Trends In Anxiety And Depression Symptoms During The Covid 19 Pandemic Results From The U.S. Census Bureau S Household Pul
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A research letter by Cai et al., Trends in Anxiety and Depression Symptoms During the COVID-19 Pandemic: Results from the US Census Bureau's Household Pulse Survey, published in J Gen Intern Med 36(6):1841–3 and online April 14, 2021. The authors analyzed the Household Pulse Survey conducted between April 23 and July 21, 2020, using modified PHQ-2 and GAD-2 screening questionnaires. Of 1,088,314 non-unique respondents, 988,349 were included, and positive screenings for depression, anxiety or either rose from 35.9 to 40.9% over the study period. A table reports changes by sex, age, education, race, 2019 family income and state COVID infection rate, and the letter discusses limitations of the modified questionnaires and single-week incidence measure.
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“Trends In Anxiety And Depression Symptoms During The Covid 19 Pandemic Results From The U.S. Census Bureau S Household Pul.”
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Trends in Anxiety and Depression Symptoms
During the COVID-19 Pandemic: Results from the US Census
Bureau’s Household Pulse Survey
KEYWORDS: COVID-19; anxiety; depression; mental health. and assessed differences between subgroups using regressions
J Gen Intern Med 36(6):1841–3
adjusted for a week indicator, a subgroup indicator, and a
DOI: 10.1007/s11606-021-06759-9 week*subgroup interaction term (Linear probability regres-
© Society of General Internal Medicine 2021 sion was chosen to facilitate interpretation of interaction
terms). Subgroups included respondent race/ethnicity (non-
Hispanic White, non-Hispanic Black, Hispanic, non-
BACKGROUND Hispanic Asian, other), sex (male, female), family income
In the first month of the US COVID-19 epidemic, the preva- (<$25,000; $25,000-$50,000, $50,000-$100,000,
lence of depressive symptoms was higher than that in 2017– $100,000+), education (less than high school, high school,
2018 1. No studies have elucidated trends in the prevalence of some college, or more), age in categories, and quintile of
depression and anxiety later in the pandemic. state-level COVID-19 incidence (measured by the 7-day mov-
ing average of new cases/100,000 on July 21 2020 3). For all
analyses, we used Stata 16.1, sample weights from the Census
OBJECTIVE Bureau to generate nationally representative estimates, and
replicate weights to calculate standard errors.
To describe trends in the proportion of the US population for
whom screening questionnaires indicate a high likelihood of
depression or anxiety symptoms during the spring and sum-
mer of 2020. RESULTS
Of the 1,088,314 non-unique respondents to the survey,
988,349 (90.8%) completed the anxiety and depression
METHODS screenings and were included in the study. Included partici-
pants had a mean age of 48.4 years and 51.5% were female.
We analyzed the Census Bureau’s Household Pulse Survey, a
Figure 1 shows week-to-week trends in positive screenings
nationally representative survey of adults conducted between
for depression, anxiety, or either, which rose from 35.9 to
April 23 and July 21, 2020. The survey was administered to
40.9% over the study period (p<0.001).
twelve samples covering about 13 weeks; households were
Table 1 provides week 1–2 and week 13 estimates by
interviewed for up to three consecutive weeks. Respondents
subgroup. At both time points, women, younger individuals,
completed a version of the Patient Health Questionnaire (PHQ-
racial/ethnic minorities, those with less education, and persons
2) and Generalized Anxiety Disorder (GAD-2) questionnaires,
with lower incomes experienced higher rates of a positive
both modified to assess the frequency of symptoms over one
screen for depression/anxiety. Table 1 provides adjusted
week rather than two. For both, a score of 3 indicates a high
difference-in-difference estimates. Men had a larger increase
probability of the disorder when used in an outpatient setting 2.
in depression/anxiety than women (2.1 percentage points,
Weighted response rates ranged from 1.3 to 3.8% by week.
95% CI 2.0, 2.2), as did individuals with family incomes
We conducted repeated cross-sectional analyses with-
$25,000–$50,000 relative to those with incomes ≥$100,000
out linkage of individuals across sample weeks, and
(4.2 percentage points, 95% CI 1.8, 6.6). Individuals living in
tabulated the proportion of respondents with PHQ-2 or
states with higher recent COVID incidence experienced larger
GAD-2 score ≥3 in each survey week (hereinafter those
increases in depression/anxiety relative to those in the lowest
with “positive screenings” for depression or anxiety).
incidence quintile (p<0.001 for each comparison).
We analyzed changes in prevalence from the first to the
final week in our sample using linear probability regressions,
Prior Presentations: None DISCUSSION
Received February 1, 2021
Accepted March 23, 2021 A substantial and rising share of the US population had
Published online April 14, 2021
positive screening tests for anxiety and depression symptoms
1841
1842 Cai et al.: Trends in Anxiety/Depression Symptoms During COVID-19 JGIM
Figure 1 “PHQ-2”=modified 2-item Patient Health Questionnaire. “GAD-2”=modified 2-item General Anxiety Disorder questionnaire.
N=988,349. Depression/Anxiety Symptoms Rose During the COVID-19 Pandemic.
during the spring and summer of 2020, amounting to 11.6 period. Although differential rates of increase between sub-
million more adults with mood symptoms over our study groups were modest, these results suggest a prevalence of
Table 1 Positive Screening for Anxiety Was Defined as a Score of 3 or Higher on a Modified General Anxiety Disorder-2 (GAD-2)
Questionnaire. DiD Difference in Difference. Positive Screening for Depression Was Defined as a Score of 3 or Higher on a Modified Patient
Health Questionaire-2 (PHQ-2). *n=939,936. †COVID Per-Capita Infection Rate Was Calculated for Each State by Taking the Center for
Disease Control’s 7-day Average of New COVID Cases as of July 21st (the Last Day of the Study Period) Divided by the State’s 2019
Population. Survey Respondents Were Then Divided into Quintiles Based on These Infection Rates
Prevalence of positive screening for anxiety or depression
Unadjusted results Adjusted results
April 23–May 5, 2020 July 16–July 21, 2020 Absolute change (95% CI) p value DiD estimate (95% CI) p
All respondents n=988,349
35.9 40.9 5.0 (4.6, 5.4) <0.001 NA NA
Sex
Male 31.0 37.0 6.1 (5.7,6.5) <0.001 Reference –
Female 40.7 44.6 4.0 (3.4,4.5) <0.001 −2.1 (−2.2, −2.0) <0.001
Age
18–44 41.9 49.3 7.5 (7.4,7.5) <0.001 3.6 (3.6,3.7) <0.001
45–65 35.7 39.5 3.8 (3.8,3.9) 0.001 Reference –
65+ 23.6 25.4 1.8 (−0.30,3.9) 0.09 −2.0 (−4.0,.1) 0.06
Education
<HS 45.4 47.3 2.0 (−0.40,4.3) 0.10 −2.9 (−5.4, −.38) 0.02
HS 36.7 42.2 5.5 (4.0,7.1) <.001 .6 (−.68 , 2.0) 0.34
Some college 34.5 39.4 4.9 (4.7,5.1) <.001 Reference –
Race
Non-Hispanic 33.6 38.8 5.3 (4.5,6.1) <0.001 Reference –
White
Non-Hispanic 38.9 42.6 3.8 (3.2,4.4) <0.001 −1.5 (−2.9, −.10) 0.04
Black
Non-Hispanic 31.9 40.3 8.4 (2.5,14.3) 0.006 3.1 (−2.0,8.2) 0.23
Asian
Non-Hispanic 43.9 48.8 4.9 (3.5,6.3) <0.001 −.4 (−.98,.17) 0.16
Other
Hispanic 42.7 46.3 3.6 (1.4,5.8) 0.002 −1.7 (−4.7,1.4) 0.28
2019 family income *
<$25K 51.0 54.1 3.1 (0.70,5.4) 0.01 −1.0 (−3.9, 1.9) 0.52
$25K–50K 38.9 47.1 8.2 (6.4,10.1) <0.001 4.2 (1.8,6.6) 0.001
$50K–100K 34.3 37.7 3.4 (2.8,4.0) <0.001 −0.62 (−0.65, −0.59) <0.001
$100K + 26.8 30.8 4.0 (3.5,4.6) <0.001 Reference –
COVID infection rate in state†
Lowest quintile 38.4 37.7 −0.7 (−1.4, −0.02) 0.04 Reference –
Quintile 2 35.3 41.1 5.8 (5.2,6.4) <.001 6.5 (6.4,6.6) <0.001
Quintile 3 35.1 41.0 5.9 (4.2,7.6) <.001 6.6 (4.2,9.0) <0.001
Quintile 4 34.8 44.2 9.4 (9.4,9.5) <.001 10.1 (9.4,10.9) <0.001
Highest quintile 35.8 42.2 6.4 (5.2,7.6) <.001 7.1 (5.2, 9.0) <0.001
JGIM Cai et al.: Trends in Anxiety/Depression Symptoms During COVID-19 1843
2
depression/anxiety symptoms over three times that of 2019 Harvard Medical School, Cambridge Health Alliance,
baseline data 4. Cambridge, MA, USA
3
Our study has limitations. Since the modified questionnaires City University of New York at Hunter College,
New York, USA
in our study assessed for symptoms over one week rather than
two, the sensitivities are likely higher and the specificities lower Corresponding Author: Christopher Cai, BA; University of Califor-
than the traditional PHQ-2 and GAD-2. Compositional changes nia San Francisco (UCSF) School of Medicine, San Francisco, CA, USA
(e-mail: chrislcai@gmail.com).
in the survey sample or confounding events (such as reactions Declarations:
to the murder of George Floyd or the federal election) could
contribute to observed trends. Our finding on the effect of Conflict of Interest: The authors declare that they do not have a
conflict of interest.
COVID-19 rates rests on incidence over a single week. Finally,
seasonal variation in mood is a potential concern; however,
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