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Dr Brett Thombs
Around the world, the COVID-19 pandemic has led to relatively limited changes in mental health symptoms compared with before the pandemic, according to new data.
At the same time, some patients — including women, parents, students, older adults, and sexual or gender minority groups — have experienced larger changes in certain symptoms and will need ongoing mental health support, the study authors say.
“The pandemic has been a mixed bag in terms of mental health and much more nuanced than has typically been reported,” senior author Brett Thombs, PhD, professor of psychiatry at McGill University and senior investigator at the Lady Davis Institute of Medical Research at Jewish General Hospital, Montreal, Quebec, Canada, told Medscape Medical News.
“Some people have struggled terribly, whereas others have kept things pretty stable, and others have even done better — they have reduced commutes and increased time with family or reprioritized in ways that have improved their lives,” he said. “Overall, though, mental health hasn’t changed very much on average.”
The study was published March 8 in BMJ.
Minimal to Small Effects
The investigators conducted a systematic review and meta-analysis of studies comparing general mental health, anxiety symptoms, or depression symptoms in January 2020 or later with mental health outcomes collected between January 2018 and December 2019. Eligible studies included 90% or more of the same participants before and during the COVID-19 pandemic or used statistical methods to account for the missing data. The authors looked at the standardized mean difference (SMD) in symptoms to understand the changes.
Among the 94,411 studies of mental health during the pandemic that the research team reviewed, 137 studies involving 134 cohorts of people from around the world were included in the analysis. Most of the studies were from high- or middle-income countries. About 76% of participants were adults, and 24% were children and adolescents between ages 10 and 19 years.
No significant differences were found for general mental health (SMD change, 0.11) or anxiety symptoms (SMD change, 0.05) in general population cohorts, although depression symptoms increased by a small but statistically significant amount (SMD change, 0.12).
Among women, the changes were somewhat larger, with general mental health (SMD change, 0.22), anxiety symptoms (SMD change, 0.20), and depression symptoms (SMD change, 0.22) becoming slightly worse.
In addition, parents had small or medium changes in general mental health (SMD change, 0.39) and anxiety symptoms (SMD change, 0.25). Depression symptoms showed greater shifts among older adults (SMD change, 0.22), university students (SMD change, 0.14), and people who identified as belonging to a sexual or gender minority group (SMD change, 0.19).
In three cohorts with data from March to June 2020 and later in September to November 2020, symptoms at later assessments appeared to be unchanged from pre-COVID-19 levels — or they increased initially and then returned to pre-COVID-19 levels.
Suggestions of Resilience
“We launched our study in April 2020 because we were concerned that there would be important effects from the pandemic on mental health,” Thombs said. “But we were also concerned that people were assuming this was the case without evidence.”
To truly understand the shifts, Thombs noted, researchers should measure both before and after an event. That’s why the investigators examined only studies that tracked mental health before and during the pandemic.
“Many studies were administering mental health questionnaires to people during the pandemic, interpreting the scores as high, and concluding that they must have changed because of the pandemic,” he said. “But this seems to have been a classic case of shaping the evidence to fit what people thought they knew, rather than using evidence to learn what is happening.”
The investigators noted several limitations of their study, including that only one of the 137 studies went beyond 2020 and that there were limited data on subgroups who may have faced more severe mental health effects during the pandemic. In addition, the studies examined exhibited substantial heterogeneity and risk of bias. The authors are continuing the research and have identified another 100 studies to add to the analysis.
“The good news is that many of them have data on some of the vulnerable groups that we weren’t able to say much about due to limited data,” he said. “We have also identified several hundred studies that track mental health across the pandemic, which will add to the picture.”
Broadly, the data provide a story of resilience, the study authors write. They plan to analyze mental health interventions that have been tested during the pandemic, with the goal of understanding which approaches may be useful for providing mental health access during other difficult situations in the future.
Ecological Fallacy?
Dr Mark Sinyor
Commenting on the findings for Medscape, Mark Sinyor, MD, a psychiatrist with Sunnybrook Health Sciences Centre and associate professor of psychiatry at the University of Toronto, Ontario, Canada, said: “Mental well-being is not solely a product of how much adversity individuals face. How we cope matters just as much or more, and, by and large, I think that people and societies have done quite a good job of coping with the adversity of the pandemic.” Sinyor wasn’t involved with this study.
“That said, it is important for readers to understand that results like these can be susceptible to something called an ecological fallacy — this is the idea that what is true for the group is also true for individuals in the group,” he said. “But we know that this is not the case. The pandemic has certainly had a substantial negative impact on the mental health of certain individuals across populations.”
Sinyor has researched suicide risk and prevention during the pandemic. Early data indicate that suicide rates generally didn’t increase during the initial months of the pandemic, though he’s currently studying how the pandemic affected suicide and related outcomes after the initial months.
“There are steps that we can take as a society (for example, income protections in times of extreme unemployment) and as professionals (for example, improving access to virtual care) that can help protect the people in our community from deteriorating mental health,” said Sinyor. “As people who work in healthcare, we must remind the public that they can overcome adversity and that we are here to help advocate for appropriate actions to help make that goal a reality.”
The study was funded by the Canadian Institutes of Health Research and McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund. Thombs has reported no competing interests, and Sinyor has reported no relevant disclosures.
BMJ. Published March 8, 2023. Full text
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.
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