Mental Distress in the United States at the
Beginning of the COVID-19 Pandemic
Calliope Holingue, PhD, MPH, Luther G. Kalb, PhD, Kira E. Riehm, MSc, Daniel Bennett, PhD, Arie Kapteyn, PhD, Cindy B. Veldhuis, PhD,
Renee M. Johnson, PhD, MPH, M. Daniele Fallin, PhD, Frauke Kreuter, PhD, Elizabeth A. Stuart, PhD, and Johannes Thrul, PhD
Objectives. To assess the impact of the COVID-19 pandemic on mental distress in US
adults.
Methods. Participants were 5065 adults from the Understanding America Study, a
probability-based Internet panel representative of the US adult population. The main
exposure was survey completion date (March 10–16, XXXXXXXXXXThe outcome was mental
distress measured via the 4-item version of the Patient Health Questionnaire.
Results.Among stateswith 50 ormore COVID-19 cases as ofMarch 10, each additional
day was significantly associated with an 11% increase in the odds of moving up a
category of distress (odds ratio = 1.11; 95% confidence interval = 1.01, 1.21; P = .02).
Perceptions about the likelihood of getting infected, death from the virus, and steps taken
to avoid infecting others were associated with increased mental distress in the model
that included all states. Individuals with higher consumption of alcohol or cannabis o
with history of depressive symptomswere at significantly higher risk for mental distress.
Conclusions. These data suggest that as the COVID-19 pandemic continues, mental distress
may continue to increase and should be regularly monitored. Specific populations are
at high risk for mental distress, particularly those with preexisting depressive symp-
toms. (Am J Public Health. 2020;110:1628–1634. https:
doi.org/10.2105/AJPH.
XXXXXXXXXX)
See also Cable, p. 1595.
The United States has entered a newhistorical phase with the rapid spread of
the novel coronavirus SARS-CoV-2 and
deaths from COVID-19. Data from China
suggest that the mental health impacts of
COVID-19 are severe.1 Thus far, there are
little data on the mental health impact of the
pandemic in the United States. This infor-
mation is critical, as there is a robust literature
on how public health crises, such as SARS o
natural disasters, can lead to mental health
challenges, including symptoms of acute
stress, loneliness, anxiety, and depression.2
Social distancing recommendations may
further increase the likelihood of mental
health symptoms, because isolation is known
to have detrimental mental health effects.3
Early findings from China indicate
the serious mental health impact of the
COVID-19 pandemic. In one survey with
1210 participants conducted in January and
Fe
uary 2020, 54% rated the psychological
impact of the COVID-19 pandemic as
moderate to severe, 29% reported moderate-
to-severe anxiety symptoms, 17% reported
moderate-to-severe depressive symptoms,
and 8% reported moderate-to-severe stress
levels.1 Another survey with XXXXXXXXXXrespon-
dents in January and Fe
uary 2020 reported
that almost 35% of the sample experienced
psychological distress.4 This study also found
egional differences in psychological distress,
with respondents from Hubei province, the
epicenter of the COVID-19 pandemic,
eporting significantly higher distress.
Moreover, people with preexisting mental
disorders could be more heavily affected by
the COVID-19 pandemic, including possi-
le relapse or exace
ation of psychiatric
conditions.5
There are marked mental health disparities
in the United States that are likely to be
exace
ated by this pandemic. For example,
serious mental distress is more common in
women and in those who are uninsured and is
often como
id with chronic somatic con-
ditions.6 In addition, those in higher income
ackets have lower rates of serious mental
distress.6 Existing research has linked eco-
nomic hardship with the incidence7 and
progression8 of mental disorders. Difficulty
withfinances not only contributes to stress but
also is a leading ba
ier to receiving mental
health and substance use disorder treatment.9
The COVID-19 pandemic has become
intertwined with an economic crisis and has
esulted in widespread job loss and economic
downturn.10 Information is needed to un-
derstand how shifting labormarket outcomes,
secondary to the COVID-19 pandemic, are
potentially exace
ating mental health dis-
parities across the United States. Research
from China has already demonstrated that
college students whose families had less stable
incomes were at increased risk of mental
distress because of COVID-19.11
ABOUT THE AUTHORS
Calliope Holingue and Luther G. Kalb are with the Department of Neuropsychology, Kennedy Krieger Institute, Baltimore,
MD.Kira E.Riehm,ReneeM. Johnson,M.Daniele Fallin, ElizabethA. Stuart, and JohannesThrul are with theDepartment
of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Daniel Bennett and Arie Kapteyn are
with the Center for Economic and Social Research, University of Southern California, Los Angeles. Cindy B. Veldhuis is with
the School of Nursing, Columbia University, New York, NY. Frauke Kreuter is with the Maryland Population Research
Center, University of Maryland, College Park.
Co
espondence should be sent to Calliope Holingue, MPH, PhD, Office 3050A, Kennedy Krieger Institute, 1750 E
Fairmount Ave, Baltimore, MD XXXXXXXXXXe-mail: XXXXXXXXXX). Reprints can be ordered at http:
www.ajph
.org by clicking on the “Reprints” link.
This article was accepted June 21, 2020.
https:
doi.org/10.2105/AJPH XXXXXXXXXX
1628 Research Peer Reviewed Holingue et al. AJPH November 2020, Vol 110, No. 11
AJPH COVID-19
https:
doi.org/10.2105/AJPH XXXXXXXXXX
https:
doi.org/10.2105/AJPH XXXXXXXXXX
mailto: XXXXXXXXXX
http:
www.ajph.org
http:
www.ajph.org
https:
doi.org/10.2105/AJPH XXXXXXXXXX
The social isolation, financial hardship, and
fear associatedwithCOVID-19 could present
a perfect storm for public mental health in the
United States. Data are needed to track the
impact of the COVID-19 pandemic on
mental health, including identifying those
in greatest need, to serve as evidence-based
information for the public and to marshal
esources across local, state, and federal
agencies. The cu
ent study addresses this
need by examining predictors of mental
distress in a nationally representative house-
hold panel during a period of rapid spread of
COVID-19 in the United States.
METHODS
Data for this project came from the
Understanding America Study (UAS), a
probability-based Internet panel recruited via
postal mailings. Eligible participants were
selected based on a random selection of ad-
dresses drawn from the post office delivery
sequence files via a commercial vendor.12
The initial panel intake survey includes an
age screening; eligible individuals are all adults
aged 18 years and older in the contacted
household. The UAS panel consists cu
ently
of 11 nationally representative sample
atches, rolled into the panel between 2014
and 2019. The cu
ent analysis used early
elease (March 17, 2020) data from the UAS
230 wave, which was fielded betweenMarch
10 andMarch 16.Thisweek of data collection
paralleled the declaration of COVID-19 as a
pandemic by theWorldHealthOrganization,
of a national emergency by the president of
theUnited States, and the beginning of school
and work closures and social distancing
ecommendations.
All active respondents of the UAS were
selected for participation, except Spanish
speakers. As such, this survey was made
available to 8502 UAS participants. Of the
8502 invited participants, 5325 completed the
survey and were counted as respondents
(overall response rate of 63%). Of those who
were not counted as respondents, 89 started
the survey without completing, and 3088
did not start the survey.
Survey weights for UAS account fo
probabilities of sample selection and align-
ment to Cu
ent Population Survey bench-
marks, along socioeconomic dimensions,
gender (male or female), race and ethnicity
(White, Black, other, Hispanic), age (18–39,
40–49, 50–59, and ‡ 60 years), education
(high school or less, some college, or bach-
elor’s degree or more), Census regions
(Northeast, Midwest, South, or West), and
fraction of Native Americans. The reference
population considered for the weights is the
US population of adults aged 18 years and
older. More information about UAS can be
found at https:
uasdata.usc.edu/index.php,
and specific information about the UAS 230
survey is at https:
uasdata.usc.edu/page
COVID-19+Corona+Virus.Weused survey
weights in all analyses.
Measures
Mental distress and substance use. The pri-
mary outcome measure of interest was the
4-item version of the Patient Health Ques-
tionnaire (PHQ-4), which has been validated
in the general population.13 This measure asks
about the frequency of being bothered by
feelings of nervousness, wo
y, depression, and
loss of interest over the past 2 weeks. Response
options include not at all (0), several days (1),
more than half the days (2), and nearly every
day (3). The total score is determined by add-
ing the scores of each of the 4 items. Scores
are categorized as normal (0–2), mild (3–5),
moderate (6–8), or severe (9–12). A score of 3
or higher for the first 2 items suggests anxiety,
while a score of 3 or higher on the last 2 items
suggests depression.14 In an earlier wave of
data collection, participants completed the
8-item version of the Center for Epidemio-
logic Studies–Depression Scale (CES-D 8).15
We used the number of symptoms a respon-
dent previously endorsed as occu
ing “much
of the time” in the past week as a measure of
historical depressive symptoms. The most re-
cent CES-D 8 was used for participants who
had multiple CES-D 8 scores from previous
waves (49% of sample had CES-D 8 score
from June 2019, 32% from June 2017, and
19% from May 2015).
COVID-19 items. Respondents were
asked to provide their best estimate of the
chance (0%–100%) that they would become
infected with COVID-19 in the next 3
months and that they would die if infected.
We classified individuals as having a per-
ception of 0%, 1% to 50%, or greater than 50%
for both of these questions. We used the
category of 0% as the reference group because
these variables were zero-inflated.
Participants were also asked whether they
had “taken any steps to stay away from othe
people to avoid infecting them.” Response
options were yes, no, and unsure. The survey
start date (between March 10 and March 16)
was used to assess whether calendar time was
associated with mental distress.
Other variables. Sociodemographic factors
included gender (female or male), age
(years), race/ethnicity (White, American
Indian or Alaska Native, Asian, Black o
African American, Hawaiian or Pacific Is-
lander, Hispanic or Latino, or multiracial),
education (high-school degree or below,
attended some college or received a 2-yea
degree, bachelor’s degree, or graduate de-
gree), marital status (ma
ied, never ma
ied,
separated or divorced, or widowed); house-
hold income (< $20 000, $20 000–$39 999,
$40 000–$59 999, $60 000–$99 999, o
‡ $100 000), and cu
ently have a job (yes
or no). Lastly, participants were asked to
estimate the number of days on which they
consumed alcohol and number of days on
which they consumed cannabis, both ove
the past week.
High- and low-count states. We classified
states according towhether they had a high o
low count of confirmed cases of COVID-19
as of March 10, 2020, the first