mental health amidst pandemic essay

• COVID-19 and your mental health

Worries and anxiety about COVID-19 can be overwhelming. Learn ways to cope as COVID-19 spreads.

At the start of the COVID-19 pandemic, life for many people changed very quickly. Worry and concern were natural partners of all that change — getting used to new routines, loneliness and financial pressure, among other issues. Information overload, rumor and misinformation didn't help.

Worldwide surveys done in 2020 and 2021 found higher than typical levels of stress, insomnia, anxiety and depression. By 2022, levels had lowered but were still higher than before 2020.

Though feelings of distress about COVID-19 may come and go, they are still an issue for many people. You aren't alone if you feel distress due to COVID-19. And you're not alone if you've coped with the stress in less than healthy ways, such as substance use.

But healthier self-care choices can help you cope with COVID-19 or any other challenge you may face.

And knowing when to get help can be the most essential self-care action of all.

Recognize what's typical and what's not

Stress and worry are common during a crisis. But something like the COVID-19 pandemic can push people beyond their ability to cope.

In surveys, the most common symptoms reported were trouble sleeping and feeling anxiety or nervous. The number of people noting those symptoms went up and down in surveys given over time. Depression and loneliness were less common than nervousness or sleep problems, but more consistent across surveys given over time. Among adults, use of drugs, alcohol and other intoxicating substances has increased over time as well.

The first step is to notice how often you feel helpless, sad, angry, irritable, hopeless, anxious or afraid. Some people may feel numb.

Keep track of how often you have trouble focusing on daily tasks or doing routine chores. Are there things that you used to enjoy doing that you stopped doing because of how you feel? Note any big changes in appetite, any substance use, body aches and pains, and problems with sleep.

These feelings may come and go over time. But if these feelings don't go away or make it hard to do your daily tasks, it's time to ask for help.

Get help when you need it

If you're feeling suicidal or thinking of hurting yourself, seek help.

• Contact your healthcare professional or a mental health professional.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.

If you are worried about yourself or someone else, contact your healthcare professional or mental health professional. Some may be able to see you in person or talk over the phone or online.

You also can reach out to a friend or loved one. Someone in your faith community also could help.

And you may be able to get counseling or a mental health appointment through an employer's employee assistance program.

Another option is information and treatment options from groups such as:

• National Alliance on Mental Illness (NAMI).
• Substance Abuse and Mental Health Services Administration (SAMHSA).
• Anxiety and Depression Association of America.

Self-care tips

Some people may use unhealthy ways to cope with anxiety around COVID-19. These unhealthy choices may include things such as misuse of medicines or legal drugs and use of illegal drugs. Unhealthy coping choices also can be things such as sleeping too much or too little, or overeating. It also can include avoiding other people and focusing on only one soothing thing, such as work, television or gaming.

Unhealthy coping methods can worsen mental and physical health. And that is particularly true if you're trying to manage or recover from COVID-19.

Self-care actions can help you restore a healthy balance in your life. They can lessen everyday stress or significant anxiety linked to events such as the COVID-19 pandemic. Self-care actions give your body and mind a chance to heal from the problems long-term stress can cause.

Take care of your body

Healthy self-care tips start with the basics. Give your body what it needs and avoid what it doesn't need. Some tips are:

• Get the right amount of sleep for you. A regular sleep schedule, when you go to bed and get up at similar times each day, can help avoid sleep problems.
• Move your body. Regular physical activity and exercise can help reduce anxiety and improve mood. Any activity you can do regularly is a good choice. That may be a scheduled workout, a walk or even dancing to your favorite music.
• Choose healthy food and drinks. Foods that are high in nutrients, such as protein, vitamins and minerals are healthy choices. Avoid food or drink with added sugar, fat or salt.
• Avoid tobacco, alcohol and drugs. If you smoke tobacco or if you vape, you're already at higher risk of lung disease. Because COVID-19 affects the lungs, your risk increases even more. Using alcohol to manage how you feel can make matters worse and reduce your coping skills. Avoid taking illegal drugs or misusing prescriptions to manage your feelings.

Take care of your mind

Healthy coping actions for your brain start with deciding how much news and social media is right for you. Staying informed, especially during a pandemic, helps you make the best choices but do it carefully.

Set aside a specific amount of time to find information in the news or on social media, stay limited to that time, and choose reliable sources. For example, give yourself up to 20 or 30 minutes a day of news and social media. That amount keeps people informed but not overwhelmed.

For COVID-19, consider reliable health sources. Examples are the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

Other healthy self-care tips are:

• Relax and recharge. Many people benefit from relaxation exercises such as mindfulness, deep breathing, meditation and yoga. Find an activity that helps you relax and try to do it every day at least for a short time. Fitting time in for hobbies or activities you enjoy can help manage feelings of stress too.
• Stick to your health routine. If you see a healthcare professional for mental health services, keep up with your appointments. And stay up to date with all your wellness tests and screenings.
• Stay in touch and connect with others. Family, friends and your community are part of a healthy mental outlook. Together, you form a healthy support network for concerns or challenges. Social interactions, over time, are linked to a healthier and longer life.

Avoid stigma and discrimination

Stigma can make people feel isolated and even abandoned. They may feel sad, hurt and angry when people in their community avoid them for fear of getting COVID-19. People who have experienced stigma related to COVID-19 include people of Asian descent, health care workers and people with COVID-19.

Treating people differently because of their medical condition, called medical discrimination, isn't new to the COVID-19 pandemic. Stigma has long been a problem for people with various conditions such as Hansen's disease (leprosy), HIV, diabetes and many mental illnesses.

People who experience stigma may be left out or shunned, treated differently, or denied job and school options. They also may be targets of verbal, emotional and physical abuse.

Communication can help end stigma or discrimination. You can address stigma when you:

• Get to know people as more than just an illness. Using respectful language can go a long way toward making people comfortable talking about a health issue.
• Get the facts about COVID-19 or other medical issues from reputable sources such as the CDC and WHO.
• Speak up if you hear or see myths about an illness or people with an illness.

COVID-19 and health

The virus that causes COVID-19 is still a concern for many people. By recognizing when to get help and taking time for your health, life challenges such as COVID-19 can be managed.

• Mental health during the COVID-19 pandemic. National Institutes of Health. https://covid19.nih.gov/covid-19-topics/mental-health. Accessed March 12, 2024.
• Mental Health and COVID-19: Early evidence of the pandemic's impact: Scientific brief, 2 March 2022. World Health Organization. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1. Accessed March 12, 2024.
• Mental health and the pandemic: What U.S. surveys have found. Pew Research Center. https://www.pewresearch.org/short-reads/2023/03/02/mental-health-and-the-pandemic-what-u-s-surveys-have-found/. Accessed March 12, 2024.
• Taking care of your emotional health. Centers for Disease Control and Prevention. https://emergency.cdc.gov/coping/selfcare.asp. Accessed March 12, 2024.
• #HealthyAtHome—Mental health. World Health Organization. www.who.int/campaigns/connecting-the-world-to-combat-coronavirus/healthyathome/healthyathome---mental-health. Accessed March 12, 2024.
• Coping with stress. Centers for Disease Control and Prevention. www.cdc.gov/mentalhealth/stress-coping/cope-with-stress/. Accessed March 12, 2024.
• Manage stress. U.S. Department of Health and Human Services. https://health.gov/myhealthfinder/topics/health-conditions/heart-health/manage-stress. Accessed March 20, 2020.
• COVID-19 and substance abuse. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/covid-19-substance-use#health-outcomes. Accessed March 12, 2024.
• COVID-19 resource and information guide. National Alliance on Mental Illness. https://www.nami.org/Support-Education/NAMI-HelpLine/COVID-19-Information-and-Resources/COVID-19-Resource-and-Information-Guide. Accessed March 15, 2024.
• Negative coping and PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/gethelp/negative_coping.asp. Accessed March 15, 2024.
• Health effects of cigarette smoking. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#respiratory. Accessed March 15, 2024.
• People with certain medical conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Accessed March 15, 2024.
• Your healthiest self: Emotional wellness toolkit. National Institutes of Health. https://www.nih.gov/health-information/emotional-wellness-toolkit. Accessed March 15, 2024.
• World leprosy day: Bust the myths, learn the facts. Centers for Disease Control and Prevention. https://www.cdc.gov/leprosy/world-leprosy-day/. Accessed March 15, 2024.
• HIV stigma and discrimination. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/basics/hiv-stigma/. Accessed March 15, 2024.
• Diabetes stigma: Learn about it, recognize it, reduce it. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/library/features/diabetes_stigma.html. Accessed March 15, 2024.
• Phelan SM, et al. Patient and health care professional perspectives on stigma in integrated behavioral health: Barriers and recommendations. Annals of Family Medicine. 2023; doi:10.1370/afm.2924.
• Stigma reduction. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/od2a/case-studies/stigma-reduction.html. Accessed March 15, 2024.
• Nyblade L, et al. Stigma in health facilities: Why it matters and how we can change it. BMC Medicine. 2019; doi:10.1186/s12916-019-1256-2.
• Combating bias and stigma related to COVID-19. American Psychological Association. https://www.apa.org/topics/covid-19-bias. Accessed March 15, 2024.
• Yashadhana A, et al. Pandemic-related racial discrimination and its health impact among non-Indigenous racially minoritized peoples in high-income contexts: A systematic review. Health Promotion International. 2021; doi:10.1093/heapro/daab144.
• Sawchuk CN (expert opinion). Mayo Clinic. March 25, 2024.

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Protecting your mental health during the coronavirus pandemic

Paul Nestadt

Elizabeth Stuart

CALLIOPE HOLINGUE, M. DANIELE FALLIN, LUKE KALB, PAUL NESTADT AND ELIZABETH STUART

The daily counts of COVID-19 cases and deaths tell the public story of the coronavirus outbreak. Privately, the effects of the pandemic aren’t as clear.

The new reality of social distancing and other safety measures is testing everyone, and those living with mental illness may find this time even more challenging if the support system they rely on is not in place.

Experts from the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health put together these tips and resources on how to protect your mental health during these trying times.

As the coronavirus pandemic has unfolded across the U.S., ordinary life has been put on pause.  Lockdowns ,  travel restrictions ,  school closings ,  work closings , and  social distancing  have created a level of social isolation previously unseen across the globe. Fears about  finances  and food  shortages  have placed additional stressors on an already anxious and sensitized population. The practices recommended by the  Centers for Disease Control and Prevention  and  World Health Organization  are necessary and designed to protect the community, particularly the most vulnerable individuals. However, this pandemic and the associated changes, including serious financial implications for many households, can have profound consequences for our mental health.

Traumatic or stressful experiences put individuals at greater risk for not only poor  physical health  but poor mental health outcomes, such as depression, anxiety, and PTSD. You may notice that yourself or others around you are more edgy, irritable, or angry; helpless; nervous or anxious; hopeless, sad, or depressed. Sleep may be disrupted and less refreshing. Practicing social distancing may leave you feeling lonely or isolated. If you are at home with children, you may have less patience than before.

Those who are especially vulnerable to COVID-19—older individuals and people with medical comorbidities or immune-comprised systems—who need to be especially stringent in following guidelines from the health authorities, may be the very people whose mental health may suffer the most. Individuals with a pre-existing mental health condition, such as an  anxiety disorder , are also at heightened risk for poor mental health outcomes as a result of coronavirus.

It is important that as a population, we learn how to protect our mental health during this stressful and ever-changing situation, while also following the guidelines set by health authorities to protect our physical health.  Here are some strategies that can be used during these challenging times to protect your and others’ mental health.

Create structure

• Create a daily schedule for you and your family. Feelings of  uncertainty  can lead to increased mental health symptoms.
• Try to limit the amount of time you spend watching, reading, or listening to the news. Get your information on the coronavirus outbreak from a trusted source, such as the  CDC  or  WHO , once or twice a day.
• Make space for activities and conversations that have nothing to do with the outbreak.

Maintain your physical health

• Protect your sleep. Good quality, sufficient sleep not only helps to support your immune system but also helps you to better manage stress and regulate emotions. Adults should aim for 7–9 hours, while children and teenagers need even more. [See recommendations by the  National Sleep Foundation ].
• Try to eat at regular times and opt for nutritious foods whenever possible. Some people may crave junk food or sugary snacks and be tempted to snack mindlessly when stressed or bored, and others may skip meals altogether.
• Maintain an exercise routine, even if you can’t go to your local gym. Exercise at home using an online workout video, or go for a walk, run, or bike ride in a sparsely populated area.

Support--and create--your community

• Create a virtual support group and check in with those around you. There are many options for connecting, including video conferencing software, such as Google Hangouts and Facetime. During this time of isolation, connecting face-to-face (online) is more important than ever. If you can’t stream, then calling and texting is important. Check out some ideas at  Wirecutter  and  Prokit  for how to be social during the quarantine.
• Crises offer a time for community cohesion and  social solidarity , and volunteering is one way to not only help others, but yourself as well. Science has repeatedly shown that volunteering can improve mental  health . Check out this  article  for a list of organizations to donate to and this article for other ways to help your neighbors and community.
• If you have children, talk to them honestly about what is going on in an age-appropriate manner. Help kids express their feelings in a positive way, whether playing in the backyard, drawing, or journaling. Check out these guides by the  Substance Abuse and Mental Health Services Administration ,  Child Mind Institute , or  National Association of School Psychologists  for tips on how to talk to your kids about coronavirus.

Take care of your spirit

• Find a place of worship that is streaming or recording services. If prayer is an important part of your life, make time for it. Stay connected to your church community through phone calls, emails, and video chats.
• Try  meditation , deep breathing, progressive muscle relaxation, or another mindfulness or  relaxation technique . Check out YouTube or phone apps such as  Calm  or  Headspace  for guided meditation exercises. Consider enlisting friends and family and practicing meditation together at least once a day.  Mindfulness  can help lower blood pressure, reduce stress, support your immune system, and protect brain health.

Continue or seek out mental health treatment

• If you are currently in mental health treatment, continue with your current plan if possible, being mindful of approaches to minimize contact with others. Consider reaching out to a mental health professional even if you haven’t before. Make sure you have ongoing access to any medications you need.
• Ask about video therapy or phone call appointments. Most states have already made emergency exemptions to insurance coverage for telehealth. Regulations have been temporarily relaxed to allow even non-medical software like Skype, Facetime, and Zoom to be used for telehealth. Even if this option wasn't available with your provider previously, it may be now! Contact them to ask about remote services.
• Avoid drugs and alcohol, particularly if you have a pre-existing mental health or substance use disorder. Check out online support groups and meetings, such as  Alcoholics Anonymous ,  Smart Recovery , and  In The Rooms .
• The need for social distancing may make it difficult to see symptoms of depression in others. In "hunker-down" mode, the in-person opportunities that we usually have to notice that friends, family, and colleagues may be struggling with a problem are no longer there. One way to think about it is that child abuse or intimate partner violence is missed more often in winter because long clothes cover bruises. Conduct regular "check ins" with your network and stay attuned to symptoms of  depression , such as persistent feelings of sadness, hopelessness, loss of interest or pleasure in activities, or changes in sleep and weight.

Remember that the emotions you may be experiencing are normal reactions to difficult circumstances. Accept that things are different right now and everyone is adjusting. Prioritize what’s most important and know that it’s okay to let some things go right now.

Be kind to yourself and others. Try to stay positive and use this time to spend more time with your children or spouse, try things you’ve been putting off, such as taking an online class, learning a new skill, or getting in touch with your creative side.

It can be hard to think past what is going on today, let alone in a week or in six months, but give yourself permission to daydream about the future and what is on the horizon. Remember that this is temporary, and things will return to normal.

• The Crisis Text Line
• Suicide Prevention Lifeline
• Veterans Crisis Line
• American Foundation for Suicide Prevention
• World Health Organization
• Centers for Disease Control and Prevention

Calliope Holingue, postdoctoral fellow in the Department of Mental Health and the Department of Neuropsychology at Kennedy Krieger Institute; M. Daniele Fallin, Mental Health chair; and Mental Health faculty Luke Kalb, Paul Nestadt, and Elizabeth Stuart co-authored this piece.

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Mental health in the post-COVID-19 era: challenges and the way forward

Ramyadarshni Vadivel ,

Sarah El Halabi ,

Samer El Hayek ,

Lamiaà Essam ,

Drita Gashi Bytyçi ,

Ruta Karaliuniene ,

Andre Luiz Schuh Teixeira ,

Sachin Nagendrappa ,

Rodrigo Ramalho ,

Victor Pereira-Sanchez ,

Ganesh Kudva Kundadak .

https://doi.org/ 10.1136/gpsych-2020-100424

• Introduction

The COVID-19 pandemic has posed a serious threat to global mental health. Multiple lines of evidence suggest that there is a varying yet considerable increase in mental health issues among the general population and vulnerable groups. 1 2 The aftermath is obscure and speculative from a social, economic, individual and public mental health perspective. Recently published studies support the existence of an emotional epidemic curve, describing a high probability of an increase in the burden of mental health issues in the postpandemic era. 3 4 Furthermore, previous major public health emergencies showed that more than half of the population developed mental health problems and required mental health intervention. 4 5 There is, therefore, an urgent need to reorganise existing mental health services to address the current unmet needs for mental health and to prepare for future challenges in the postpandemic era in terms of prevention and management.

• The burden of mental health issues in the post-COVID-19 pandemic era

The current evidence and published literature related to previous epidemics suggest that mental health issues may arise after the peak of the pandemic, with increased prevalence among the vulnerable population and people with risk factors ( box 1 ). 4 The surge in mental health issues may remain untreated or undiagnosed due to interrupted mental health services and other challenges for mental health services in the post-COVID-19 pandemic era.

Mental health issues, vulnerable population and risk factors

Mental health issues : including grief reactions, substance use disorders, anxiety, sleep disorders, depression, suicides, post-traumatic stress disorders, panic disorders. 4,25,26

New-onset mental health issues : due to COVID-19-related stress, fear and loneliness; enduring neuropsychiatric symptoms or disorders (eg, acute ischaemic stroke, headache, dizziness, ataxia, delirium and seizures) of COVID-19 infection due to cytokine storms. 27

Relapse of pre-existing mental illness : due to reduced access to therapeutic resources, disruption of therapies, service provision and social support. 4 10

Suicides : due to neuropsychiatric manifestations and the socioeconomic impact of COVID-19. 4

Other issues : COVID-19-related stigma, discrimination and hate crimes. 21,28

Vulnerable population : children and adolescents; elderly; unemployed and homeless persons; COVID-19 survivors; healthcare workers (HCWs); those with pre-existing psychiatric disorders; grass-roots workers; pregnant women; people with disabilities and chronic diseases; migrants; refugees; lesbian, gay, bisexual, transgender and queer (LGBTQ) community; racial and ethnic minorities. 7,21,29

Risk factors : the death of either parent, caregivers or loved ones, misinformation, loss of peer support because of closure of school or workplace, academic loss, medical comorbidities, uncertainties, stigma, prolonged isolation, social rejection, work stress, burn-out, being in direct contact with active cases and facing economic burdens. 4,25

• Challenges for mental health services in post-COVID-19 pandemic era

The paucity of human resources, infrastructure and burn-out of mental health professionals (MHPs)

In many countries, MHPs have been redeployed for the provision of medical services in COVID-19 care centres. 6 MHPs and physicians working in COVID-19 services are experiencing an increased level of mental health issues owing to work stress and the death of patients and loved ones. 7 8 If the mental health of MHPs remains unaddressed, then these professionals may not be able to provide efficient mental health services in the postpandemic era. In low and middle-income countries (LMICs) where MHPs are scarce, this could further widen the treatment gap for mental disorders. 9 10

Assessing mental health issues

In the postpandemic era, it may be difficult to identify mental disorders aetiologically related to COVID-19 (eg, anxiety due to cytokine storm) owing to a lack of specific diagnostic or screening tools. 11 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or International Classification of Diseases 10th Revision/Eleventh Revision-based diagnostic interviews may under-report or over-report the underlying conditions.

The impact of misinformation (‘the infodemic’)

In some countries, particularly LMICs, waves of misinformation about COVID-19 are going to persist owing to multiple reasons (eg, religious and/or political beliefs). Surprisingly, most countries are not well prepared for managing this infodemic. 3 The inability to access accurate information will strain the individual’s mental health and may lead to an increase in polarisation and the occurrence of hate crimes. 12

Access to mental healthcare services

Lack of preparedness, overburdened mental health services, increased prevalence of mental health issues and interrupted mental health services will limit access to mental healthcare facilities in the postpandemic era, particularly in LMICs. Many psychiatric facilities and outpatient departments are currently converted to manage COVID-19. 13 14 Therefore, people with mental illness may not seek help from these services owing to a fear of infection. Many pharmaceutical industries have changed their focus to the preparation of COVID-19-related drugs, vaccines and preventive kits (sanitisers), which may hamper the production of psychopharmacological drugs. Perceived job insecurity, financial problems and unemployment contribute to significant risks for psychiatric disorders and pose an important barrier in accessing mental healthcare.

Psychotherapy

The complex and ever-changing dynamics of the COVID-19 pandemic will be a challenge for psychotherapeutic services owing to a lack of physical and social connection. 15 In LMICs, the dearth of telepsychiatric services will limit accessibility to psychotherapy. 10

Support systems

Adults, children, adolescents and families are affected by the loss of the structured support found in schools, childcare facilities or physical workplaces. 4 Rebuilding this extrafamilial system will be challenging.

Public health paradox and injustice

A substantial body of evidence suggests that people with the highest level of mental health needs often have the least access to services. 16 In a post-COVID-19 pandemic era, it will get exaggerated owing to economic recession, strain on resources and unemployment.

• Recommendations for postpandemic mental health service preparedness

Because of the limited scientific understanding of the COVID-19 pandemic and mental health thus far, postpandemic preparedness is difficult. The pandemic is an unpredictable, irregular occurrence and its impact could be difficult to measure and explore. Considering this, we recommend using the components of the mental health preparedness and action framework (MHPAF) for postpandemic preparedness. MHPAF consists of five interlinked components, including preparation and coordination, monitoring and assessment, sustainability of mental healthcare services, infodemic management and communications. 3 This framework has been used to evaluate pandemic preparedness in some countries like Kenya and the USA. 17 However, postpandemic mental health preparedness could be more challenging in countries that are inadequately prepared for pandemics. In addition to preparing for the components of MHPAF, we suggest a few additional interventions for effective and efficient management of postpandemic psychiatric services.

Mental healthcare delivery

COVID-19 has affected mental healthcare delivery because of the redeployment of MHPs. We need to reconsider a few practical approaches or models of care for effective delivery in the postpandemic era.

Telepsychiatry

Telepsychiatry needs to be developed through a government-supported service platform centred on community health service centres to enable easier access to psychiatric care, especially among vulnerable populations (eg, the elderly). However, the digital divide, access to marginalised populations and poverty are major barriers to telepsychiatry services in LMICs. This could affect the feasibility and acceptability of telepsychiatry in many countries. Considering this challenge, it is imperative that healthcare workers reach out to patients and aim at equitable access of telepsychiatric facilities.

Infodemic management

More robust regulation of social media companies by non-partisan, non-corporate, global regulators is needed to clamp down on the spreading of fake news, anti-vaccine movement and polarising content. All countries should take stringent steps towards infodemic management by the formulation of guidelines for responsible media reporting. Additionally, infoveillance (information monitoring), building eHealth literacy and capacity, knowledge refinement and accurate and timely knowledge translation should be encouraged. 18

Integrative care

National public health policies should be designed to provide integrated care for mental health in different settings such as hospitals, primary care services, communities, schools, universities, colleges and workplaces. 19 Formalising liaison between these settings with mental health services would help to promptly identify and holistically address emerging mental health needs. Developing support groups, screening of at-risk groups, peer counselling services, establishing dedicated crisis helplines, preparation for long-term plans and expanding support services can facilitate early access to mental health needs.

Community mental health services

Community mental health services should be well prepared to screen, identify people at risk, provide psychological first aid and facilitate onward referral services. 20 Primary healthcare workers and organisational gatekeepers (eg, pharmacists, geriatric caregivers and school teachers) should be trained to identify individuals at risk and direct them to proper evaluation and treatment.

Human resources, education and training

Current redeployment of, and potential burn-out among, MHPs in the COVID-19 setting is affecting preparations for the delivery of mental health services for the postpandemic era. Policymakers and stakeholders should consider this as a priority. In many countries (like India), grass-roots medical staff (Accredited Social Health Activist-ASHA, teacher) are playing an important role in prescreening and triage, door-to-door visits, follow-up and on-site screening of COVID-19. Therefore, grass-roots workers should be trained in identifying and managing pandemic-associated psychiatric and psychosocial issues.

Formulate guidelines and protocols

Many people have been exposed to similar health risks, isolation, grief and economic uncertainty, individually and with their families. Therefore, certain common themes should be used to formulate guidelines to improve access to care.

Assessment and intervention

The use of a toolkit or stepped care or matched care model through primary care physicians can improve the coverage of mental health services in the postpandemic era by allowing them to manage common mental disorders of mild severity. 20

Suicide prevention

In anticipation of an increase in suicide rates, efforts should be made to reduce access to means (eg, more stringent gun control) and for better resourcing with suicide prevention agencies along with global decriminalisation of suicide/attempt(s). In addition, early screening for mental illness and treatment should be encouraged.

Prospective cohort studies should be carried out to identify risk factors and exposure levels, track outcomes and compare outcomes among subgroups. These studies are important to monitor the effect of various interventions and strategies.

Stigma and discrimination

Interventions are needed to reduce stigmatisation and discrimination towards minority or vulnerable groups and to inform policy changes. 21 22 General and specific interventions should be directed towards identification of drivers (eg, misinformation), facilitators (eg, lack of regulations) and intersecting factors (eg, occupation such as healthcare workers) towards reducing stigma and discrimination. 21

Networks and services

A multinational network of MHPs in collaboration with World Health Organisation (WHO) should be set up to enable the sharing of research and clinical practice paradigms in the post-COVID-19 era. This network should focus on building resilience both in the community and on an individual level.

Approach for addressing postpandemic mental health and services

Addressing emergent challenges with appropriate interventions could be challenging in many countries particularly in low-resource settings. Therefore, efforts should be taken for the prevention of mental health issues on a large scale and organisation of services for early identification of mental health issues. These approaches to mental healthcare prevention and treatment after the COVID-19 crisis can be classified as universal, selective or indicated. 23 24

Universal approach

This is a population-wide intervention that will help reduce the overall burden of mental health issues (stress, anxiety and fear) through prevention; therefore, it is imperative to have a universal approach for each country ( box 2 ).

Focus of universal approach in the postpandemic era

Promoting mental health wellness and reducing distress through adequate sleep, healthy diet and exercise, mindfulness‐based programmes (eg, yoga) and awareness about mental health issues. 30,31

Using traditional and social media for mental health awareness campaigns and to encourage individuals to seek help with responsible, transparent and timely media reporting. 3

Establishing community support for those at risk and encouraging to stay connected and maintain relationships.

Establishing primary screening services for common mental health issues such as anxiety, depression and suicidal thoughts.

Establishing the national suicide prevention helplines or other helplines. 32

Integrating basic mental health services into primary care for early identification of COVID-19-related mental health issues.

Developing self-help resources and promoting healthy coping strategies.

Ensuring financial support for people through governmental and non-governmental organisations (eg, loans and credit).

Selective approach

It should be used for an individual having the risk factors for developing mental health issues. For example, a vulnerable population and individuals with risk factors mentioned above. A screening toolkit or guidelines should be developed to identify these groups of people. 20

Indicated approach

It should be designed for individuals having signs and symptoms of the mental issues as mentioned above. This approach ought to be guided by well-defined guidelines before the intervention. Some people with mental health issues might not seek help because of fear of COVID-19 infection, stigma and poor motivation. It is therefore important to identify these individuals through a network of hospitals and community health workers.

Active outreach

It can be helpful for people with a history of psychiatric disorders, COVID-19 survivors and older adults.

To conclude, there is an immediate need to identify the long-term mental health consequences of the COVID-19 pandemic. Clinicians, researchers and policymakers are expected to be prepared for these mental health issues in terms of assessment, interventions and the model of care in the postpandemic era.

Dr. Ramyadarshni Vadivel obtained her MBBS degree from the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, in 2008. Now, she is an advanced trainee in mental health and addictions of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). She is also working as a senior registrar in the addictions services of Waikato District Health Board (DHB) in Hamilton, New Zealand. She has been working in Waikato DHB since December 2017 and training in RANZCP since June 2016. She is a member of the Early Career Psychiatrist (ECP) Section of the World Psychiatric Association (WPA) and Network of Early Career Professionals working in the area of Addiction Medicine (NECPAM). In addition, she is a recipient of the World Congress of Social Psychiatry Young Fellow (WCSPYF) (2013), Japan Young Psychiatrists Organisation (JYPO) Fellowship (2013), and WPA ECP fellowship (2018), among other academic awards. Her main research interests include neurostimulation in the treatment of psychiatric disorders, with a special interest in addictions, smartphones and the use of technology in psychiatry and psychiatry in special populations (migration and refugees). She is currently a member of the worldwide network of ECP researchers working on the impact of the COVID-19 pandemic on different areas of mental health and addictions.

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Mental Health and COVID-19: Early evidence of the pandemic’s impact: Scientific brief, 2 March 2022

The COVID-19 pandemic has had a severe impact on the mental health and wellbeing of people around the world while also raising concerns of increased suicidal behaviour. In addition access to mental health services has been severely impeded. However, no comprehensive summary of the current data on these impacts has until now been made widely available.

This scientific brief is based on evidence from research commissioned by WHO, including an umbrella review of systematic reviews and meta-analyses and an update to a living systematic review. Informed by these reviews, the scientific brief provides a comprehensive overview of current evidence about:

• the impact of the COVID-19 pandemic on the prevalence of mental health symptoms and mental disorders
• the impact of the COVID-19 pandemic on prevalence of suicidal thoughts and behaviours
• the risk of infection, severe illness and death from COVID-19 for people living with mental disorders
• the impact of the COVID-19 pandemic on mental health services
• the effectiveness of psychological interventions adapted to the COVID-19 pandemic to prevent or reduce mental health problems and/or maintain access to mental health services

The Covid -19 pandemic has had a substantial impact on the lives of people around the world. It has disrupted work, education, health care, the economy, and relationships, with some groups more negatively effected than others, especially children and front-line workers.

Some people have benefited from changes like remote learning and work, while others face a mental health crisis.

Even as the pandemic wanes, there are still uncertainties. In addition, much remains unknown about the effects of long Covid .

Adapted from APA’s Stress in America survey and the Monitor on Psychology 2022 emerging trends report

Resources from APA

COVID-19 impacts on doctoral education

Research was affected, but psychology graduates had fewer disruptions than those in other fields

Antidepressant use during and after the COVID-19 pandemic

Use skyrocketed among teen girls and young women, but there was no such rise among teen boys and young men

Changes coming to psychology practice after COVID-19

Now that the covid -19 public health emergency has ended, psychologists should prepare for changes coming to telehealth practice

The reality of pediatric long COVID

Psychologists are playing an integral role in research and interventions to support children in their recovery

More resources about Covid -19

Crowds, obedience, and the psychology of group behavior, with Stephen Reicher, PhD

The challenge of long COVID, with Tracy Vannorsdall, PhD, and Rowena Ng, PhD

Ambiguous loss and the “myth of closure,” with Pauline Boss, PhD

Back to the office? The future of remote and hybrid work, with Tsedal Neeley, PhD

More podcasts about COVID-19

News from APA

Statewide pandemic restrictions not related to psychological distress

Exposure to Covid -19 a stronger predictor of distress than state restrictions six months after pandemic began

COVID-19 pandemic led to increase in loneliness around the world

People around the world experienced an increase in loneliness during the Covid -19 pandemic, which, although small, could have implications for people’s long-term mental and physical health, longevity, and well-being

People wrongly believe their friends will protect them from COVID-19

People may feel less vulnerable and take fewer safety precautions about Covid -19 when they are with, or even just think about, their friends instead of acquaintances or strangers

Coping with COVID-19 stress easier with a dose of humor

Funny memes may help people cope with the stress of the COVID-19 pandemic, making viewers feel calmer and more content

More news about COVID-19

COVID-19 resources for practitioners

Find the latest advocacy updates, reimbursement and licensing/regulatory guidance, and other information to help navigate the changing government, industry, and public responses to Covid -19.

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Need to talk to someone? View this list of crisis hotlines offering confidential telephone counseling or search for a psychologist near you.

Continuing education

Prolonged Grief Disorder: An Integrated Multicultural Perspective

Discusses the diagnostic criteria for prolonged grief disorder, a framework of grief, how adaption to loss can be derailed, and the influence of the Covid -19 pandemic on the incidence of prolonged grief disorder.

Another Kind of Long Covid : The Psychosocial Impact of Covid -19 on Neuropsychological Development

Identify ways that psychosocial changes during the Covid -19 pandemic may have altered the development of cognitive, emotional, and social skills, and discuss the implications for long-term functioning.

Structural Predictors of Underemployment During COVID-19 Pandemic: A Psychology of Working Perspective

Explain the effects of the Covid -19 pandemic on underemployment in this article from The Counseling Psychologist , Vol. 50, No. 4.

Feeling Down in Lockdown: Effects of COVID-19 Pandemic on Emotionally Vulnerable Individuals

Discuss the unique impact that Covid -19 had on college age students, and explain how the pandemic impacted college students with pre-existing internalizing symptoms and psychopathology during prepandemic and lockdown in this article from The Counseling Psychologist , Vol. 50, No. 3.

Magination Press children’s books

What to Do When the News Scares You: A Kid’s Guide to Understanding Current Events

Unstuck! 10 Things to Do to Stay Safe and Sane During the Pandemic

A Kid’s Guide to Coronavirus

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Vaccine Hesitancy and Refusal

Asian America and the COVID-19 Pandemic

Risk Perception, Decision Making, and Risk Communication in the Time of COVID-19

Mitigating the Impact of the Pandemic on Families and Couples

COVID-19: Uncovering Mental Health

Groups in a Dangerous Time: Virtual Work and Therapy in the COVID-19 Era

COVID-19: Insights on the Pandemic’s Traumatic Effects and Global Implications

Telepsychotherapy in the Age of COVID-19

Greater Good Science Center • Magazine • In Action • In Education

Seven Ways the Pandemic Is Affecting Our Mental Health

Epidemiologists and virologists around the world are scrambling to understand and prevent the spread of the novel coronavirus. There is another group of researchers who are concerned about a slightly different foe: the mental health pandemic.

Facing an infectious disease, we have been forced to maintain distance from each other, all while going through levels of fear, uncertainty, job loss, and grief that are unprecedented for many people.

“In an ironic twist, many of the strategies that are critical to ensuring our collective public health during this pandemic may put people at greater risk for . . . mental health issues,” write Frederick Buttell and Regardt J. Ferreira at Tulane University in a recent, special issue of the journal Psychological Trauma .

In brand-new studies coming out of China, Spain, the United States, and other countries, researchers are discovering in real time how we are collectively coping with this worldwide event. The results are not uplifting, but they aren’t surprising either. We are suffering, some of us worse than others. You don’t have to have lost a job or a loved one to be affected. Humans are complex, and so are emotional responses to the pandemic.

When this all started, we learned how viruses spread and how to wash our hands like pros. Now we have lessons to learn about what happens to mental health in a crisis like this, so we can find ways to address it.

1. We’re anxious, depressed, and traumatized

As COVID-19 spread through China in January and February, researchers were already sending out questionnaires to citizens locked down in their homes. In half a dozen studies with over 10,000 respondents, they found that people were experiencing worse mental health problems than before the pandemic—high symptoms of stress, anxiety, depression, and post-traumatic stress disorder (PTSD). Up to half showed serious signs of depression (depending on the study), while up to 35 percent showed serious anxiety . 

One survey followed over 1,700 people in 190 Chinese cities from late January to late February. During the height of the pandemic, their stress, anxiety, and depression didn’t change. Their symptoms of PTSD declined slightly—but they were still high enough to be worrisome. People weren’t getting worse, but they also didn’t seem to be getting used to pandemic life.

The results look no better in other countries. In late March, nearly 3,500 people were surveyed in Spain, when the country ranked second in the world in COVID-19 deaths. Many people met the criteria for clinical mental health problems: 19 percent for depression, almost a quarter for anxiety, and 16 percent for PTSD. Within a week after Slovenia declared an epidemic, over half of the thousands of people surveyed had high stress levels. In April, 14 percent of Americans were experiencing serious psychological distress, more than triple the rate in 2018.

And studies find that this stress and anxiety fuels poor sleep , creating a vicious cycle. The more we lay awake at night during the pandemic, rehashing worries we have no control over, the worse our mental health becomes.

2. Some of us are lonely, but not all

Stay-at-home orders and social distancing have left many people isolated, so it makes sense that we would be feeling lonely. And, indeed, nearly 1 in 7 U.S. adults said they were often or always lonely in April 2020, up over 25 percent from 2018. But another study in the U.S., Canada, and the U.K. found that people’s feelings of connection to others didn’t change much from before to during the pandemic. When one group of researchers surveyed over 1,500 people in the U.S. from January to April, they were surprised to find “remarkable resilience.” Not only did people not become lonelier over time, but they actually gained a greater sense of support from others. 

All the phone calls and video chats with family and friends may be helping, write Martina Luchetti and her coauthors from Florida State University, as well as a new sense of togetherness. “Many people have felt part of community-wide efforts to slow the spread of the virus. The feeling of . . . being in this together may increase resilience.”

Greater Good’s Guide to Well-Being During Coronavirus

Practices, resources, and articles for individuals, parents, and educators facing COVID-19

However, this hasn’t been true for everyone. People who are younger or living alone, or who have a chronic health condition, are lonelier than other groups. In fact, one study in the U.S. in April and May (before any restrictions were lifted) found that almost two thirds of people under 30 had high levels of loneliness, and 37 percent felt they had low support from their family.

“Feeling cut off from social groups may lead one to feel vulnerable and pessimistic about one’s circumstances,” write Cindy H. Liu and her coauthors.

3. Domestic violence has increased

In early April, the United Nations called for immediate global action to combat the increasing violence against women and girls during the pandemic.

According to news reports, domestic violence is increasing worldwide. At one police station just over 100 miles from Wuhan, China, for example, reports were three times higher in February 2020 compared to February 2019. In New Orleans, domestic aggravated assaults jumped 37 percent from January to April. Similar trends have been reported in Spain, Italy, Germany, and Brazil. As people are stuck at home, calls to helplines are surging. 

Scientific surveys are only just beginning, but some preliminary results confirm these trends. Among people who were already experiencing domestic violence, the violence has gotten worse in nearly 60 percent of cases, report Buttell and Ferreira.

In their view, this comes down to a variety of factors: people spending more time at home with abusive partners, unemployment and other financial stressors causing conflict, shelters shutting their doors, and police being discouraged from making arrests.

Needless to say, the threat of abuse is compounding the stress, anxiety, and fear that many people are already experiencing during the pandemic.

4. The effects depend on your personality, lifestyle, and demographics

While older people have greater health risks from COVID-19, it seems to be younger people who are struggling emotionally. According to studies from Spain , China , and Slovenia , younger people tend to be more depressed, anxious, stressed, and traumatized in the era of COVID-19. The same is true for women , who may also be more lonely . 

There’s no clear explanation for why this might be true, but researchers have some speculations. Women tend to have worse mental health in general, and certain stressors right now—like the added burden of caregiving and the risk of losing jobs—may fall more heavily on women.

For younger people, it could be the disruptions to their routines that are to blame, particularly for college students who have had to adjust to online schooling. In studies across both China and the United States , the more the pandemic was affecting people’s daily lives, the more anxious they felt.

Personality also influences how we fare in tough times. Two related traits that seem to matter during the pandemic are our ability to tolerate uncertainty and our ability to tolerate distress. While it’s hard for anyone to struggle or face the unknown, some people are less comfortable with it than others. And right now, it’s those people who seem to be ruminating more, feeling more afraid , and experiencing more depression, anxiety, and PTSD .

5. It’s worse for disadvantaged groups

In studies across the world, researchers investigated what else might make people vulnerable to mental health problems during the pandemic. They found a few key factors that put people at risk.

For one, people with poor health or chronic diseases tend to have higher symptoms of stress, anxiety, depression , and PTSD , several studies found . Of course, this might be because these are also the people with greater health risks from COVID-19.

Your income and education matter, too. The less stable your income and the less educated you are , studies suggest, the more anxiety, depression, and stress you will experience. The pandemic is threatening the economy, affecting everyone’s financial future, but the situation is worse for people who were already struggling. In a very real sense, we’re not all in the same boat.

“It is an inescapable fact that people lower on the socioeconomic ladder are struggling more”

A Pew survey of nearly 5,000 Americans in April found that the lowest-income people were most afraid of getting COVID-19, too. “[While] Americans may be struggling with the emotional challenges of the pandemic, it is an inescapable fact that people lower on the socioeconomic ladder are struggling more,” says psychologist David Sbarra.

6. The effects are compounded by racism

Those unequal effects extend all the way to who lives and who dies.

In fact, Black people are more likely to be infected, less likely to be tested and treated, and less likely to survive if they get COVID-19. According to Andrea King Collier in an article for Greater Good , a history of racism means the Black community is confronting the pandemic with worse health, less access to care, and more distrust of the medical system. 

That means they have more reason to be fearful for their own lives, and they are more likely to experience loss. In fact, Pew research suggests that more than a quarter of Black Americans know someone who was hospitalized or died from COVID-19, compared to 1 in 10 white Americans.

These hardships worsened after the police killing of George Floyd, a Black man in Minnesota. His death catalyzed nationwide protests for racial justice—but at the same time, many observers say, it made the pandemic even harder for many Black Americans.

“Black people have been hit on all sides with the threat of loss of life,” says Riana Anderson, assistant professor at the University of Michigan’s School of Public Health. “It is exhausting. Depleting. Depressing. And absolutely an additional stressor.” She argues that family and community support is a strength of the Black community, but physical distancing restrictions have made it more difficult to access that power.

Other people of color are suffering disproportionally under the pandemic, too. Nearly one-fifth of Latino adults were experiencing serious psychological distress in April 2020; the CDC estimates that Latinos make up over half of the U.S. agricultural workforce, a group of essential workers whose jobs put them at greater risk of infection. Discrimination against Asians has risen since the pandemic started in Wuhan, China.

Anti-Racist Resources from Greater Good

Stories, tips, and tools to reduce prejudice in society and in ourselves.

All of these inequities create mental health problems that are even more aggravated by reduced and unequal access to mental health services .

7. Your work situation matters

One of the biggest disruptions to our daily lives today is how the pandemic has affected our work.

Doctors, nurses, and paramedics are taking on the urgent task of caring for COVID-19 patients, while other essential workers are putting themselves at risk to sell food, deliver mail, and pick up trash. Many office jobs have transitioned to remote work, asking employees to isolate at home, with many precariously juggling work and care for children or elders.

Other people have been unable to continue work during the pandemic, waiting for the time when they’ll be called back, while some have been laid off entirely. Unemployment in the U.S. more than quadrupled from February to April, leveling off in July at 10 percent.

A Chinese survey in mid-February examined some of these work situations, though not all. What was clear is that people who are unable to work temporarily—even if they don’t get laid off—have worse mental health. And while working in an office might seem risky, it was the people working from home who were actually more distressed and less satisfied with their lives.

Caring for yourself and others

There’s a lot we don’t have control over in this situation, which is stressful in and of itself. You may have some of the risk factors mentioned above, and there’s nothing you can do about it.

But what can you control? That’s the first question to ask.

For example, research from 28 countries conducted in mid-March found that the more people used social media, the more fearful they were. Frequent social media users in China were more likely to feel both depressed and anxious at the same time. Part of the reason may be because, particularly when the pandemic was ramping up, it was the main topic of discussion online. If being on Facebook doesn’t feel good, consider putting limits on social media time.

Does that mean ignorance is bliss? No. Finding the right sources of information is key. In fact, Chinese people who were highly satisfied with the health information they got about COVID-19 tended to have lower stress, anxiety, depression , and PTSD . Being informed helps reduce uncertainty and anxiety—but overloading ourselves with information can also be unsettling . Online or offline, reading news or imagining worst-case scenarios with family, the people who spent three or more hours a day focusing on COVID-19 were more anxious . 

Besides taking breaks from news and social media, practicing basic safety and hygiene could go a long way for your mental health. In Chinese studies in January and February, people who engaged in proper hand washing, wore masks , and avoided sharing utensils tended to experience less depression, anxiety, stress, and PTSD.

Since March, Greater Good has been sharing tips for well-being during COVID-19 . For the most part, these are nothing new. In normal life and in a pandemic, we fare better when we try to stay connected in our relationships , cope with stress in healthy ways , and find a sense of agency .

But we can’t self-improve our way out of the pain and difficulty. What we’re going through right now is a trauma , or at least a major stressor on a global scale. This is one of those times when life really is harder by a little bit or a lot, depending on your situation. Feeling bad is part of being human—and right now, that’s something many of us need to face, even as we work to feel better, stay connected, and help others.

About the Author

Kira M. Newman

Kira M. Newman is the managing editor of Greater Good . Her work has been published in outlets including the Washington Post , Mindful magazine, Social Media Monthly , and Tech.co, and she is the co-editor of The Gratitude Project . Follow her on Twitter!

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Exposing the Impact of Social Media on Teenage Mental Health: A Journey of Self-Discovery

Michaela, maryland.

High school began for me amid the pandemic. Like so many others, my mental health was affected. Virtual land became my reality. I turned to screens for connection. As a 14-year-old with a still-developing brain, my thoughts and feelings were ripe for programming. I experienced many ups and downs, like riding a roller coaster; only at every turn the pervasive influence of social media infected my psyche. Social media is a significant part of teenage experiences; scary to say, it became my life. Instagram, TikTok, and Snapchat, the triad of our digital age, wished me good morning and bid me goodnight. I became infected with the “holy trinity” of body dysmorphia: obsessive mirror usage, unreal concern about a body part, and constant comparison syndrome. The digital forms of others and the carefully curated versions of myself, programmed me, leaving indelible marks on my mind.

It began innocently enough. A kid having a phone was not in my mom’s repertoire. She felt that kids didn’t need a phone. Mom set a “when you start high school” bar for the phone. As fate would have it, I had an overnight camp during middle school. Worried about me being alone, Mom caved. I got my phone. Everyone at camp had Snapchat, and asked for my “Snap.” Mom let me download it because she trusted me. I never gave her any reason not to trust me. I was a good girl.

Fast forward four years, and I’m still a good girl, but that person became buried under lies. Lies that were virtual aspects of me, through disappearing conversations, photos on the “for your eyes only” section, and perfectly angled poses. I needed those perfection posts as constant reinforcement of this idealized image I crafted. Sadly, even with these “perfect” photos, I obsessed about what I wasn’t. I felt less than because I didn’t have the “hourglass” shape. In reality, strangers would come up to me and ask me if I was a model. I have that body. Tall, lean, athletically fit. A model’s body that everyone wants. Ironic, isn’t it?

Consequently, the last four years of school, were heavily influenced by the digital demons to the point that I forgot who I was. My friends had to approve my posts. I couldn’t make a decision without them. I had to time posts so a friend could be “first” to comment. I compulsively bought fake “likes” to make me appear more popular.

In the throes of this virtual maelstrom, my family challenges reached a crescendo with the death of my dogs and my father’s life-threatening illness. Seeking solace, I unwittingly dove deeper into socials for escape, inadvertently exacerbating my mental health struggles.

Then a significant senior year victory occurred. I was offered a scholarship to play collegiate Division 1 soccer. The pressure may have been off for college, but my commitment post opened a wormhole for jealousy to take its aim. I expected friends to be excited. That was my first mistake, followed by more, including me taking almost every word they said personally. I accept responsibility. I took everything to heart and it hurt. In a seemingly innocuous incident where friends mocked a filter that was used on my photos, I hit my limit.

I spontaneously decided to deactivate my Instagram. I decided to pull away from toxicity. I decided to find myself. I felt liberated. No, I do not regret it.

However, the aftermath was unexpected. Friends, dropped me. I was forwarded anonymous posts on an “extreme confessions” Instagram account. Those posts about me were degrading, offensive, and vile. I was shocked and confused, especially since the initial response about me deactivating social media was “good for you” and “I’ll do it with you.”

No one ever joined me. To the contrary, they stood against me.

Have you ever heard of “Crab Mentality” or the crab-bucket effect? It basically means, “If I can’t have it, you can’t either.” Crabs that try to climb out of the bucket are pulled back down by the others.

I felt like a crab.

But I decided to be THE crab that makes it out of the bucket before I was completely cooked like the rest.

How do we fix this? Or better yet, how do we prevent social media addiction? I have nieces who are nine and seven. I don’t want them or any children lured into the chaos.

Obviously, a supportive community is paramount. Implementing educational programs that promote media literacy, and coping mechanisms for teenage girls focusing on building self-esteem and embracing individuality. Additionally, requiring mental health classes incorporating mindfulness and breathwork techniques can help immensely.

To prevent addiction and brainwashing, social media should be treated like any dangerous substance. Longitudinal studies are needed to determine the ramifications social media use has on developing brains. Laws against underage (U18) usage should be enforced; if violated, parents are fined, or repeat offenders jailed. It could be the wake-up call needed. Typically, when presented with what “could happen,” parents don’t usually get the message until it’s too late. That being the case, let’s be smart about using technology, instead of it using us through brain hacking and notification dopamine hits. Everyone can stay connected through texting or a call, an app is not needed.

In conclusion, the journey to reclaiming mental health amidst the pressures of social media requires a collective effort. In the spirit of truth, however, it takes desire from the inflicted person to choose self-love and individuality. By fostering compassion, promoting confidence, and cultivating a support system, we can empower teenagers to break free from the shackles of unrealistic standards and embrace their inimitability.

NIH recognizes these talented essay winners for their thoughtfulness and creativity in addressing youth mental health. These essays are written in the students' own words, are unedited, and do not necessarily represent the views of NIH, HHS, or the federal government.

Page published May 31, 2024

May 2024: NIH Announces Winners of High School Mental Health Essay Contest

Dec. 2023: High School Students Invited to Reflect on Mental Health Stigma in National Essay Contest

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• Published: 22 December 2020

Impact of COVID-19 on adolescents’ mental health: a systematic review

• Gilbert Sterling Octavius   ORCID: orcid.org/0000-0002-6439-6265 1 ,
• Felicia Rusdi Silviani 1 ,
• Alicya Lesmandjaja 1 ,
• Angelina 2   na1 &
• Andry Juliansen 2   na1  

Middle East Current Psychiatry volume  27 , Article number:  72 ( 2020 ) Cite this article

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The impact of COVID-19 towards psychology and mental health is anticipated to be significant and may affect the population disproportionately, especially adolescent as the vulnerable category. We aimed to analyze the impact of COVID-19 towards adolescents’ mental health.

A systematic search was conducted from Cochrane, Google Scholar, Scielo, and PubMed. Inclusion criteria included all types of studies which observed the effect of COVID-19 and its related causes, such as lockdown, on adolescents’ mental health. All studies were assessed for its level of evidence according to Oxford 2011 criteria and Newcastle Ottawa Scale (NOS). Three studies (Seçer and Ulaş, Int J Ment Health Addict: 1–14, 2020; Zhou et al., Eur Child Adolesc Psychiatry 29:749–58, 2020; Qu et al., Lancet: 1–17, 2020) showed that COVID-19 was a risk factor for mental health problems in adolescents while Oosterhoff et al. (J Adolesc Health 67: 179–185, 2020) showed that adolescents who preferred to stay at home during this pandemic reported less anxiety and depressive symptoms

COVID-19 has been found to be associated with mental health changes in adolescents which meant management of COVID-19 should also focus on mental health as well.

Coronavirus disease-19 (COVID-19) was found initially in Wuhan, Hubei Province, China, on December 31, 2019, and it continues to be a pandemic [ 1 ]. Until July 13, 2020, it has infected about 12,750,275 people and caused 566,355 deaths around the world while showing no signs of slowing down [ 2 ]. Based on this fact, many countries around the world had applied physical distancing and closed public places such as schools, campuses, offices, and public places to curb the transmission [ 3 , 4 , 5 , 6 ]. On the other hand, physical distancing has impacted mental health by depriving social contact, especially the adolescent [ 1 , 7 , 8 ]. Adolescent is defined as individuals in the 10–19 years age group [ 9 ] in which it is a vulnerable age group to develop negative mental health impairment because they are very sensitive to psychological and social transformation. Adolescent experiences higher peer interaction and social world than with their family, and even forms complex peer relationship compared to their younger counterparts such as babies and children. Any separation from peer relationships such as rejection, bullying, or loneliness has been linked to mental health disorder such as depression, anger, fear, stress, and anxiety [ 10 ]. Physical distancing had led individuals to cut off social interaction unintentionally because individuals had the tendencies to avoid conversation in order to limit meetings. Although most adolescents were exposed to physical distancing, lockdown, or quarantine during this pandemic of COVID-19, the adolescents’ mental health changes can be variative based on their circumstances and motivation to obey physical distancing [ 11 ]. This study aims to analyze the impact of COVID-19 towards adolescent’s mental health, with the hypothesis that COVID-19 is associated with poor mental health outcomes on adolescents.

This systematic review was conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement [ 12 ]. The protocol of this systematic review has been registered in The International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020195764).

We included cohort studies and cross-sectional studies which observed the effect of COVID-19 and its related causes such as lockdown on adolescents’ mental health impact such as depression, fear, and anger. Exclusion criteria comprise of studies that include correspondents with age group extending below and over the adolescents’ age range (10–19 years old), as well as studies which include adolescents with pre-existing mental health problems such as autism spectrum disorder (ASD) or post-traumatic stress disorder (PTSD).

A systematic literature search was performed on July 7, 2020, using four different databases such as Cochrane, Google Scholar, Scielo, and PubMed using keywords listed in Table 1 . Literature selection was performed from 2019 onwards and restricted to only publications that are in English language.

Data from each study was extracted in a standardized form, compiling study citations, baseline characteristics of the included subjects, and the study findings. Study citations included the name of the first author, year of publication, and title of the study. Meanwhile, characteristics of each study refered to study design, location of the study, and patients’ characteristics (age, ethnicity, gender, sample size, and family income). The study findings extracted involved the odds ratio, R 2 , or β value analyzed in each study.

Three independent reviewers conducted the quality assessment of the studies (GS, FR, AL). The included studies were critically appraised using Newcastle Ottawa Quality Assessment Scale (NOS) for case control and cohort studies [ 13 ]. Any discrepancies of NOS score between reviewers were discussed until it reached a conclusion. If the discrepancies are still not settled, two expert reviewers (A, AJ) were consulted, and decisions were made by them. High-quality studies were defined as studies fulfilling NOS score of minimum 7 (Table 2 ). Data was synthesized based on a minimum of four different and high-quality studies with consistent finding. The obtained data was analyzed considering the method of variable analysis used, study size, odds/hazard ratio, along with its confidence interval.

Literature search was done using keywords listed in Table 1 . Out of 5876 articles identified, 48 articles were retrieved after title and abstract screening. Duplicates were then removed, and after ensuring the remaining articles were appropriate according to the writers’ inclusion and exclusion criteria, four articles were chosen for this study which were studies by Qu et al. [ 14 ], Oosterhoff et al. [ 15 ], Zhou et al. [ 11 ], and Seçer and Ulaş [ 16 ]. The flow of our study selection is presented in Fig. 1 according to the PRISMA statement [ 12 ].

PRISMA flowchart of study selection

The summary of baseline study characteristics is presented in Table 3 . All studies had level 2 of evidence based on Oxford 2011 and were considered high-quality based on each NOS score (Table 2 ). All studies were cross-sectional studies except for Qu et al. [ 14 ], which was a prospective study, which means that temporality or causality cannot be established. Each study also used different questionanires to assess pyschosocial impact and mental health except Zhou et al. [ 11 ] and Qu et al. [ 14 ] which both used Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7) to assess depression and anxiety, respectively. All of the questionnaires are self-administered online except in the study of Qu et al. [ 14 ] which initially was administered by trained staffs.

The study done by Zhou et al. [ 11 ] showed that prevalence of mild-to-severe depressive and anxiety symptoms in Chinese adolescents during COVID-19 outbreak was 43.7% and 37.4% respectively. The prevalence of adolescents with both depressive and anxiety symptoms was 31.3%. They found that adolescents living in cities were less depressed (37.7%). Zhou et al. [ 11 ] also found that adolescents living in cities were less likely to have depressive or anxiety symptoms (37.7% vs 47.5% and 32.5% vs 40.4%). The scores in COVID-19 knowledge, prevention, and control measures, and projections of COVID-19 were higher in adolescents without depressive and or anxiety symptoms. Utilizing multivariate logistic regression analysis, Zhou et al. [ 11 ] found that female gender (OR (Depression[DE]) = 1.15, 1.05–1.26; OR (Anxiety[AN]) = 1.10, 1.00–1.21), living in Hubei province (OR DE = 1.58, 1.34–1.87; OR AN = 1.64, 1.39–1.93), and being in the junior grade three (OR DE = 1.40, 1.11–1.75; OR AN = 1.32, 1.04–1.67) were risk factors for depressive and anxiety symptoms.

The study done by Qu et al. [ 14 ] is the only study included to be using prospective cohort as its study design. First, the authors did the first survey round as a baseline data which assessed their background factors, depression, anxiety, resilience, and childhood maltreatment using the questionnaires listed in Table 3 . The second round of survey was done 3 months after the first round of data gathering, and after excluding invalid questionnaires the valid follow-up rate was 74.91% and varied by region ( p < 0.001). They found that just before the pandemic, 51.51% of adolescents reported depressive symptoms and 38.53% reported anxiety symptoms. After home confinement, the number dropped to 38.29% and 23.73% respectively (all p < 0.0001). After Propensity Score Matching (PSM) matching, adolescents with exposure risk still had more depression (60.54%; p = 0.0023) and anxiety symptoms (41.26%; p = 0.0072) than those without any exposure risks (45.95% and 28.83% respectively). Exposure risk was defined as anyone in the surrounding living environment of the participant who was infected with COVID-19. Qu et al. concluded that adolescents with exposure risks (assessed with assessed with PSM analysis [PSM] analysis) are 2.3 times more likely to suffer from depression (1.7–3.1; p < 0.0001) and 2.1 times more likely to suffer from anxiety symptoms (1.6–2.8; p < 0.0001) in adolescents with exposure risk.

Using standardized structural equation modeling (SEM), Seçer and Ulaş [ 16 ] found that fear of COVID-19 positively predicts emotional reactivity ( β = .50, p < 0.01) which positively predicts experiential avoidance ( β = .59, p < 0.01) and depression-anxiety ( β = .81, p < 0.01). Oosterhoff et al. [ 15 ] did not find any association between degree of social distancing and any indicator of mental or social health. This study also found that those who were social distancing because of social responsibility reported less anxiety symptoms ( R 2 = 0.03, standard error (SE) = 0.12 [− 0.21, 0.27]), depressive symptoms ( R 2 = − 0.05, SE = 0.12 [− 0.29, 0.19]), and burdensomeness ( R 2 = − 0.35, SE = 0.19 [− 0.73, 0.03]) ( p < 0.05) which was also found in adolescents who would have preferred to stay at home ( R 2 anxiety = − 0.3, SE = 0.11 [− 0.51, − 0.09], R 2 depressive = − 0.35, SE = 0.1 [− 0.55, − 0.14], and R 2 belongingness = − 0.03, SE = 0.16 [− 0.29, 0.35) ( p < 0.05). Additionally, adolescents who were social distancing because a friend told them they should reported greater depressive symptoms ( R 2 = 0.26, SE = 0.13 [0.02, 0.51]) ( p < 0.05) while adolescents who were social distancing because they wanted to avoid judgment reported greater anxiety symptoms ( R 2 = 0.35, SE = 0.17 [0.03,0.68]) ( p < 0.05).

COVID-19 is an unprecedented infectious disease which has taken a massive toll on deaths. Sudden changes in lifestyle, including lockdown, quarantine, or physical distancing coupled with the loss of loved ones, may take a toll on mental and emotional health. Although there has been several studies in the past trying to elucidate how quarantine and isolation affect mental health, the extent on how far adolescents’ mental health is affected is unknown [ 17 ]. In this systematic review, three included studies show that COVID-19 impacts on adolescents’ mental health with one study citing that there was no significant impact.

The cohort result from Qu et al. [ 14 ] should be interpreted carefully. There was 25.09% drop-out from the participants in the first round to the second round, so the result from first and second round might not be able to be compared directly. The study also found that the incidence and severity of anxiety and depressive symptoms dropped significantly after home confinement. It meant that mental health was not affected in overall adolescent population, but only in exposure risk population. Furthermore, there was only 2.2% subjects that reported a risk of exposure. As this study analyzed COVID-19 exposure risk as independent variable, the low number of subjects in exposure risk might not be able to represent a real general population. Despite its limitations, this study had a baseline data to compare pre-home confinement and intra-home confinement, which made it one of the best quality studies among the others.

Zhou et al. [ 11 ] presented a similar finding with Qu et al. [ 14 ] that living in community with high number of COVID-19 cases was a risk factor towards depression and anxiety. These two studies also used same questionnaires to assess depressive and anxiety symptoms. However, Zhou et al. [ 11 ] found that awareness of COVID-19 was a protective factor against depressive and anxiety symptoms while Qu et al. [ 14 ] stated that some protective factors, such as good parent-child relationship, few adverse experiences, good family structure, and high resilience could be outweighed by exposure of COVID-19. These different results showed that there were a lot of factors that might affect the rise of depressive and anxiety symptoms in adolescent in COVID-19 pandemic era.

Study by Seçer and Ulaş was unique because it is the only study which assessed obsessive-compulsive disorder (OCD) due to fear of COVID-19 [ 16 ]. The reasoning behind it was due to the fear of this disease, adolescents will start a washing and hoarding obsession. Although the study did not mention the number of positive cases in the area, the common denominator of fear of COVID-19 is still maintained in this study. Seçer and Ulaş [ 16 ] went a step further by theorizing that emotional reactivity might be one of the various psychopathologies that might explain depression, anxiety, and OCD in adolescents while experiential avoidance mediates fear of COVID-19 and OCD symptoms. However, while trying to establish a causality, this paper is a cross-sectional study which means that further studies need to consider other study designs in order to establish the direct link between fear of COVID-19 with OCD symptoms, if possible.

Although the study done by Oosterhoff et al. [ 15 ] found that there was no association between degree of social distancing and mental or social health, this study found that motivations for social distancing were differentially associated with degree of social distancing as well as depressive symptoms, anxiety symptoms, burdensomeness, and belongingness. Adolescents who were social distancing because they wanted to avoid social judgment reported more anxiety symptoms which might be explained by the fact that past researches shows that symptomatic youths are more sensitive towards social judgment or peer rejection [ 18 ]. This study also found that adolescents who prefer to stay at home reported lower anxiety and depressive symptoms because adolescents who chose to stay at home might be struggling less with reduced social contact [ 15 ]. However, some motivations studied have low samples such as “no alternatives” (17.8%), “friends said I should” (13.9%), “avoid judgment” (7%), and others (4.4%) which could affect the significancy of the associations studied. High compliance towards social distancing in the sample population could be seen from the motivations of social responsibility (78.1%) and not wanting others to get sick (77.9%). It implies that the adolescents in the population studied have a good knowledge of COVID-19 which confers protective factor towards depression and anxiety just like in the study done by Zhou et al. [ 11 ].

Onset of depression is affected by both genetic factors and external environmental factors such as stressful life events [ 19 , 20 ]. Adolescents are especially vulnerable to stressful life events and could lead to lower levels of motivation, lower concentration, poorer achivement [ 21 ], psychological distress, anxiety, depression [ 22 ], and suicide [ 23 ]. In fact, mental health conditions account for 16% of the global burden of disease and injury in people aged 10–19 years old and half of all mental health conditions starting at 14 years old, but most cases were undetected and untreated [ 24 ]. Moreover, non-emergency medical services were halted or redirected towards more emergency cases and hence medical care for affected adolescents will be affected [ 25 ]. Fear of COVID-19 significantly increased negative affect, anxiety, and depression [ 26 ]. Qu et al. [ 14 ] stated that long-term confinement had no adverse mental health impact on adolescents from regions with a low incidence of COVID-19. Compared to Qu et al. [ 14 ], the exposure risk of COVID-19, living area, and fear of COVID-19 which could be the risk factors for mental health changes on adolescents are not measured in Oosterhoff et al.’s study [ 15 ]. A study done by Fitzpatrick stated that the fear of COVID-19 is not distributed uniformly across the USA, and there were specific concentrated COVID-19 fear in more crowded populated communities, communities with higher presumptive and reported cases of COVID-19, and urban locations [ 27 ]. Most studies were also originated from high-income countries, which may affect the generalizability of the findings to low-income and middle-income countries which are often under-presented in terms of generating evidences through empirical studies [ 28 ]. Therefore, the result which was conducted in high income countries such as the Oosterhoff’s [ 15 ] study cannot be generalized to other low- and middle-income countries that were exposed to COVID-19.

Adolescents who are infected by COVID-19 would also need psychiatric care as 10% of infected children who experienced trauma due to infection and its consequences might be diagnosed with PTSD [ 29 ]. Psychiatrists and pediatricians need to be aware of warning signs of mental health problems in COVID-19 infected children such as mood swings and psychosis-like symptoms as psychiatrists need to work directly with young patients and their families in order to screen and detect mental disorders as soon as possible with adequate personal protective equipment [ 25 ].

Zhou et al.’s [ 11 ] study suggested that the level of knowledge, prevention, and control measures for COVID-19 are protective factors against the development of depressive and anxiety symptoms. However, there are media/press sources that might give false information and reports about COVID-19 which could lead to anxiety and depressive symptoms of the public. A study by Zhong et al. also suggested that health education aimed at increasing knowledge of COVID-19 are important to keep optimistic attitudes [ 30 ]. This is related to a statement from Zhou’s study that said positive and optimistic attitudes towards COVID-19 epidemic’s development are also protective factors against depressive and anxiety symptoms [ 11 ].

The government and health authorities’ role are important in COVID-19 crisis to provide adequate information and deny any false information to keep the public informed. In crisis situation like this, it is convenient to educate and provide public with the accurate information through digital media platform. A study by Liu suggested that the uses of digital media might initiate preventive behaviors directly or indirectly. It states that seeking information about COVID-19 from online news media, media social networking (MSNs), social live streaming services (SLSSs) was associated with increased preventive practices [ 31 ]. Since there are a lot of misinterpreted informations from the internet, it is important to obtain information from a credible website such as the national Centers for Disease Control (CDC), World Health Organization (WHO), or from other sources endorsed by these authorities, rather than a general search on the internet or social media [ 32 ].

A rapid systematic review done by Imran et al. found that quarantine is associated with significant negative impact on mental health of children and adolescents which might persist for months or years after the quarantine. Although the cause of quarantine is very diverse (from natural disasters such as Tsunami in Aceh 2004 to children requiring ventilators at home), this study proposed some interventions that could be done to reduce the impact of mental health during quarantine such as provision of psychosocial support, dissemination of accurate information, limit exposure to news, positive parenting, social connectivity, as well as behavior activation complemented with sleep hygiene, exercise, and healthy eating [ 33 ]. Another systematic review done by Loades et al. [ 34 ] which assessed the impact of social isolation and loneliness due to COVID-19 on children’s and adolescent’s mental health found that children and adolescents are more prone towards high rates of depression and anxiety during and after enforced isolation ends which might last up to 0.25 to 9 years later.

Our study is limited by exclusion of articles written in languages other than English as well as unexplored gray literatures. The studies included also did not measure any baseline characteristics except for study done by Qu et al. [ 14 ]. Moreover, this systematic review could not be proceeded to meta-analysis due to the heterogenous use of variable analysis. Therefore, we recommend future studies to use a more homogenous questionnaire as well as their odds ratio presentation clearly to depict the effect of COVID-19’s mental health impact in adolescents. Lastly, correlation between those who were at low risk of contracting COVID-19 and the lesser impact on mental health risk may be independent of the actual risk and was just based on individual’s subjective perceptions.

Taken together, this is the first systematic review that shows the impact of COVID-19 on mental health among adolescents. Hence, this study might be important in the aspect of a more holistic approach towards adolescents who are affected by COVID-19, whether directly or indirectly. In the long term, there might be a surging incidence and prevalence of mental health disorders which might be attributed to COVID-19 and hence awareness and interventions are needed which might require cooperations between the adolescents, families, medical care workers, and the governments.

COVID-19 has been found to be associated with adolescents mental health changes, especially the fear of COVID-19 in a population with adequate exposure of COVID-19 was proved to create adverse mental health condition such as anxiety and depression. adolescents who had experienced previous trauma with addition of social isolation/quarantine and loneliness were more prone towards anxiety and depression during and even after the enforced isolation ends. On the other hand, some protective factors were found to help adolescents stay away from any mental health adverse impacts due to COVID-19. Physical-psychosocial support provision, adequate and accurate information from credible source about COVID-19, and good motivation to obey physical distancing has shown to decrease the likelihood of negative mental health changes in adolescent. Through this systematic review, psychiatrist, pediatrician, parents, or other parties who accompany or take care of adolescents hopefully can raise awareness to detect mental health changes in order to decrease adverse mental health impacts in adolescent’s future. Further study needs to be done to find other factors which may be associated to mental health changes besides fear of COVID-19 and social distancing.

Availability of data and materials

Available upon request

Abbreviations

Autism spectrum disorder

Centers for Disease Control

Coronavirus disease-19

Generalized Anxiety Disorder Scale

Media Social Networking

Newcastle Ottawa Scale

Obsessive compulsive disorder

Patient Health Questionnaire

Preferred Reporting Items for Systematic Reiew and Meta-Analysis

The International Prospective Register of Systematic Reviews

Propensity Score Matching

Post-traumatic stress disorder

Social Live Streaming Services

World Health Organization

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Angelina and Andry Juliansen contributed equally to this work.

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Faculty of Medicine, University of Pelita Harapan, Karawaci, Tangerang, Banten, Indonesia

Gilbert Sterling Octavius, Felicia Rusdi Silviani & Alicya Lesmandjaja

Department of Pediatric, Faculty of Medicine, University of Pelita Harapan, Karawaci, Tangerang, Banten, Indonesia

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GSO, FRS, and AL did the conception of this systematic review while GSO registered the procedure on PROSPERO website. Data collections are done by GSO, FRS, and AL with disputes between the articles that were selected and settled by A and AJ. GSO and FRS drafted the article while A and AJ did critical revision of the article. Final approval of the version to be published was granted by all authors.

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Octavius, G.S., Silviani, F.R., Lesmandjaja, A. et al. Impact of COVID-19 on adolescents’ mental health: a systematic review. Middle East Curr Psychiatry 27 , 72 (2020). https://doi.org/10.1186/s43045-020-00075-4

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• Mental health

Is a Mental Health Crisis the Next Pandemic?

New study confirms mental and physical health declining post-covid-19 pandemic..

Posted March 17, 2021 | Reviewed by Gary Drevitch

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Key Points:

• New surveys are revealing the depth of the damage to mental health caused by the pandemic across the United States. Two-thirds of adults say their sleep quality has declined in the past year, more than half have experienced undesired weight change, and one in four are drinking more.
• Changes forced on people by the pandemic have limited their access to coping tools such as exercise and social support.
• Continued stigma around discussing mental health problems, and a lack of access to care, have kept many people from getting professional help.

Between the social isolation , economic instability, political turmoil, racial violence, death and sickness, and overall uncertainty about the future, it is no wonder that mental health in America is on the decline, that depression and anxiety levels are on the rise, and that the demand for mental health and addiction treatment is skyrocketing.

We know the toll that chronic stress can take on the body, mind, and spirit. Not only have the events of the past 12 months taken their toll on our mental health, but our physical health has suffered as well. This is not surprising given the inextricable link between physical and mental health.

We are facing a national mental health crisis that could yield serious health and social consequences for years to come. —American Psychological Association (APA).

A study published by the American Psychological Association (APA) confirms what most of us have already suspected. According to a survey conducted by the Harris Poll in late February 2021, 1 in 5 adults reported that their mental health has worsened over the past year. Parents of young children, essential workers, young people, low-income populations, and people of color[ have been especially hard hit. For those of us on the front lines of the current mental health crisis, or what the APA predicted to be a “second pandemic,” the results of this study came as no surprise.

Disrupted Sleep, Weight Changes, and Increased Substance Use

According to the Harris poll, some of the most significant manifestations of the cumulative stress of the past year among the population have been disrupted sleep patterns, weight changes, and increased substance use. Among Generation Z adults in particular (18-24-year-olds), disrupted sleep patterns (31%) and weight changes (28%) have been two of the most common effects.

Whether it is getting too much or not nearly enough, most Americans (67%) reported that their sleep has been negatively affected over the past year. Racing minds plus disrupted schedules and routines (or lack thereof) are contributing factors.

More than half of adults in the United States have experienced undesired weight changes since the start of the pandemic, either gaining or losing; 42 percent have gained on average about 29 pounds over the last year. This can be attributed to limited access to exercise facilities, the forced sedentary lifestyle for many during lockdown, and more broadly, a lack of motivation to be physically active, and the use of food to cope with boredom , anxiety, loneliness, and depression.

According to the study, nearly one in four adults (23%) reported drinking more alcohol to cope with stress during the pandemic. Among those with early elementary school-age children (5-7-year-olds), this number jumps to almost half.

Stripped of Our Coping Tools

Survey responses reveal that physical health may be declining due to an inability to cope in healthy ways with the stresses of the pandemic. —APA

Many of the resources that we have relied on for coping during times of distress have been forcibly removed from our toolbox of skills by the pandemic. One of our most essential resources when it comes to our mental well-being is social support.

Quarantine, isolation, and social distancing practices do not just affect us physically; they create a recipe for psychological disaster. This is particularly the case for those who already struggle with mental health conditions in non-pandemic times. “Our bodies are not built to withstand long-term trauma ,” says clinical psychologist Sabrina Romanoff. “In turn, we become deregulated and adapt. While this helps us to survive and hold onto a semblance of sanity, we may tend to make choices that are not as hypervigilant and safe as we would in the throes of the beginning stages of a trauma.”

The collective trauma of the events that have occurred over the past year has consumed not just our clients; as mental health professionals, we are not immune either. We can only do our best to pull from our experience and what we know to be effective in coping with trauma, and impart that knowledge to our clients and apply it to ourselves. Below are just a few suggestions.

Kindness is the humanity we show to others. If you’re feeling down or depressed, there’s no better way to snap out of it [than] by doing something good for someone else in need. he greatest blessing in the pandemic has been the countless acts of sacrifice, service, and love shown by ordinary folks doing extraordinary acts of kindness around the world. —Elia Gourgouris, PhD, Certified American Red Cross Disaster Mental Health Relief expert

Pet therapy

A lot of my clients have raved of the benefits of their new “COVID puppies/kitties” that gave them distraction, affection, exercise, and kept loneliness at bay. Vast research proves that interaction with animals boosts our dopamine , serotonin, and oxytocin , which helps us feel connected. —Kriya Lendzion, licensed mental health clinician and addictions therapist

Support groups

Group therapy may be particularly helpful for those struggling with the emotional repercussions of the last year. Until it is deemed safe enough to return to in-person therapy, such services are available and easily accessible remotely. Perhaps building the foundation for the therapeutic relationship and connections with peers online now, with the anticipation of joining in person and deepening those bonds, we can add to our toolbox of coping mechanisms.

Remember That You Are Not Alone

A pillar of self-compassion is our shared humanity, the idea that we are never alone. More than a platitude, we now have empirical evidence that says, “You are not alone in this.” Whether you are experiencing increasing anxiety, lower mood, lack of motivation, difficulty sleeping , or overall pandemic fatigue, a large part of the population is feeling similar effects after what has been an unfathomably turbulent year.

One of the tenets of the Buddhist philosophy is the acknowledgment that there is no permanence in life. Nothing will last forever. In times when life feels hopeless, it is imperative to remember this and to remember that there is a light at the end of what has felt like a very dark tunnel. We can now look forward to spending time with old friends and family members we have not seen in more than a year, celebrating holidays and birthdays, planning future vacations, and most of all, appreciating all that we previously took for granted.

Although we have not been exactly here before, we have been through similar times. We made it through the polio epidemic, the Spanish flu, the AIDS crisis, and other global catastrophes that have occurred throughout human history. And time proves over and over again what a resilient bunch we humans are. This is especially the case for children, who have a remarkable ability to bounce back from hardship and adversity.

No Room for Mental Health Stigma

These reported health impacts signal many adults may be having difficulties managing stressors, including grief and trauma, and are likely to lead to significant, long-term individual and societal consequences, including chronic illness and additional strain on the nation’s health care system. —APA, Stress in America, “One Year Later, a New Wave of Pandemic Health Concerns”

When we experience debilitating symptoms of a physical condition such as cancer or a deadly virus, it makes perfect sense to seek professional treatment. Insurance companies and employers agree with this; hence policies around healthcare coverage and sick days. This application should be no different for mental health conditions, especially when symptoms threaten daily functioning. Perhaps the combination of increased access to care via remote channels and the ongoing strain of the events of the past year have encouraged more people, including those who perhaps otherwise would not have sought out treatment, to be more open to doing so.

A clear and present fear among mental healthcare providers and clients alike is the potential discontinuation of insurance coverage for remote therapy services. To lift reimbursement policies for remote mental health services is to cut off access to care for countless numbers of individuals in need. Parity in telehealth services should have been the norm even prior to the pandemic, but now—perhaps more than ever, as new norms develop in the way we live and how we receive treatment—it is imperative that managed care companies, which so many of us rely on, keep up with the changing times and be a part of the solution to the mental health crisis in America.

To find a therapist, visit the Psychology Today Therapy Directory

American Psychological Association (2021). Stress in America, One Year Later, a New Wave of Pandemic Health Concerns.

American Psychological Association (2020). Stress in America, A National Mental Health Crisis.

Allison Abrams, LCSW-R , is a licensed psychotherapist in NYC, as well as a writer and advocate for mental health awareness and destigmatization.

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University students' mental health amidst the COVID-19 pandemic in Georgia

Affiliations.

• 1 David Tvildiani Medical University, Tbilisi, Georgia.
• 2 V. V. Zakusov Research Institute of Pharmacology, Moscow, Russia.
• 3 Department of Psychiatry, Narcology, Psychotherapy and Clinical Psychology, International Centre for Education and Research in Neuropsychiatry,Samara State Medical University, Russia.
• 4 Independent Researcher, Tbilisi, Georgia.
• 5 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece.
• 6 Faculty of Medicine, Medical University of Sofia, Bulgaria.
• PMID: 35657336
• DOI: 10.1177/00207640221099420

Aims: We aimed to identify the prevalence of anxiety, depression, and suicidality and identify relevant risk and protecting factors among university students during the COVID-19 pandemic in Georgia.

Materials and methods: We conducted an anonymous online survey ( n = 984, convenience sample by approaching all universities in Georgia and some student organizations) using valid instruments (e.g., STAI to assess anxiety, CES-D for depression, and RASS to assess suicidality). We calculated frequencies and prevalence and applied regression analysis and Chi-square tests to identify risk and protecting factors.

Findings: Respondents' mental health had been significantly affected (with a high prevalence of depression (46.7%) and anxiety (79%)) during the pandemic (which coincided with political turmoil and caused an economic crisis) in Georgia. Some of the critical factors affecting mental health were: female sex ( p = .000), bad general health condition (anxiety p = .001, depression p = .004), finances (anxiety and depression p < .001), reduced physical activity (anxiety p < .001, depression p = .014), and a history of self-harming (suicidality p < .001). Less family conflicts (anxiety and depression p < .05), absence of nightmares (anxiety and depression p < .001), moderate or low fears of COVID-19 (anxiety p < .001), and lower substance use (anxiety p = .023) were among the potentially protective factors. International students coped better, despite vulnerability. Medical students had a lower risk of depression.

Conclusions: In the complex socioeconomic context, mental health of students in Georgia suffered a lot during the COVID-19 pandemic, requiring thorough planning and delivery of student support services in higher educational institutions during and after the pandemic.

Keywords: COVID-19; Georgia; anxiety; depression; mental health; university students.

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Mental Health and Its Predictors during the Early Months of the COVID-19 Pandemic Experience in the United States

Yanmengqian zhou.

1 Department of Communication Arts and Sciences, Pennsylvania State University, 234 Sparks Building, University Park, PA 16802, USA; ude.usp@62mle

Erina L. MacGeorge

Jessica gall myrick.

2 Donald P. Bellisario College of Communications, Pennsylvania State University, 201 Carnegie Building, University Park, PA 16802, USA; ude.usp@34mgj

Associated Data

To date, there has been relatively little published research on the mental health impacts of COVID-19 for the general public at the beginning of the U.S.’ experience of the pandemic, or the factors associated with stress, anxiety, depression, and post-traumatic growth during this time. The current study provides a longitudinal examination of the predictors of self-reported stress, anxiety, depression, and post-traumatic growth for U.S. residents between April and May, 2020, including the influence of demographic, psychosocial, and behavioral factors on these outcomes. The findings indicate that, generally, the early months of the U.S. COVID-19 experience were characterized by a modest negative impact on mental health. Younger adults, people with pre-existing health conditions, and those experiencing greater perceived risk, higher levels of rumination, higher levels of co-rumination, greater social strain, or less social support reported worse mental health. Positive mental health was associated with the adoption of coping strategies, especially those that were forward-looking, and with greater adherence to national health-protection guidelines. The findings are discussed with regard to the current status of health-protective measures and mental health in the U.S., especially as these impact future management of the on-going pandemic.

1. Introduction

In mid-March of 2020, the World Health Organization declared COVID-19 to be a global pandemic and, in the U.S., a national emergency was declared. Starting in this same timeframe, health-protective measures were put into effect by government bodies at multiple levels across the country. Although variable in onset, duration, and stringency, these measures included school, business, and government closings, social distancing and quarantine requirements, and face-covering policies (this latter largely after April 3rd, based on revised guidance from the Centers for Disease Control and Prevention (CDC) [ 1 ]). Thus, as illness and death toll climbed through March and April, so too did the public’s need to cope with significant “secondary” stressors, such as temporary or permanent job loss and associated financial difficulties, challenges obtaining food and other material goods, educating and caring for children at home, physical separation from family and friends, and the discomforts (both physical and psychological) associated with wearing masks and other face coverings.

As the pandemic and public health measures escalated, experts in various fields quickly began to note the probability of negative impact on mental health in the general public and the need for additional or improved mental health services [ 2 , 3 , 4 , 5 ]). Indeed, the probability that COVID-19 will have at least short-term negative effects on mental health among the U.S. general public is suggested by research from prior pandemics, especially SARS-CoV-1 [ 6 ] and by recently-published studies (for a review, see [ 7 ]), especially those conducted with Chinese citizens who first experienced the pandemic’s outbreak and their government’s extensive measures to prevent the disease from spreading [ 8 , 9 , 10 , 11 , 12 , 13 ]. These studies document detrimental effects of COVID-19 on depression, anxiety, post-traumatic stress, and sleep quality. Similar negative effects have also been reported from other countries [ 14 , 15 , 16 , 17 ], along with increases in smoking and alcohol consumption, and decreased physical activity [ 16 ]. These studies have also identified various factors that either make mental health issues more likely or protect against them. For example, in a very large ( N = 52,730) cross-sectional Chinese study conducted in January and early February of 2020, Qiu et al. [ 11 ] found that psychological distress was higher for women, young adults (18–30) and the elderly (over 60), migrant workers, people who lived closer to the center of the epidemic in China, and those for whom healthcare access was problematic. A longitudinal study by Wang et al. [ 12 ] conducted between January 31st and March 1st identified confidence in doctors, satisfaction with health information, and adopting precautionary measures (e.g., hand-washing) as factors protective against stress, anxiety, and depression.

To date, there have been few empirical research reports on the mental health conditions of the general public at the beginning of the US experience of the COVID-19 pandemic, or the factors that were associated with mental health at that time. Understanding the shifts in the public’s mental health status during the pandemic and the factors that may be influencing changes in mental health is relevant to understanding public responses to the on-going pandemic, planning for subsequent management of COVID-19, and preparing for future pandemics. Accordingly, the current study provides a longitudinal examination of self-reported stress, anxiety, depression, and post-traumatic growth as experienced by U.S. residents in April and May, 2020. The goal of this study was to gain insights into the influence of various demographic, psychosocial, and behavioral factors that may shape changes in these mental health outcomes across the course of a pandemic. Psychosocial factors examined included perceived health and financial risks, rumination and co-rumination about the pandemic, social support, and social strain. Behavioral factors measured included adherence to national public health guidelines (issued by the Centers for Disease Control and Prevention (CDC) on March 16) and coping strategies. Demographic factors were gender, age, race, ethnicity, education, region of residence, political party, political orientation (liberal-conservative), employment status, pre-existing health conditions, experience of COVID-19-consistent symptoms, and COVID-19 testing.

2.1. Study Design and Participants

Participants aged 18 to 90 were recruited through Qualtrics.com to take part in a series of online surveys. Qualtrics recruits its panelists from various online sources (e.g., website intercept recruitment, member referrals, targeted emails, customer loyalty portals, and social media). Qualtrics panels are frequently used in health-related research to obtain representative samples, and studies show that samples obtained through Qualtrics have demographic attributes that align (with approximately 10% variation) with the 2010 Census data [ 18 ]. For this study, potential participants were sent an email invitation by Qualtrics with a link to the questionnaire and information about participation incentives (typically worth $4–$5 per survey). Once the participants provided informed consent, they were directed to complete the study survey. In total, 1021 participants were recruited at Wave 1, 633 continued at Wave 2, and 442 remained at Wave 3 (56.71% attrition between Wave 1 and Wave 3). As the study was conducted online, we could not control participants’ environment or level of engagement with the study. We did, however, utilize mechanisms available through Qualtrics for quality control: the median duration of study completion was computed during a soft launch, and subsequent participants who spent less than one-third of that time on the study were dropped. Wave 1 took place on April 20, Wave 2 between May 4 and May 8, and Wave 3 between May 18 and May 22, with a two-week lag between initiation of each wave. All procedures were approved by the Institutional Review Board at the Pennsylvania State University (STUDY00014927) and participants provided informed consent prior to beginning the surveys.

Details of the demographic characteristics of the Wave 1 sample are shown in Table 1 . The average age of participants was slightly over 45 years old. The sample was divided near-evenly between males and females and identified primarily as White (75%) or Black (11%), with less representation from other racial groups. Almost 10% were of Hispanic or Latino ethnicity. By design, participants were drawn in near-equal numbers from the four U.S. Census regions. Compared with participants who completed all three waves ( n = 442), participants who did not provide any data three times (i.e., dropped out after Wave 1 or 2; n = 579) tended to be younger with a mean difference ( M diff ) of 7.11 years (t = −6.70, p < 0.001), and experience less stress, anxiety, and depression at Wave 1 ( M diff = 1.35, t = −3.56, p < 0.001; M diff = 1.25, t = −3.37, p < 0.001; M diff = 1.40, t = −3.46, p < 0.001). No other comparisons between dropouts and completers were significant.

Sample demographic statistics ( N wave1 = 1021).

2.2. Measures

Mental health outcome variables . Mental health outcomes were measured using: (1) the Depression, Anxiety, and Stress Scale (DASS-21) [ 19 ], which was assessed at all three time points; and (2) the Posttraumatic Growth Inventory (PTGI) [ 20 ], which was assessed at Wave 3. The DASS-21 assesses symptoms of depression (e.g., dispirited, pessimistic, unable to experience joy), anxiety (e.g., apprehensive, shaky, pounding heart), and stress (e.g., tension, impatience, irritability), whereas the PGTI focuses on positive outcomes of coping with traumatic events (e.g., relating to others, new possibilities, personal strength, spiritual change, appreciation of life). Results of a confirmatory factor analysis (CFA) showed that a three-factor structure was a good fit to the data for the DASS-21: χ 2 = 609.31, df = 181, CFI = 0.98, RMSEA = 0.048 (90% CI [0.044, 0.052], SRMR = 0.02 (Wave 1); χ 2 = 498.97, df = 181, CFI = 0.97, RMSEA = 0.053 (90% CI [0.047, 0.058], SRMR = 0.02 (Wave 2); χ 2 = 503.35, df = 181, CFI = 0.96, RMSEA = 0.063 (90% CI [0.057, 0.070], SRMR = 0.03 (Wave 3). For the PTGI, we fitted and compared a five-factor model (see [ 20 ]) and a second-order model. Fit indices were nearly identical for the two models. The second-order model, however, showed a lower BIC value compared to the five-factor model. We thus selected the second-order model as our final model: χ 2 = 514.80, df = 184, CFI = 0.96, RMSEA = 0.064 (90% CI [.057, 0.070], SRMR = 0.03, and used PTGI as a unidimensional scale (i.e., computed as sum of all items).

Psychosocial predictors . Except for perceived social strain, which was measured only at Wave 3, all other psychosocial predictors were measured at all three waves. Perceived health and financial risk were each measured with two 11-point Likert-scale items adapted from Griffin et al. [ 21 ]: “How likely is it that the COVID-19 pandemic will harm your health/financial security?” (0 = will certainly not harm my health/financial security and 10 = certain to harm my health/financial security) and “If you develop COVID-19/if the COVID-19 pandemic were harmful to your financial security, how serious do you think the harm would be?” (0 = not serious at all and 10 = as serious as it could possibly be). Each variable was modeled as the product of the two items which assessed perceived susceptibility and perceived severity respectively. Rumination was assessed using three 5-point Likert-scale items (e.g., “I can’t stop thinking about the COVID-19 pandemic;” 1 = strongly disagree, 5 = strongly agree). Co-rumination was also measured with three 5-point Likert scale items (e.g., “In any interaction I have, I am usually talking about the COVID-19 pandemic;” 1 = strongly disagree, 5 = strongly agree). Perceived social support was measured using the brief form of the Perceived Social Support Questionnaire (F-SozU K-6) [ 22 ] (e.g., “I receive a lot of understanding and security from others;” 1 = not true at all, 5 = very true). Perceived social strain was assessed by asking participants to first list the initials of up to seven people who typically provide them with support and then indicate how often in the past month each initial listed was a source of strain for them (e.g., making demands, criticizing you, letting you down, or getting on your nerves)” (1 = not at all, 5 = very often). The variable was computed by dividing the sum of perceived social strain for all listed initials by the number of initials listed.

Behavioral predictors . At each wave, participants were asked to indicate their adherence to national guidelines distributed nationally via postcard on March 16 (The President’s Coronavirus Guidelines for America, 2020) and the guideline issued by the CDC on April 3 on mask-wearing [ 1 ] in the past two weeks on a scale where 1 = not at all, 5 = completely with an additional “does not apply” option. Adherence was computed by averaging the score for all items where participants did not indicate “does not apply.” Coping strategy was measured using items (e.g., “Find activities to help me keep the event off my mind;” 1 = not at all, 7 = to a great extent) adapted from the Perceived Ability to Cope with Trauma (PACT) scale [ 23 ]. This scale assesses two general types of coping strategies: forward-focused, which has an optimistic focus on moving forward after the traumatic event, and trauma-focused, which focuses on processing the trauma. CFA results showed that three items had low factor loadings (i.e., <0.40). Dropping these items, the two-factor model reflecting the same structure as in [ 23 ] showed a good fit to the model: χ 2 = 290.34, df = 110, CFI = 0.95, RMSEA = 0.061 (90% CI [0.052, 0.070], SRMR = 0.05. A composite score was created for forward-focused strategy and trauma-focused strategy respectively by averaging the corresponding items.

Demographic predictors . Political orientation was assessed by asking participants to rate themselves on a scale ranging from 1 = extremely liberal to 7 = extremely conservative. Details of the other demographic predictors are provided in Table 2 . Employment status and COVID-19 symptoms and testing were measured at all waves. All other demographic predictors were measured once at Wave 1.

Simple Regression of Mental Health Outcomes on Demographic Predictors and Change in Demographic Predictors over Time.

Note . PTG = Posttraumatic growth. All coefficients are standardized. *** p < 0.001, ** p < 0.01, * p < 0.05. Ref = Reference group. Descriptive statistics with differing superscripts (i.e., a vs. b ) changed significantly in proportion, p < 0.05.

2.3. Statistical Analyses

Repeated measures ANOVAs were conducted to compare the mean scores of continuous predictors and outcomes across waves. Marginal homogeneity tests were used to examine the proportional change of categorical variables. Correlations were performed to assess relationships between variables across time points. A series of multiple linear regressions were conducted to assess the relationships between the psychosocial, behavioral, and demographic predictors and mental health outcomes. Standardized regression coefficients were reported. All analyses were performed in R [ 24 ], and p < 0.05 was employed as the threshold for statistical significance.

3.1. Mental Health Outcomes over Time

Table 3 summarizes the descriptive statistics for each subscale of the DASS-21 at all three waves and the PTGI at Wave 3, significant differences across waves (as compared using repeated measures ANOVA), and the bivariate correlations between these outcomes. Depression, anxiety, and stress were highly correlated with each other across all waves. PTGI was correlated with stress and anxiety at all three waves, but not depression. Stress at Wave 3 was significantly lower than stress at Wave 1 and Wave 2. Depression at Wave 2 and Wave 3 were both significantly lower than depression at Wave 1. Similarly, anxiety at Wave 2 and Wave 3 were also both significantly lower than anxiety at Wave 1. No other comparisons were significant. Compared with norms developed from prior research with DASS scales (for which it is recommended to multiply the DASS-21 scores by two) [ 19 ], participants, on average, scored in the normal range on stress (full scale range: 0–21) in all three waves. At Wave 1, 56.92% of the participants reported normal stress levels, 8.62% had mild stress, 11.85% had moderate stress, 14.10% had severe stress, and 9.40% had extremely severe stress. At Wave 2, 59.72% of the participants were at normal stress levels, 9.32% had mild stress, 12.32% had moderate stress, 10.90% had severe stress, and 7.74% had extremely severe stress. At Wave 3, 64.48% of the participants were in the normal range, 6.56% had mild stress, 12.44% had moderate stress, 11.54% had severe stress, and 4.98% had extremely severe stress. Participants reported moderate depression (full scale range: 0-21) at Wave 1 (with 44.37% normal scores, 8.23% having mild depression, 15.38% having moderate depression, 11.46% having severe depression, and 20.57% having extremely severe depression), which decreased to a milder level at Waves 2 and 3. Specifically, at Wave 2, 50.08% of the participants were in the normal range, 8.69% had mild depression, 15.17% had moderate depression, 10.27% had severe depression, and 15.80% had extremely severe depression; at Wave 3, 55.88% had normal levels, 7.92% had mild depression, 11.54% had moderate depression, 9.28% had severe depression, and 15.38% had extremely severe depression Participants also reported, on average, a moderate level of anxiety (full scale range: 0–21) at Wave 1 (with 48.38% normal, 6.86% mild anxiety, 10.38% moderate anxiety, 8.03% severe anxiety, and 26.34% with extremely severe anxiety), which then also decreased to milder levels at Waves 2 and 3. Specifically, at Wave 2, 57.82% of the participants were in the normal range, 4.11% had mild anxiety, 9.16% had moderate anxiety, 5.85% had severe anxiety, and 23.06% had extremely severe anxiety; at Wave 3, 62.44% were in the normal range, 3.85% had mild anxiety, 9.05% had moderate anxiety, 3.39% had severe anxiety, and 21.27% had extremely severe anxiety.

Means, Standard Deviations, and Bivariate Correlations of Mental Health Outcomes.

Note . PTG = Posttraumatic growth. *** p < 0.001, * p < 0.05. Stress, depression, and anxiety were Depression, Anxiety and Stress (DASS-21) subscales. Means with differing superscripts (i.e., a vs. b ) within each DASS-21 subscale are significantly different from each other, p < 0.05.

3.2. Changes in Predictors over Time

Table 4 and Table 5 present the descriptive statistics and bivariate correlations between all psychosocial predictors and all behavioral predictors, respectively. A series of repeated measures ANOVA were conducted to examine mean differences in the predictors assessed at multiple waves; these statistics are reported in Table 4 and Table 5 . A series of marginal homogeneity tests were performed to examine the proportional change in the demographic features assessed at multiple waves; these statistics are reported in Table 2 .

Means, Standard Deviations, and Bivariate Correlations of Psychosocial Predictors.

Note. HR = Perceived health risk; FR = Perceived financial risk; RM = Rumination; CRM = Co-rumination; PS = Perceived social support; Strain = Perceived social strain. *** p < 0.001, ** p < 0.01, * p < 0.05. Means with differing superscripts (i.e., a vs. b vs. c ) within each variable are significantly different from each other, p < 0.05. Reliability of each scale (italicized) is presented on the diagonal (NA = not applicable).

Bivariate Correlations among Behavioral Predictors.

Note. *** p < 0.001. Means with differing superscripts (i.e., a vs. b ) for the variable “adherence to national guidelines” are significantly different from each other, p < 0.05. Coping strategies were assessed at T3 only. Reliability of each scale (italicized) is presented on the diagonal (NA = not applicable).

Psychosocial predictors. Perceived risk to health did not change significantly across waves. Perceived financial risk was significantly lower at Waves 2 and 3 compared to Wave 1. Rumination at Wave 2 was significantly lower compared to rumination at Wave 1 and rumination at Wave 3 was also significantly lower than at Wave 2. Similarly, co-rumination decreased significantly across waves. Perceived support was significantly higher at Wave 3 than Wave 1, but did not differ from Wave 2. Social strain did not change significantly across time.

Behavioral predictors. Adherence to national guidelines was significantly lower at Wave 3 compared to that at Waves 1 and 2. The difference between Wave 1 and Wave 2 was not significant.

Employment. Results of the marginal homogeneity test suggested that there was a significant change in the proportion of participants’ employment status from Wave 1 to Waves 2 and 3. This significant global effect, however, could not be pinpointed to any specific categories as none of the post-hoc pairwise tests were significant. No significant change in proportion was observed from Wave 2 to 3 (see Table 2 for distribution across waves).

COVID-19 symptoms and testing. Results of the marginal homogeneity test showed that there was no significant change in the proportion of participants’ experience of COVID-19-consistent symptoms (i.e., yes vs. no vs. not sure) across waves (see Table 2 ). The proportion of participants’ testing of COVID-19, however, changed significantly from Wave 1 to Waves 2 and 3. Post-hoc pairwise comparison showed that there was a significant change from having not been tested for COVID-19 at Wave 1 to having tested negative for COVID-19 at Waves 2 and 3. No other pairwise comparison was significant. The global change in COVID-19 testing status from Wave 2 to 3 was non-significant (see Table 2 ).

3.3. Demographic Predictors of Mental Health Outcomes

Table 2 and Table 6 present the standardized coefficients from two sets of regression analyses involving the demographic predictors (see also Supplementary Materials Tables S1 and S2 for confidence interval of the coefficients). The first set of coefficients were obtained by regressing each demographic predictor separately on the mental health outcomes at each wave, and thus represent “zero-order” effects of these variables (see Table 2 ). The second set of coefficients were obtained with “full-predictor” analyses: simultaneously regressing all of the predictors (demographic, psychosocial, behavioral) on the outcomes at each wave, and thus determining the effects of each demographic variable controlling for all other predictors (see Table 6 ). Both were included for their value in comparing findings across studies that report zero-order demographic effects, and for identifying the strongest demographic effects.

Multiple Regression of Mental Health Outcomes on Demographic Predictors.

Note . PTG = Posttraumatic growth. All coefficients are standardized. *** p < 0.001, ** p < 0.01, * p < 0.05. Ref = Reference group.

Gender. The zero-order models showed that, compared to males, females experienced less stress and depression at Wave 1 and less anxiety at all waves, along with less post-traumatic growth. However, in the full-predictor model, the only significant finding was that females experienced more stress than males at Wave 2.

Age. In both analyses, age negatively predicted stress, depression, and anxiety at all three time points.

Race. In the zero-order models, compared to White participants, Asian participants reported greater stress, depression, and posttraumatic growth at Wave 3 and greater anxiety at all three waves. Participants who self-identified as more than one race reported greater depression at Waves 2 and 3 compared to White participants. In addition, participants who self-identified as Black or African-American reported greater posttraumatic growth compared to those who self-identified as White. In the full-predictor models, compared to White participants, participants who self-identified as Black or African-American reported less stress at Waves 2 and 3 and greater posttraumatic growth.

Ethnicity. In the zero-order analyses, participants who self-identified as Hispanic or Latino experienced greater anxiety at Wave 1 and posttraumatic growth at Wave 3 compared to non-Hispanic or Latino participants. In the full-predictor models, participants who self-identified as Hispanic or Latino experienced less stress and anxiety at Wave 2 and greater posttraumatic growth at Wave 3 compared to non-Hispanic or Latino participants.

Education. In the zero-order models, education was not a predictor of any outcomes, but in the full model, higher levels of education predicted greater anxiety at Wave 1.

Region . In the zero-order models, compared to people residing in the northeast region, Midwest residents reported less depression at Wave 2, less stress at Waves 1 and 2, and less anxiety at all three time points. However, in the full-predictor models, region of residence did not predict any mental health outcomes.

Political party and orientation . In the zero-order models, at Wave 1, participants who self-identified as Democrat or Independent reported less depression, and Independents also reported less stress compared to those who strongly identified with the Republican Party. Democratic-leaning Independents and Republican-leaning Independents both reported less anxiety than strong Republicans. At Wave 2, Republican-leaning Independents again reported less anxiety than strong Republicans. Participants who were more conservative reported lower levels of depression at Wave 1 and lower levels of anxiety, depression, and stress at Wave 2. In the full-predictor models, there were fewer effects for political party or orientation. At Wave 2, participants who self-identified as Republicans reported greater stress and anxiety compared to Democrats. Participants who self-identified as Independents also reported greater stress at Wave 2 compared to Democrats. Participants who were more conservative also reported lower levels of stress and anxiety at Wave 2 and greater posttraumatic growth at Wave 3.

Pre-existing health conditions. In the zero-order analysis, individuals who had more pre-existing health conditions reported greater stress, anxiety, and depression at all three Waves. These effects all persisted in the full-predictor models.

COVID-19 symptoms and testing. In the zero-order models, compared to those who did not have any symptoms consistent with COVID-19, those who experienced COVID-19-consistent symptoms showed greater anxiety, depression, and stress at all waves. This group also reported greater posttraumatic growth. People who were unsure if they had symptoms consistent with COVID-19 also scored higher on all three DASS-21 subscales except stress at Wave 2. This group, however, reported less posttraumatic growth compared to people who did have any COVID-19-consistent symptoms. Different effects emerged in the full-predictor models. At Wave 1, participants who reported having tested negative for COVID-19 reported greater anxiety compared to those who had not tested for COVID-19. They also reported comparatively greater posttraumatic growth at Wave 3.

Employment. In the zero-order models, compared to people who were unemployed prior to the pandemic, those who reported being full-time employed by someone else scored higher on all mental health outcomes. People who reported being part-time employed by someone else also reported greater stress and anxiety at Wave 1. Those who were full-time employed reported higher levels of stress, depression, and anxiety at Wave 1 as well as higher levels of posttraumatic growth at Wave 3. People who were laid off, furloughed, or otherwise unemployed due to COVID-19 experienced greater stress at Wave 1. In the full-predictor models, two effects persisted: compared to people who were unemployed prior to the pandemic, those who reported being full-time employed by someone else or full-time self-employed scored higher on posttraumatic growth.

3.4. Psychosocial and Behavioral Predictors of Mental Health Outcomes

Table 7 presents the standardized coefficients for each psychosocial and behavioral predictor from the “full-predictor” analyses for each Wave (see also Supplementary Materials Table S3 for confidence interval of the coefficients). In these analyses, all predictors (demographic, psychosocial, behavioral) were simultaneously regressed on the outcomes, thus assessing the effects of each predictor controlling for all other predictors. For predictors assessed at multiple waves, regression analyses were conducted with wave-specific predictors (e.g., Wave 1 mental health outcomes were regressed on Wave 1 assessments of risk, rumination, social support, etc., whereas Wave 2 mental health outcomes were regressed on Wave 2 assessments).

Regression of Mental Health Outcomes on Psychosocial and Behavioral Predictors.

Note . PTG = Posttraumatic growth. All coefficients are standardized. *** p < 0.001, ** p < 0.01, * p < 0.05.

Results showed that perceived health risk positively predicted anxiety at Waves 1 and 2. Perceived financial risk positively predicted stress at all three times and depression at Wave 3. Rumination positively predicted stress and depression at all waves. Co-rumination positively predicted stress at Wave 1 and stress, depression, and anxiety at Wave 2. Perceived social support negatively predicted depression at all times and stress at Wave 3. Perceived social strain positively predicted stress, depression, and anxiety at all three waves. Posttraumatic growth was positively predicted by perceived health risk, perceived social support, and perceived social strain. Adherence to national guidelines negatively predicted stress at all three times and anxiety at Wave 1. Use of the forward-focused coping strategy negatively predicted depression at all three waves and stress at Wave 2 and positively predicted posttraumatic growth. Use of trauma-focused coping strategy positively predicted depression at Time 1 and posttraumatic growth.

4. Discussion

The current study examined the impact of COVID-19 and related events on mental health in the U.S. general public during April and May 2020. The average impact during this period appears to have been modest at the start, and trended downward over time. Symptoms of stress, anxiety, and depression were highest at Wave 1 (data collected April 20, or approximately one month into the US-based experience of the pandemic) and declined over the two remaining waves, with stress remaining in the “normal” range of the DASS throughout, and anxiety and depression falling from “moderate” to “mild” levels. Although these findings diverge somewhat from polls suggesting slightly higher levels of stress, anxiety, or depression during the survey period, this divergence is likely to reflect the distinction between the type and number of items used for public polling (e.g., “In the past seven days, have you felt anxiety, depression, loneliness or hopelessness?” [ 25 ]) and the DASS-21’s more conservative, symptom-based assessment. At the same time, despite averages in the normal range and the downward trends across waves, substantial percentages of our participants reported experiencing severe or extremely severe symptoms, particularly of depression and anxiety. These findings align with reports from other countries [ 14 , 15 , 16 , 17 ] and with the concerns of mental health professionals [ 2 , 3 , 4 , 5 ]; they also underscore the value of examining the predictors of mental distress during the pandemic.

4.1. Demographic Factors

The strongest, most consistent demographic effects on mental health came from pre-existing health conditions and age. The influence of pre-existing health conditions is unsurprising, given that COVID-19 was recognized very quickly as more likely to be severe or deadly for those with such conditions, and warnings to this effect were incorporated in the national public health guidelines. Despite the association between age and COVID-19 mortality, greater age was associated with less stress, depression, and anxiety, in both zero-order and full-predictor models. This finding is likely to reflect the relationship between age and emotional stability [ 26 ], along with ways in which the negative impact of COVID-19 was especially strong for younger people (e.g., colleges closed, part-time and “gig” work affected, lower likelihood of savings or health insurance to rely on, social and entertainment opportunities constricted; [ 27 , 28 , 29 ]). It is also consistent with research showing greater anxiety and depression in younger Chinese experiencing the pandemic [ 10 ].

Strikingly, race and ethnicity did not have strong or consistent effects on mental health, and the effects that emerged included greater post-traumatic growth for Black and Hispanic/Latino populations. However, the data collection predated both the eruption of Black Lives Matter protests following the death of George Floyd (May 25), and the emergence of data indicating that COVID-19 was disproportionately affecting communities of color [ 30 ]. From a present-day perspective, it is also striking that differences owing to political identification were relatively weak and inconsistent across outcomes, but a muted influence of political party aligns with data collection in April and May, prior to heightened politicization of the management and impact of reopening, and prior to the significant upturn in U.S. COVID-19 cases and deaths that occurred after an initial “flattening of the curve” [ 31 ]. It will be important that subsequent studies continue to examine how key demographic factors are associated with mental health as the pandemic’s impact continues to be felt.

4.2. Psychosocial and Behavioral Factors

Generalizing across the findings, it is clear that mental health outcomes for the general public in the U.S. were influenced by psychosocial and behavioral factors. Collectively, these findings are consistent with research on past pandemics and research from China and elsewhere on COVID-19, indicating that mental health during and after a pandemic is influenced by perceived risk, threat, and fear associated with the disease [ 32 , 33 , 34 ], rumination and co-rumination [ 35 ], social support [ 32 ], coping behaviors [ 36 ], and health-protective behaviors [ 12 ].

It is also the case that the various psychosocial and behavioral factors we assessed predicted different mental health outcomes in differing ways, despite strong correlations between stress, anxiety, and depression. For example, perceived health risk predicted anxiety at Waves 1 and 2, along with post-traumatic growth at Wave 3, but did not predict stress or depression, whereas perceived financial risk predicted stress but not anxiety or post-traumatic growth, and only predicted depression at Wave 3. These findings are interpretable with regard to the uncertainty associated with these types of risk—susceptibility to the health risk of COVID-19 is fraught with uncertainty, which generates anxiety about the future, whereas some type of financial risk or harm from COVID-19 is already a reality for many people, thus contributing to stress rather than anxiety. The minimal influence of risk perceptions on depression observed in this study differs from recently-released research with COVID-19 healthcare workers in Turkey [ 34 ], but this difference may be a function of lower risk perceptions (on average) in a general-public sample, or insufficient duration of perceived risk to generate depression; research on the SARS pandemic suggests that depression is related to risk perceptions over a longer span of time [ 32 ].

Ruminating about COVID-19 was associated with stress and depression across all three waves. These findings align with the negative effects of rumination in regard to other stressors, including natural disasters [ 37 , 38 ], and with recent research from Turkey showing that rumination about COVID-19 had a negative impact on well-being [ 33 ]. Co-rumination predicted stress at Waves 1 and 2, and anxiety and depression at Wave 2, but was no longer predictive of any mental health outcomes at Wave 3. This pattern of results has no clear explanation, but may be related to the average decline in co-rumination over time, or to changes in the content of conversations related to COVID-19 (e.g., conversations about the pandemic may have focused on more neutral or positive topics). Co-rumination deserves further research attention as the pandemic progresses, insofar as repetitive and non-productive discussion of shared stressors generally exacerbates mental health issues [ 37 ] but this phenomenon has been most frequently studied in child and young adult populations [ 39 ].

Capturing the extent to which one perceives being supported by others, perceived social support was consistently and negatively associated with depression (and with stress at Wave 3), and positively associated with post-traumatic growth. This observation is consistent with a huge volume of evidence that perceiving others as available to provide support and assistance buffers the negative health impacts of stressful events (including natural disasters [ 40 ]), and promotes viewing those events as positive in various ways [ 41 ]. Indeed, research with Chinese college students documents a positive influence of support on anxiety related to COVID-19 [ 8 ]. In counterpoint to the beneficial effects of social support, social strain (which included making demands, criticizing, letting down, and getting on one’s nerves) was the strongest and most consistent predictor of health outcomes across waves, correlated with heightened stress, anxiety, and depression, and with post-traumatic growth (albeit more weakly). The negative impact of social strain on mental health is well-documented in other contexts [ 42 ], but deserves continued focus in the wake of COVID-19, given the probability that strain is heightened under stay-at-home orders that simultaneously create unwanted togetherness with some (i.e., co-residents) and distance from others.

Forward-focused coping, including behaviors such as looking for a silver lining, distracting attention from the event and its associated emotions, and following a regular schedule and engaging in enjoyable activities, was protective against depression at all waves (and stress at Wave 2), whereas trauma-focused coping was positively associated with depression at Wave 1. Both types of coping were positively associated with post-traumatic growth at Wave 3. The demonstrated value of forward-focused coping aligns with research on people quarantined in Spain [ 36 ], showing efforts to sustain a healthy lifestyle (e.g., balanced diet, maintaining routines, time outdoors, avoiding COVID-19 news) were protective against anxiety and depression. The inconsistent effect of trauma-focused coping is not unexpected given the evidence that the effect of trauma-focused coping changes over time [ 43 ]. In the context of COVID-19, it is possible that effortful processing of the pandemic at the initial stages where it was characterized with high novelty and uncertainty was particularly overwhelming and thus depression-inducing. Over time, however, as it became increasingly normal to cognitively process the trauma, the negative effect might have begun to fade.

Adherence to national guidelines predicted reduced stress across all three waves, and anxiety at Wave 1. This finding is consistent with research indicating that Chinese individuals who adopted precautionary measures such as hand-washing experienced less stress, anxiety, and depression [ 12 ]. More broadly, it indicates that taking principled action to protect physical health from risk is also beneficial to mental health.

5. Limitations

This study has several limitations. Budget constraints motivated our use of Qualtrics.com, which provides national U.S. samples that tend to be representative demographically and politically, but are not random [ 44 ]. Our findings may thus reflect biases in our sample. In addition, our sample was diminished by attrition across waves, especially between Wave 1 and Wave 2, and we were unable to measure all constructs at all waves. The data were collected during April and May of 2020, but we do not know if the relationships observed will be stable as the pandemic proceeds and new developments occur, including a rising death toll in the U.S. Lastly, as the data did not contain any pre-pandemic baseline measures, we were not able to establish any causal relationship between the COVID-19 pandemic and the mental health outcomes.

6. Conclusions

Limitations notwithstanding, our findings suggest that the early months of the U.S.’ experience of the pandemic were characterized by a modest mental health impact in the general public, an effect that was more pronounced for younger people and those with pre-existing health conditions, and for those experiencing greater perceived risk, higher levels of rumination or co-rumination, less social support, and greater social strain. More positive mental health was associated with the adoption of coping strategies, especially those that were forward-looking, and with greater adherence to national health-protection guidelines.

It is important to note that our Wave 3 data collection coincided with the leveling-off or decline in reported COVID-19 cases and deaths in many states in mid-May [ 45 ], and with states “reopening,” or announcing plans for reopening [ 46 ]. As such, lowering levels of mental distress may help explain increasingly less cautious behavior exhibited by the American public between mid-May and the present [ 47 ] insofar as people who are less stressed or anxious about COVID-19 are likely to undertake fewer health-protective measures [ 48 ]. Unfortunately, with early efforts to “flatten the curve” largely abandoned and exponential growth occurring in many states (as of August, 2020), it seems probable that the US was both insufficiently stressed in March and April to promote long-term health-protective attitudes, and that there will be as-yet-determined mental health effects associated with COVID-19 illness, death, job loss, and renewed efforts to contain the spread.

As the pandemic continues, our study suggests that public health interventions can be focused on heightening perceived health risk [ 49 ], promoting adherence to health-protective guidelines such as mask-wearing [ 50 ], discouraging non-productive rumination and co-rumination [ 51 ], encouraging social support and reducing social strain [ 52 ], and guiding on healthy coping strategies that focus on the future [ 53 ]. This will be no easy task, and one that will require coordinated, sustained efforts from all areas of society.

Supplementary Materials

The confidence interval for all standardized coefficients from the regression models is available as Supplementary Materials. The following are available online at https://www.mdpi.com/1660-4601/17/17/6315/s1 , Table S1: 95% Confidence Interval for Standardized Coefficients from Simple Regression of Mental Health Outcomes on Demographic Predictors, Table S2: 95% Confidence Interval for Standardized Coefficients from Multiple Regression of Mental Health Outcomes on Demographic Predictors, Table S3: 95% Confidence Interval for Standardized Coefficients from Regression of Mental Health Outcomes on Psychosocial and Behavioral Predictors.

Author Contributions

Conceptualization, E.L.M., J.G.M., and Y.Z.; formal analysis, Y.Z.; writing—original draft preparation, E.L.M. and Y.Z.; writing—review and editing, J.G.M.; funding acquisition: E.L.M. All authors have read and agreed to the published version of the manuscript.

This research was funded by the Department of Communication Arts & Sciences at the Pennsylvania State University.

Conflicts of Interest

The authors declare no conflict of interest.