Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020

Adverse mental health symptoms among US adults were more prevalent during the early phase (April-June 2020) of the coronavirus disease 2019 (COVID-19) pandemic compared with prepandemic estimates (eg, 3-fold increased prevalences of anxiety and depression symptoms, 2-fold increased prevalence of suicidal ideation).^1,2 In June 2020, 2238 (40.9%) of 5470 US adults reported adverse mental or behavioral health symptoms. During this time, the prevalence of symptoms was lower in adults aged 65 years or older (141 of 933 [15.1%]) than in young adults aged 18 to 24 years (547 of 731 [74.9%]; P < .001).¹ Given suggestions that acute increases in the prevalence of adverse mental health symptoms may represent a transient response to mass trauma,³ we sought to determine whether these patterns persisted in September 2020 and to examine disproportionately affected demographic groups.

In this survey study from August 28 to September 6, 2020, US adults aged 18 years or older completed 139-item internet-based surveys through Qualtrics for The COVID-19 Outbreak Public Evaluation (COPE) Initiative. Surveys were administered to an online respondent panel maintained by Qualtrics, a commercial survey company with networks of participant pools. Respondents reported demographic characteristics and completed questions assessing attitudes, behaviors, and beliefs about COVID-19, mitigation measures, and mental and behavioral health. When possible, brief, validated instruments were used or adapted.

Demographic quota sampling and survey weighting were used to make the sample representative of the US population by age, sex, and race/ethnicity, and weighted values are presented. Participants reported symptoms of anxiety and depression, COVID-19−related trauma- and stressor-related disorders, starting or increasing substance use to cope with pandemic-related stress, or having seriously considered suicide within 30 days. The Monash University Human Research Ethics Committee approved the study protocol, and participants provided informed consent electronically. The article followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

Multivariable Poisson regressions with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% CIs for any adverse mental or behavioral health symptom with the following factors: sex, age, sexual orientation, race/ethnicity, Census region, urban/rural residence, and unpaid caregiver status. Separate models were run for the following collinear factors: disability status, insomnia symptoms, prior psychiatric diagnosis (anxiety, depression, posttraumatic stress disorder, or a substance use disorder), and age-excluded employment status. Age was not adjusted for in the model that included employment status to avoid collinearity between these variables. Continuity-corrected McNemar tests were used to assess longitudinal differences in adverse mental health symptom prevalences among respondents who completed surveys in June 2020 and September 2020. All calculations were performed in Python version 3.7.8 (Python Software Foundation) and R version 4.0.2 (The R Project for Statistical Computing) using the R survey package version 3.29. P values were 2-sided, and statistical significance was set at P < .05. Detailed methods¹ describing the recruitment process, survey, screening tools, and analyses can be found in the eAppendix in the Supplement.

Overall, 5285 of 11 953 potential participants (44.2%) completed September 2020 surveys; 5186 of these respondents (98.1%) met secondary screening criteria and were analyzed (1155 [22.3%] were recontacted after April 2020; 1605 [30.9%] were recontacted after June 2020; 2426 [46.8%] were first-time respondents). Overall, 1710 (33.0%) reported anxiety or depression symptoms, 1536 (29.6%) reported COVID-19–related trauma- and stressor-related disorder symptoms, 781 (15.1%) reported increased substance use, 618 (11.9%) reported having seriously considered trying to kill themselves in August, and 2237 (43.1%) reported at least 1 of these symptoms (Table 1).

Adverse mental or behavioral health symptoms were more prevalent among adults younger than 65 years vs adults aged 65 years or older (eg, 18-24 years, aPR, 3.56 [95% CI, 3.04-4.18]) and among multigenerational caregivers vs noncaregivers (aPR, 1.93 [95% CI, 1.78-2.08]) and respondents with prior psychiatric diagnoses vs those with no prior diagnoses (aPR, 1.98 [95% CI, 1.83-2.15]) (Table 2). Prevalence of adverse mental or behavioral health symptoms was also higher among respondents with disabilities or insomnia symptoms vs those without, caregivers for adults vs noncaregivers, essential workers and unemployed respondents vs nonessential workers, and respondents who were lesbian, gay, or bisexual vs heterosexual. Among respondents who were recontacted after June 2020, prevalence of adverse mental health symptoms did not differ significantly between June 2020 and September 2020.

In a later phase of the COVID-19 pandemic (September 2020), the prevalence of adverse mental health symptoms among US adults remained elevated compared with prepandemic estimates.^1,2 This finding contradicts the notion that adverse mental health symptoms were transient, self-limiting responses. Despite increased COVID-19–related morbidity and mortality risk,⁴ adverse mental health symptoms among older adults remained less prevalent.^1,2,5,6 Although quota sampling and survey weighting were used, internet-based survey samples are limited and may not fully represent the 2020 US population.¹ Nonetheless, evidence of sustained adverse mental health symptoms among more than 5000 community-dwelling US adults highlights the need to promote preventive behaviors, expand mental health care access, and integrate medical and behavioral health services to mitigate the mental health effects of COVID-19.

Accepted for Publication: December 27, 2020.

Published: February 19, 2021. doi:10.1001/jamanetworkopen.2020.37665

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Czeisler MÉ et al. JAMA Network Open.

Corresponding Author: Mark É. Czeisler, AB, Turner Institute for Brain and Mental Health, Monash University, 18 Innovation Walk, Clayton Campus, Level 5, Clayton, VIC 3800, Australia (mark.czeisler@fulbrightmail.org).

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

Concept and design: M. É. Czeisler, Lane, C. A. Czeisler, Howard, Rajaratnam.

Acquisition, analysis, or interpretation of data: M. É. Czeisler, Wiley, C. A. Czeisler, Howard, Rajaratnam.

Drafting of the manuscript: M. É. Czeisler, Lane.

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

Statistical analysis: M. É. Czeisler, Wiley.

Obtained funding: M. É. Czeisler, Lane, C. A. Czeisler, Howard, Rajaratnam.

Administrative, technical, or material support: Lane, C. A. Czeisler, Rajaratnam.

Supervision: Howard, Rajaratnam.

Conflict of Interest Disclosures: Mr Czeisler reported receiving grants from the Australian-American Fulbright Commission administered through a 2020 Fulbright Future Scholarship funded by The Kinghorn Foundation during the conduct of the study and receiving personal fees from Vanda Pharmaceuticals outside the submitted work. Dr Czeisler reported receiving grants to support The COVID-19 Outbreak Public Evaluation (COPE) Initiative and grants from Brigham and Women's Physician's Organization during the conduct of the study; being a paid consultant to or speaker for Ganésco, Institute of Digital Media and Child Development, Klarman Family Foundation, M. Davis and Co, Physician's Seal, Samsung Group, State of Washington Board of Pilotage Commissioners, Tencent Holdings, Teva Pharma Australia, and Vanda Pharmaceuticals, in which Dr. Czeisler holds an equity interest; receiving travel support from Aspen Brain Institute, Bloomage International Investment Group, UK Biotechnology and Biological Sciences Research Council, Bouley Botanical, Dr Stanley Ho Medical Development Foundation, Illuminating Engineering Society, National Safety Council, Tencent Holdings, and The Wonderful Co; receiving institutional research and/or education support from Cephalon, Mary Ann and Stanley Snider via Combined Jewish Philanthropies, Harmony Biosciences, Jazz Pharmaceuticals PLC, Johnson and Johnson, Neurocare, Peter Brown and Margaret Hamburg, Philips Respironics, Regeneron Pharmaceuticals, Regional Home Care, Teva Pharmaceuticals Industries, Sanofi S.A., Optum, ResMed, San Francisco Bar Pilots, Schneider National, Serta, Simmons Betting, Sysco, Vanda Pharmaceuticals; being or having been an expert witness in legal cases, including those involving Advanced Power Technologies; Aegis Chemical Solutions; Amtrak; Casper Sleep; C and J Energy Services; Complete General Construction; Dallas Police Association; Enterprise Rent-A-Car; Steel Warehouse Co; FedEx; Greyhound Lines; Palomar Health District; PAR Electrical, Product, and Logistics Services; Puckett Emergency Medical Services; South Carolina Central Railroad Co; Union Pacific Railroad; UPS; and Vanda Pharmaceuticals; serving as the incumbent of an endowed professorship provided to Harvard University by Cephalon; and receiving royalties from McGraw Hill and Philips Respironics for the Actiwatch-2 and Actiwatch Spectrum devices. Dr Czeisler's interests were reviewed and are managed by the Brigham and Women's Hospital and Mass General Brigham in accordance with their conflict of interest policies. Dr Rajaratnam reported receiving institutional consulting fees from CRC for Alertness, Safety, and Productivity; Teva Pharmaceuticals; Vanda Pharmaceuticals; Circadian Therapeutics; BHP Billiton; and Herbert Smith Freehills; receiving grants from Teva Pharmaceuticals and Vanda Pharmaceuticals; and serving as chair for the Sleep Health Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: Funding for survey data collection was supported in part by research grants from the US Centers for Disease Control and Prevention Foundation, with funding from BNY Mellon and from WHOOP, to Monash University acting through its Faculty of Medicine, Nursingy, and Health Sciences, and by institutional support from Philips Respironics and Alexandra Dane to Brigham and Women’s Hospital, the Turner Institute for Brain and Mental Health, Monash University, and Institute for Breathing and Sleep, Austin Hospital.

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.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Additional Contributions: We gratefully acknowledge all survey respondents, as well as Laura K. Barger, PhD (Brigham and Women’s Hospital), Rebecca Robbins, PhD (Brigham and Women’s Hospital), and Elise R. Facer-Childs, PhD (Monash University) for their contributions to the survey instrument and study design, and Matthew D. Weaver, PhD (Brigham and Women’s Hospital) for his analytic advice. None of these individuals received compensation for their help. We also thank Mallory Colys, BSc (Qualtrics); Sneha Baste, BIndDes (Hons), (Qualtrics); Daniel Chong, BSc (Qualtrics); and Rebecca Toll, BMedSc, (Qualtrics), who were compensated as Qualtrics employees, for support in survey data collection.