross-sectional studies capture these differences, but they cannot disentangle existing sex or gender differences from COVID-19–specific changes. To isolate pandemic-related changes, we included only longitudinal studies with pre–COVID-19 and during COVID-19 assessments, and thus we excluded most of the studies evaluated in the 2 prior reviews of mental health symptoms that reported significant sex or gender associations.^48,49

Strengths and Limitations

The strengths of our study include the use of data from longitudinal change instead of cross-sectional comparisons, which avoids conflation of ongoing differences with change from before the pandemic to during the pandemic. Additionally, we searched 10 databases, including Chinese-language databases. We also implemented well-defined inclusion criteria, such as specific thresholds for proportions of the population assessed and management of losses to follow-up, to support interpretability of change estimates.

There are also important limitations to consider. First, many included studies had methodological weaknesses related to sampling, recruitment, and missing data. Only 2 studies (<10%) were rated yes on all items, including those related to the sampling frame, enrollment of eligible participants, and follow-up.^38,39 High heterogeneity was present in most of our meta-analyses, and analyses included data from many different populations. The general mental health meta-analysis included studies that measured somewhat different constructs (eg, general psychological symptoms, mixed anxiety and depression symptoms). We were unable to examine heterogeneity by factors such as sample characteristics (only 1 cohort reported changes by race or ethnicity), pandemic stage, or methodological quality due to the number of cohorts (1-12 cohorts) in each meta-analysis and the low number of studies with higher methodological adequacy. Second, the geographic representativeness of our study was limited. Of 27 included cohorts, 18 were from high-income countries, 7 from China, and 2 from other Asian countries. We did not identify eligible studies from African, South American, and other countries. Third, we could not test for publication bias, although we do not believe that this was associated with the results since only 4 of 27 included cohorts published sex-based or gender-based comparisons. Fourth, none of the included cohorts reported results from gender-diverse individuals or gender minority groups. Sex and gender are well-recognized important determinants of health and well-being, and although gender minority groups may have been at risk for psychological distress and worsening of mental health symptoms during the pandemic,^53,54 none of the cohorts that we included recorded outcomes for gender-diverse individuals, as suggested by the Sex and Gender Equity in Research (SAGER) guidelines.⁵⁵

Conclusions

This systematic review and meta-analysis of 27 cohorts (1-12 cohorts per analysis) did not find that the COVID-19 pandemic was associated with mental health differences across sex or gender groups. There was high risk of bias for most studies and substantive heterogeneity in all analyses, however. Thus, it is possible that pooled estimates could diverge from true results in different populations or be associated with other factors that we could not evaluate. The lack of data from gender-diverse groups emphasizes the need for adherence to SAGER guidelines to ensure reporting of data from sex and gender minority groups, even if numbers are small, to facilitate synthesis. Our findings also underscore the need for research on populations for which there were little or no data during the COVID-19 pandemic, including gender-diverse individuals and in resource-limited countries, as well as for investment in infrastructure to capture high-quality mental health evidence across populations on an ongoing basis.

Supplement 1.

eMethods 1. Search Strategy

eMethods 2. Title and Abstract and Full-Text Review Inclusion and Exclusion Criteria Coding Guides

eMethods 3. Adequacy of Study Methods and Reporting—Adapted Joanna Briggs Institute Checklist for Prevalence Studies

eTable 1. Confidence Intervals for Proportion Change When Assuming That 30% and 70% of Pre–COVID-19 Cases Were Cases During COVID-19

eFigure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Flowchart

eTable 2. Adequacy of Methods and Reporting of Included Studies (N = 29)

jamanetwopen-e2627595-s001.pdf^{(780.1KB, pdf)}

Supplement 2.

Data Sharing Statement

jamanetwopen-e2627595-s002.pdf^{(14.8KB, pdf)}

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49.Ashtari S, Rahimi-Bashar F, Karimi L, et al. Psychological distress impact of coronavirus disease (COVID-19) outbreak on three continents: a systematic review and meta-analysis. Adv Exp Med Biol. 2023;1412:73-95. [DOI] [PubMed] [Google Scholar]
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51.Kuehner C. Why is depression more common among women than among men? Lancet Psychiatry. 2017;4(2):146-158. doi: 10.1016/S2215-0366(16)30263-2 [DOI] [PubMed] [Google Scholar]
52.Boyd A, Van de Velde S, Vilagut G, et al. ; EU-WMH Investigators . Gender differences in mental disorders and suicidality in Europe: results from a large cross-sectional population-based study. J Affect Disord. 2015;173:245-254. doi: 10.1016/j.jad.2014.11.002 [DOI] [PubMed] [Google Scholar]
53.Tibubos AN, Otten D, Ernst M, Beutel ME. A systematic review on sex- and gender-sensitive research in public mental health during the first wave of the COVID-19 crisis. Front Psychiatry. 2021;12:712492. doi: 10.3389/fpsyt.2021.712492 [DOI] [PMC free article] [PubMed] [Google Scholar]
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55.Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev. 2016;1(1):2. doi: 10.1186/s41073-016-0007-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eMethods 1. Search Strategy

eMethods 2. Title and Abstract and Full-Text Review Inclusion and Exclusion Criteria Coding Guides

eMethods 3. Adequacy of Study Methods and Reporting—Adapted Joanna Briggs Institute Checklist for Prevalence Studies

eTable 1. Confidence Intervals for Proportion Change When Assuming That 30% and 70% of Pre–COVID-19 Cases Were Cases During COVID-19

eFigure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Flowchart

eTable 2. Adequacy of Methods and Reporting of Included Studies (N = 29)

jamanetwopen-e2627595-s001.pdf^{(780.1KB, pdf)}

Supplement 2.

Data Sharing Statement

jamanetwopen-e2627595-s002.pdf^{(14.8KB, pdf)}

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[zoi260756r55] 55.Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev. 2016;1(1):2. doi: 10.1186/s41073-016-0007-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Mental Health Symptom Changes by Sex or Gender Before and During the COVID-19 Pandemic

Gabriel Chun Yin Sung, BASc

Yin Wu, PhD

Suiqiong Fan, MScPH

Tiffany Dal Santo, MSc

Nadia P González-Domínguez, MScPH

Ying Sun, MPH

Letong Li, BA

Kexin Li, MPH

Xiaowen Jiang, BA

Amina Tasleem, MPH

Yutong Wang, MPH

Jill T Boruff, MLIS

Palak Desai, MScPH

Brienne Tougas, BA

Monica D’Onofrio, BSc

Ankur Krishnan, MSc

Claire Adams, PhD

Chen He, MScPH

Richard S Henry, PhD

Afra Alkan, PhD

Danielle B Rice, PhD

Sarah Markham, PhD

Marleine Azar, MD

Elsa-Lynn Nassar, MSc

Sophie Hu, MSc

Mara Cañedo-Ayala, BSc

Dipika Neupane, MSc

Andrea Benedetti, PhD

Brett D Thombs, PhD

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Data Sources

Study Selection

Data Extraction and Synthesis

Main Outcomes and Measures

Results

Conclusion and Relevance

Introduction

Methods

Eligibility Criteria

Search Strategy

Selection of Eligible Studies

Data Extraction and Adequacy Assessment

Statistical Analyses

Results

Search Results and Selection of Eligible Studies

Characteristics of Included Studies

Table 1. Characteristics of Included Studies (N = 29).

Adequacy of Study Methods and Reporting

Mental Health Symptom Changes

Table 2. Outcomes From Included Studies by Sex or Gendera.

Figure 1. Forest Plots of Meta-Analyses for Continuous Measures of Mental Health Symptoms.

Figure 2. Forest Plots of Meta-Analyses for Dichotomous Measures of Mental Health Symptoms.

Discussion

Strengths and Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 2. Outcomes From Included Studies by Sex or Gender^a.