Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic

<!DOCTYPE html> <html lang="en" > <head > <meta charset="UTF-8" /> <meta http-equiv="X-UA-Compatible" content="IE=edge" /> <meta name="HandheldFriendly" content="True" /> <meta name="MobileOptimized" content="320" /> <meta name="viewport" content="width=device-width, initial-scale=1.0" /> <link rel="stylesheet" href="/static/assets/style-70b9163a.css" /> <script type="module" crossorigin="" src="/static/assets/base_style-ec2bc71e.js"></script> <link rel="stylesheet" href="/static/assets/style-ef962842.css" /> <link rel="stylesheet" href="/static/assets/style-3ade8b5c.css" /> <script type="module" crossorigin="" src="/static/assets/article_style-d757a0dd.js"></script> <style> @media screen and (min-width: 64em) { div.pmc-wm { background: repeat-y; background-image: url("data:image/svg+xml,%3Csvg xmlns='http://www.w3.org/2000/svg' width='20' height='350' xmlns:xlink='http://www.w3.org/1999/xlink'%3E%3Cdefs%3E%3Cfilter x='-.02' y='0' width='1.05' height='1' id='c'%3E%3CfeFlood flood-color='%23FFF'/%3E%3CfeComposite in='SourceGraphic'/%3E%3C/filter%3E%3Ctext id='b' font-family='Helvetica' font-size='11pt' style='opacity:1;fill:%23005ea2;stroke:none;text-anchor:middle' x='175' y='14'%3E%3C/text%3E%3Cpath id='a' style='fill:%23005ea2' d='M0 8h350v3H0z'/%3E%3C/defs%3E%3Cuse xlink:href='%23a' transform='rotate(90 10 10)'/%3E%3Cuse xlink:href='%23b' transform='rotate(90 10 10)' filter='url(%23c)'/%3E%3C/svg%3E"); padding-left: 3rem; } } </style> <link rel="apple-touch-icon" sizes="180x180" href="/static/img/favicons/apple-touch-icon.png" /> <link rel="icon" type="image/png" sizes="48x48" href="/static/img/favicons/favicon-48x48.png" /> <link rel="icon" type="image/png" sizes="32x32" href="/static/img/favicons/favicon-32x32.png" /> <link rel="icon" type="image/png" sizes="16x16" href="/static/img/favicons/favicon-16x16.png" /> <link rel="manifest" href="/static/img/favicons/site.webmanifest" /> <link rel="mask-icon" href="/static/img/favicons/safari-pinned-tab.svg" color="#0071bc" /> <meta name="msapplication-config" content="/static/img/favicons/browserconfig.xml" /> <meta name="theme-color" content="#ffffff" /> <title> Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic - PMC </title>  <meta name="ncbi_app" content="cloudpmc-viewer" /> <meta name="ncbi_db" content="pmc" /> <meta name="ncbi_phid" content="76C1770574B45993087705000FB6D764.m_1" />  <meta name="ncbi_pdid" content="article" /> <link rel="preconnect" href="https://www.google-analytics.com" /> <link rel="dns-prefetch" href="https://cdn.ncbi.nlm.nih.gov" /> <link rel="preconnect" href="https://code.jquery.com" /> <meta name="ncbi_domain" content="abm"> <meta name="ncbi_type" content="fulltext"> <meta name="ncbi_pcid" content="journal"> <meta name="ncbi_feature" content="associated_data"> <link rel="canonical" href="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/"> <meta name="robots" content="INDEX,NOFOLLOW,NOARCHIVE"> <meta name="citation_journal_title" content="Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine"> <meta name="citation_title" content="Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic"> <meta name="citation_author" content="Kira E Riehm"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author" content="Calliope Holingue"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author_institution" content="Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA"> <meta name="citation_author" content="Emily J Smail"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author" content="Arie Kapteyn"> <meta name="citation_author_institution" content="Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA"> <meta name="citation_author" content="Daniel Bennett"> <meta name="citation_author_institution" content="Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA"> <meta name="citation_author" content="Johannes Thrul"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author_institution" content="Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia"> <meta name="citation_author" content="Frauke Kreuter"> <meta name="citation_author_institution" content="Joint Program in Survey Methodology, University of Maryland, College Park, College Park, MD, USA"> <meta name="citation_author_institution" content="School of Social Sciences, University of Mannheim, Mannheim, Germany"> <meta name="citation_author_institution" content="Statistical Methods Group, Institute for Employment Research, Nuremberg, Germany"> <meta name="citation_author" content="Emma E McGinty"> <meta name="citation_author_institution" content="Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA"> <meta name="citation_author" content="Luther G Kalb"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author_institution" content="Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA"> <meta name="citation_author" content="Cindy B Veldhuis"> <meta name="citation_author_institution" content="School of Nursing, Columbia University, New York, NY, USA"> <meta name="citation_author" content="Renee M Johnson"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author" content="M Daniele Fallin"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_author" content="Elizabeth A Stuart"> <meta name="citation_author_institution" content="Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA"> <meta name="citation_publication_date" content="2021 Feb 8"> <meta name="citation_volume" content="55"> <meta name="citation_issue" content="2"> <meta name="citation_firstpage" content="93"> <meta name="citation_doi" content="10.1093/abm/kaaa126"> <meta name="citation_pmid" content="33555336"> <meta name="citation_abstract_html_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/"> <meta name="citation_fulltext_html_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/"> <meta name="citation_pdf_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/pdf/kaaa126.pdf"> <meta name="description" content="Cross-sectional studies have found that the coronavirus disease 2019 (COVID-19) pandemic has negatively affected population-level mental health. Longitudinal studies are necessary to examine trajectories of change in mental health over time and ..."> <meta name="og:title" content="Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic"> <meta name="og:type" content="article"> <meta name="og:site_name" content="PubMed Central (PMC)"> <meta name="og:description" content="Cross-sectional studies have found that the coronavirus disease 2019 (COVID-19) pandemic has negatively affected population-level mental health. Longitudinal studies are necessary to examine trajectories of change in mental health over time and ..."> <meta name="og:url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/"> <meta name="og:image" content="https://cdn.ncbi.nlm.nih.gov/pmc/cms/images/pmc-card-share.jpg?_=0"> <meta name="twitter:card" content="summary_large_image"> <meta name="twitter:site" content="@ncbi"> </head> <body > <a class="usa-skipnav " href="#main-content"> Skip to main content </a> <section class="usa-banner " aria-label="Official website of the United States government" > <div class="usa-accordion"> <header class="usa-banner__header"> <div class="usa-banner__inner"> <div class="grid-col-auto"> <img aria-hidden="true" class="usa-banner__header-flag" src="/static/img/us_flag.svg" alt="" /> </div> <div class="grid-col-fill tablet:grid-col-auto" aria-hidden="true"> <p class="usa-banner__header-text"> An official website of the United States government </p> <span class="usa-banner__header-action">Here's how you know</span> </div> <button type="button" class="usa-accordion__button usa-banner__button " aria-expanded="false" aria-controls="gov-banner-default" data-testid="storybook-django-banner" > <span class="usa-banner__button-text">Here's how you know</span> </button> </div> </header> <div class="usa-banner__content usa-accordion__content" id="gov-banner-default" hidden> <div class="grid-row grid-gap-lg"> <div class="usa-banner__guidance tablet:grid-col-6"> <img class="usa-banner__icon usa-media-block__img" src="/static/img/icon-dot-gov.svg" alt="" aria-hidden="true" /> <div class="usa-media-block__body"> <p> <strong>Official websites use .gov</strong> <br /> A <strong>.gov</strong> website belongs to an official government organization in the United States. </p> </div> </div> <div class="usa-banner__guidance tablet:grid-col-6"> <img class="usa-banner__icon usa-media-block__img" src="/static/img/icon-https.svg" alt="" aria-hidden="true" /> <div class="usa-media-block__body"> <p> <strong>Secure .gov websites use HTTPS</strong> <br /> A <strong>lock</strong> ( <span class="icon-lock"> <svg xmlns="http://www.w3.org/2000/svg" width="52" height="64" viewBox="0 0 52 64" class="usa-banner__lock-image" role="graphics-symbol" aria-labelledby="banner-lock-description" focusable="false"> <title id="banner-lock-title">Lock</title> <desc id="banner-lock-description"> Locked padlock icon </desc> <path fill="#000000" fill-rule="evenodd" d="M26 0c10.493 0 19 8.507 19 19v9h3a4 4 0 0 1 4 4v28a4 4 0 0 1-4 4H4a4 4 0 0 1-4-4V32a4 4 0 0 1 4-4h3v-9C7 8.507 15.507 0 26 0zm0 8c-5.979 0-10.843 4.77-10.996 10.712L15 19v9h22v-9c0-6.075-4.925-11-11-11z" /> </svg> </span>) or <strong>https://</strong> means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. </p> </div> </div> </div> </div> </div> </section> <div class="usa-overlay"> </div> <header class="usa-header usa-header--extended usa-header--wide" data-testid="header" data-header > <div class="ncbi-header"> <div class="ncbi-header__container"> <a class="ncbi-header__logo-container" href="/"> <img alt=" PMC home page " class="ncbi-header__logo-image" src="/static/img/ncbi-logos/nih-nlm-ncbi--white.svg" /> </a>  <button type="button" class="usa-menu-btn ncbi-header__hamburger-button " aria-label="Show menu" data-testid="navMenuButton" > <svg aria-hidden="true" class="ncbi-hamburger-icon" fill="none" focusable="false" height="21" viewBox="0 0 31 21" width="31" xmlns="http://www.w3.org/2000/svg"> <path clip-rule="evenodd" d="M0.125 20.75H30.875V17.3333H0.125V20.75ZM0.125 12.2083H30.875V8.79167H0.125V12.2083ZM0.125 0.25V3.66667H30.875V0.25H0.125Z" fill="#F1F1F1" fill-rule="evenodd" /> </svg> </button>  <div class="ncbi-header__desktop-buttons">  <button type="button" class="usa-button usa-button--unstyled ncbi-header__desktop-button " aria-expanded="false" aria-controls="search-field-desktop-navigation" aria-label="Show search overlay" data-testid="toggleSearchPanelButton" data-toggle-search-panel-button > <svg class="usa-icon " role="graphics-symbol" aria-hidden="true" > <use xlink:href="/static/img/sprite.svg#search" /> </svg> Search </button>  <div class="ncbi-header__login-dropdown"> <button type="button" class="usa-button usa-button--unstyled ncbi-header__desktop-button ncbi-header__login-dropdown-button " aria-expanded="false" aria-controls="login-dropdown-menu" aria-label="Show login menu" data-testid="toggleLoginMenuDropdown" data-desktop-login-button > <svg class="usa-icon " role="graphics-symbol" aria-hidden="true" > <use xlink:href="/static/img/sprite.svg#person" /> </svg> <span data-login-dropdown-text>Log in</span>  <svg class="usa-icon ncbi-header__login-dropdown-icon ncbi-header__login-dropdown-icon--expand-less ncbi-header__login-dropdown-icon--hidden" role="graphics-symbol" aria-hidden="true" data-login-dropdown-up-arrow> <use xlink:href="/static/img/sprite.svg#expand_less" /> </svg>  <svg class="usa-icon ncbi-header__login-dropdown-icon ncbi-header__login-dropdown-icon--expand-more ncbi-header__login-dropdown-icon--hidden" role="graphics-symbol" aria-hidden="true" data-login-dropdown-down-arrow> <use xlink:href="/static/img/sprite.svg#expand_more" /> </svg> </button>  <ul class="usa-nav__submenu ncbi-header__login-dropdown-menu" id="login-dropdown-menu" data-desktop-login-menu-dropdown hidden> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/myncbi/" class="usa-link " > Dashboard </a> </li> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/myncbi/collections/bibliography/" class="usa-link " > Publications </a> </li> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/account/settings/" class="usa-link " > Account settings </a> </li> <li class="usa-nav__submenu-item"> <button type="button" class="usa-button usa-button--outline ncbi-header__login-dropdown-logout-button " data-testid="desktopLogoutButton" data-desktop-logout-button > Log out </button> </li> </ul> </div> </div> </div> </div>  <div class="ncbi-search-panel ncbi--show-only-at-desktop" data-testid="searchPanel" data-header-search-panel hidden> <div class="ncbi-search-panel__container"> <form action="https://www.ncbi.nlm.nih.gov/search/all/" aria-describedby="search-field-desktop-navigation-help-text" autocomplete="off" class="usa-search usa-search--big ncbi-search-panel__form" data-testid="form" method="GET" role="search"> <label class="usa-sr-only" data-testid="label" for="search-field-desktop-navigation"> Search… </label> <input class="usa-input" data-testid="textInput" id="search-field-desktop-navigation" name="term" placeholder="Search NCBI" type="search" value="" /> <button type="submit" class="usa-button " data-testid="button" > <span class="usa-search__submit-text"> Search NCBI </span> </button> </form> </div> </div> <nav aria-label="Primary navigation" class="usa-nav"> <p class="usa-sr-only" id="primary-navigation-sr-only-title"> Primary site navigation </p>  <button type="button" class="usa-nav__close ncbi-nav__close-button " aria-label="Close navigation menu" data-testid="navCloseButton" > <img src="/static/img/usa-icons/close.svg" alt="Close" /> </button>  <form class="usa-search usa-search--small ncbi--hide-at-desktop margin-top-6" role="search"> <label class="usa-sr-only" for="search-field"> Search </label> <input class="usa-input" id="search-field-mobile-navigation" type="search" placeholder="Search NCBI" name="search" /> <button type="submit" class="usa-button " >  <img src="data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIGhlaWdodD0iMjQiIHZpZXdCb3g9IjAgMCAyNCAyNCIgd2lkdGg9IjI0Ij48cGF0aCBkPSJNMCAwaDI0djI0SDB6IiBmaWxsPSJub25lIi8+PHBhdGggZmlsbD0iI2ZmZiIgZD0iTTE1LjUgMTRoLS43OWwtLjI4LS4yN0E2LjQ3MSA2LjQ3MSAwIDAgMCAxNiA5LjUgNi41IDYuNSAwIDEgMCA5LjUgMTZjMS42MSAwIDMuMDktLjU5IDQuMjMtMS41N2wuMjcuMjh2Ljc5bDUgNC45OUwyMC40OSAxOWwtNC45OS01em0tNiAwQzcuMDEgMTQgNSAxMS45OSA1IDkuNVM3LjAxIDUgOS41IDUgMTQgNy4wMSAxNCA5LjUgMTEuOTkgMTQgOS41IDE0eiIvPjwvc3ZnPg==" class="usa-search__submit-icon" alt="Search" /> </button> </form>   <div class="ncbi-nav__mobile-login-menu ncbi--hide-at-desktop" data-mobile-login-menu hidden> <p class="ncbi-nav__mobile-login-menu-status"> Logged in as: <strong class="ncbi-nav__mobile-login-menu-email" data-mobile-login-email-text></strong> </p> <ul class="usa-nav__primary usa-accordion"> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/myncbi/" class="usa-link " > Dashboard </a> </li> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/myncbi/collections/bibliography/" class="usa-link " > Publications </a> </li> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/account/settings/" class="usa-link " > Account settings </a> </li> </ul> </div> <button type="button" class="usa-button ncbi-nav__mobile-login-button ncbi--hide-at-desktop " data-testid="mobileLoginButton" data-mobile-login-button > Log in </button> </nav> </header> <section class="pmc-header pmc-header--basic" aria-label="PMC Header with search box"> <div class="pmc-nav-container"> <div class="pmc-header__bar"> <div class="pmc-header__logo"> <a href="/" title="Home" aria-label="PMC Home"></a> </div> <button type="button" class="usa-button usa-button--unstyled pmc-header__search__button" aria-label="Open search" data-ga-category="search" data-ga-action="PMC" data-ga-label="pmc_search_panel_mobile" > <svg class="usa-icon width-4 height-4 pmc-icon__open" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#search"></use> </svg> <svg class="usa-icon width-4 height-4 pmc-icon__close" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#close"></use> </svg> </button> </div> <div class="pmc-header__search"> <form class="usa-search usa-search--extra usa-search--article-right-column pmc-header__search__form" autocomplete="off" role="search"> <label class="usa-sr-only" for="pmc-search">Search PMC Full-Text Archive</label> <span class="autoComplete_wrapper flex-1"> <input class="usa-input width-full maxw-none" required="required" placeholder="Search PMC Full-Text Archive" id="pmc-search" type="search" name="term" data-autocomplete-url="/search/autocomplete/"/> </span> <button class="usa-button" type="submit" formaction="https://www.ncbi.nlm.nih.gov/pmc/" data-ga-category="search" data-ga-action="PMC" data-ga-label="PMC_search_button" > <span class="usa-search__submit-text">Search in PMC</span> <img src="/static/img/usa-icons-bg/search--white.svg" class="usa-search__submit-icon" alt="Search" /> </button> </form> <ul class="pmc-header__search__menu"> <li> <a class="usa-link" href="https://www.ncbi.nlm.nih.gov/pmc/advanced/" data-ga-action="featured_link" data-ga-label="advanced_search"> Advanced Search </a> </li> <li> <a class="usa-link" href="/journals/" data-ga-action="featured_link" data-ga-label="journal list"> Journal List </a> </li> <li> <a class="usa-link" href="/about/userguide/" data-ga-action="featured_link" data-ga-label="user guide"> User Guide </a> </li> </ul> </div> </div> </section> <div class="usa-section padding-top-0 desktop:padding-top-6 pmc-article-section" data-article-db="pmc" data-article-id="7929474"> <div class="grid-container pmc-actions-bar" aria-label="Actions bar" role="complementary"> <div class="grid-row"> <div class="grid-col-fill display-flex"> <div class="display-flex"> <ul class="usa-list usa-list--unstyled usa-list--horizontal"> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex mob"> <button type="button" class="usa-button pmc-sidenav__container__open usa-button--unstyled width-auto display-flex" aria-label="Open resources" data-extra-class="is-visible-resources" data-ga-category="resources_accordion" data-ga-action="click" data-ga-label="mobile_icon" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#more_vert"></use> </svg> </button> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex mob"> <a href="https://doi.org/10.1093/abm/kaaa126" class="usa-link display-flex" role="button" target="_blank" rel="noreferrer noopener" aria-label="View on publisher site" data-ga-category="actions" data-ga-action="click" data-ga-label="publisher_link_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#launch"></use> </svg> </a> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <a href="pdf/kaaa126.pdf" class="usa-link display-flex" role="button" aria-label="Download PDF" data-ga-category="actions" data-ga-action="click" data-ga-label="pdf_download_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> </a> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <button class="usa-button usa-button--unstyled collections-dialog-trigger collections-button display-flex collections-button-empty" aria-label="Save article in MyNCBI collections." data-ga-category="actions" data-ga-action="click" data-ga-label="collections_button_mobile" data-collections-open-dialog-enabled="false" data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpmc.ncbi.nlm.nih.gov%2Farticles%2FPMC7929474%2F%23open-collections-dialog" data-in-collections="false" > <svg class="usa-icon width-4 height-4 usa-icon--bookmark-full" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-full.svg#icon"></use> </svg> <svg class="usa-icon width-4 height-4 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-empty.svg#icon"></use> </svg> </button> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <button role="button" class="usa-button usa-button--unstyled citation-dialog-trigger display-flex" aria-label="Open dialog with citation text in different styles" data-ga-category="actions" data-ga-action="open" data-ga-label="cite_mobile" data-all-citations-url="/resources/citations/7929474/" data-citation-style="nlm" data-download-format-link="/resources/citations/7929474/export/" > <svg class="usa-icon width-4 height-4 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#format_quote"></use> </svg> </button> </li> <li class="pmc-permalink display-flex"> <button type="button" class="usa-button usa-button--unstyled display-flex" aria-label="Show article permalink" aria-expanded="false" aria-haspopup="true" data-ga-category="actions" data-ga-action="open" data-ga-label="permalink_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#share"></use> </svg> </button> <div class="pmc-permalink__dropdown" hidden> <div class="pmc-permalink__dropdown__container"> <h2 class="usa-modal__heading margin-top-0 margin-bottom-2">PERMALINK</h2> <div class="pmc-permalink__dropdown__content"> <input type="text" class="usa-input" value="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/" aria-label="Article permalink"> <button class="usa-button display-inline-flex pmc-permalink__dropdown__copy__btn margin-right-0" title="Copy article permalink" data-ga-category="save_share" data-ga-action="link" data-ga-label="copy_link"> <svg class="usa-icon" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span class="margin-left-1">Copy</span> </button> </div> </div> </div> </li> </ul> </div> <button type="button" class="usa-button pmc-sidenav__container__open usa-button--unstyled width-auto display-flex" aria-label="Open article navigation" data-extra-class="is-visible-in-page" data-ga-category="actions" data-ga-action="open" data-ga-label="article_nav_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#list"></use> </svg> </button> </div> </div> </div> <div class="grid-container desktop:padding-left-6"> <div id="article-container" class="grid-row grid-gap"> <div class="grid-col-12 desktop:grid-col-8 order-2 pmc-layout__content"> <div class="grid-container padding-left-0 padding-right-0"> <div class="grid-row desktop:margin-left-neg-6"> <div class="grid-col-12"> <div class="pmc-layout__disclaimer" role="complementary" aria-label="Disclaimer note"> As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.<br/> Learn more: <a class="usa-link" data-ga-category="Link click" data-ga-action="Disclaimer" data-ga-label="New disclaimer box" href="/about/disclaimer/">PMC Disclaimer</a> | <a class="usa-link" data-ga-category="Link click" data-ga-action="PMC Copyright Notice" data-ga-label="New disclaimer box" href="/about/copyright/"> PMC Copyright Notice </a> </div> </div> </div> <div class="grid-row pmc-wm desktop:margin-left-neg-6">  <main id="main-content" class="usa-layout-docs__main usa-layout-docs grid-col-12 pmc-layout pmc-prose padding-0" > <section class="pmc-journal-banner text-center line-height-none" aria-label="Journal banner"><img src="https://cdn.ncbi.nlm.nih.gov/pmc/banners/logo-abm.jpg" alt="Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine logo" usemap="#pmc-banner-imagemap" width="500" height="75"><map name="pmc-banner-imagemap"><area alt="Link to Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine" title="Link to Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine" shape="default" href="https://academic.oup.com/abm" target="_blank" rel="noopener noreferrer"></map></section><article lang="en"><section aria-label="Article citation and metadata"><section class="pmc-layout__citation font-secondary font-xs"><div> <div class="display-inline-block"><button type="button" class="cursor-pointer text-no-underline bg-transparent border-0 padding-0 text-left margin-0 text-normal text-primary" aria-controls="journal_context_menu">Ann Behav Med</button></div>. 2021 Feb 8;55(2):93–102. doi: <a href="https://doi.org/10.1093/abm/kaaa126" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">10.1093/abm/kaaa126</a> </div> <nav id="journal_context_menu" hidden="hidden"><ul class="menu-list font-family-ui" role="menu"> <li role="presentation"><a href="https://www.ncbi.nlm.nih.gov/pmc/?term=%22Ann%20Behav%20Med%22%5Bjour%5D" class="usa-link" role="menuitem">Search in PMC</a></li> <li role="presentation"><a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Ann%20Behav%20Med%22%5Bjour%5D" lang="en" class="usa-link" role="menuitem">Search in PubMed</a></li> <li role="presentation"><a href="https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Ann%20Behav%20Med%22%5BTitle%20Abbreviation%5D" class="usa-link" role="menuitem">View in NLM Catalog</a></li> <li role="presentation"><a href="?term=%22Ann%20Behav%20Med%22%5Bjour%5D" class="usa-link" role="menuitem" data-add-to-search="true">Add to search</a></li> </ul></nav></section><section class="front-matter"><div class="ameta p font-secondary font-xs"> <hgroup><h1>Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic</h1></hgroup><div class="cg p"> <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Riehm%20KE%22%5BAuthor%5D" class="usa-link" aria-describedby="id1"><span class="name western">Kira E Riehm</span></a><div hidden="hidden" id="id1"> <h3> <span class="name western">Kira E Riehm</span>, <span class="degrees">MSc</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Riehm%20KE%22%5BAuthor%5D" class="usa-link"><span class="name western">Kira E Riehm</span></a> </div> </div> <sup>1,</sup><sup>✉</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Holingue%20C%22%5BAuthor%5D" class="usa-link" aria-describedby="id2"><span class="name western">Calliope Holingue</span></a><div hidden="hidden" id="id2"> <h3> <span class="name western">Calliope Holingue</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p"> <sup>2</sup> Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Holingue%20C%22%5BAuthor%5D" class="usa-link"><span class="name western">Calliope Holingue</span></a> </div> </div> <sup>1,</sup><sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Smail%20EJ%22%5BAuthor%5D" class="usa-link" aria-describedby="id3"><span class="name western">Emily J Smail</span></a><div hidden="hidden" id="id3"> <h3> <span class="name western">Emily J Smail</span>, <span class="degrees">BSc</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Smail%20EJ%22%5BAuthor%5D" class="usa-link"><span class="name western">Emily J Smail</span></a> </div> </div> <sup>1</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kapteyn%20A%22%5BAuthor%5D" class="usa-link" aria-describedby="id4"><span class="name western">Arie Kapteyn</span></a><div hidden="hidden" id="id4"> <h3> <span class="name western">Arie Kapteyn</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>3</sup> Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kapteyn%20A%22%5BAuthor%5D" class="usa-link"><span class="name western">Arie Kapteyn</span></a> </div> </div> <sup>3</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Bennett%20D%22%5BAuthor%5D" class="usa-link" aria-describedby="id5"><span class="name western">Daniel Bennett</span></a><div hidden="hidden" id="id5"> <h3> <span class="name western">Daniel Bennett</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>3</sup> Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Bennett%20D%22%5BAuthor%5D" class="usa-link"><span class="name western">Daniel Bennett</span></a> </div> </div> <sup>3</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Thrul%20J%22%5BAuthor%5D" class="usa-link" aria-describedby="id6"><span class="name western">Johannes Thrul</span></a><div hidden="hidden" id="id6"> <h3> <span class="name western">Johannes Thrul</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p"> <sup>4</sup> Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Thrul%20J%22%5BAuthor%5D" class="usa-link"><span class="name western">Johannes Thrul</span></a> </div> </div> <sup>1,</sup><sup>4</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kreuter%20F%22%5BAuthor%5D" class="usa-link" aria-describedby="id7"><span class="name western">Frauke Kreuter</span></a><div hidden="hidden" id="id7"> <h3> <span class="name western">Frauke Kreuter</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>5</sup> Joint Program in Survey Methodology, University of Maryland, College Park, College Park, MD, USA</div> <div class="p"> <sup>6</sup> School of Social Sciences, University of Mannheim, Mannheim, Germany</div> <div class="p"> <sup>7</sup> Statistical Methods Group, Institute for Employment Research, Nuremberg, Germany</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kreuter%20F%22%5BAuthor%5D" class="usa-link"><span class="name western">Frauke Kreuter</span></a> </div> </div> <sup>5,</sup><sup>6,</sup><sup>7</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22McGinty%20EE%22%5BAuthor%5D" class="usa-link" aria-describedby="id8"><span class="name western">Emma E McGinty</span></a><div hidden="hidden" id="id8"> <h3> <span class="name western">Emma E McGinty</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>8</sup> Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22McGinty%20EE%22%5BAuthor%5D" class="usa-link"><span class="name western">Emma E McGinty</span></a> </div> </div> <sup>8</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kalb%20LG%22%5BAuthor%5D" class="usa-link" aria-describedby="id9"><span class="name western">Luther G Kalb</span></a><div hidden="hidden" id="id9"> <h3> <span class="name western">Luther G Kalb</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p"> <sup>2</sup> Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kalb%20LG%22%5BAuthor%5D" class="usa-link"><span class="name western">Luther G Kalb</span></a> </div> </div> <sup>1,</sup><sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Veldhuis%20CB%22%5BAuthor%5D" class="usa-link" aria-describedby="id10"><span class="name western">Cindy B Veldhuis</span></a><div hidden="hidden" id="id10"> <h3> <span class="name western">Cindy B Veldhuis</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>9</sup> School of Nursing, Columbia University, New York, NY, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Veldhuis%20CB%22%5BAuthor%5D" class="usa-link"><span class="name western">Cindy B Veldhuis</span></a> </div> </div> <sup>9</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Johnson%20RM%22%5BAuthor%5D" class="usa-link" aria-describedby="id11"><span class="name western">Renee M Johnson</span></a><div hidden="hidden" id="id11"> <h3> <span class="name western">Renee M Johnson</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Johnson%20RM%22%5BAuthor%5D" class="usa-link"><span class="name western">Renee M Johnson</span></a> </div> </div> <sup>1</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Fallin%20MD%22%5BAuthor%5D" class="usa-link" aria-describedby="id12"><span class="name western">M Daniele Fallin</span></a><div hidden="hidden" id="id12"> <h3> <span class="name western">M Daniele Fallin</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Fallin%20MD%22%5BAuthor%5D" class="usa-link"><span class="name western">M Daniele Fallin</span></a> </div> </div> <sup>1</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Stuart%20EA%22%5BAuthor%5D" class="usa-link" aria-describedby="id13"><span class="name western">Elizabeth A Stuart</span></a><div hidden="hidden" id="id13"> <h3> <span class="name western">Elizabeth A Stuart</span>, <span class="degrees">PhD</span> </h3> <div class="p"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Stuart%20EA%22%5BAuthor%5D" class="usa-link"><span class="name western">Elizabeth A Stuart</span></a> </div> </div> <sup>1</sup> </div> <ul class="d-buttons inline-list"> <li><button class="d-button" aria-controls="aip_a" aria-expanded="false">Author information</button></li> <li><button class="d-button" aria-controls="anp_a" aria-expanded="false">Article notes</button></li> <li><button class="d-button" aria-controls="clp_a" aria-expanded="false">Copyright and License information</button></li> </ul> <div class="d-panels font-secondary-light"> <div id="aip_a" class="d-panel p" style="display: none"> <div class="p" id="AF0001"> <sup>1</sup> Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Room 798, Baltimore, MD, USA</div> <div id="AF0002"> <sup>2</sup> Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA</div> <div id="AF0003"> <sup>3</sup> Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA</div> <div id="AF0004"> <sup>4</sup> Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia</div> <div id="AF0005"> <sup>5</sup> Joint Program in Survey Methodology, University of Maryland, College Park, College Park, MD, USA</div> <div id="AF0006"> <sup>6</sup> School of Social Sciences, University of Mannheim, Mannheim, Germany</div> <div id="AF0007"> <sup>7</sup> Statistical Methods Group, Institute for Employment Research, Nuremberg, Germany</div> <div id="AF0008"> <sup>8</sup> Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA</div> <div id="AF0009"> <sup>9</sup> School of Nursing, Columbia University, New York, NY, USA</div> <div class="author-notes p"><div class="fn" id="c1"> <sup>✉</sup><p class="display-inline">Kira E. Riehm <span>kriehm@jhu.edu</span></p> </div></div> </div> <div id="anp_a" class="d-panel p" style="display: none"><div class="notes p"><section id="historyarticle-meta1" class="history"><p>Collection date 2021 Feb.</p></section></div></div> <div id="clp_a" class="d-panel p" style="display: none"> <div>© Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.</div> <p>This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (<a href="https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model</a>)</p> <div class="p"><a href="/about/copyright/" class="usa-link">PMC Copyright notice</a></div> </div> </div> <div>PMCID: PMC7929474 PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/33555336/" class="usa-link">33555336</a> </div> </div></section></section><section aria-label="Article content"><section class="body main-article-body"><section class="abstract" id="abstract1"><h2>Abstract</h2> <section id="s0100"><h3 class="pmc_sec_title">Background</h3> <p>Cross-sectional studies have found that the coronavirus disease 2019 (COVID-19) pandemic has negatively affected population-level mental health. Longitudinal studies are necessary to examine trajectories of change in mental health over time and identify sociodemographic groups at risk for persistent distress.</p></section><section id="s0101"><h3 class="pmc_sec_title">Purpose</h3> <p>To examine the trajectories of mental distress between March 10 and August 4, 2020, a key period during the COVID-19 pandemic.</p></section><section id="s0102"><h3 class="pmc_sec_title">Methods</h3> <p>Participants included 6,901 adults from the nationally representative Understanding America Study, surveyed at baseline between March 10 and 31, 2020, with nine follow-up assessments between April 1 and August 4, 2020. Mixed-effects logistic regression was used to examine the association between date and self-reported mental distress (measured with the four-item Patient Health Questionnaire) among U.S. adults overall and among sociodemographic subgroups defined by sex, age, race/ethnicity, household structure, federal poverty line, and census region.</p></section><section id="s0103"><h3 class="pmc_sec_title">Results</h3> <p>Compared to March 11, the odds of mental distress among U.S. adults overall were 1.84 (95% confidence interval [CI] = 1.65–2.07) times higher on April 1 and 1.92 (95% CI = 1.62–2.28) times higher on May 1; by August 1, the odds of mental distress had returned to levels comparable to March 11 (odds ratio [OR] = 0.80, 95% CI = 0.66–0.96). Females experienced a sharper increase in mental distress between March and May compared to males (females: OR = 2.29, 95% CI = 1.85–2.82; males: OR = 1.53, 95% CI = 1.15–2.02).</p></section><section id="s0104"><h3 class="pmc_sec_title">Conclusions</h3> <p>These findings highlight the trajectory of mental health symptoms during an unprecedented pandemic, including the identification of populations at risk for sustained mental distress.</p></section><section id="kwd-group1" class="kwd-group"><p><strong>Keywords:</strong> COVID-19, Mental health, Sociodemographic disparities, Psychiatric epidemiology</p></section></section><section class="abstract" id="abstract2"><hr class="headless"> <p>The prevalence of mental distress among U.S. adults fluctuated between March and August 2020, with a peak observed in mid-April; women experienced a proportionally larger increase in prevalence of mental distress compared to men.</p></section><section id="s1"><h2 class="pmc_sec_title">Introduction</h2> <p>The coronavirus disease 2019 (COVID-19) pandemic, declared a national emergency by President Trump on March 13, 2020 [<a href="#CIT0001" class="usa-link" aria-describedby="CIT0001">1</a>], has induced unprecedented changes to daily life in the USA. Starting with California on March 19, 2020, stay-at-home orders swept across the nation, eventually covering approximately 95% of the population [<a href="#CIT0002" class="usa-link" aria-describedby="CIT0002">2</a>]. Unemployment rates skyrocketed to historical highs of almost 15% in April and remained high throughout the summer [<a href="#CIT0003" class="usa-link" aria-describedby="CIT0003">3</a>]. On May 28, 2020, the death toll from COVID-19 surpassed 100,000 deaths and has continued to climb since, with projections of an increased caseload during the fall and winter months [<a href="#CIT0004" class="usa-link" aria-describedby="CIT0004">4</a>]. Collectively, these tragic events represent devastating losses to Americans—losses of social connectedness, stable employment, and the lives of family and friends—and are likely to have significant implications for population-level mental health [<a href="#CIT0005" class="usa-link" aria-describedby="CIT0005">5–7</a>].</p> <p>Models of changes in mental distress after disasters, developed based on evidence from natural disasters and other public health crises, suggest that the prevalence of mental distress is likely to fluctuate in the population across the phases of the COVID-19 pandemic [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>]. Mental distress refers to distress in response to an external stressor and can be characterized by anxiety, depression, and loneliness; this is different from a psychological disorder (e.g., major depression) that is a pattern of persistent behavioral or psychological symptoms that can influence multiple areas of life [<a href="#CIT0009" class="usa-link" aria-describedby="CIT0009">9</a>]. Initial response to an external stressor, such as a pandemic, is often uncertainty and fear followed by panic and shock. Other responses to external stressors can include a honeymoon phase, where an individual might engage in altruistic behaviors and confidence in a return to normal, and a disillusionment phase, where optimism wanes and prolonged stress results in exhaustion [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>]. A number of commentaries and reviews have been written about the potential impact of the COVID-19 pandemic on mental distress [<a href="#CIT0006" class="usa-link" aria-describedby="CIT0006">6</a>, <a href="#CIT0007" class="usa-link" aria-describedby="CIT0007">7</a>, <a href="#CIT0010" class="usa-link" aria-describedby="CIT0010">10–12</a>]. One study compared the prevalence of symptoms of serious psychological distress between two nationally representative samples of adults and found a higher prevalence of symptoms of serious psychological distress in April 2020 compared to 2018 (13.6% vs. 3.9%) [<a href="#CIT0013" class="usa-link" aria-describedby="CIT0013">13</a>]. Similarly, a study comparing the prevalence of depressive symptoms between 2017–2018 and April 2020 in two population-based surveys showed an increase of more than threefold [<a href="#CIT0014" class="usa-link" aria-describedby="CIT0014">14</a>]. Another study observed increases in the prevalence of mental distress between March 10 and March 16, 2020, in states with early COVID-19 activity [<a href="#CIT0005" class="usa-link" aria-describedby="CIT0005">5</a>]. Finally, a study of three consecutive, nationally representative samples collected between March 18 andApril 18, 2020, observed significant increases in symptoms of acute stress and depression over time [<a href="#CIT0015" class="usa-link" aria-describedby="CIT0015">15</a>].</p> <p>Together, these studies provide important preliminary evidence about how the COVID-19 pandemic may have influenced mental distress. However, longitudinal evidence remains scant; the existing literature is limited to the early months of the pandemic or focuses only on high-risk populations [<a href="#CIT0016" class="usa-link" aria-describedby="CIT0016">16</a>]. It is essential to current and future public health planning to understand how population-level mental distress has changed over time and if there are sociodemographic subgroups that may be at high risk of mental distress. Indeed, the negative ramifications of the COVID-19 pandemic, including caseload, mortality, and loss of employment, has disproportionately affected racial/ethnic minorities, low-income adults, young adults, and women, which may, in turn, translate to greater mental distress [<a href="#CIT0017" class="usa-link" aria-describedby="CIT0017">17–19</a>]. To address this need, we conducted a descriptive study of the epidemiology of mental distress over the course of the COVID-19 pandemic. Specifically, our objectives were to (a) examine changes in the prevalence of mental distress from March 10 to August 4, 2020, among U.S. adults and (b) determine if trajectories of mental distress differed between key sociodemographic subgroups. We hypothesized that sociodemographic groups made vulnerable to the negative implications of the COVID-19 pandemic would be more likely to experience adverse patterns of mental distress (i.e., greater relative increases over time and blunted recovery).</p></section><section id="s2"><h2 class="pmc_sec_title">Methods</h2> <section id="s3"><h3 class="pmc_sec_title">Participants</h3> <p>Participants were drawn from the Understanding America Study (UAS), a probability-based, nationally representative Internet panel of adults (18 years and older) representing the USA. Addresses used to sample participants come from the U.S. Postal Service Delivery Sequence file, prepared by the Marketing Systems Group to form a sampling frame of all household addresses in the USA. The recruitment involves several steps, including prepaid and conditional incentives and several reminders. Potential participants without prior internet access are provided with tablets and broadband internet connections. Once respondents have joined the panel, they are surveyed via computer, mobile device, or tablet. Respondents were compensated with $20 for 30 min of survey time. Informed consent was sought from all participants. UAS panel procedures have been approved by the University of Southern California Institutional Review Board. Additional details regarding the UAS methodology can be found on the UAS website (<a href="https://UASdata.usc.edu" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://UASdata.usc.edu</a>).</p> <p>The baseline wave of data collection consisted of a tracking survey fielded on March 10; respondents had until March 31 to complete the survey. Starting on April 1, respondents were invited to participate in biweekly surveys according to a staggered schedule, whereby one fourteenth of the sample was invited every day. Participants who consented to further surveys completed follow-up surveys every 14 days between April 1 and August 4, during which there were nine follow-up surveys administered.</p> <p>Overall, there were 8,547 eligible panel members. The response rate at baseline was 81.8%, and the average response rate across the nine follow-up surveys was 72.2%. Given the low proportion of missing data across the study period (6.4%), we included only complete cases at each time point in our analyses. Altogether, 6,901 participants were included in our analyses. These participants completed an average of 8.5 out of 10 possible surveys (baseline and nine follow-up surveys). <a href="#F1" class="usa-link">Figure 1</a> presents the details of participant inclusion, response rates, and the proportion of missing data at each survey. <a href="#sup1" class="usa-link">Supplementary Table 1</a> presents the number of observations per day, and <a href="#sup1" class="usa-link">Supplementary Table 2</a> presents comparisons between participants completing all 10 surveys to those completing 9 or fewer surveys.</p> <figure class="fig xbox font-sm" id="F1"><h4 class="obj_head">Fig. 1.</h4> <p class="img-box line-height-none margin-x-neg-2 tablet:margin-x-0 text-center"><a class="tileshop" target="_blank" href="https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7962764_kaaa126_fig1.jpg"><img class="graphic zoom-in" src="https://cdn.ncbi.nlm.nih.gov/pmc/blobs/f22f/7962764/4a8bf1312b2d/kaaa126_fig1.jpg" loading="lazy" height="1431" width="762" alt="Fig. 1."></a></p> <div class="p text-right font-secondary"><a href="figure/F1/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <figcaption><p>Participant flow diagram.</p></figcaption></figure></section></section><section id="s4"><h2 class="pmc_sec_title">Measures</h2> <section id="s5"><h3 class="pmc_sec_title">Mental Distress</h3> <p>The outcome of interest was mental distress, measured with the four-item Patient Health Questionnaire (PHQ-4) [<a href="#CIT0020" class="usa-link" aria-describedby="CIT0020">20</a>]. The PHQ-4 has been demonstrated to have adequate construct validity and is reliable in the general population [<a href="#CIT0021" class="usa-link" aria-describedby="CIT0021">21</a>]. Two items measuring depressive symptoms are drawn from the PHQ-9, and two items measuring anxiety symptoms are drawn from the seven-item Generalized Anxiety Disorder scale [<a href="#CIT0020" class="usa-link" aria-describedby="CIT0020">20</a>]. Participants were asked for the frequency over the past 2 weeks with which they had been bothered by “feeling nervous, anxious, or on edge,” “not being able to stop or control worrying,” “feeling down, depressed, or hopeless,” and “little interest or pleasure in doing things.” Scores were obtained by summing the four items (range 0–12), which were classified into categories indicating mental distress severity based on validated cut points (normal [0–2], mild [3–5], moderate [6–8], or severe [9–12]) [<a href="#CIT0020" class="usa-link" aria-describedby="CIT0020">20</a>]. We dichotomized these categories into a binary outcome (normal vs. mild/moderate/severe mental distress).</p></section><section id="s6"><h3 class="pmc_sec_title">Survey Date</h3> <p>We used survey date as the time scale to assess changes over time. Survey date was entered into each model as a continuous variable representing the number of days since March 10, ending on August 4 (range, 0–147). Given the evidence of nonlinear changes in mental distress over time, we modeled survey date with restricted cubic splines, which generate smoothed curves for longitudinal continuous exposures. Cubic splines capture features that may be missed by traditional techniques, such as linear models or categorization into bins [<a href="#CIT0022" class="usa-link" aria-describedby="CIT0022">22</a>]. We generated splines with five knots using the percentiles recommended by Harrell (5, 27.5, 50, 72.5, and 95) [<a href="#CIT0023" class="usa-link" aria-describedby="CIT0023">23</a>]. The knots corresponded to the following dates: March 12 (Day 2), April 26 (Day 47), May 27 (Day 78), June 29 (Day 111), and July 29 (Day 141).</p></section><section id="s7"><h3 class="pmc_sec_title">Sociodemographic Characteristics</h3> <p>Sociodemographic characteristics were measured at baseline as time-fixed variables. These included age (18–29, 30–49, 50–64, or 65+), sex (female or male), race/ethnicity (monoracial non-Hispanic White, monoracial Non-Hispanic Black, Hispanic/Latino, or other), and state of residence classified according to census regions (Midwest, South, West, and Northeast). We also included an indicator for whether an individual was living in a household above or below the Federal Poverty Line (FPL). Data for household income was recorded in categories; we calculated the median for each category and divided this by the number of individuals reported in the household to estimate the income per household member. This was used to classify individuals as living in a household above or below the poverty line according to the 2020 Federal Poverty Guidelines. We also included a variable reflecting the household structure in which an individual resided. Respondents reported their relationships to other household members and the ages of those members; we used this to classify individuals into five categories of household structure (living alone, living with a partner only, living with a partner and children, living with children only, and other).</p></section><section id="s8"><h3 class="pmc_sec_title">Statistical Analysis</h3> <section id="s9"><h4 class="pmc_sec_title">Association of date and sociodemographic characteristics with <em>mental distress</em> </h4> <p>We used mixed-effects logistic regression models with a random effect for participants to accommodate repeated measures. Analyses were conducted in three stages. First, we estimated a series of univariate models to examine the association of each sociodemographic characteristic with the prevalence of mental distress across the entire survey period. Second, we estimated a single model with the splines for days since March 10 as covariates to examine the trajectory of mental distress over time among all U.S. adults. Third, we estimated a series of models with interactions between the splines for days since March 10 and each sociodemographic characteristic to determine whether trajectories of mental distress over time differed between sociodemographic subgroups. Wald tests were used to determine whether interactions were significant. The <em>margins</em> and the <em>xbrcspline</em> commands in Stata were used to generate predicted probabilities of mental distress and to estimate odds ratios (ORs) for mental distress on given survey dates compared to March 11, respectively, in the overall sample and stratified by each sociodemographic subgroup [<a href="#CIT0024" class="usa-link" aria-describedby="CIT0024">24</a>]. March 11 was used as the reference date instead of March 10 due to a higher number of observations (2,252 vs. 415, respectively).</p></section><section id="s10"><h4 class="pmc_sec_title">Sensitivity analyses</h4> <p>We conducted four sets of analyses to test the sensitivity of our results to multivariate adjustment for other sociodemographic characteristics, alternative dichotomizations of PHQ-4 scores, modeling with ordinal logistic regression, and use of survey weights (see <a href="#sup1" class="usa-link">Supplementary Material</a>).</p></section><section id="s11"><h4 class="pmc_sec_title">Inference</h4> <p>All analyses incorporated survey weights that account for probabilities of sample selection and survey nonresponse and are aligned with Current Population Survey benchmarks. Missing observations due to survey nonresponse were handled with full information maximum likelihood estimation. Statistical significance was assessed at the <em>p</em> < .05 level. Analyses were conducted using Stata version 16 (StataCorp Inc., College Station, TX) and R (R studio version 1.2.5042; R version 4.0.0).</p></section></section></section><section id="s12"><h2 class="pmc_sec_title">Results</h2> <section id="s13"><h3 class="pmc_sec_title">Associations of Sociodemographic Characteristics With the Prevalence of Mental Distress</h3> <p>The sample characteristics and ORs for prevalence of mental distress across the study period are reported in <a href="#T1" class="usa-link">Table 1</a>. The odds of mental distress were higher in female (OR = 4.00; 95% confidence interval [CI] = 3.47–4.61) compared to male respondents; Hispanic/Latino (OR = 1.78; 95% CI = 1.44–2.19) and other race/ethnicity (OR = 1.36; 95% CI = 1.44–2.19) compared to White respondents; adults living alone (OR = 2.81; 95% CI = 2.27–3.48), with a partner and children (OR = 1.82; 95% CI = 1.51–2.20), with children only (OR = 3.96; 95% CI = 2.79–5.61), and in other household structures (OR = 3.75; 95% CI = 3.10–4.55) compared to adults living with a partner only; adults living below the FPL (OR = 4.58; 95% CI = 3.67–5.73), compared to above the FPL; and adults living in the West (OR = 1.79; 95% CI = 1.50–2.13) census region compared to the South census region. The odds of mental distress were lower in older-age groups (30–49: OR = 0.38; 95% CI = 0.29–0.49; 50–64: OR = 0.19; 95% CI = 0.15–0.24; 65+: OR = 0.09; 95% CI = 0.07–0.11) compared to those aged 18–29 and in Black respondents compared to White respondents (OR = 0.56; 95% CI = 0.43–0.71).</p> <section class="tw xbox font-sm" id="T1"><h4 class="obj_head">Table 1.</h4> <div class="caption p"><p>Descriptive statistics of sample characteristics for U.S. adults at the first survey wave and associations with mental distress across the survey period (<em>N</em> = 6,901)</p></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="vsides" rules="groups"> <thead><tr> <th rowspan="1" colspan="1">Variable</th> <th rowspan="1" colspan="1"> <em>n</em> (%)</th> <th rowspan="1" colspan="1">OR (95% CI)</th> </tr></thead> <tbody> <tr> <td rowspan="1" colspan="1">Sex</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Male</td> <td rowspan="1" colspan="1">2,860 (48.3)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> Female</td> <td rowspan="1" colspan="1">4,041 (51.7)</td> <td rowspan="1" colspan="1"> <strong>4.00 (3.47, 4.61)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1">Age</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> 18–29</td> <td rowspan="1" colspan="1">822 (13.2)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> 30–49</td> <td rowspan="1" colspan="1">2,546 (40.5)</td> <td rowspan="1" colspan="1"> <strong>0.38 (0.29, 0.49)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> 50–64</td> <td rowspan="1" colspan="1">2,042 (26.5)</td> <td rowspan="1" colspan="1"> <strong>0.19 (0.15, 0.24)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> 65+</td> <td rowspan="1" colspan="1">1,491 (19.8)</td> <td rowspan="1" colspan="1"> <strong>0.09 (0.07, 0.11)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1">Race</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> White</td> <td rowspan="1" colspan="1">4,515 (62.7)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> Black</td> <td rowspan="1" colspan="1">538 (11.9)</td> <td rowspan="1" colspan="1"> <strong>0.56 (0.43, 0.71)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> Hispanic/Latino</td> <td rowspan="1" colspan="1">1,140 (16.7)</td> <td rowspan="1" colspan="1"> <strong>1.78 (1.44, 2.19)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> Other</td> <td rowspan="1" colspan="1">708 (8.7)</td> <td rowspan="1" colspan="1"> <strong>1.36 (1.06, 1.73)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1">Household structure</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> With partner only</td> <td rowspan="1" colspan="1">2,030 (27.9)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> Alone</td> <td rowspan="1" colspan="1">1,170 (16.2)</td> <td rowspan="1" colspan="1"> <strong>2.81 (2.27, 3.48)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> With partner and kids</td> <td rowspan="1" colspan="1">1,637 (24.7)</td> <td rowspan="1" colspan="1"> <strong>1.82 (1.51, 2.20)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> With kids only</td> <td rowspan="1" colspan="1">306 (4.5)</td> <td rowspan="1" colspan="1"> <strong>3.96 (2.79, 5.61)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> Other</td> <td rowspan="1" colspan="1">1,758 (26.6)</td> <td rowspan="1" colspan="1"> <strong>3.75 (3.10, 4.55)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1">Federal poverty line</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Above</td> <td rowspan="1" colspan="1">5,992 (83.8)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> Below</td> <td rowspan="1" colspan="1">909 (16.2)</td> <td rowspan="1" colspan="1"> <strong>4.58 (3.67, 5.73)</strong> </td> </tr> <tr> <td rowspan="1" colspan="1">Census region</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> South</td> <td rowspan="1" colspan="1">1,778 (38.0)</td> <td rowspan="1" colspan="1">ref.</td> </tr> <tr> <td rowspan="1" colspan="1"> Midwest</td> <td rowspan="1" colspan="1">1,593 (20.7)</td> <td rowspan="1" colspan="1">0.94 (0.78, 1.14)</td> </tr> <tr> <td rowspan="1" colspan="1"> Northeast</td> <td rowspan="1" colspan="1">725 (17.5)</td> <td rowspan="1" colspan="1">1.12 (0.88, 1.41)</td> </tr> <tr> <td rowspan="1" colspan="1"> West</td> <td rowspan="1" colspan="1">2,805 (23.8)</td> <td rowspan="1" colspan="1"> <strong>1.79 (1.50, 2.13)</strong> </td> </tr> </tbody> </table></div> <div class="p text-right font-secondary"><a href="table/T1/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <div class="tw-foot p"><div class="fn" id="fn-0100"><p>All percentages are weighted. Bold font indicates statistical significance.</p></div></div></section></section><section id="s14"><h3 class="pmc_sec_title">Trajectory of Mental Distress Over Time</h3> <p>ORs for mental distress on given days, compared to March 11, are reported in <a href="#T2" class="usa-link">Table 2</a>. Compared to March 11, the odds of mental distress among U.S. adults overall were 1.84 (95% CI = 1.65–2.07) times higher on April 1, 1.92 (95% CI = 1.62–2.28) times higher on May 1, 0.82 (95% CI = 0.69–0.96) times lower on June 1, 0.83 (95% CI = 0.70–1.00) times lower on July 1, and 0.80 (95% CI = 0.66–0.96) times lower on August 1.</p> <section class="tw xbox font-sm" id="T2"><h4 class="obj_head">Table 2.</h4> <div class="caption p"><p>Odds ratios (ORs) for mental distress on different dates in the survey period, compared to March 11, 2020, overall and stratified by sociodemographic characteristics</p></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="vsides" rules="groups"> <thead> <tr> <th rowspan="1" colspan="1">Population</th> <th rowspan="1" colspan="1">Prevalence of mental distress on March 11 (%)</th> <th rowspan="1" colspan="1">OR for mental distress<sup>a</sup>, OR (95% CI)</th> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1"> <em>p</em>-value <em>for</em> interaction<sup>b</sup> </th> </tr> <tr> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1"></th> <th rowspan="1" colspan="1">April 1</th> <th rowspan="1" colspan="1">May 1</th> <th rowspan="1" colspan="1">June 1</th> <th rowspan="1" colspan="1">July 1</th> <th rowspan="1" colspan="1">August 1</th> <th rowspan="1" colspan="1"></th> </tr> </thead> <tbody> <tr> <td rowspan="1" colspan="1">Overall</td> <td rowspan="1" colspan="1">26.1</td> <td rowspan="1" colspan="1"> <strong>1.84 (1.65, 2.07)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.92 (1.62, 2.28)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.82 (0.69, 0.96)</strong> </td> <td rowspan="1" colspan="1">0.83 (0.70, 1.00)</td> <td rowspan="1" colspan="1"> <strong>0.80 (0.66, 0.96)</strong> </td> <td rowspan="1" colspan="1">N/A</td> </tr> <tr> <td rowspan="1" colspan="1">Sex</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Male</td> <td rowspan="1" colspan="1">20.3</td> <td rowspan="1" colspan="1"> <strong>1.69 (1.41, 2.02)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.53 (1.15, 2.02)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.62 (0.48, 0.82)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.74 (0.55, 0.99)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.60 (0.44, 0.83)</strong> </td> <td rowspan="1" colspan="1"> <strong>.014</strong> </td> </tr> <tr> <td rowspan="1" colspan="1"> Female</td> <td rowspan="1" colspan="1">30.2</td> <td rowspan="1" colspan="1"> <strong>1.98 (1.72, 2.28)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.29 (1.85, 2.82)</strong> </td> <td rowspan="1" colspan="1">0.99 (0.82, 1.21)</td> <td rowspan="1" colspan="1">0.91 (0.73, 1.14)</td> <td rowspan="1" colspan="1">0.97 (0.77, 1.23)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1">Age</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> 18–29</td> <td rowspan="1" colspan="1">41.8</td> <td rowspan="1" colspan="1"> <strong>1.39 (1.01, 1.91)</strong> </td> <td rowspan="1" colspan="1">1.27 (0.80, 2.03)</td> <td rowspan="1" colspan="1"> <strong>0.58 (0.37, 0.90)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.47 (0.28, 0.80)</strong> </td> <td rowspan="1" colspan="1">0.63 (0.35, 1.13)</td> <td rowspan="1" colspan="1">.674</td> </tr> <tr> <td rowspan="1" colspan="1"> 30–49</td> <td rowspan="1" colspan="1">29.2</td> <td rowspan="1" colspan="1"> <strong>2.09 (1.72, 2.53)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.32 (1.74, 3.11)</strong> </td> <td rowspan="1" colspan="1">0.94 (0.72, 1.23)</td> <td rowspan="1" colspan="1">0.99 (0.74, 1.33)</td> <td rowspan="1" colspan="1">0.83 (0.61, 1.13)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> 50–64</td> <td rowspan="1" colspan="1">24.9</td> <td rowspan="1" colspan="1"> <strong>1.82 (1.49, 2.21)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.84 (1.37, 2.47)</strong> </td> <td rowspan="1" colspan="1">0.77 (0.57, 1.03)</td> <td rowspan="1" colspan="1">0.81 (0.59, 1.11)</td> <td rowspan="1" colspan="1">0.78 (0.56, 1.09)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> 65+</td> <td rowspan="1" colspan="1">16.2</td> <td rowspan="1" colspan="1"> <strong>1.82 (1.42, 2.33)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.93 (1.33, 2.80)</strong> </td> <td rowspan="1" colspan="1">0.88 (0.62, 1.26)</td> <td rowspan="1" colspan="1">0.94 (0.64, 1.40)</td> <td rowspan="1" colspan="1">0.94 (0.62, 1.41)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1">Race</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> White</td> <td rowspan="1" colspan="1">24.9</td> <td rowspan="1" colspan="1"> <strong>1.91 (1.67, 2.19)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.92 (1.58, 2.35)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.75 (0.62, 0.90)</strong> </td> <td rowspan="1" colspan="1">0.81 (0.66, 1.00)</td> <td rowspan="1" colspan="1"> <strong>0.74 (0.60, 0.92)</strong> </td> <td rowspan="1" colspan="1">.811</td> </tr> <tr> <td rowspan="1" colspan="1"> Black</td> <td rowspan="1" colspan="1">20.1</td> <td rowspan="1" colspan="1"> <strong>1.39 (0.94, 2.06)</strong> </td> <td rowspan="1" colspan="1">1.50 (0.85, 2.65)</td> <td rowspan="1" colspan="1">0.93 (0.57, 1.53)</td> <td rowspan="1" colspan="1">0.73 (0.41, 1.32)</td> <td rowspan="1" colspan="1">0.74 (0.40, 1.36)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Hispanic/Latino</td> <td rowspan="1" colspan="1">32.1</td> <td rowspan="1" colspan="1"> <strong>1.93 (1.41, 2.65)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.13 (1.31, 3.47)</strong> </td> <td rowspan="1" colspan="1">0.92 (0.58, 1.45)</td> <td rowspan="1" colspan="1">0.92 (0.55, 1.55)</td> <td rowspan="1" colspan="1">0.96 (0.54, 1.71)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Other</td> <td rowspan="1" colspan="1">29.5</td> <td rowspan="1" colspan="1"> <strong>1.84 (1.27, 2.65)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.12 (1.17, 3.86)</strong> </td> <td rowspan="1" colspan="1">1.03 (0.52, 2.05)</td> <td rowspan="1" colspan="1">0.92 (0.47, 1.81)</td> <td rowspan="1" colspan="1">0.96 (0.46, 1.99)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1">Household structure</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> With partner only</td> <td rowspan="1" colspan="1">21.1</td> <td rowspan="1" colspan="1"> <strong>1.76 (1.42, 2.17)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.83 (1.33, 2.51)</strong> </td> <td rowspan="1" colspan="1">0.84 (0.61, 1.14)</td> <td rowspan="1" colspan="1">0.88 (0.62, 1.23)</td> <td rowspan="1" colspan="1">0.93 (0.64, 1.33)</td> <td rowspan="1" colspan="1">.589</td> </tr> <tr> <td rowspan="1" colspan="1"> Alone</td> <td rowspan="1" colspan="1">26.4</td> <td rowspan="1" colspan="1"> <strong>1.59 (1.23, 2.07)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.58 (1.08, 2.32)</strong> </td> <td rowspan="1" colspan="1">0.80 (0.55, 1.16)</td> <td rowspan="1" colspan="1">0.86 (0.58, 1.26)</td> <td rowspan="1" colspan="1">0.78 (0.51, 1.19)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> With partner and kids</td> <td rowspan="1" colspan="1">25.4</td> <td rowspan="1" colspan="1"> <strong>2.04 (1.61, 2.59)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.02 (1.40, 2.91)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.69 (0.49, 0.97)</strong> </td> <td rowspan="1" colspan="1">0.76 (0.52, 1.10)</td> <td rowspan="1" colspan="1">0.72 (0.49, 1.06)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> With kids only</td> <td rowspan="1" colspan="1">24.1</td> <td rowspan="1" colspan="1"> <strong>1.92 (1.19, 3.09)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.04 (1.00, 4.18)</strong> </td> <td rowspan="1" colspan="1">0.89 (0.47, 1.67)</td> <td rowspan="1" colspan="1">1.03 (0.51, 2.11)</td> <td rowspan="1" colspan="1">1.13 (0.50, 2.56)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Other</td> <td rowspan="1" colspan="1">33.1</td> <td rowspan="1" colspan="1"> <strong>1.92 (1.53, 2.42)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.17 (1.54, 3.05)</strong> </td> <td rowspan="1" colspan="1">0.94 (0.68, 1.29)</td> <td rowspan="1" colspan="1">0.81 (0.56, 1.18)</td> <td rowspan="1" colspan="1">0.70 (0.47, 1.05)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1">Federal poverty line</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Above</td> <td rowspan="1" colspan="1">24.1</td> <td rowspan="1" colspan="1"> <strong>1.93 (1.71, 2.19)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.06 (1.71, 2.47)</strong> </td> <td rowspan="1" colspan="1">0.85 (0.71, 1.01)</td> <td rowspan="1" colspan="1">0.87 (0.72, 1.06)</td> <td rowspan="1" colspan="1">0.83 (0.67, 1.02)</td> <td rowspan="1" colspan="1">.496</td> </tr> <tr> <td rowspan="1" colspan="1"> Below</td> <td rowspan="1" colspan="1">39.1</td> <td rowspan="1" colspan="1"> <strong>1.46 (1.08, 1.97)</strong> </td> <td rowspan="1" colspan="1">1.39 (0.89, 2.17)</td> <td rowspan="1" colspan="1">0.70 (0.46, 1.08)</td> <td rowspan="1" colspan="1">0.68 (0.42, 1.08)</td> <td rowspan="1" colspan="1">0.67 (0.41, 1.10)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1">Census region</td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> South</td> <td rowspan="1" colspan="1">23.4</td> <td rowspan="1" colspan="1"> <strong>1.77 (1.46, 2.14)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.75 (1.32, 2.32)</strong> </td> <td rowspan="1" colspan="1"> <strong>0.72 (0.55, 0.94)</strong> </td> <td rowspan="1" colspan="1">0.73 (0.54, 1.00)</td> <td rowspan="1" colspan="1">0.79 (0.57, 1.11)</td> <td rowspan="1" colspan="1">.930</td> </tr> <tr> <td rowspan="1" colspan="1"> Midwest</td> <td rowspan="1" colspan="1">25.7</td> <td rowspan="1" colspan="1"> <strong>1.87 (1.51, 2.33)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.02 (1.44, 2.85)</strong> </td> <td rowspan="1" colspan="1">0.90 (0.64, 1.27)</td> <td rowspan="1" colspan="1">0.93 (0.63, 1.36)</td> <td rowspan="1" colspan="1">0.87 (0.58, 1.31)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> Northeast</td> <td rowspan="1" colspan="1">26.7</td> <td rowspan="1" colspan="1"> <strong>2.02 (1.43, 2.84)</strong> </td> <td rowspan="1" colspan="1"> <strong>2.08 (1.25, 3.46)</strong> </td> <td rowspan="1" colspan="1">0.75 (0.48, 1.17)</td> <td rowspan="1" colspan="1">0.73 (0.46, 1.17)</td> <td rowspan="1" colspan="1">0.68 (0.40, 1.16)</td> <td rowspan="1" colspan="1"></td> </tr> <tr> <td rowspan="1" colspan="1"> West</td> <td rowspan="1" colspan="1">27.8</td> <td rowspan="1" colspan="1"> <strong>1.82 (1.51, 2.19)</strong> </td> <td rowspan="1" colspan="1"> <strong>1.98 (1.48, 2.65)</strong> </td> <td rowspan="1" colspan="1">0.95 (0.72, 1.26)</td> <td rowspan="1" colspan="1">0.98 (0.72, 1.34)</td> <td rowspan="1" colspan="1">0.83 (0.61, 1.14)</td> <td rowspan="1" colspan="1"></td> </tr> </tbody> </table></div> <div class="p text-right font-secondary"><a href="table/T2/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <div class="tw-foot p"> <div class="fn" id="fn-0101"><p>Bold font indicates statistical significance.</p></div> <div class="fn" id="fn-0102"><p> <sup>a</sup>Reference is odds of mental distress on March 11, 2020.</p></div> <div class="fn" id="fn-0103"><p> <sup>b</sup>Interaction terms are between the splines for days since March 10, 2020 and each sociodemographic characteristic.</p></div> </div></section></section><section id="s15"><h3 class="pmc_sec_title">Trajectories of Mental Distress Over Time Among Sociodemographic Subgroups</h3> <p>Predicted probabilities of mental distress and 95% CIs on each day of the survey period, for each sociodemographic subgroup, are displayed in <a href="#F2" class="usa-link">Fig. 2</a>. Interactions between survey date and age, race/ethnicity, household structure, FPL, and census region were not statistically significant. The interaction between survey date and sex was statistically significant, indicating that trajectories of mental distress differed between males and females. Females experienced a sharper increase in mental distress between March and May than males (females: OR = 2.29, 95% CI = 1.85–2.82; males: OR = 1.53, 95% CI = 1.15–2.02), and mental distress declined more precipitously among males than females moving into June (females: OR = 0.99, 95% CI = 0.82–1.21; males: OR = 0.62, 95% CI = 0.48–0.82).</p> <figure class="fig xbox font-sm" id="F2"><h4 class="obj_head">Fig. 2.</h4> <p class="img-box line-height-none margin-x-neg-2 tablet:margin-x-0 text-center"><a class="tileshop" target="_blank" href="https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7962764_kaaa126_fig2.jpg"><img class="graphic zoom-in" src="https://cdn.ncbi.nlm.nih.gov/pmc/blobs/f22f/7962764/a7ed36f70259/kaaa126_fig2.jpg" loading="lazy" height="1734" width="773" alt="Fig. 2."></a></p> <div class="p text-right font-secondary"><a href="figure/F2/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <figcaption><p>Predicted probabilities (bold lines) of self-reported mental distress with 95% confidence intervals (shaded areas) by date of survey completion, stratified by different sociodemographic characteristics, among U.S. adults in the UAS Panel, 2020 (<em>n</em> = 6,901).</p></figcaption></figure></section><section id="s16"><h3 class="pmc_sec_title">Sensitivity Analyses</h3> <p>The results of the sensitivity analyses are described in the <a href="#sup1" class="usa-link">Supplementary Material</a>. In analyses with an alternative dichotomization of PHQ-4 scores, the interaction term between the splines for survey date and sex was not statistically significant, suggesting that the movement between the normal and mild categories of mental distress primarily accounted for the differences in trajectories between male and female participants. Otherwise, the pattern of results was broadly consistent with the main analyses.</p></section></section><section id="s17"><h2 class="pmc_sec_title">Discussion</h2> <p>In this study, we examined longitudinal changes in mental distress in a nationally representative sample of U.S. adults between March 10 and August 4, 2020. The prevalence of mental distress appeared to peak in mid-April to early May and declined thereafter. By June 1, the odds of mental distress were comparable to the odds observed on March 11, and this remained the case throughout the remainder of the study period ending on August 4. Across the study period, sociodemographic characteristics associated with a heightened prevalence of mental distress included female sex; younger age; Hispanic/Latino race/ethnicity; living alone, with a partner and children, with children only, or in another household structure; living below the FPL; and living in states in the West census region. Trajectories of mental distress over the four-and-a-half month study period were broadly similar between sociodemographic subgroups. However, differences at some points in the study period were observed between females and males; specifically, females experienced a greater relative increase in mental distress in April and May and a slower decrease thereafter compared to males. Collectively, these findings suggest that public health responses to the COVID-19 pandemic should implement universal and selective approaches to address the needs of both the population at large and specific sociodemographic subgroups.</p> <p>Sex, age, and race/ethnicity are sociodemographic characteristics that are often associated with mental distress [<a href="#CIT0025" class="usa-link" aria-describedby="CIT0025">25</a>, <a href="#CIT0026" class="usa-link" aria-describedby="CIT0026">26</a>]. In the context of the COVID-19 pandemic, another study found that low-income status, Hispanic/Latino ethnicity, and younger age (i.e., 18–29) were associated with serious psychological distress during April 2020 [<a href="#CIT0013" class="usa-link" aria-describedby="CIT0013">13</a>]. These sociodemographic differences in mental distress, as well as others observed in our study, are likely to stem from a variety of sources. These include regional differences in COVID-19 activity; a second pandemic of systemic racism [<a href="#CIT0019" class="usa-link" aria-describedby="CIT0019">19</a>]; prolonged social isolation [<a href="#CIT0006" class="usa-link" aria-describedby="CIT0006">6</a>]; and financial instability. Our study builds on existing findings by examining the trajectories of mental distress over time, extending until the beginning of August 2020. The overall trajectory of mental distress observed in our study population is in line with models of postdisaster mental distress, reflecting an initial increase in mental distress, followed by a honeymoon phase of decreased mental distress and return to normalcy [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>]. As the pandemic worsens and extends into the winter, we hypothesize that the disillusionment phase, characterized by mental fatigue and exhaustion, may be imminent [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>].</p> <p>In contrast to the stark disparities observed in the prevalence of mental distress between subgroups, trajectories of change over time were broadly similar between sociodemographic subgroups. The absolute odds of mental distress were approximately four times higher across the study period in females compared to males; additionally, females experienced a greater relative increase in mental distress in April and May compared to males. A possible explanation is that some stressors created by the pandemic, including increased childcare and caregiving responsibilities, are traditionally gendered activities and may have resulted in greater stress among women [<a href="#CIT0027" class="usa-link" aria-describedby="CIT0027">27</a>]. Additionally, loss of employment due to the pandemic has disproportionately impacted women, who are more likely than men to be employed in sectors of the economy hit hardest during the pandemic, such as leisure and hospitality [<a href="#CIT0018" class="usa-link" aria-describedby="CIT0018">18</a>]. Finally, women make up approximately 78% of the health care workforce in the USA [<a href="#CIT0003" class="usa-link" aria-describedby="CIT0003">3</a>]; increased mental distress among health care workers during the pandemic has been widely documented [<a href="#CIT0028" class="usa-link" aria-describedby="CIT0028">28</a>] and may have been more prominent among women. Future research should examine whether these sex-related disparities in mental distress have persisted into more recent phases of the pandemic, and how sex relates to transitions between the honeymoon and disillusionment phases of postdisaster mental distress [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>].</p> <p>Based on our findings, we recommend that both universal and selective interventions to support mental health be deployed. Universal interventions are valuable since prior work has shown residual mental distress after the actual pandemic [<a href="#CIT0029" class="usa-link" aria-describedby="CIT0029">29</a>] and could prevent the development of longer-term adverse outcomes. Opportunities include equitable access to psychotherapy through state and federally funded mechanisms, evidenced-based public health campaigns to reduce stigma around seeking care, and mental health screening and treatment, particularly in the primary care settings that serve as the locus of care for most U.S. adults. Given high levels of mental distress over time among adults in low-income households, screening and treatment should be priorities in the settings that disproportionately serve low-income adults, such as federally qualified health centers and rural health clinics. Health care financing policy changes may facilitate the integration of mental health treatment into these settings, including enhanced reimbursement for clinicians practicing in primary care medical homes, which has been shown to improve mental illness identification and treatment [<a href="#CIT0030" class="usa-link" aria-describedby="CIT0030">30</a>, <a href="#CIT0031" class="usa-link" aria-describedby="CIT0031">31</a>], through the 2015 Medicare Access and CHIP Reauthorization Act and the behavioral health integration billing codes introduced by the Center for Medicare and Medicaid services in 2017 [<a href="#CIT0032" class="usa-link" aria-describedby="CIT0032">32–34</a>].</p> <p>Some limitations related to the content of this study should be noted. We were unable to study all sociodemographic characteristics that may have influenced mental distress during the study period, including time-varying covariates, such as employment status; intersectional identities, such as racial/ethnic minorities living in poverty; and aspects of identity not measured in the UAS, such as sexual or gender identity. In addition, our study results are largely descriptive, and we did not examine prepandemic predictors of trajectories of mental distress, such as lifetime trauma or prior mental disorders. We also did not examine the effect of other historical events that occurred during this period on mental distress, such as the death of George Floyd and the wildfires on the West coast. These will be important objectives for subsequent studies to address.</p> <p>Other limitations relate to our study design. First, we used measures of mental distress from March 11 as the baseline for comparisons; measures of mental distress were not available in this sample prior to March 10. If increases in mental distress in response to the pandemic had already occurred by this date, our comparisons over time may have been underestimated. Second, although survey dates were randomly assigned at each follow-up wave, they were not randomly assigned for the baseline wave. There may be systematic differences between participants who responded on earlier compared to later dates. Third, there were some sociodemographic differences observed between participants who responded to all surveys compared to those who missed at least one survey, as well as between participants missing data at baseline and those with no missing values. To the extent that participants who missed at least one survey, or were missing data at baseline, differed in their trajectory of mental distress, this may have biased our findings. Fourth, although our survey weights were adjusted for nonresponse at baseline, they were not poststratified to account for nonresponse at each follow-up wave, which may have affected the representativeness of our sample. Fifth, to yield more readily interpretable parameters, we chose to model mental distress as a dichotomous outcome instead of continuously; this may have resulted in some loss of information and variability.</p> <p>Between March and August 2020, the prevalence of mental distress among U.S. adults increased, peaked in approximately mid-April, and then returned to prepandemic levels. High levels of mental distress were observed in some sociodemographic subgroups, including young adults and those living below the FPL. Interventions and resources to support mental health during the COVID-19 pandemic should be targeted both toward the adult population broadly as well as selectively toward certain sociodemographic subgroups at higher risk. The data presented herein reflect only the first 5 months of the pandemic; it is possible that more recent changes in mental distress have occurred in the meantime, such as exhaustion and fatigue, reflecting the disillusionment phase of models of postdisaster mental distress [<a href="#CIT0008" class="usa-link" aria-describedby="CIT0008">8</a>]. It will, therefore, be important to track long-term mental distress and related outcomes as the pandemic continues in the USA and worldwide.</p></section><section id="sec23"><h2 class="pmc_sec_title">Supplementary Material</h2> <section class="sm xbox font-sm" id="sup1"><div class="caption p"><span>kaaa126_suppl_Supplementary_Materials</span></div> <div class="media p"><div class="caption"> <a href="/articles/instance/7962764/bin/kaaa126_suppl_supplementary_materials.docx" data-ga-action="click_feat_suppl" class="usa-link">Click here for additional data file.</a><sup> (34.1KB, docx) </sup> </div></div></section></section><section id="a1" class="ack"><h2 class="pmc_sec_title">Acknowledgments</h2> <p>The authors would like to thank Dr. Elizabeth Colantuoni for her assistance with methodological aspects of the study design. The Understanding America Study is funded from several sources, including the Social Security Administration and the National Institute on Aging under grant 5U01AG054580. The survey that collected the mental health- and COVID-19-related data used in this paper was funded by the Center for Economic and Social Research at the University of Southern California and received substantial support from the Bill and Melinda Gates Foundation. Work on the current manuscript was in part supported by the National Institute of Child Health and Human Development (U54 HD079123). This work was also supported by a RAPID grant from the National Science Foundation (grant number 2028683) and by a Capital Group COVID-19 Response Fund Grant. C.B.V.’s participation in this research was made possible through an National Institute of Health/National Institute on Alcohol Abuse and Alcoholism Ruth Kirschstein Postdoctoral Research Fellowship (F32AA025816). K.E.R. was supported by the National Institute of Mental Health Mental Health Services and Systems Training Program (5T32MH109436-03) and by a Doctoral Foreign Study Award from the Canadian Institutes of Health Research.</p></section><section id="s0105"><h2 class="pmc_sec_title">Compliance with Ethical Standards</h2> <p> <strong>Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards</strong> The authors report no financial relationships with commercial interests. The project described in this paper relies on data from survey(s) administered by the Understanding America Study (UAS), which is maintained by the Center for Economic and Social Research at the University of Southern California (USC). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of USC or UAS. For any questions or more information about the UAS, contact Tania Gutsche, Project and Panel Manager, Center for Economic and Social Research, University of Southern California, at <span>tgutsche@usc.edu</span>.</p> <p> <strong>Authors’ Contributions</strong> Ms. K.E. Riehm, conceptualized and designed the study, carried out data analyses, drafted the initial manuscript, and revised the manuscript. Dr. C. Holingue and Dr. E.A. Stuart conceptualized and designed the study and revised the manuscript. Ms. E. J. Smail assisted with data analyses and reviewing the manuscript. Drs. E. A. Stuart, J. Thrul, F. Kreuter, D. Bennett, and A. Kapteyn designed the survey. Drs. D. Bennett and A. Kapteyn designed and implemented the survey. Drs. D. Bennett, A. Kapteyn, R.M. Johnson, L.G. Kalb, C.B. Veldhuis, M.D. Fallin, F. Kreuter, E.E. McGinty, and J. Thrul assisted with interpreting results and reviewing the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.</p> <p> <strong>Ethical Approval</strong> UAS panel procedures have been approved by the University of Southern California Institutional Review Board.</p> <p> <strong>Informed Consent</strong> Informed consent was sought from all participants.</p></section><section id="r1" class="ref-list"><h2 class="pmc_sec_title">References</h2> <section id="r1_sec2"><ul class="ref-list font-sm" style="list-style-type:none"> <li id="CIT0001"> <span class="label">1.</span><cite> Taylor DB. How the coronavirus pandemic unfolded: A timeline. NY Times. 2020. Available at <a href="https://www.nytimes.com/article/coronavirus-timeline.html" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://www.nytimes.com/article/coronavirus-timeline.html</a>. Accessibility verified June 30, 2020.</cite> [<a href="https://scholar.google.com/scholar_lookup?journal=NY%20Times.&publication_year=2020&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0002"> <span class="label">2.</span><cite> Mervosh S, Lu D, Swales V. See which states and cities have told residents to stay at home. NY Times. 2020. Available at <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html</a>. Accessibility verified June 30, 2020.</cite> [<a href="https://scholar.google.com/scholar_lookup?journal=NY%20Times.&publication_year=2020&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0003"> <span class="label">3.</span><cite> Bureau of Labor Statistics, U.S. Department of Labor. The Employment Situation—May 2020. Available at <a href="https://www.bls.gov/news.release/pdf/empsit.pdf" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://www.bls.gov/news.release/pdf/empsit.pdf</a>. Accessibility verified June 30, 2020.</cite> </li> <li id="CIT0004"> <span class="label">4.</span><cite> Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20(5):533–534.</cite> [<a href="https://doi.org/10.1016/S1473-3099(20)30120-1" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7159018/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32087114/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Lancet%20Infect%20Dis.&title=An%20interactive%20web-based%20dashboard%20to%20track%20COVID-19%20in%20real%20time&volume=20&issue=5&publication_year=2020&pages=533-534&pmid=32087114&doi=10.1016/S1473-3099(20)30120-1&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0005"> <span class="label">5.</span><cite> Holingue C, Kalb LG, Riehm KE, et al. Mental distress in the United States at the beginning of the 2019 coronavirus disease (COVID-19) pandemic. Am J Public Health. In press. doi: <a href="https://doi.org/10.2105/AJPH.2020.305857" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">10.2105/AJPH.2020.305857</a>.</cite> [<a href="https://doi.org/10.2105/AJPH.2020.305857" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7542294/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32941066/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Am%20J%20Public%20Health.&title=Mental%20distress%20in%20the%20United%20States%20at%20the%20beginning%20of%20the%202019%20coronavirus%20disease%20(COVID-19)%20pandemic&pmid=32941066&doi=10.2105/AJPH.2020.305857&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0006"> <span class="label">6.</span><cite> Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Intern Med. Online ahead of print, April 10, 2020. doi: <a href="https://doi.org/10.1001/jamainternmed.2020.1562" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">10.1001/jamainternmed.2020.1562</a>.</cite> [<a href="https://doi.org/10.1001/jamainternmed.2020.1562" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32275292/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=JAMA%20Intern%20Med&title=The%20mental%20health%20consequences%20of%20COVID-19%20and%20physical%20distancing:%20The%20need%20for%20prevention%20and%20early%20intervention&pmid=32275292&doi=10.1001/jamainternmed.2020.1562&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0007"> <span class="label">7.</span><cite> Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. Online ahead of print, April 13 2020. doi: <a href="https://doi.org/10.1056/NEJMp2008017" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">10.1056/NEJMp2008017</a>.</cite> [<a href="https://doi.org/10.1056/NEJMp2008017" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32283003/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=N%20Engl%20J%20Med.&title=Mental%20health%20and%20the%20Covid-19%20pandemic&pmid=32283003&doi=10.1056/NEJMp2008017&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0008"> <span class="label">8.</span><cite> DeWolfe DJ. Training Manual for Mental Health and Human Service Workers in Major Disasters. 2nd ed. HHS Publication No. ADM 90–538. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.</cite> [<a href="https://scholar.google.com/scholar_lookup?title=Training%20Manual%20for%20Mental%20Health%20and%20Human%20Service%20Workers%20in%20Major%20Disasters&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0009"> <span class="label">9.</span><cite> Horwitz AV. Distinguishing distress from disorder as psychological outcomes of stressful social arrangements. Health. 2007;11(3):273–289.</cite> [<a href="https://doi.org/10.1177/1363459307077541" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/17606693/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Health&title=Distinguishing%20distress%20from%20disorder%20as%20psychological%20outcomes%20of%20stressful%20social%20arrangements&volume=11&issue=3&publication_year=2007&pages=273-289&pmid=17606693&doi=10.1177/1363459307077541&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0010"> <span class="label">10.</span><cite> Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA. Online ahead of print, May 11, 2020. doi: 10.1001/jama.2020.8598.</cite> [<a href="https://doi.org/10.1001/jama.2020.8598" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=JAMA&title=COVID-19%20and%20racial/ethnic%20disparities&doi=10.1001/jama.2020.8598&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0011"> <span class="label">11.</span><cite> Otu A, Charles CH, Yaya S. Mental health and psychosocial well-being during the COVID-19 pandemic: The invisible elephant in the room. Int J Ment Health Syst. 2020;14(1):38.</cite> [<a href="https://doi.org/10.1186/s13033-020-00371-w" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7257210/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32514302/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Int%20J%20Ment%20Health%20Syst&title=Mental%20health%20and%20psychosocial%20well-being%20during%20the%20COVID-19%20pandemic:%20The%20invisible%20elephant%20in%20the%20room&volume=14&issue=1&publication_year=2020&pages=38&pmid=32514302&doi=10.1186/s13033-020-00371-w&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0012"> <span class="label">12.</span><cite> Holmes EA, O’Connor RC, Perry VH, et al. Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. Lancet Psychiatry. 2020;7(6):547–560.</cite> [<a href="https://doi.org/10.1016/S2215-0366(20)30168-1" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7159850/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32304649/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Lancet%20Psychiatry&title=Multidisciplinary%20research%20priorities%20for%20the%20COVID-19%20pandemic:%20A%20call%20for%20action%20for%20mental%20health%20science&volume=7&issue=6&publication_year=2020&pages=547-560&pmid=32304649&doi=10.1016/S2215-0366(20)30168-1&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0013"> <span class="label">13.</span><cite> McGinty EE, Presskreischer R, Han H, et al. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA. Online ahead of print, June 3, 2020. doi: 10.1001/jama.2020.9740.</cite> [<a href="https://doi.org/10.1001/jama.2020.9740" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7270868/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32492088/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=JAMA&title=Psychological%20distress%20and%20loneliness%20reported%20by%20US%20adults%20in%202018%20and%20April%202020&pmid=32492088&doi=10.1001/jama.2020.9740&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0014"> <span class="label">14.</span><cite> Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2019686-e2019686.</cite> [<a href="https://doi.org/10.1001/jamanetworkopen.2020.19686" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7489837/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32876685/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=JAMA%20Netw%20Open&title=Prevalence%20of%20depression%20symptoms%20in%20US%20adults%20before%20and%20during%20the%20COVID-19%20pandemic&volume=3&issue=9&publication_year=2020&pages=e2019686-e2019686&pmid=32876685&doi=10.1001/jamanetworkopen.2020.19686&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0015"> <span class="label">15.</span><cite> Holman EA, Thompson RR, Garfin DR, Silver RC. The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health in the United States. Sci Adv. 2020;6(42):eabd5390.</cite> [<a href="https://doi.org/10.1126/sciadv.abd5390" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7556755/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32948511/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Sci%20Adv.&title=The%20unfolding%20COVID-19%20pandemic:%20A%20probability-based,%20nationally%20representative%20study%20of%20mental%20health%20in%20the%20United%20States&volume=6&issue=42&publication_year=2020&pages=eabd5390&pmid=32948511&doi=10.1126/sciadv.abd5390&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0016"> <span class="label">16.</span><cite> Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049.</cite> [<a href="https://doi.org/10.15585/mmwr.mm6932a1" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7440121/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32790653/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=MMWR%20Morb%20Mortal%20Wkly%20Rep.&title=Mental%20health,%20substance%20use,%20and%20suicidal%20ideation%20during%20the%20COVID-19%20pandemic%E2%80%94United%20States,%20June%2024%E2%80%9330,%202020&volume=69&issue=32&publication_year=2020&pages=1049&pmid=32790653&doi=10.15585/mmwr.mm6932a1&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0017"> <span class="label">17.</span><cite> Karpman M, Zuckerman S, Gonzalez D, et al. The COVID-19 pandemic is straining families’ abilities to afford basic needs. Available at <a href="https://www.urban.org/sites/default/files/publication/102124/the-covid-19-pandemic-is-straining-families-abilities-to-afford-basic-needs_2.pdf" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://www.urban.org/sites/default/files/publication/102124/the-covid-19-pandemic-is-straining-families-abilities-to-afford-basic-needs_2.pdf</a>. Accessibility verified June 30, 2020.</cite> [<a href="https://scholar.google.com/scholar_lookup?title=The%20COVID-19%20pandemic%20is%20straining%20families%E2%80%99%20abilities%20to%20afford%20basic%20needs&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0018"> <span class="label">18.</span><cite> Kochhar R. Hispanic women, immigrants, young adults, those with less education hit hardest by COVID-19 job losses. Available at <a href="https://www.pewresearch.org/fact-tank/2020/06/09/hispanic-women-immigrants-young-adults-those-with-less-education-hit-hardest-by-covid-19-job-losses" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://www.pewresearch.org/fact-tank/2020/06/09/hispanic-women-immigrants-young-adults-those-with-less-education-hit-hardest-by-covid-19-job-losses</a>. Accessibility verified June 30, 2020.</cite> [<a href="https://scholar.google.com/scholar_lookup?title=Hispanic%20women,%20immigrants,%20young%20adults,%20those%20with%20less%20education%20hit%20hardest%20by%20COVID-19%20job%20losses&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0019"> <span class="label">19.</span><cite> Egede LE, Walker RJ. Structural racism, social risk factors, and Covid-19—A dangerous convergence for Black Americans. N Engl J Med. 2020;383(12):e77.</cite> [<a href="https://doi.org/10.1056/NEJMp2023616" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7747672/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32706952/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=N%20Engl%20J%20Med.&title=Structural%20racism,%20social%20risk%20factors,%20and%20Covid-19%E2%80%94A%20dangerous%20convergence%20for%20Black%20Americans&volume=383&issue=12&publication_year=2020&pages=e77&pmid=32706952&doi=10.1056/NEJMp2023616&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0020"> <span class="label">20.</span><cite> Kroenke K, Spitzer RL, Williams JBW, et al. An ultra-brief screening scale for anxiety and depression: The PHQ–4. Psychosomatics. 2009;50(6):613–621.</cite> [<a href="https://doi.org/10.1176/appi.psy.50.6.613" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19996233/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Psychosomatics&title=An%20ultra-brief%20screening%20scale%20for%20anxiety%20and%20depression:%20The%20PHQ%E2%80%934&volume=50&issue=6&publication_year=2009&pages=613-621&pmid=19996233&doi=10.1176/appi.psy.50.6.613&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0021"> <span class="label">21.</span><cite> Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1):86–95.</cite> [<a href="https://doi.org/10.1016/j.jad.2009.06.019" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19616305/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Affect%20Disord.&title=A%204-item%20measure%20of%20depression%20and%20anxiety:%20Validation%20and%20standardization%20of%20the%20Patient%20Health%20Questionnaire-4%20(PHQ-4)%20in%20the%20general%20population&volume=122&issue=1&publication_year=2010&pages=86-95&pmid=19616305&doi=10.1016/j.jad.2009.06.019&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0022"> <span class="label">22.</span><cite> Gauthier J, Wu QV, Gooley TA. Cubic splines to model relationships between continuous variables and outcomes: a guide for clinicians. Bone Marrow Transplant. 2020;55(4):675–680.</cite> [<a href="https://doi.org/10.1038/s41409-019-0679-x" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31576022/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Bone%20Marrow%20Transplant.&title=Cubic%20splines%20to%20model%20relationships%20between%20continuous%20variables%20and%20outcomes:%20a%20guide%20for%20clinicians&volume=55&issue=4&publication_year=2020&pages=675-680&pmid=31576022&doi=10.1038/s41409-019-0679-x&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0023"> <span class="label">23.</span><cite> Harrell FE, Jr. Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis. Switzerland: Springer International Publishing; 2015.</cite> [<a href="https://scholar.google.com/scholar_lookup?title=Regression%20Modeling%20Strategies:%20With%20Applications%20to%20Linear%20Models,%20Logistic%20and%20Ordinal%20Regression,%20and%20Survival%20Analysis&publication_year=2015&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0024"> <span class="label">24.</span><cite> Orsini N. XBRCSPLINE: Stata Module to Tabulate Differences in Predicted Responses After Restricted Cubic Spline Models. Statistical Software Components S457092. Boston College Department of Economics; 2019. Available at <a href="https://econpapers.repec.org/software/bocbocode/s457092.htm" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">https://econpapers.repec.org/software/bocbocode/s457092.htm</a>.</cite> [<a href="https://scholar.google.com/scholar_lookup?title=XBRCSPLINE:%20Stata%20Module%20to%20Tabulate%20Differences%20in%20Predicted%20Responses%20After%20Restricted%20Cubic%20Spline%20Models.%20Statistical%20Software%20Components%20S457092&publication_year=2019&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0025"> <span class="label">25.</span><cite> Eaton WW, Kalaydjian A, Scharfstein DO, et al. Prevalence and incidence of depressive disorder: The Baltimore ECA follow-up, 1981–2004. Acta Psychiatr Scand. 2007;116(3):182–188.</cite> [<a href="https://doi.org/10.1111/j.1600-0447.2007.01017.x" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC3700526/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/17655559/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Acta%20Psychiatr%20Scand.&title=Prevalence%20and%20incidence%20of%20depressive%20disorder:%20The%20Baltimore%20ECA%20follow-up,%201981%E2%80%932004&volume=116&issue=3&publication_year=2007&pages=182-188&pmid=17655559&doi=10.1111/j.1600-0447.2007.01017.x&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0026"> <span class="label">26.</span><cite> Breslau J, Kendler KS, Su M, et al. Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States. Psychol Med. 2005;35(3):317–327.</cite> [<a href="https://doi.org/10.1017/s0033291704003514" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC2748985/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15841868/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Psychol%20Med.&title=Lifetime%20risk%20and%20persistence%20of%20psychiatric%20disorders%20across%20ethnic%20groups%20in%20the%20United%20States&volume=35&issue=3&publication_year=2005&pages=317-327&pmid=15841868&doi=10.1017/s0033291704003514&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0027"> <span class="label">27.</span><cite> Collins C, Landivar LC, Ruppanner L, et al. COVID-19 and the gender gap in work hours. Gend Work Organ. Online ahead of print, July 2, 2020. doi: 10.1111/gwao.12506.</cite> [<a href="https://doi.org/10.1111/gwao.12506" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7361447/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32837019/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Gend%20Work%20Organ&title=COVID-19%20and%20the%20gender%20gap%20in%20work%20hours&pmid=32837019&doi=10.1111/gwao.12506&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0028"> <span class="label">28.</span><cite> Charney AW, Katz C, Southwick SM, et al. A call to protect the health care workers fighting COVID-19 in the United States. Am J Psychiatry. 2020; doi: 10.1176/appi.ajp.2020.20040535.</cite> [<a href="https://doi.org/10.1176/appi.ajp.2020.20040535" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32731814/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Am%20J%20Psychiatry.&title=A%20call%20to%20protect%20the%20health%20care%20workers%20fighting%20COVID-19%20in%20the%20United%20States&publication_year=2020&pmid=32731814&doi=10.1176/appi.ajp.2020.20040535&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0029"> <span class="label">29.</span><cite> Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020;395(10227):912–920.</cite> [<a href="https://doi.org/10.1016/S0140-6736(20)30460-8" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7158942/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32112714/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Lancet&title=The%20psychological%20impact%20of%20quarantine%20and%20how%20to%20reduce%20it:%20Rapid%20review%20of%20the%20evidence&volume=395&issue=10227&publication_year=2020&pages=912-920&pmid=32112714&doi=10.1016/S0140-6736(20)30460-8&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0030"> <span class="label">30.</span><cite> Sklar M, Aarons GA, O’Connell M, et al. Mental health recovery in the patient-centered medical home. Am J Public Health. 2015;105(9):1926–1934.</cite> [<a href="https://doi.org/10.2105/AJPH.2015.302683" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC4539809/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26180945/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Am%20J%20Public%20Health.&title=Mental%20health%20recovery%20in%20the%20patient-centered%20medical%20home&volume=105&issue=9&publication_year=2015&pages=1926-1934&pmid=26180945&doi=10.2105/AJPH.2015.302683&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0031"> <span class="label">31.</span><cite> Domino ME, Wells R, Morrissey JP. Serving persons with severe mental illness in primary care–based medical homes. Psychiatr Serv. 2015;66(5):477–483.</cite> [<a href="https://doi.org/10.1176/appi.ps.201300546" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25686809/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Psychiatr%20Serv.&title=Serving%20persons%20with%20severe%20mental%20illness%20in%20primary%20care%E2%80%93based%20medical%20homes&volume=66&issue=5&publication_year=2015&pages=477-483&pmid=25686809&doi=10.1176/appi.ps.201300546&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0032"> <span class="label">32.</span><cite> McGinty EE, Daumit GL. Integrating mental health and addiction treatment into general medical care: The role of policy. Psychiatr Serv. Online ahead of print, June 3, 2020. doi: 10.1176/appi.ps.202000183.</cite> [<a href="https://doi.org/10.1176/appi.ps.202000183" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7606646/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32487007/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Psychiatr%20Serv.&title=Integrating%20mental%20health%20and%20addiction%20treatment%20into%20general%20medical%20care:%20The%20role%20of%20policy&pmid=32487007&doi=10.1176/appi.ps.202000183&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0033"> <span class="label">33.</span><cite> Cross DA, Qin X, Huckfeldt P, et al. Use of Medicare’s behavioral health integration service codes in the first two years: An observational study. J Gen Intern Med. Online ahead of print, December 16, 2019. doi: 10.1007/s11606-019-05579-2.</cite> [<a href="https://doi.org/10.1007/s11606-019-05579-2" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC7728892/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31845107/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Gen%20Intern%20Med.&title=Use%20of%20Medicare%E2%80%99s%20behavioral%20health%20integration%20service%20codes%20in%20the%20first%20two%20years:%20An%20observational%20study&pmid=31845107&doi=10.1007/s11606-019-05579-2&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="CIT0034"> <span class="label">34.</span><cite> Carlo AD, Baden AC, McCarty RL, et al. Early health system experiences with collaborative care (CoCM) billing codes: A qualitative study of leadership and support staff. J Gen Intern Med. 2019;34(10):2150–2158.</cite> [<a href="https://doi.org/10.1007/s11606-019-05195-0" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC6816741/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31367872/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Gen%20Intern%20Med.&title=Early%20health%20system%20experiences%20with%20collaborative%20care%20(CoCM)%20billing%20codes:%20A%20qualitative%20study%20of%20leadership%20and%20support%20staff&volume=34&issue=10&publication_year=2019&pages=2150-2158&pmid=31367872&doi=10.1007/s11606-019-05195-0&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> </ul></section></section><section id="_ad93_" lang="en" class="associated-data"><h2 class="pmc_sec_title">Associated Data</h2> <p class="font-secondary"><em>This section collects any data citations, data availability statements, or supplementary materials included in this article.</em></p> <section id="_adsm93_" lang="en" class="supplementary-materials"><h3 class="pmc_sec_title">Supplementary Materials</h3> <section class="sm xbox font-sm" id="db_ds_supplementary-material1_reqid_"><div class="caption p"><span>kaaa126_suppl_Supplementary_Materials</span></div> <div class="media p"><div class="caption"> <a href="/articles/instance/7962764/bin/kaaa126_suppl_supplementary_materials.docx" data-ga-action="click_feat_suppl" class="usa-link">Click here for additional data file.</a><sup> (34.1KB, docx) </sup> </div></div></section></section></section></section><footer class="p courtesy-note font-secondary font-sm text-center"><hr class="headless"> <p>Articles from Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine are provided here courtesy of <strong>Oxford University Press</strong></p></footer></section></article> </main> </div> </div> </div>  <div class="pmc-sidenav desktop:grid-col-4 display-flex"> <section class="pmc-sidenav__container" aria-label="Article resources and navigation"> <button type="button" class="usa-button pmc-sidenav__container__close usa-button--unstyled"> <img src="/static/img/usa-icons/close.svg" role="img" alt="Close" /> </button> <div class="display-none desktop:display-block"> <section class="margin-top-4 desktop:margin-top-0"> <h2 class="margin-top-0">ACTIONS</h2> <ul class="usa-list usa-list--unstyled usa-list--actions"> <li> <a href="https://doi.org/10.1093/abm/kaaa126" class="usa-button usa-button--outline width-24 font-xs usa-link--external padding-left-0 padding-right-0" target="_blank" rel="noreferrer noopener" data-ga-category="actions" data-ga-action="click" data-ga-label="publisher_link_desktop" > <span class="height-3 display-inline-flex flex-align-center">View on publisher site</span> </a> </li> <li> <a href="pdf/kaaa126.pdf" class="usa-button usa-button--outline width-24 display-inline-flex flex-align-center flex-justify-start padding-left-1" data-ga-category="actions" data-ga-action="click" data-ga-label="pdf_download_desktop" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1">PDF (827.5 KB)</span> </a> </li> <li> <button role="button" class="usa-button width-24 citation-dialog-trigger display-inline-flex flex-align-center flex-justify-start padding-left-1" aria-label="Open dialog with citation text in different styles" data-ga-category="actions" data-ga-action="open" data-ga-label="cite_desktop" data-all-citations-url="/resources/citations/7929474/" data-citation-style="nlm" data-download-format-link="/resources/citations/7929474/export/" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#format_quote"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1 button-label">Cite</span> </button> </li> <li> <button class="usa-button width-24 collections-dialog-trigger collections-button display-inline-flex flex-align-center flex-justify-start padding-left-1 collections-button-empty" aria-label="Save article in MyNCBI collections." data-ga-category="actions" data-ga-action="click" data-ga-label="collections_button_desktop" data-collections-open-dialog-enabled="false" data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpmc.ncbi.nlm.nih.gov%2Farticles%2FPMC7929474%2F%23open-collections-dialog" data-in-collections="false"> <svg class="usa-icon width-3 height-3 usa-icon--bookmark-full" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-full.svg#icon"></use> </svg> <svg class="usa-icon width-3 height-3 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-empty.svg#icon"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1">Collections</span> </button> </li> <li class="pmc-permalink"> <button type="button" class="usa-button usa-button--outline width-24 display-inline-flex flex-align-center flex-justify padding-left-1 shadow-none" aria-label="Show article permalink" aria-expanded="false" aria-haspopup="true" data-ga-category="actions" data-ga-action="open" data-ga-label="permalink_desktop" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#share"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1 button-label">Permalink</span> </button> <div class="pmc-permalink__dropdown" hidden> <div class="pmc-permalink__dropdown__container"> <h2 class="usa-modal__heading margin-top-0 margin-bottom-2">PERMALINK</h2> <div class="pmc-permalink__dropdown__content"> <input type="text" class="usa-input" value="https://pmc.ncbi.nlm.nih.gov/articles/PMC7929474/" aria-label="Article permalink"> <button class="usa-button display-inline-flex pmc-permalink__dropdown__copy__btn margin-right-0" title="Copy article permalink" data-ga-category="save_share" data-ga-action="link" data-ga-label="copy_link"> <svg class="usa-icon" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span class="margin-left-1">Copy</span> </button> </div> </div> </div> </li> </ul> </section> </div> <section class="pmc-resources margin-top-6 desktop:margin-top-4" data-page-path="/articles/PMC7929474/"> <h2 class="margin-top-0">RESOURCES</h2> <div class="usa-accordion usa-accordion--multiselectable" data-allow-multiple> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-similar-articles" data-ga-category="resources_accordion" data-ga-action="open_similar_articles" data-ga-label="/articles/PMC7929474/" data-action-open="open_similar_articles" data-action-close="close_similar_articles" > Similar articles </button> </h3> <div id="resources-similar-articles" class="usa-accordion__content usa-prose" data-source-url="/resources/similar-article-links/33555336/" > </div> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-cited-by-other-articles" data-ga-category="resources_accordion" data-ga-action="open_cited_by" data-ga-label="/articles/PMC7929474/" data-action-open="open_cited_by" data-action-close="close_cited_by" > Cited by other articles </button> </h3> <div id="resources-cited-by-other-articles" class="usa-accordion__content usa-prose" data-source-url="/resources/cited-by-links/33555336/" > </div> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-links-to-ncbi-databases" data-ga-category="resources_accordion" data-ga-action="open_NCBI_links" data-ga-label="/articles/PMC7929474/" data-action-open="open_NCBI_links" data-action-close="close_NCBI_link" > Links to NCBI Databases </button> </h3> <div id="resources-links-to-ncbi-databases" class="usa-accordion__content usa-prose" data-source-url="/resources/db-links/7929474/" > </div> </div> </section> <section class="usa-in-page-nav usa-in-page-nav--wide margin-top-6 desktop:margin-top-4" data-title-text="On this page" data-title-heading-level="h2" data-scroll-offset="0" data-root-margin="-10% 0px -80% 0px" data-main-content-selector="main" data-threshold="1" hidden ></section> </section> </div> <div class="overlay" role="dialog" aria-label="Citation Dialog" hidden> <div class="dialog citation-dialog" aria-hidden="true"> <div class="display-inline-flex flex-align-center flex-justify width-full margin-bottom-2"> <h2 class="usa-modal__heading margin-0">Cite</h2> <button type="button" class="usa-button usa-button--unstyled close-overlay text-black width-auto" tabindex="1"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#close"></use> </svg> </button> </div> <div class="citation-text-block"> <div class="citation-text margin-bottom-2"></div> <ul class="usa-list usa-list--unstyled display-inline-flex flex-justify width-full flex-align-center"> <li> <button class="usa-button usa-button--unstyled text-no-underline display-flex flex-align-center copy-button dialog-focus" data-ga-category="save_share" data-ga-action="cite" data-ga-label="copy" tabindex="2"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span>Copy</span> </button> </li> <li> <a href="#" role="button" class="usa-button usa-button--unstyled text-no-underline display-flex flex-align-center export-button" data-ga-category="save_share" data-ga-action="cite" data-ga-label="download" title="Download a file for external citation management software" tabindex="3"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> <span class="display-none mobile-lg:display-inline">Download .nbib</span> <span class="display-inline mobile-lg:display-none">.nbib</span> </a> </li> <li> <div class="display-inline-flex flex-align-center"> <label class="usa-label margin-top-0">Format:</label> <select aria-label="Format" class="usa-select citation-style-selector padding-1 margin-top-0 border-0 padding-right-4" tabindex="4" > <option data-style-url-name="ama" value="AMA" > AMA </option> <option data-style-url-name="apa" value="APA" > APA </option> <option data-style-url-name="mla" value="MLA" > MLA </option> <option data-style-url-name="nlm" value="NLM" selected="selected"> NLM </option> </select> </div> </li> </ul> </div> </div> </div> <div class="overlay" role="dialog" hidden> <div id="collections-action-dialog" class="dialog collections-dialog" aria-hidden="true"> <div class="display-inline-flex flex-align-center flex-justify width-full margin-bottom-2"> <h2 class="usa-modal__heading margin-0">Add to Collections</h2> </div> <div class="collections-action-panel action-panel"> <form id="collections-action-dialog-form" class="usa-form maxw-full collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors" data-existing-collections-url="/list-existing-collections/" data-add-to-existing-collection-url="/add-to-existing-collection/" data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/" data-myncbi-max-collection-name-length="100" data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/"> <input type="hidden" name="csrfmiddlewaretoken" value="gvnZxTEbL2VJ7AVhmibRuJbwXbu5zobVIWt822Ll4JMGdD7Eyxxy7WIFBWGfN6iC"> <fieldset class="usa-fieldset margin-bottom-2"> <div class="usa-radio"> <input type="radio" id="collections-action-dialog-new" class="usa-radio__input usa-radio__input--tile collections-new margin-top-0" name="collections" value="new" data-ga-category="collections_button" data-ga-action="click" data-ga-label="collections_radio_new" /> <label class="usa-radio__label" for="collections-action-dialog-new">Create a new collection</label> </div> <div class="usa-radio"> <input type="radio" id="collections-action-dialog-existing" class="usa-radio__input usa-radio__input--tile collections-existing" name="collections" value="existing" checked="true" data-ga-category="collections_button" data-ga-action="click" data-ga-label="collections_radio_existing" /> <label class="usa-radio__label" for="collections-action-dialog-existing">Add to an existing collection</label> </div> </fieldset> <fieldset class="usa-fieldset margin-bottom-2"> <div class="action-panel-control-wrap new-collections-controls"> <label for="collections-action-dialog-add-to-new" class="usa-label margin-top-0"> Name your collection <abbr title="required" class="usa-hint usa-hint--required text-no-underline">*</abbr> </label> <input type="text" name="add-to-new-collection" id="collections-action-dialog-add-to-new" class="usa-input collections-action-add-to-new" pattern="[^"&=<>/]*" title="The following characters are not allowed in the Name field: "&=<>/" maxlength="" data-ga-category="collections_button" data-ga-action="create_collection" data-ga-label="non_favorties_collection" required /> </div> <div class="action-panel-control-wrap existing-collections-controls"> <label for="collections-action-dialog-add-to-existing" class="usa-label margin-top-0"> Choose a collection </label> <select id="collections-action-dialog-add-to-existing" class="usa-select collections-action-add-to-existing" data-ga-category="collections_button" data-ga-action="select_collection" data-ga-label="($('.collections-action-add-to-existing').val() === 'Favorites') ? 'Favorites' : 'non_favorites_collection'"> </select> <div class="collections-retry-load-on-error usa-input-error-message selection-validation-message"> Unable to load your collection due to an error<br> <a href="#">Please try again</a> </div> </div> </fieldset> <div class="display-inline-flex"> <button class="usa-button margin-top-0 action-panel-submit" type="submit" data-loading-label="Adding..." data-pinger-ignore data-ga-category="collections_button" data-ga-action="click" data-ga-label="add"> Add </button> <button class="usa-button usa-button--outline margin-top-0 action-panel-cancel" aria-label="Close 'Add to Collections' panel" ref="linksrc=close_collections_panel" data-ga-category="collections_button" data-ga-action="click" data-ga-label="cancel"> Cancel </button> </div> </form> </div> </div> </div> </div> </div> </div> <footer class="ncbi-footer ncbi-dark-background " > <div class="ncbi-footer__icon-section"> <div class="ncbi-footer__social-header"> Follow NCBI </div> <div class="grid-container ncbi-footer__ncbi-social-icons-container"> <a href="https://twitter.com/ncbi" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="40" height="40" viewBox="0 0 40 40" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="m6.067 8 10.81 13.9L6 33.2h4.2l8.4-9.1 7.068 9.1H34L22.8 18.5 31.9 8h-3.5l-7.7 8.4L14.401 8H6.067Zm3.6 1.734h3.266l16.8 21.732H26.57L9.668 9.734Z"> </path> </svg> <span class="usa-sr-only">NCBI on X (formerly known as Twitter)</span> </a> <a href="https://www.facebook.com/ncbi.nlm" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="16" height="29" focusable="false" aria-hidden="true" viewBox="0 0 16 29" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M3.8809 21.4002C3.8809 19.0932 3.8809 16.7876 3.8809 14.478C3.8809 14.2117 3.80103 14.1452 3.54278 14.1492C2.53372 14.1638 1.52334 14.1492 0.514288 14.1598C0.302626 14.1598 0.248047 14.0972 0.248047 13.8936C0.256034 12.4585 0.256034 11.0239 0.248047 9.58978C0.248047 9.37013 0.302626 9.30224 0.528931 9.3049C1.53798 9.31688 2.54837 9.3049 3.55742 9.31555C3.80103 9.31555 3.8809 9.26097 3.87957 9.00272C3.87158 8.00565 3.85428 7.00592 3.90753 6.00884C3.97142 4.83339 4.31487 3.73115 5.04437 2.78467C5.93095 1.63318 7.15699 1.09005 8.56141 0.967577C10.5582 0.79319 12.555 0.982221 14.5518 0.927641C14.7102 0.927641 14.7462 0.99287 14.7449 1.13664C14.7449 2.581 14.7449 4.02668 14.7449 5.47104C14.7449 5.67604 14.6517 5.68669 14.4946 5.68669C13.4523 5.68669 12.4113 5.68669 11.3703 5.68669C10.3506 5.68669 9.92057 6.10868 9.90593 7.13904C9.89661 7.7647 9.91525 8.39303 9.89794 9.01869C9.88995 9.26364 9.96583 9.31822 10.2015 9.31688C11.7204 9.30623 13.2393 9.31688 14.7595 9.3049C15.0257 9.3049 15.0723 9.3728 15.0444 9.62439C14.89 10.9849 14.7515 12.3467 14.6144 13.7085C14.5691 14.1571 14.5785 14.1585 14.1458 14.1585C12.8386 14.1585 11.5313 14.1665 10.2254 14.1518C9.95119 14.1518 9.89794 14.2317 9.89794 14.4899C9.90593 19.0799 9.89794 23.6752 9.91125 28.2612C9.91125 28.5674 9.8407 28.646 9.53186 28.6433C7.77866 28.6273 6.02414 28.6366 4.27094 28.634C3.82499 28.634 3.87158 28.6992 3.87158 28.22C3.87602 25.9472 3.87913 23.6739 3.8809 21.4002Z"> </path> </svg> <span class="usa-sr-only">NCBI on Facebook</span> </a> <a href="https://www.linkedin.com/company/ncbinlm" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="25" height="23" viewBox="0 0 26 24" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M14.6983 9.98423C15.6302 9.24808 16.5926 8.74754 17.6762 8.51991C19.673 8.09126 21.554 8.30824 23.1262 9.7526C24.2351 10.7723 24.7529 12.1115 25.0165 13.5612C25.1486 14.3363 25.2105 15.1218 25.2015 15.9081C25.2015 18.3043 25.2015 20.6898 25.2082 23.0806C25.2082 23.3468 25.1549 23.444 24.8621 23.4414C23.1297 23.4272 21.3992 23.4272 19.6704 23.4414C19.4041 23.4414 19.3429 23.3588 19.3442 23.1019C19.3535 20.5194 19.3442 17.9368 19.3442 15.3543C19.3442 14.0005 18.3258 12.9448 17.0266 12.9488C15.7273 12.9528 14.6983 14.0071 14.6983 15.361C14.6983 17.9328 14.6917 20.5047 14.6983 23.0753C14.6983 23.3708 14.6198 23.444 14.3296 23.4427C12.6185 23.4294 10.9079 23.4294 9.19779 23.4427C8.93155 23.4427 8.86099 23.3735 8.86232 23.1086C8.8783 19.7619 8.88628 16.4144 8.88628 13.066C8.88628 11.5688 8.87874 10.0708 8.86365 8.57182C8.86365 8.3575 8.90758 8.27896 9.14054 8.28029C10.9048 8.29094 12.6687 8.29094 14.4321 8.28029C14.6464 8.28029 14.6983 8.34818 14.6983 8.54653C14.6903 9.00047 14.6983 9.45441 14.6983 9.98423Z"> </path> <path d="M6.55316 15.8443C6.55316 18.2564 6.55316 20.6699 6.55316 23.082C6.55316 23.3629 6.48127 23.4388 6.19906 23.4374C4.47737 23.4241 2.75568 23.4241 1.03399 23.4374C0.767751 23.4374 0.69986 23.3629 0.701191 23.1006C0.709178 18.2648 0.709178 13.4281 0.701191 8.59053C0.701191 8.34026 0.765089 8.27237 1.01669 8.2737C2.74991 8.28435 4.48048 8.28435 6.20838 8.2737C6.47462 8.2737 6.5465 8.33627 6.54517 8.6065C6.54783 11.0186 6.55316 13.4308 6.55316 15.8443Z"> </path> <path d="M3.65878 0.243898C5.36804 0.243898 6.58743 1.45529 6.58743 3.1406C6.58743 4.75801 5.32145 5.95742 3.60819 5.96807C3.22177 5.97614 2.83768 5.90639 2.47877 5.76299C2.11985 5.61959 1.79344 5.40546 1.51897 5.13334C1.24449 4.86123 1.02755 4.53668 0.881058 4.17902C0.734563 3.82136 0.661505 3.43788 0.666231 3.05141C0.67555 1.42601 1.9362 0.242566 3.65878 0.243898Z"> </path> </svg> <span class="usa-sr-only">NCBI on LinkedIn</span> </a> <a href="https://github.com/ncbi" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="28" height="27" viewBox="0 0 28 28" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M16.7228 20.6334C17.5057 20.5527 18.2786 20.3944 19.0301 20.1608C21.3108 19.4193 22.5822 17.8259 22.963 15.4909C23.1228 14.5112 23.1814 13.5287 22.9883 12.5437C22.8106 11.6423 22.4013 10.8028 21.8007 10.1076C21.7526 10.0605 21.7197 10 21.7064 9.934C21.6931 9.86799 21.7 9.79952 21.7262 9.73748C22.0856 8.6206 21.9711 7.51969 21.601 6.42677C21.582 6.3497 21.5345 6.2827 21.468 6.23923C21.4016 6.19577 21.3211 6.17906 21.2429 6.19248C20.7329 6.21649 20.2313 6.33051 19.7611 6.52928C19.1103 6.7908 18.4899 7.12198 17.9104 7.51703C17.84 7.56996 17.7581 7.60551 17.6713 7.62078C17.5846 7.63605 17.4954 7.6306 17.4112 7.60489C15.2596 7.05882 13.0054 7.06203 10.8554 7.61421C10.7806 7.63586 10.7018 7.63967 10.6253 7.62534C10.5487 7.611 10.4766 7.57892 10.4148 7.53167C9.64788 7.03247 8.85171 6.58918 7.96368 6.33359C7.65781 6.24338 7.34123 6.19458 7.02239 6.18849C6.94879 6.17986 6.87462 6.19893 6.81432 6.242C6.75402 6.28507 6.71191 6.34904 6.69621 6.42145C6.32342 7.51437 6.2209 8.61527 6.56307 9.73348C6.59635 9.84264 6.64694 9.93316 6.54177 10.0516C5.47666 11.2604 5.09988 12.6834 5.19574 14.2676C5.2663 15.4244 5.46201 16.5466 6.01454 17.5769C6.84399 19.1171 8.21664 19.9119 9.85158 20.3352C10.3938 20.4706 10.9444 20.5698 11.4998 20.632C11.5384 20.7492 11.4506 20.7798 11.408 20.8291C11.1734 21.1179 10.9894 21.4441 10.8634 21.7942C10.7622 22.0458 10.8315 22.4039 10.6065 22.5516C10.263 22.7766 9.83827 22.8485 9.42421 22.8871C8.17936 23.0056 7.26471 22.4877 6.6283 21.4348C6.25552 20.8184 5.76956 20.3325 5.08523 20.0663C4.76981 19.9325 4.42139 19.8967 4.08537 19.9638C3.7898 20.029 3.73788 20.1901 3.93891 20.4111C4.03639 20.5234 4.14989 20.6207 4.27575 20.6999C4.9796 21.1318 5.51717 21.7884 5.80152 22.5636C6.37002 23.9973 7.48039 24.5697 8.93825 24.6323C9.43741 24.6575 9.93768 24.615 10.4254 24.5058C10.5892 24.4672 10.6531 24.4872 10.6517 24.6762C10.6451 25.4936 10.6637 26.3123 10.6517 27.131C10.6517 27.6635 10.1684 27.9297 9.58663 27.7393C8.17396 27.2671 6.84977 26.5631 5.66838 25.656C2.59555 23.2891 0.720966 20.1861 0.217704 16.3376C-0.357453 11.9127 0.911353 8.00824 3.98551 4.73881C6.11909 2.42656 8.99932 0.939975 12.1203 0.540191C16.5351 -0.0601815 20.4347 1.14323 23.7232 4.16373C26.2449 6.47869 27.724 9.37672 28.1048 12.7726C28.5828 17.0325 27.3686 20.7945 24.4768 23.9827C22.9762 25.6323 21.0956 26.8908 18.9982 27.6488C18.8783 27.6927 18.7585 27.738 18.636 27.7726C18.0356 27.9404 17.6189 27.6395 17.6189 27.0098C17.6189 25.7452 17.6308 24.4806 17.6295 23.2159C17.6329 22.9506 17.6128 22.6856 17.5696 22.4238C17.4325 21.6664 17.3419 21.484 16.7228 20.6334Z"> </path> </svg> <span class="usa-sr-only">NCBI on GitHub</span> </a> <a href="https://ncbiinsights.ncbi.nlm.nih.gov/" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="26" height="26" viewBox="0 0 27 27" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M23.7778 26.4574C23.1354 26.3913 22.0856 26.8024 21.636 26.3087C21.212 25.8444 21.4359 24.8111 21.324 24.0347C19.9933 14.8323 14.8727 8.80132 6.09057 5.85008C4.37689 5.28406 2.58381 4.99533 0.779072 4.99481C0.202773 4.99481 -0.0229751 4.83146 0.00455514 4.21479C0.0660406 3.08627 0.0660406 1.95525 0.00455514 0.826734C-0.0413285 0.0815827 0.259669 -0.0193618 0.896534 0.00266238C6.96236 0.222904 12.3693 2.24179 16.9889 6.16209C22.9794 11.2478 26.1271 17.7688 26.4372 25.648C26.4629 26.294 26.3179 26.5271 25.6609 26.4684C25.0827 26.417 24.4991 26.4574 23.7778 26.4574Z"> </path> <path d="M14.8265 26.441C14.0924 26.441 13.2371 26.6795 12.6626 26.3786C12.0092 26.0372 12.3781 25.0644 12.246 24.378C11.1154 18.5324 6.6849 14.5497 0.74755 14.1001C0.217135 14.0615 -0.0104482 13.9422 0.0134113 13.3659C0.0519536 12.1454 0.0482829 10.9213 0.0134113 9.69524C-0.00127145 9.14464 0.196946 9.03268 0.703502 9.04736C9.21217 9.27128 16.5994 16.2511 17.2804 24.7231C17.418 26.4446 17.418 26.4446 15.6579 26.4446H14.832L14.8265 26.441Z"> </path> <path d="M3.58928 26.4555C2.64447 26.4618 1.73584 26.0925 1.06329 25.4289C0.39073 24.7653 0.00933763 23.8617 0.0030097 22.9169C-0.00331824 21.9721 0.365937 21.0635 1.02954 20.3909C1.69315 19.7184 2.59675 19.337 3.54156 19.3306C4.48637 19.3243 5.39499 19.6936 6.06755 20.3572C6.7401 21.0208 7.1215 21.9244 7.12782 22.8692C7.13415 23.814 6.7649 24.7226 6.10129 25.3952C5.43768 26.0677 4.53409 26.4491 3.58928 26.4555Z"> </path> </svg> <span class="usa-sr-only">NCBI RSS feed</span> </a> </div> </div> <div data-testid="gridContainer" class="grid-container ncbi-footer__container"> <div class="grid-row ncbi-footer__main-content-container" data-testid="grid"> <div class="ncbi-footer__column"> <p class="ncbi-footer__circled-icons-heading"> Connect with NLM </p> <div class="ncbi-footer__circled-icons-list"> <a href=https://twitter.com/nlm_nih class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="32" height="32" viewBox="0 0 40 40" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="m6.067 8 10.81 13.9L6 33.2h4.2l8.4-9.1 7.068 9.1H34L22.8 18.5 31.9 8h-3.5l-7.7 8.4L14.401 8H6.067Zm3.6 1.734h3.266l16.8 21.732H26.57L9.668 9.734Z"> </path> </svg> <span class="usa-sr-only">NLM on X (formerly known as Twitter)</span> </a> <a href=https://www.facebook.com/nationallibraryofmedicine class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="13" height="24" viewBox="0 0 13 24" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M4.11371 23.1369C4.11371 23.082 4.11371 23.0294 4.11371 22.9745V12.9411H0.817305C0.6709 12.9411 0.670898 12.9411 0.670898 12.8016C0.670898 11.564 0.670898 10.3287 0.670898 9.09341C0.670898 8.97903 0.705213 8.95158 0.815017 8.95158C1.8673 8.95158 2.91959 8.95158 3.97417 8.95158H4.12057V8.83263C4.12057 7.8055 4.12057 6.7738 4.12057 5.74897C4.1264 4.92595 4.31387 4.11437 4.66959 3.37217C5.12916 2.38246 5.94651 1.60353 6.95717 1.1921C7.64827 0.905008 8.3913 0.764035 9.13953 0.778051C10.0019 0.791777 10.8644 0.830666 11.7268 0.860404C11.8869 0.860404 12.047 0.894717 12.2072 0.90158C12.2964 0.90158 12.3261 0.940469 12.3261 1.02968C12.3261 1.5421 12.3261 2.05452 12.3261 2.56465C12.3261 3.16857 12.3261 3.7725 12.3261 4.37642C12.3261 4.48165 12.2964 4.51367 12.1912 4.51138C11.5369 4.51138 10.8804 4.51138 10.2261 4.51138C9.92772 4.51814 9.63058 4.5526 9.33855 4.61433C9.08125 4.6617 8.84537 4.78881 8.66431 4.97766C8.48326 5.16652 8.3662 5.40755 8.32972 5.66661C8.28476 5.89271 8.26027 6.1224 8.25652 6.35289C8.25652 7.19014 8.25652 8.02969 8.25652 8.86923C8.25652 8.89439 8.25652 8.91955 8.25652 8.95615H12.0219C12.1797 8.95615 12.182 8.95616 12.1614 9.10714C12.0768 9.76596 11.9876 10.4248 11.9029 11.0813C11.8312 11.6319 11.7626 12.1824 11.697 12.733C11.6719 12.9434 11.6787 12.9434 11.4683 12.9434H8.26338V22.899C8.26338 22.979 8.26338 23.0591 8.26338 23.1392L4.11371 23.1369Z"> </path> </svg> <span class="usa-sr-only">NLM on Facebook</span> </a> <a href=https://www.youtube.com/user/NLMNIH class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="21" height="15" viewBox="0 0 21 15" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M19.2561 1.47914C18.9016 1.15888 18.5699 0.957569 17.2271 0.834039C15.5503 0.678484 13.2787 0.655608 11.563 0.65332H9.43556C7.71987 0.65332 5.4483 0.678484 3.77151 0.834039C2.43098 0.957569 2.097 1.15888 1.74242 1.47914C0.813665 2.32097 0.619221 4.62685 0.598633 6.89384C0.598633 7.31781 0.598633 7.74101 0.598633 8.16345C0.626084 10.4121 0.827391 12.686 1.74242 13.521C2.097 13.8412 2.4287 14.0425 3.77151 14.1661C5.4483 14.3216 7.71987 14.3445 9.43556 14.3468H11.563C13.2787 14.3468 15.5503 14.3216 17.2271 14.1661C18.5676 14.0425 18.9016 13.8412 19.2561 13.521C20.1712 12.6929 20.3725 10.451 20.3999 8.22064C20.3999 7.74025 20.3999 7.25986 20.3999 6.77946C20.3725 4.54907 20.1689 2.30724 19.2561 1.47914ZM8.55942 10.5311V4.65201L13.5601 7.50005L8.55942 10.5311Z" fill="white" /> </svg> <span class="usa-sr-only">NLM on YouTube</span> </a> </div> </div> <address class="ncbi-footer__address ncbi-footer__column"> <p> <a class="usa-link usa-link--external" href="https://www.google.com/maps/place/8600+Rockville+Pike,+Bethesda,+MD+20894/%4038.9959508, -77.101021,17z/data%3D!3m1!4b1!4m5!3m4!1s0x89b7c95e25765ddb%3A0x19156f88b27635b8!8m2!3d38.9959508! 4d-77.0988323" rel="noopener noreferrer" target="_blank">National Library of Medicine <br/> 8600 Rockville Pike<br/> Bethesda, MD 20894</a> </p> </address> <ul class="usa-list usa-list--unstyled ncbi-footer__vertical-list ncbi-footer__column"> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/web_policies.html" class="usa-link usa-link--alt ncbi-footer__link" > Web Policies </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/freedom-information-act-office" class="usa-link usa-link--alt ncbi-footer__link" > FOIA </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.hhs.gov/vulnerability-disclosure-policy/index.html" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > HHS Vulnerability Disclosure </a> </li> </ul> <ul class="usa-list usa-list--unstyled ncbi-footer__vertical-list ncbi-footer__column"> <li class="ncbi-footer__vertical-list-item"> <a href="https://support.nlm.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > Help </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/accessibility.html" class="usa-link usa-link--alt ncbi-footer__link" > Accessibility </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/careers/careers.html" class="usa-link usa-link--alt ncbi-footer__link" > Careers </a> </li> </ul> </div> <div class="grid-row grid-col-12" data-testid="grid"> <ul class="ncbi-footer__bottom-links-list"> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.nlm.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > NLM </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > NIH </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.hhs.gov/" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > HHS </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.usa.gov/" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > USA.gov </a> </li> </ul> </div> </div> </footer> <script type="text/javascript" src="https://cdn.ncbi.nlm.nih.gov/core/pinger/pinger.js"> </script> <button class="back-to-top" data-ga-category="pagination" data-ga-action="back_to_top"> <label>Back to Top</label> <svg class="usa-icon order-0" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#arrow_upward"></use> </svg> </button> <script src="https://code.jquery.com/jquery-3.5.0.min.js" integrity="sha256-xNzN2a4ltkB44Mc/Jz3pT4iU1cmeR0FkXs4pru/JxaQ=" crossorigin="anonymous"> </script> <script type="text/javascript">var exports = {};</script> <script src="/static/CACHE/js/output.13b077bc3ffd.js"></script> <script type="application/javascript"> window.ncbi = window.ncbi || {}; window.ncbi.pmc = window.ncbi.pmc || {}; window.ncbi.pmc.options = { logLevel: 'INFO', staticEndpoint: '/static/', citeCookieName: 'pmc-cf', }; </script> <script type="module" crossorigin="" src="/static/assets/base-9bea7450.js"></script> <script type="module" crossorigin="" src="/static/assets/article-722d91a2.js"></script> </body> </html>

CINXE.COM

Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic - PMC