Factors Associated With Symptoms of Depression and Anxiety Among Women Experiencing Homelessness and Unstable Housing During the COVID-19 Pandemic

Logistic regression was conducted for binary outcomes with Firth penalized likelihood estimation to account for small cell sizes. Linear regression was performed for continuous outcomes. Results from the penalized log likelihood χ 2 test and the t test statistics for logistic and linear regression used 2-tailed tests under an α < .05. Data were analyzed with SAS statistical software version 9.4 (SAS Institute).


Introduction
The prevalence of depression among individuals in the US has increased 300% during the COVID-19 pandemic, with a greater burden of illness in individuals with lower incomes. 1 With the goal of informing adaptation of services for socioeconomically marginalized individuals, we surveyed mental health symptoms and social challenges experienced during the COVID-19 pandemic among women experiencing homelessness and unstable housing (HUH). Extrapolating from the available evidence, 2,3 there are approximately 440 000 women experiencing HUH in the US.

Methods
Between July and December 2020, we used previously developed methods 3 to conduct a crosssectional study among women in San Francisco, California, recruited from homeless shelters, street encampments, free meal programs, and low-income hotels. Eligibility criteria included female sex at birth, age 18 years or older, and a lifetime history of sleeping in public, a shelter, or temporarily with friends or acquaintances (ie, couch-surfing). Interviews, including verbal consent for study participation, were conducted via telephone, and participants were sent $50 reimbursement for completing an interview. Study procedures were approved by the University of California, San Francisco, institutional review board.

Outcome variables included symptoms of depression measured by the Patient Health
Questionnaire-9 (range, 0-27, with higher scores indicating more symptoms; moderate-to-severe depression was defined as a score Ն10) 4 and symptoms of anxiety measured by the Generalized Anxiety Disorder Assessment-7 (range, 0-21 with higher scores indicating more symptoms; moderate-to-severe anxiety was defined as a score Ն10). 5 We examined associations between depression and anxiety symptoms and challenges experienced since the beginning of the pandemic (March 2020). Covariates included factors previously associated with depression and anxiety: race/ethnicity (self-reported in response to National Institutes of Health categories), recent homelessness (slept in a shelter or in public), unmet subsistence needs (ie, insufficient access to food, clothing, housing, or hygiene resources), social isolation (feeling isolated and unable to rely on others), increased difficulty managing symptoms of a chronic medical condition (HIV, cardiovascular disease, diabetes, asthma, or emphysema), and increased difficulty getting treatment for mental health, substance use, or a chronic medical condition.
Logistic regression was conducted for binary outcomes with Firth penalized likelihood estimation to account for small cell sizes. Linear regression was performed for continuous outcomes.
Results from the penalized log likelihood χ 2 test and the t test statistics for logistic and linear regression used 2-tailed tests under an α < .05. Data were analyzed with SAS statistical software version 9.4 (SAS Institute).
Seventy-one participants (55%) had depression and 54 (42%) had anxiety during the pandemic, which is similar to the prepandemic prevalence of symptom scores indicating depression (49% of women) and anxiety (36% of women) in this population. 6  health outcomes were similarly observed in women with increased difficulties getting mental health care and managing symptoms of a chronic medical condition.

Discussion
The COVID-19 pandemic has created a parallel mental health crisis that disproportionately affects individuals with low incomes. 1 Approximately one-half of women experiencing HUH surveyed here experienced depression and/or anxiety symptoms during the pandemic and, in addition to unmet subsistence needs and social isolation, these symptoms were associated with increased challenges accessing non-COVID-19 care and managing symptoms for chronic medical conditions. These findings are from women experiencing HUH, who are among our most socioeconomically disadvantaged citizens and already at high risk for poor health outcomes. 3 A limitation of the study is that it is a single sample from 1 city, and the effects of COVID-19 may vary by location. However, because San Francisco is a well-resourced city with multiple programs aimed at assisting individuals experiencing HUH, associations between a lack of access to non-COVID-19 health care and mental health conditions are as likely to exist as those reported here and could be more substantial for women experiencing HUH in other US cities. Improving access to basic subsistence needs is critical.
It is further critical to decrease barriers to care for chronic medical conditions besides COVID-19, which are strongly tied to mental health yet are in danger of being overlooked and undertreated during the pandemic.