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Clinical Context

The prevalence of depression among US adults increased approximately 3-fold during the COVID-19 pandemic. Similar reports have been published in other countries, and higher rates of depression have been documented among special populations, such as children and healthcare workers. One study found a global prevalence of depression of 33.7% in May 2020 across a diverse collection of nations.^[1]

The authors of the current study noted that the current increases in the prevalence of depression have reached a greater magnitude compared with previous estimations of increases after large traumatic events such as Hurricane Ike and the Ebola outbreak in West Africa. At the same time, the wave of depression associated with COVID-19 is not uniform. Persons reporting higher levels of economic stress during the pandemic have a higher risk for depression.

The current study by Ettman and colleagues evaluates the prevalence of depressive symptoms over the first year of the pandemic and sociodemographic influences on these symptoms.

Study Synopsis and Perspective

A year into the COVID-19 pandemic, the share of the US adult population reporting symptoms of elevated depression had more than tripled from prepandemic levels and worsened significantly since restrictions went into effect, a study of more than 1000 adults surveyed at the start of the pandemic and 1 year into it has reported.

The study also found that younger adults, people with lower incomes and savings, unmarried people, and individuals exposed to multiple stress factors were most vulnerable to elevated levels of depression through the first year of the pandemic.

“The pandemic has been an ongoing exposure,” lead author Catherine K. Ettman, a PhD candidate at Brown University, Providence, Rhode Island, said in an interview.

“Mental health is sensitive to economic and social conditions. While living conditions have improved for some people over the last 12 months, the pandemic has been disruptive to life and economic well-being for many,” said Ms. Ettman, who is also chief of staff and director of strategic initiatives in the office of the dean at Boston University, Boston, Massachusetts. Her study was published in Lancet Regional Health – Americas.^[2]

Ettman and coauthors reported that 32.8% (95% CI: 29.1%, 36.8%) of surveyed adults had elevated depressive symptoms in 2021 compared with 27.8% (95% CI: 24.9%, 30.9%) in the early months of the pandemic in 2020 (P = .0016). That compares with a rate of 8.5% before the pandemic, a figure based on a prepandemic sample of 5065 patients from the National Health and Nutrition Examination Survey (NHANES) reported previously by Ettman and associates.^[3]

“The COVID-19 pandemic and its economic consequences have displaced social networks, created ongoing stressors, and reduced access to the resources that protect mental health,” Ettman said.

Four Groups Most Affected

In this latest research, a longitudinal panel study of a nationally representative group of US adults, the researchers surveyed participants in March and April 2020 (n = 1441) and the same group again in March and April 2021 (n = 1161).^[2] The participants completed the Patient Health Questionnaire–9 (PHQ-9)^[4] and were enrolled in the COVID-19 and Life Stressors Impact on Mental Health and Well-Being study.

The study found that elevated depressive symptoms were most prevalent in 4 groups^[1]:

• Younger patients, with 43.9% of patients aged 18 to 39 years self-reporting elevated depressive symptoms, compared with 32.4% of patients aged 40 to 59 years and 19.1% of patients aged ≥ 60 years
• People with lower incomes, with 58.1% of people making ≤ $19,999 reporting elevated symptoms, compared with 41.3% of individuals making $20,000 to $44,999, 31.4% of people making $45,000 to $74,999, and 14.1% of persons making ≥ $75,000
• People with < $5000 in family savings, with a rate of 50.5%, compared with 24.2% of individuals with more than that
• People never married, with a rate of 39.8% vs 37.7% of individuals living with a partner; 31.5% widowed, divorced, or separated; and 18.3% married

The study also found correlations between the number of self-reported stressors and elevated depression symptoms: a rate of 51.1% in people with ≥ 4 stressors; 25.8% in persons with 2 or 3 stressors; and 17% in people with 1 or no stressors.

Among the groups reporting the lowest rates of depressive symptoms in 2021 were people making more than $75,000 a year; persons with 1 or no COVID-19 stressors; and non-Hispanic Asian persons.

“Stressors such as difficulties finding childcare, difficulties paying for housing, and job loss were associated with greater depression 12 months into the COVID-19 pandemic,” Ettman said. “Efforts to address stressors and improve access to childcare, housing, employment, and fair wages can improve mental health.”

The duration of the pandemic is another explanation for the significant rise in depressive symptoms, senior author Sandro Galea, MD, MPH, DrPH, said in an interview. 

“The COVID-19 pandemic is different from other traumatic events in its ongoing length, in its widespread reach, and in its inequities,” Galea added. “Unlike acute traumatic events, the COVID-19 pandemic has been ongoing.”

He said clinicians, public health officials, and policy makers need to be aware of the impact COVID-19 has had on mental health.

“We can take steps as a society to treat and prevent depression and create conditions that allow all populations to be healthy,” said Galea, who is dean and a professor of family medicine at Boston University.

Age of Sample Cited as Limitation

The study builds on existing evidence linking depression trends and the COVID-19 pandemic, David Puder, MD, a medical director at Loma Linda University, Loma Linda, California, said in an interview; however, he noted it had some limitations.

“The age range is only 18 and older, so we don’t get to see what is happening with a highly impacted group of students who have not been able to go to school and be with their friends during COVID,” said Puder, who also hosts the podcast Psychiatry & Psychotherapy. “Further, the PHQ-9 is often a screening tool for depression and is not best used for changes in mental health over time.”

At the same time, Puder said, one of the study’s strengths was that it showed how depressive symptoms increased during the COVID lockdown.

“It shows certain groups are at higher risk, including those with less financial resources and those with higher amounts of stress,” Puder said.

Ettman, Galea, and Puder reported no relevant disclosures.

Clinical Implications

• The current study by Ettman and colleagues builds on other research by demonstrating that the rate of elevated depressive symptoms increased in a cohort of US adults between 2020 and 2021. Rates of elevated depression symptoms from 2020-2021 increased compared with rates from 2017-2018.
• Lower income was the sociodemographic variable most associated with increased depressive symptoms in 2021.
• Implications for the healthcare team: The healthcare team should screen adults for depression, particularly during the COVID-19 pandemic. Patients facing financial hardship are at particularly increased risk for depression.

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