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Elsevier - PMC COVID-19 Collection logoLink to Elsevier - PMC COVID-19 Collection
. 2021 May 26;291:331–337. doi: 10.1016/j.jad.2021.05.045

Predictors of Change in Mental Health during the COVID-19 Pandemic

Ilana Haliwa a, Jenna Wilson a, Jerin Lee b, Natalie J Shook a,b,
PMCID: PMC9754804  PMID: 34087628

Abstract

Background

: Cross-sectional data suggest that depression, anxiety, and stress have increased during the COVID-19 pandemic. However, longitudinal research is needed to test changes in mental health and determine factors that contribute to change. The purpose of this study was to compare anxiety, depression, and stress pre-pandemic to during the pandemic within the same sample and identify predictors of change (i.e., disease threat, changes to daily life, social isolation, financial worries).

Method

: Three national samples of U.S. adults were recruited through an online platform (Amazon's Mechanical Turk). Participants completed online surveys pre-pandemic (September – December 2019) and during the pandemic(April - June 2020).

Results

: Across the three samples, mini-meta analyses revealed significant increases in anxiety and stress (Cohen's ds = 0.17, 0.16, respectively; ps < 0.01). Financial concern and effects of COVID-19 on daily life predicted higher levels of depression, anxiety, and stress during the pandemic across all three samples (ds = 0.24, 0.40, and 0.40, respectively; ps < 0.001).

Limitations

: Response rates for follow-up surveys were relatively low, with some noted differences between those who did and did not complete both surveys.

Conclusions

: Significant increases in anxiety and stress were observed across three samples of U.S. adults from before to during the COVID-19 pandemic. Financial concern and effects of the pandemic on daily life emerged as the most consistent predictors of psychological distress across these samples.

Keywords: Coronavirus, Covid-19, Depression, Anxiety, Stress


The coronavirus disease 2019 (COVID-19) pandemic has had widespread consequences for the health and well-being of the global population. In addition to the serious physical health effects of the disease, there are significant concerns about the impact of the pandemic on mental health (see Rajkumar, 2020; Torales et al., 2020). In U.S. national polls, many individuals report that their mental health has deteriorated due to the pandemic (e.g., Panchal et al., 2020; Pew Research Center, 2020a), but these are perceived declines, not clinical assessments. Findings from cross-sectional comparisons to pre-pandemic prevalence rates are mixed. Some studies suggest that anxiety, depression, and stress are higher during the COVID-19 pandemic (e.g., Ettman et al., 2020; McGinty et al., 2020; Rossi et al., 2020; Wang et al., 2020; Wilson et al., 2020; Xiong et al., 2020), whereas other studies found limited evidence of changes in mental health (Magnavita et al., 2020a). However, very few studies have longitudinally assessed mental health in the same sample pre- and during the pandemic (Daly et al., 2020; Pierce et al., 2020), and none have individually assessed anxiety, depression, and stress. Furthermore, it is unclear what factors underlie any changes. The COVID-19 pandemic has impacted physical, social, and economic well-being (Benke et al., 2020; (Knowles and Olatunji, 2021) Pew Research Center, 2020b), all of which have implications for mental health. The goals of the present research were to determine the extent to which anxiety, depression, and stress have changed from pre-pandemic to during the pandemic at the individual level and which consequences of the pandemic account for changes in mental health.

Several studies have compared cross-sectional data collected during the pandemic to different pre-pandemic samples or population prevalence rates, generally finding higher rates of depression, anxiety and stress during the pandemic (e.g., Ettman et al., 2020; McGinty et al., 2020; Rossi et al., 2020; Wang et al., 2020; Wilson et al., 2020; Xiong et al., 2020). For example, among a nationally representative sample of U.S. adults, depression prevalence was higher during the pandemic (24.6% mild, 14.8% moderate, 7.9% moderately severe, 5.1% severe) compared to pre-pandemic levels derived from a separate national survey (16.2% mild; 5.7% moderate. 2.1% moderately severe, 0.7% severe; Ettman et al., 2020). Similarly, a recent review of cross-sectional studies assessing mental health during the COVID-19 pandemic found rates of depression (14.6% – 32.8%), anxiety (6.33% – 18.7%), and stress (27.2%) that were higher than pre-pandemic national averages (Xiong et al., 2020). Although informative, the aforementioned studies do not compare mental health outcomes within the same individuals before and during the pandemic, and thus cannot make accurate conclusions about individual level changes. There may be fundamental, unaccounted for differences between individuals who volunteer to take part in research studies during the COVID-19 pandemic compared to those who agreed to take part in studies pre-pandemic.

To date, only two studies have assessed mental health outcomes longitudinally within a single sample before and during the pandemic. Both studies used data from the UK Household Longitudinal Study, which assessed general mental health with the 12-item General Health Questionnaire (GHQ-12; Goldberg and Williams, 1988). Both studies found that mental distress had increased from pre-pandemic to during the pandemic (Daly et al., 2020; Pierce et al., 2020). However, the GHQ-12 only assesses general mental health and does not measure specific forms of mental distress (e.g., depression, anxiety, stress). Thus, it is unclear the extent to which anxiety, depression, and stress specifically have changed from pre-pandemic levels to during the pandemic at an individual level.

The primary contributors to any deterioration in mental health are also unknown. The COVID-19 pandemic is associated with multiple stressors that have implications for mental health. First, the physical health threat posed by infectious diseases, such as COVID-19, may increase stress and anxiety (Knowles & Olatunji, 2021). Indeed, greater concern about COVID-19 and likelihood of contracting COVID-19 are associated with higher levels of depression and anxiety (e.g., CDC, 2020; Huang and Zhao, 2020; Magnavita et al., 2020b; Wilson et al., 2020). Second, the pandemic has disrupted most people's daily lives, with many having to start telecommuting for work, transition to distance learning for themselves or their children, find alternative childcare, limit or eliminate travel and regular activities (e.g., exercising at a gym, dining out), etc. These changes to daily life have been associated with greater depression (Benke et al., 2020; Magnavita et al., 2021; Rossi et al., 2020), anxiety (Benke et al., 2020; Cao et al., 2020; Rossi et al., 2020), and stress (Carroll et al., 2020; Rossi et al., 2020).

Third, recommended preventive behaviors (e.g., social distancing, self-quarantine) to reduce exposure to and spread of COVID-19 may have negative effects on mental health. Generally, social isolation is associated with decreased mental health (e.g., (Leigh-Hunt, 2017)) . Indeed, greater self-quarantining and social distancing during the COVID-19 pandemic, as well as the severe acute respiratory syndrome (SARS) epidemic, were associated with higher levels of anxiety and depression (Benke et al., 2020; Hawryluk et al., 2004). Finally, the COVID-19 pandemic has negatively impacted the economy, with over 15% of U.S. adults losing their employment, 21% having their pay reduced, and steeper declines in stocks than during the Great Recession of 2007–2008 (Pew Research Center, 2020b, 2020c). Indeed, financial concerns during the pandemic have been associated with greater psychological distress, anxiety, and depression (Cao et al., 2020; Ettman et al., 2020; McGinty et al., 2020; Wilson et al., 2020), with one study finding levels of financial anxiety to be equal to levels of health anxiety during the pandemic (Bareket – Bojmel et al., 2020). Each of these pandemic-related stressors may have potential negative consequences for mental health, and it is crucial to identify which factor(s) uniquely contribute to declines in mental health during the COVID-19 pandemic in order to target stressors and provide the most effective care.

The primary goal of the present project was to determine the extent to which anxiety, depression, and stress changed from pre-pandemic to during the pandemic in three samples of U.S. adults. We expected anxiety, depression, and stress levels to have increased over time. We also sought to identify what factors (i.e., concern about COVID-19, perceived likelihood of infection, disruption of daily life, social distancing, self-quarantine, and financial concerns) accounted for anxiety, depression, and stress levels during the pandemic, controlling for pre-pandemic mental health. Although we expected each factor to be associated with higher levels of anxiety, depression, and stress at a bivariate level, we did not have specific hypotheses about which factors would be significantly associated with mental health when considered simultaneously.

1. Method

1.1. Participants

Participants were U.S. residents recruited through Amazon's Mechanical Turk (MTurk) to complete three separate online surveys involving measures of anxiety, depression, and stress prior to the COVID-19 pandemic (September-December 2019). Early in the COVID-19 pandemic (April-June 2020), participants were invited to complete follow-up surveys consisting of the same mental health measures and questions about stressors related to the COVID-19 pandemic (see Supplemental Materials for detailed demographic descriptions of each sample).

1.1.1. Sample 1

Nine hundred and twelve participants completed the initial survey (December 4–10, 2019). After screening for problematic responses (i.e., duplicate IP addresses, straight line responses, or nonsensical open-ended responses), 619 individuals were invited to complete a follow-up survey (April 3–15, 2020). Three hundred forty-four of the original respondents completed the follow-up survey (58% response rate1 ). Of those, 44 participants were excluded from analyses due to missing data on key variables. Thus, the final sample included 300 individuals (58.7% women; M age = 41.38 years, SD = 12.37, range: 19–84; 76.3% White; 87.3% completed at least some college; Mdn income = $50,000–59,999).

1.1.2. Sample 2

Four hundred and sixty-eight participants completed the initial survey (October 6–13, 2019). After screening for problematic responses, 404 individuals were invited to complete a follow-up survey (May 14–25, 2020). Of the original respondents, 146 individuals completed the follow-up survey (36% response rate2 ; 53.4% women, M age = 43.75 years, SD = 12.77, range: 19–76 years; 76% White; 89% completed at least some college; Mdn income = $40,000-$59,999).

1.1.3. Sample 3

Four hundred forty-one participants completed the initial survey (September 18–26, 2019). After screening for problematic responses, 401 individuals were invited to complete a follow-up survey (June 10–19, 2020). One hundred forty-two of the original respondents completed the follow-up survey (35% response rate3 ; 50% women; M age = 40.46 years, SD = 12.98, range: 18–75; 71.1% White; 86% completed at least some college; Mdn income = $50,000-$59,999).

1.2. Measures

Full versions of each study measure can be found in Supplemental Materials.

1.2.1. Depression

Participants in Samples 1 and 3 completed the abbreviated 8-item version of the Patient Health Questionnaire (PHQ-8; Kroenke et al., 2009). Scores range from 0 to 24, with the following severity ratings: minimal depressive symptoms (0–4), mild depressive symptoms (5–9), moderate depressive symptoms (10–14), moderately severe depressive symptoms (15–19), and severe depressive symptoms (20–24). Scores ≥ 10 indicate current depression.

Participants in Sample 2 completed the depression subscale of the Depression Anxiety Stress Scale (DASS-21; Lovibond and Lovibond, 1995). Scores range from 0 to 21, with the following severity ratings: normal (0–4), mild depressive symptoms (5–6), moderate depressive symptoms (7–10), severe depressive symptoms (11–13), and extremely severe depressive symptoms (14+).

1.2.2. Anxiety

Participants in Samples 1 and 3 completed the General Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006). Scores range from 0 to 21, with the following severity ratings: minimal to none (0–4), mild (5–9), moderate (10–14), and severe (15+). Scores ≥ 10 indicate generalized anxiety.

Participants in Sample 2 completed the anxiety subscale of the DASS-21(Lovibond and Lovibond, 1995). Scores range from 0 to 21, with the following severity ratings: normal (0–3), mild (4–5), moderate (6–7), severe (8–9), and extremely severe (10+).

1.2.3. Stress

Participants in Samples 1 and 3 completed versions of the Perceived Stress Scale (PSS; Cohen et al., 1983). A shortened, four-item version of this scale (PSS-4; Cohen et al., 1983) was used with Sample 1,4 whereas the full 10-item PSS was used with Sample 3. For the PSS-4, scores range from 0 to 16, where scores above 6 are considered higher than average (Warttig et al., 2013). For the PSS-10, scores range from 0 to 40, with the following severity ratings: low stress (0–13), moderate stress (14–26), and high stress (27+).

Participants in Sample 2 completed the stress subscale of the DASS-21 (Lovibond and Lovibond, 1995). Scores range from 0 to 21, with the following severity ratings: normal (0–7), mild (8–9), moderate (10–12), severe (13–16), and extremely severe (17+).

1.2.4. Concern about COVID-19

Six items assessed the extent to which participants were concerned about COVID-19 (Shook et al., 2020). Items were standardized and averaged. Higher scores indicated more COVID-19 concern.

1.2.5. Likelihood of contracting COVID-19

Participants were asked ‘How likely do you think you are to contract the coronavirus, COVID-19?’ on a scale from 1 (not at all) to 5 (extremely likely).

1.2.6. COVID-19 affecting daily life

Participants were asked “How much is the coronavirus, COVID-19, affecting your daily life?” a scale from 1 (not at all) to 5 (a great deal).

1.2.7. Social distancing

Four items assessed the extent to which participants perceived they were social distancing (Shook et al., 2020). Items were standardized and averaged. Higher scores indicated greater social distancing.

1.2.8. Self-quarantining

Participants were asked to indicate whether or not they self-quarantined (i.e., stay at home to avoid contracting or spreading COVID-19) over the past week. Participants who indicated “yes” were asked to indicate the number of days (1–7) they self-quarantined. Participants who indicated “no” were scored as 0 days. Scores reflected number of days spent in self-quarantine over the past week.

1.2.9. Financial concern

Five items assessed participants’ financial concern during the pandemic. One item assessed participants concern about the U.S. economy, and the other four items assessed concern about personal and family finances. The five items were standardized and averaged. Higher scores indicated greater financial concern.

1.2.10. Demographics

Participants reported their age, gender, ethnicity/race, education, and income.

1.3. Procedure

Participants were recruited via MTurk for three larger research projects between September and December 2019. These projects were approved by the university's institutional review board. After providing electronic consent, participants completed online surveys which included the respective measures of anxiety, depression, and stress. Measures were presented in a random order, except for the demographics which appeared last. Participants were compensated $1 for Samples 1 and 3, and $2 for Sample 2.

Between April and June 2020, participants were invited to complete a follow-up survey through MTurk. After providing electronic consent, participants completed the respective measures of anxiety, depression, and stress a second time, as well as the questions about COVID-19 concerns, daily disruption from COVID-19, likelihood of contracting COVID-19, social distancing, self-quarantining, and financial concerns. Measures were presented in a random order, except for the demographics which appeared last. All participants were compensated $5.

1.4. Statistical analysis

Paired samples t-tests were calculated using IBM SPSS version 26 to determine whether mental health had changed from pre-pandemic levels to during the pandemic in each sample. Given the relatively small sample sizes and utilization of different measures, mini meta-analysis (Goh et al., 2016) was conducted to determine whether there was evidence of change in mental health across the three samples. We used fixed effects in which the mean effect size was weighted by sample size. T-values were transformed into Cohen's d.

Partial correlations were estimated to assess bivariate associations between mental health outcomes during the pandemic and COVID-19 related stressors, controlling for mental health pre-pandemic. To determine which COVID-19 related stressor uniquely accounted for mental health during the pandemic, multiple linear regression models were estimated for each mental health outcome in each sample using IBM SPSS version 26. For each model, mental health pre-pandemic (i.e., depression, anxiety, and stress) was controlled for. COVID-19 concern, COVID-19 affecting daily life, social distancing, self-quarantining, financial concern, and perceived likelihood of contracting COVID-19 were entered as simultaneous predictors. Mini meta-analysis was utilized to estimate effects across all three samples (Goh et al., 2016).

2. Results

Means, standard deviations, and Cronbach's alphas for all variables are presented in Table 1 . For Samples 1 and 3, using the GAD-7 and PHQ-8, clinical cutoffs for current depression and generalized anxiety were calculated. For Sample 1, 21.3% and 19% of participants met clinical cutoffs for current depression and generalized anxiety, respectively, pre-pandemic compared to 27% and 29.7% during the pandemic. For Sample 3, 24.6% and 20.4% of participants met clinical cutoffs for current depression and generalized anxiety, respectively, pre-pandemic compared to 23.9% and 19.7% during the pandemic. A breakdown of depression, anxiety, and stress severity for each sample can be found in Table 2 .

Table 1.

Means, Standard Deviations, and Cronbach's Alphas for Study Variables and Comparison of Mental Health Pre-pandemic to during the Pandemic by Sample.

Pre-pandemic Pandemic Time Comparison
Sample 1 (N = 300) M(SD) Cronbach's alpha M(SD) Cronbach's alpha t p d
PHQ-8 5.92 (5.26) 0.90 5.79 (6.04) 0.92 −0.55 0.585 0.03
GAD-7 5.58 (5.02) 0.92 6.55 (5.98) 0.94 3.41 0.001 0.20
PSS-4 6.21 (3.58) 0.75 6.54 (3.58) 0.80 1.91 0.06 0.11
Likelihood of COVID-19 2.48 (0.98)
COVID Concern −0.01 (0.83) 0.91
Effects on daily life 3.74 (1.09)
Social distancing 0.00 (0.81) 0.82
Self-quarantine days 4.94 (2.76)
Financial concern 0.01 (0.76) 0.82
Sample 2 (N = 146)
DASS-D 4.81 (5.92) 0.96 4.79 (5.67) 0.94 −0.05 0.92 0.00
DASS-A 3.53 (4.89) 0.93 3.25 (4.51) 0.91 −1.20 0.23 0.10
DASS-S 5.01 (5.45) 0.93 5.40 (5.22) 0.92 1.39 0.17 0.12
Likelihood of COVID-19 2.32 (1.02)
COVID Concern 0.01 (0.78) 0.88
Effects on daily life 3.48 (1.10)
Social distancing 0.03 (0.77) 0.79
Self-quarantine days 4.29 (2.95)
Financial concern 0.00 (0.75) 0.80
Sample 3 (N = 142)
PHQ-8 5.15 (5.81) 0.93 5.32 (6.08) 0.92 0.49 0.62 0.04
GAD-7 4.64 (5.35) 0.93 4.82 (5.60) 0.94 0.51 0.62 0.04
PSS-10 15.74 (7.42) 0.83 15.69 (7.35) 0.82 −0.12 0.91 0.01
Likelihood of COVID-19 2.18 (1.02)
COVID Concern 0.00 (0.80) 0.89
Effects on daily life 3.11 (1.14)
Social distancing 0.00 (0.80) 0.81
Self-quarantine days 3.85 (3.08)
Financial concern 0.01 (0.79) 0.85

Notes: DASS: Depression, Anxiety, and Stress Scales; GAD-7: Generalized Anxiety Disorder; PHQ-8: Patient Health Questionnaire; PSS: Perceived Stress Scale.

Table 2.

Depression, Anxiety, and Stress Severity by Sample.

Sample 1 (N = 300)
Depression (PHQ-8) Minimal Mild Moderate Moderately severe Severe
Pre-pandemic 43.30% 33.40% 13.60% 6.70% 1.00%
Pandemic 55.70% 17.30% 15.00% 9.30% 2.70%
Anxiety (GAD-7) Minimal - none Mild Moderate Severe
Pre-pandemic 46.30% 34.70% 11.70% 7.30%
Pandemic 44.70% 25.60% 17.70% 12.00%
Stress (PSS 4) Below average Above average
Pre-pandemic 41.30% 58.70%
Pandemic 39.30% 60.70%
Sample 2 (N = 146)
Depression (DASS-21) Normal Mild Moderate Severe Extremely severe
Pre-pandemic 61.00% 8.20% 11.60% 7.60% 11.60%
Pandemic 59.60% 7.50% 13.00% 8.30% 11.60%
Anxiety (DASS-21)
Pre-pandemic 69.20% 8.90% 4.10% 2.70% 15.10%
Pandemic 71.20% 5.50% 6.20% 4.80% 12.30%
Stress (DASS-21)
Pre-pandemic 73.30% 8.20% 4.80% 9.60% 4.10%
Pandemic 68.50% 8.20% 14.40% 5.50% 3.40%
Sample 3 (N = 142)
Depression (PHQ-8) Minimal - none Mild Moderate Moderately severe Severe
Pre-pandemic 64.10% 11.30% 15.40% 7.80% 1.40%
Pandemic 55.60% 20.50% 14.00% 5.00% 4.90%
Anxiety (GAD-7) Minimal - none Mild Moderate Severe
Pre-pandemic 59.90% 19.70% 16.20% 4.20%
Pandemic 60.60% 19.70% 11.20% 8.50%
Stress (PSS 10) Low Medium High
Pre-pandemic 43.70% 47.80% 8.50%
Pandemic 39.40% 52.10% 8.50%

2.1. Change in mental health

To determine whether mental health changed significantly in each sample, paired samples t-tests were conducted (see Table 1). For Sample 1, anxiety during the pandemic was significantly higher than anxiety pre-pandemic. None of the other comparisons were significant for any samples. However, based on the mini meta-analyses (Goh et al., 2016), across all samples there were significant small effects indicating that anxiety and stress increased during the pandemic (ds =0.17 and 0.16, respectively; ps < 0.01). No significant effect was found for change in depression (d = −0.01, p = .407).

2.2. Predictors of mental health during the pandemic

Partial correlations between mental health outcomes during the pandemic and COVID-19 related stressors, controlling for mental health pre-pandemic are presented in Table 3 . Greater financial concern was significantly associated with higher depression, anxiety, and stress levels during the pandemic across all three samples. COVID-19 affecting daily life more was significantly associated with greater depression (Samples 2 and 3), anxiety (all samples), and stress (Samples 1 and 2). Greater perceived likelihood of contracting COVID-19 was associated with higher levels of depression (Sample 2) and anxiety (Sample 1). Greater COVID-19 concern was associated with greater anxiety during the pandemic (Samples 1 and 3). Greater social distancing was significantly associated with greater depression and anxiety in Sample 3.

Table 3.

Partial Correlations for All Study Variables by Sample, Controlling for Pre-Pandemic Depression, Anxiety, and Stress.

Sample 1
1 2 3 4 5 6 7 8
1. Depression Time 2
2. Anxiety Time 2 0.65***
3. Stress Time 2 0.37*** 0.44***
4. COVID likelihood 0.08 0.17** 0.04
5. COVID concern −0.04 0.13* 0.013 0.35***
6. Effects on daily life 0.11 0.22*** 0.16** 0.30*** 0.40***
7. Social distancing −0.02 0.07 −0.09 0.18** 0.34*** 0.36***
8. Self-quarantine days −0.06 −0.01 0.07 0.06 0.27*** 0.15* 0.26***
9. Financial concern 0.17** 0.28*** 0.29*** 0.20** .21*** 0.41*** 0.17** 0.00
Sample 2
1 2 3 4 5 6 7 8
1. Depression Time 2
2. Anxiety Time 2 0.50***
3. Stress Time 2 0.51*** 0.51***
4. COVID likelihood 0.19* 0.14 0.15
5. COVID concern 0.03 −0.09 0.01 0.28**
6. Effects on daily life 0.29*** 0.20* 0.30*** 0.28** 0.15
7. Social distancing −0.06 0.06 −0.05 0.03 0.23** −0.04
8. Self-quarantine days 0.00 0.07 0.09 0.09 0.32*** 0.11 0.21*
9. Financial concern 0.23** 0.30*** 0.18* 0.28** 0.23** 0.39*** 0.16 0.26**
Sample 3
1 2 3 4 5 6 7 8
1. Depression Time 2
2. Anxiety Time 2 0.75***
3. Stress Time 2 0.53*** 0.59***
4. COVID likelihood 0.13 0.15 0.07
5. COVID concern 0.16 0.17* 0.09 0.28**
6. Effects on daily life 0.34*** 0.33*** 0.16 0.27** 0.34***
7. Social distancing 0.20* 0.18* 0.04 0.18* 0.65*** 0.36***
8. Self-quarantine days 0.02 0.10 0.01 0.03 0.26** 0.1 0.47***
9. Financial concern 0.32*** 0.31*** 0.21* 0.34*** 0.26** 0.50*** 0.20* 0.09

Notes: *p <0.05, **p <0.01, ***p <0.001.

To assess unique contributions of each COVID-19 stressor to mental health, multiple linear regression models were estimated for anxiety, depression, and stress. All regression models were significant (see Table 4 ). When accounting for all COVID-19 stressors and mental health pre-pandemic, greater financial concern was significantly associated with greater depression (Sample 1), anxiety (Samples 1 and 2), and stress (Sample 1) during the pandemic. COVID-19 affecting daily life was positively associated with depression (Samples 2 and 3), anxiety (Sample 3), and stress (Sample 2). In Sample 1, greater social distancing was associated with less stress, whereas greater self-quarantining was associated with more stress.

Table 4.

Linear Regression Predicting Pandemic Mental Health by Sample, including standardized beta (unstandardized beta, SE).

Sample 1 Sample 2 Sample 3
Predictor Depression Anxiety Stress Depression Anxiety Stress Depression Anxiety Stress
Depression Pre-pandemic 0.44*** 0.30*** 0.12* 0.88*** −0.02 0.13 0.66*** 0.30 0.21
(0.50, 0.06) (0.34, 0.07) (0.08, 0.04) (0.85, 0.08) (0.02, 0.06) (0.12, 0.08) (0.69, 0.11) (0.29, 0.11) (0.27, 0.14)
Anxiety Pre-pandemic 0.27*** 0.34*** 0.18** −0.02 0.87*** 0.14 0.06 0.27* 0.10
(0.33, 0.06) (0.40, 0.07) (0.13, 0.04) (−0.02, 0.12) (0.80, 0.10) (0.15, 0.12) (0.07, 0.12) (0.28, 0.12) (0.14, 0.14)
Stress Pre-pandemic 0.11* 0.01 0.37*** −0.11 −0.13 0.52*** −0.02 0.10* 0.48***
(0.19, 0.08) (0.01, 0.10) (0.37, 0.054) (−0.12, 0.13) (−0.12, 0.10) (0.49, 0.12) (−0.02, 0.08) (0.08, 0.08) (0.48, 0.10)
COVID likelihood 0.05 0.07 0.00 0.07 −0.06 0.05 0.00 0.02 0.00
(0.29, 0.25) (0.42, 0.29) (−0.02, 0.16) (0.41, 0.29) (0.24, 0.23) (0.23, 0.28) (0.01, 0.36) (0.12, 0.35) (−0.03, 0.42)
COVID concern −0.07 0.02 −0.05 −0.07 −0.13* −0.05 0.03 0.01 0.01
(−0.49, 0.31) (0.16, 0.36) (−0.20, 0.20) (−0.49, 0.38) (−0.73, 0.30) (−0.31, 0.37) (0.19, 0.46) (0.06, 0.45) (0.11, 0.55)
Effects on daily life 0.05 0.08 0.09 0.13* 0.06 0.15** 0.16* 0.15* 0.04
(−0.29, 0.25) (0.45, 0.28) (0.30, 0.26) (0.66, 0.27) (0.25, 0.21) (0.72, 0.26) (0.86, 0.34) (0.74, 0.34) (0.26, 0.41)
Social distancing −0.03 −0.02 −0.13** −0.02 0.04 −0.03 0.02 0.04 0.02
(−0.20, 0.30) (−0.12, 0.35) (−0.58, 0.20) (−0.17, 0.36) (0.20, 0.28) (−0.22, 0.25) (0.14, 0.44) (0.30, 0.44) (0.17, 0.53)
Self-quarantining −0.02 −0.02 0.09* −0.01 0.02 0.04 −0.02 0.03 −0.02
(−0.04, 0.09) (−0.05, 0.10) (0.11, 0.06) (−0.03, 0.10) (0.04, 0.08) (0.07, 0.09) (0.81, 0.52) (0.05, 0.11) (−0.04, 0.13)
Financial concern 0.10* 0.17** 0.21*** 0.09 0.15** 0.05 0.11 0.14 0.11
(0.82, 0.33) (1.32, 0.38) (−0.02, 0.16) (0.41, 0.29) (0.24, 0.23) (0.23, 0.28) (0.81, 0.52) (0.96, 0.52) (−0.03, 0.42)
R2 0.63*** 0.50*** 0.55*** 0.72*** 0.72*** 0.69*** 0.64*** 0.59*** 0.66***

Notes: *p <0.05, **p < .01, ***p < .001.

As financial concern and COVID-19 affecting daily life were the most consistent significant predictors across the regression analyses, mini meta-analyses were conducted to test the effect of these predictors on each mental health variable across the samples. Significant small effects on depression, anxiety, and stress were revealed for both financial concern (ds = 0.24, 0.40, and 0.40, respectively; ps < 0.001) and COVID-19 affecting daily life (ds = 0.29, 0.23, and 0.24, respectively; ps < 0.01).

3. Discussion

Utilizing mini meta-analysis with three U.S. adult samples, we found evidence of significant increases in anxiety and stress from pre-pandemic to during the pandemic, but there was not evidence of change in depression. Additionally, financial concern and COVID-19 affecting daily life emerged as the most consistent predictors of anxiety, stress, and depression during the pandemic, while controlling for pre-pandemic mental health. This study is the first to directly assess change in depression, anxiety, and stress from pre-pandemic to during the pandemic within the same samples, allowing for the evaluation of individual level change.

These findings expand upon prior work, which found worsened general mental health during the pandemic compared to pre-pandemic in a single UK sample (Daly et al., 2020; Pierce et al., 2020) and further clarify which dimensions of mental health (i.e., anxiety and stress) have changed. This work is consistent with cross-sectional comparisons to pre-pandemic prevalence of psychological distress suggesting that anxiety and stress are higher during the COVID-19 pandemic (Ettman et al., 2020; Rossi et al., 2020; Wang et al., 2020; Wilson et al., 2020; Xiong et al., 2020). However, we did not find significant changes in depression. This may be due, in part, to the nature of the COVID-19 threat. Disease threat and uncertainty are particularly salient within the context of anxiety and stress (Grupe and Nitschke, 2013). Previous findings of higher depression during the pandemic may be due to comorbidities among depression, anxiety, and stress (Hirschfeld, 2001) or sample differences (see Limitations section).

The present study also identified predictors of anxiety, depression, and stress during the pandemic, controlling for pre-pandemic mental health. Consistent with prior research (McGinty et al., 2020; Benke et al., 2020), financial concern and COVID-19 affecting daily life emerged as potential contributors to increased depression, anxiety, and stress during the pandemic. Importantly, we identified the unique contribution of these factors above other stressors (i.e., disease threat, changes to daily life, social isolation, financial worries) and while controlling for pre-pandemic mental health. Based on individual sample analyses, the impact of these stressors seemed to vary based on the timeline of the COVID-19 pandemic. Financial concern significantly predicted depression, anxiety, and stress in Sample 1 (April 3–15 2020) and anxiety in Sample 2 (May 14–25 2020), but did not emerge as a significant predictor of mental health for Sample 3 (June 10–19 2020). These differences may be, in part, due to distribution of stimulus checks which began April 15, 2020. Stimulus checks may have buffered the impact of financial concern on mental health for Samples 2 and 3. COVID-19 affecting daily life did not significantly predict mental health in Sample 1, but did in Samples 2 (depression and stress) and 3 (depression and anxiety). As the pandemic progressed, its effects on daily life may have compounded as telecommuting for work, closures of schools and daycare centers, and decreased access to reinforcing activities (e.g., exercising at a gym, dining out, social gatherings) continued. Indeed, there are reports of increased burnout among health-care workers, parents, and the general population as the pandemic progressed (Griffith, 2020; Morgantini et al., 2020; Yildirim and Solmaz, 2020), which is associated with depression, anxiety, and stress (Koutsimani et al., 2019; Yildirim and Solmaz, 2020). Thus, the impact of COVID-19 affecting daily life on mental health may have been stronger in later samples.

These findings have important clinical and policy implications. Financial concern and the effects of COVID-19 on daily life may be important targets for prevention and intervention strategies to mitigate the negative mental health impacts of the COVID-19 pandemic, or future pandemics. Interventions that empower individuals to better accept and cope with disruption to daily life (e.g., mindfulness training) could mitigate negative mental health consequences from the impact of the COVID-19 pandemic on everyday routine. In addition to policy-level changes (e.g., additional congressional relief efforts, housing relief), financial support services such as housing assistance and financial education may also help buffer against increased psychological distress due to financial concerns arising from the pandemic.

4. Limitations

Findings of the present study should be interpreted in the context of certain methodological limitations. The data are correlational and thus causation cannot be inferred. Although sample demographics were similar to the U.S. adult population (U.S. Census Bureau, 2019), our samples were not nationally representative, limiting generalizability. Further, the initial, pre-pandemic surveys were not designed and participants were not recruited with the intention to conduct a follow-up survey. Indeed, response rates for the follow-up surveys were relatively low, and participants who completed the follow-up surveys tended to be older and reported lower levels of psychological distress than those who declined to complete the follow-up survey. It is possible that the present sample was skewed towards lower levels of psychological distress overall, which may contribute to the lack of observed change in depression pre- to during the pandemic. All measures were self-report which may be biased (e.g., social desirability) and raise concerns of common method variance which may inflate effect size (Podsakoff et al., 2003).

5. Conclusions

The COVID-19 pandemic has had negative consequences for mental health (Panchal et al., 2020; Pew Research Center, 2020a), as well as impacts on several known predictors of psychological distress: physical health, changes to daily life, social isolation, and financial concern. The present study demonstrated significant increases in anxiety and stress across three samples of U.S. adults. Financial concern and effects of the pandemic on daily life emerged as the most consistent predictors of psychological distress across these samples. As such, these may serve as important targets for interventions to mitigate negative impacts on mental health during the remainder of the COVID-19 pandemic.

Role of the funding source

Funding source had no involvement in study design, in the collection, analysis, and interpretation of data, in the writing of the report, nor in the decision to submit this article for publication.

Conflict of interest

The authors have no conflicts of interest to disclose.

CRediT authorship contribution statement

Ilana Haliwa: Data curation, Writing - original draft, Writing - review & editing, Formal analysis. Jenna Wilson: Data curtion, Writing - original draft, Writing - review & editing, Formal analysis. Jerin Lee: Investigation, Data curtion, Writing - original draft, Writing - review & editing, Formal analysis. Natalie J. Shook: Conceptualization, Methodology, Investigation, Resources, Writing - review & editing, Supervision, Project administration, Funding acquisition.

Acknowledgements

This work was supported by a Rapid Response to Examine Social and Behavioral Implications of COVID-19 grant from the University of Connecticut Institute for Collaboration on Health, Intervention, and Policy.

Footnotes

1

Sample 1 participants who did not complete the follow-up survey were significantly younger (t(611.42) = 7.24, p < .001), and reported more depression (t(476.35) = −4.51, p < .001) and anxiety (t(451.59) = −3.52, p < .001) than those who completed the follow-up survey. No significant differences were revealed for gender, race, or stress.

2

Sample 2 participants who did not complete the follow-up survey were significantly younger (t(391) = −5.74, p < .001), and reported more depression (t(397) = 2.53, p = .01), anxiety (t(332.44) = 3.40, p < .001), and stress (t(397) = 3.27, p < .001) than those who completed the follow-up survey. No significant differences were revealed for gender or race.

3

Sample 3 participants who did not complete the follow-up survey were significantly younger (t(154.50) = −2.66, p = .009), and reported more depression (t(315.46) = 5.46, p < .001), anxiety (t(320.45) = 5.48, p < .001), and stress (t(234.84) = 3.45, p = .001) than those who completed the follow-up survey. No significant differences were revealed for gender or race.

4

Due to an experimenter error, there was a discrepancy between the wording of the instructions and each item. The instructions asked participants to consider their feelings and thoughts over the past week, but each item started with “In the last month…”

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2021.05.045.

Appendix. Supplementary materials

mmc1.docx (33.8KB, docx)

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