Major depressive disorder is a leading cause of disability worldwide, and a major risk factor for suicide. It is also an illness that is remarkably sensitive to the social determinants of health—worsening depressive symptoms have been associated with adverse childhood experiences, racism and discrimination, unemployment, food insecurity, and a host of other social and environmental factors.1 The coronavirus disease 2019 (COVID-19) pandemic has led to massive social and economic disruptions around the world and in the United States. In their study examining the prevalence of depressive symptoms before and during the pandemic, Ettman et al2 have effectively documented an important mental health implication of the COVID-19 pandemic. The authors found higher prevalence rates of depression across all severity levels during COVID-19 compared with rates of depression before the pandemic in the US. Not surprisingly, for certain populations (eg, people with lower incomes and people with greater levels of stress associated with the pandemic), depressive symptoms were even more pronounced.
The emergence of COVID-19 has brought renewed attention to disparities and inequities in health outcomes that exist for US residents who are most commonly oppressed and marginalized in US society.3 These inequities in outcomes are persistent across many conditions but are particularly salient when considering mental illnesses and substance use disorders. Ample data support the understanding that the social determinants of health and mental health are most responsible for health disparities and inequities,4 and the findings of this study by Ettman et al2 add to our understanding of how these social determinants of mental health are associated with inequities in the incidence and prevalence of depression in the context of the COVID-19 pandemic.
Ettman et al2 emphasize that the COVID-19 pandemic has been a traumatic event for many US residents and that these findings are consistent with other infectious disease epidemics. It is worth pausing to consider exactly how the social determinants of mental health contribute to this trauma. As a result of the pandemic, unemployment in the US is at its highest rate since the Great Depression, and many more people have been burdened with the uncertainty and anxiety of job insecurity. The multivariable analysis performed in the study by Ettman et al2 emphasizes various social determinants of mental health as associated with increased stress loads. These social determinants of health are interconnected, and because of the inadequate structure of safety net systems in the US, lack of employment can lead to increasing poverty, loss of health insurance, housing insecurity, and food insecurity. These social determinants have been exacerbated for many families and communities during the COVID-19 pandemic.
Perceived discrimination is associated with major depressive disorder, and interpersonal and structural discrimination are associated with a higher prevalence of anxious and depressive symptoms.5 While rates of depression increased during the pandemic across all racial and ethnic population groups, Ettman et al2 specifically note the increased rate of depressive symptoms in Asian populations (26 of 674 participants [4.4%] before COVID-19 vs 8 of 36 participants [23.1%] during COVID-19), at a time when many members of these ethnic groups have experienced public acts of interpersonal discrimination regarding the origins and spread of COVID-19—both from everyday US residents as well as high-ranking public officials. COVID-19 is also unfolding amidst protests calling for increased racial equity for Black populations. Racism and discrimination are powerful social determinants of mental health that are contributing to the increasing trauma that the collective consciousness in the US is currently experiencing. These preliminary findings must be closely explored in the future.
Another concerning finding in this study is the increased prevalence of severe depressive symptoms. While prevalence rates of depressive symptoms increased at all severity levels, the greatest increase was seen with those with severe depressive symptoms (prevalence: before COVID-19, 0.7% [95% CI, 0.5%-0.9%]; during COVID-19, 5.1% [95% CI, 3.8%-6.8%]), the type of depression that requires intensive specialty treatment to effectively manage. Although severe depression is not as common as moderate and mild depression, it is still a major contributor to the overall disability burden of depression and is associated with the increased suicide risk associated with depression. These findings may help to explain why suicide rates increase with high levels of unemployment and during recessions and global pandemics. There is urgent need for greater examination of increased suicide risk associated with COVID-19.
The results highlighted by Ettman et al2 are grim. Just as US preparation for the COVID-19 pandemic was not ideal, there is little evidence that preparation for the mental health implications of COVID-19 are under way. So far, steps taken to address the social determinants of mental health, which could serve as an effective preventive tool, have not gone far enough. Enhanced unemployment benefits expired as of July 31, 2020, before many Americans could safely return to work or find new employment opportunities. Residents face the increasing risk of eviction from their housing, and state and federal policies have not done enough to protect people from housing insecurity and possible homelessness. While there is a temporary pause on new federal restrictions for Supplemental Nutrition Assistance Program (SNAP) eligibility, it is unclear how long the moratorium will last.6
Capturing the mental health outcomes associated with COVID-19 among the US population is critically important. These findings serve to alert our attention to yet another impending public health crisis as a result of this pandemic—the increase in cases of major depression. To effectively prepare to face this public health crisis, health care practitioners and policy makers must commit to addressing the social determinants of health and mental health. Convincing data support investments in public health and social welfare benefits (eg, food, housing, unemployment benefits) over investments in health care services (eg, Medicaid, Medicare) to achieve better health outcomes.7 By documenting the increased risk of depression that is waiting on the horizon after new cases of COVID-19 subside, the study by Ettman et al2 might remind us of the importance of investing (both during and after the COVID-19 pandemic) in stable housing, unemployment benefits, access to healthy food, and policies that end discrimination and exclusion to effectively manage a highly disabling, common mental health condition that will likely only increase in prevalence as the pandemic rages on.
Published: September 2, 2020. doi:10.1001/jamanetworkopen.2020.20104
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Shim RS. JAMA Network Open.
Corresponding Author: Ruth S. Shim, MD, MPH, Department of Psychiatry and Behavioral Sciences, University of California, 2230 Stockton Blvd, Sacramento, CA 95817 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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