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Figure.  Psychological Distress Among US Adults Aged 18 Years or Older Overall and by Subgroup, April 2020 vs 2018
Psychological Distress Among US Adults Aged 18 Years or Older Overall and by Subgroup, April 2020 vs 2018

April 2020 measures are from wave 1 of the Johns Hopkins COVID-19 Civic Life and Public Health Survey, fielded April 7-13, 2020 (N = 1468 adults aged ≥18 years). 2018 Measures of psychological distress are from the 2018 National Health Interview Survey (N = 25 417 adults aged ≥18 years). Psychological distress was measured using the Kessler 6 Psychological Distress Scale, with scores of 13 or higher indicating serious psychological distress. The error bars indicate 95% CIs.

aRace/ethnicity was collected as part of the demographic profile in both the April 2020 Johns Hopkins survey and the 2018 National Health Interview Survey. In both surveys, the options were defined by the study investigators, and participants classified their own race/ethnicity.

1.
Dennis  JM.  Technical Overview of the AmeriSpeak Panel NORC’s Probability-Based Household Panel. NORC at the University of Chicago; 2019.
2.
Kessler  RC, Barker  PR, Colpe  LJ,  et al.  Screening for serious mental illness in the general population.   Arch Gen Psychiatry. 2003;60(2):184-189. doi:10.1001/archpsyc.60.2.184PubMedGoogle ScholarCrossref
3.
Centers for Disease Control and Prevention. National Center for Health Statistics: data, questionnaires, and related documentation. Accessed May 13, 2020. https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm
4.
Lai  J, Ma  S, Wang  Y,  et al.  Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.   JAMA Network Open. 2020;3(3):e203976-e.Google Scholar
5.
Kaiser Family Foundation; The Economist. Survey on Loneliness and Social Isolation in the United States, the United Kingdom, and Japan. Published 2018. Accessed May 13, 2020. http://files.kff.org/attachment/Topline-Kaiser-Family-Foundation-The-Economist-Survey-on-Loneliness-and-Social-Isolation-in-the-United-States-the-United-Kingdom-and-Japan
6.
American Association for Public Opinion Research. Report on online panels. Published June 2010. Accessed May 14, 2020. https://www.aapor.org/Education-Resources/Reports/Report-on-Online-Panels.aspx
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    1 Comment for this article
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    Isolation, Loneliness and Psychological Distress During COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The invaluable and sensitive research letter on psychological distress and loneliness will strike a touching chord with everyone who has experienced such symptoms, or knows someone who has, especially during the COVID-19 pandemic which shows little sign of abatement.

    The important findings based on a  comparison of national data from 2018 and an independent representative national survey in April 2020 for respondents aged 18 years or older would be enhanced considerably with further surveys and clinical analysis according to:

    (1) updating the findings from the early days of the pandemic in April 2020 through to August 2020;
    /> (2) expanding the analysis to include elementary school children and high school students;

    (3) using gradations of psychological distress from serious to medium and mild, together with degrees of loneliness, isolation, social distancing, quarantining, and lockdowns;

    (4) conditioning on a wider set of control variables, including race, ethnicity, and varying degrees of income and employment disparities;

    (5) including non-healthcare essential services providers who are faced with a higher likelihood of contracting the disease in the workplace;

    (6) conducting separate surveys for front line healthcare workers, who are known to suffer from both COVID-19 and acute mental health issues, ranging from medium through to extremely serious cases of morbidity and mortality.

    It is not surprising that the symptoms of psychological distress and loneliness are greater in 2020 than in 2018, but this disparity will have increased substantially as the pandemic continues to grow exponentially rather than flattening.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    June 3, 2020

    Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020

    Author Affiliations
    • 1Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
    • 2Department of Political Science, Johns Hopkins University, Baltimore, Maryland
    JAMA. 2020;324(1):93-94. doi:10.1001/jama.2020.9740

    Coronavirus disease 2019 (COVID-19) introduced stressors to mental health, including loneliness stemming from social isolation, fear of contracting the disease, economic strain, and uncertainty about the future. We fielded a national survey measuring symptoms of psychological distress and loneliness among US adults in April 2020 and compared results with national data from 2018.

    Methods

    We fielded the Johns Hopkins COVID-19 Civic Life and Public Health Survey from April 7 to April 13, 2020, using NORC’s AmeriSpeak Panel. AmeriSpeak is a probability-based panel designed to be representative of the US adult population. The panel is sourced from NORC’s area probability sample and from a US Postal Service address–based sample covering 97% of US households.1 The panel has a recruitment rate of 34% and includes approximately 35 000 members. The sample for the Johns Hopkins survey was drawn from this panel and the survey was administered online. NORC obtains informed consent prior to enrolling individuals in the panel. The Johns Hopkins Bloomberg School of Public Health institutional review board deemed this study not human participants research and waived informed consent.

    We measured the prevalence of symptoms of serious psychological distress in the overall sample and among demographic subgroups using the Kessler 6 Psychological Distress Scale, with the validated measure of serious distress defined as a score of 13 or higher on the 0- to 24-point scale.2 We also measured the proportion of respondents who reported that they always or often feel lonely in response to the item “How often do you feel lonely?” with response options always, often, sometimes, rarely, and never.

    We compared the prevalence of symptoms of serious psychological distress in April 2020 with an identical measure from the 2018 National Health Interview Survey (NHIS), which used the Kessler 6 scale among 25 417 adults aged 18 years or older in household interviews. The 2018 NHIS response rate was 64.2%.3

    For each measure, we calculated proportions and 95% CIs using Stata version 15 (StataCorp). The Johns Hopkins and NHIS survey data were analyzed separately. Analyses of both data sets incorporated survey sampling weights to generate nationally representative estimates.

    Results

    The survey response rate was 70.4%, with a final sample of 1468 adults aged 18 years or older.

    In April 2020, 13.6% (95% CI, 11.1%-16.5%) of US adults reported symptoms of serious psychological distress, relative to 3.9% (95% CI, 3.6%-4.2%) in 2018 (Figure). Among the subgroups examined, in April 2020, symptoms of psychological distress were highest among young adults aged 18 to 29 years (24.0% [95% CI, 16.3%-33.8%]), adults with household income of less than $35 000 per year (19.3% [95% CI, 14.2%-25.6%]), and Hispanic adults (18.3% [95% CI, 11.2%-28.3%]). The corresponding prevalence estimates for these 3 groups in 2018 were 3.7% (95% CI, 3.0%-4.6%), 7.9% (95% CI, 7.1%-8.6%), and 4.4% (95% CI, 3.7%-5.4%), respectively. The lowest prevalence of serious psychological distress among the subgroups examined in April 2020 was observed in adults aged 55 years or older (7.3% [95% CI, 4.8%-10.9%]). In April 2020, 13.8% (95% CI, 11.4%-16.6%) of US adults reported that they always or often felt lonely.

    Discussion

    The prevalence of reported symptoms of psychological distress among US adults was higher in 2020 during the COVID-19 pandemic than in 2018. This finding builds on prior research documenting psychological distress among health care workers responding to COVID-19.4

    The measure of serious psychological distress derived from the Kessler 6 scale has been shown to accurately predict serious mental illness,2 suggesting acute distress during COVID-19 may transfer to longer-term psychiatric disorders. In April 2020, 13.8% of US adults reported that they always or often felt lonely. In comparison, a national survey using an identical measure of loneliness found that 11% of US adults reported always or often feeling lonely in April and May 2018.5 Because loneliness increased only slightly from 2018 to 2020, other factors may be driving psychological distress during the COVID-19 pandemic.

    The NORC AmeriSpeak panel used probability-based recruitment consistent with best-practice standards for survey research,6 but results may be vulnerable to sampling biases. The degree to which US adults classified as essential workers during the COVID-19 pandemic were represented in the survey sample is unknown. While both surveys are designed to be nationally representative of US adults, the sampling and recruitment methods and mode of administration varied in the Johns Hopkins April 2020 and NHIS 2018 surveys. There is a potential for selection bias if individuals were more likely to respond to a survey about psychological distress in April 2020 vs 2018.

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Emma E. McGinty, PhD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 359, Baltimore, MD 21205 (bmcginty@jhu.edu).

    Accepted for Publication: May 19, 2020.

    Published Online: June 3, 2020. doi:10.1001/jama.2020.9740

    Author Contributions: Dr McGinty had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: McGinty, Han, Barry.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: McGinty.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: McGinty, Presskreischer.

    Obtained funding: McGinty, Han, Barry.

    Administrative, technical, or material support: Barry.

    Supervision: McGinty, Han, Barry.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Dr McGinty reported receiving a Faculty Innovation Award from Johns Hopkins University. Dr Han reported receiving a grant from the Robert Wood Johnson Foundation. Dr Barry reported receiving endowment funds from the Johns Hopkins Bloomberg School of Public Health.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Dennis  JM.  Technical Overview of the AmeriSpeak Panel NORC’s Probability-Based Household Panel. NORC at the University of Chicago; 2019.
    2.
    Kessler  RC, Barker  PR, Colpe  LJ,  et al.  Screening for serious mental illness in the general population.   Arch Gen Psychiatry. 2003;60(2):184-189. doi:10.1001/archpsyc.60.2.184PubMedGoogle ScholarCrossref
    3.
    Centers for Disease Control and Prevention. National Center for Health Statistics: data, questionnaires, and related documentation. Accessed May 13, 2020. https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm
    4.
    Lai  J, Ma  S, Wang  Y,  et al.  Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.   JAMA Network Open. 2020;3(3):e203976-e.Google Scholar
    5.
    Kaiser Family Foundation; The Economist. Survey on Loneliness and Social Isolation in the United States, the United Kingdom, and Japan. Published 2018. Accessed May 13, 2020. http://files.kff.org/attachment/Topline-Kaiser-Family-Foundation-The-Economist-Survey-on-Loneliness-and-Social-Isolation-in-the-United-States-the-United-Kingdom-and-Japan
    6.
    American Association for Public Opinion Research. Report on online panels. Published June 2010. Accessed May 14, 2020. https://www.aapor.org/Education-Resources/Reports/Report-on-Online-Panels.aspx
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