COVID-19 is linked to an increase in adverse mental health with women, individuals with pre-existing health conditions, and those experiencing socioeconomic adversity at an increased risk.
The COVID-19 pandemic has resulted in wide-ranging direct and indirect changes to population health across the globe. In addition to the known health implications of contracting COVID-19, initial research has uncovered the additional effects of the pandemic, and measures used to control it, on mental health.
To improve our understanding of this impact, researchers from the University of Bristol, the University of Edinburgh, University College London, and the Icahn School of Medicine analysed longitudinal measures of mental health from two UK longitudinal studies: the Avon Longitudinal Study of Parents and Children (ALSPAC) and Generation Scotland. Their research addressed two core aims: first, to compare incidences of depression, anxiety, and mental well-being before the pandemic with those during it; and second, to highlight which populations are at most risk of experiencing mental health impacts during the pandemic.
Established in 1991, the Avon Longitudinal Study of Parents and Children (ALSPAC) charts the lives of 14,500 people born in the former county of Avon between April 1991 and December 1992 as well as the lives of their parents and their children, where applicable.
Generation Scotland is a Scotland-wide family-based study which recruited adults (18+) through the Scottish GP Research Network. The main cohort comprises 24,000 volunteers in 7,000 family groups.
On average, pre-pandemic assessment of depression, anxiety and well-being was undertaken between two and seven years (ALSPAC-young), seven and 20 years (ALSPAC-parent), and four and five years (Generation Scotland) prior to the measures taken during the pandemic.
For the ALSPAC-parent cohort, pre-pandemic depression was measured using the Edinburgh Postnatal Depression Scale (EDPS) – a 10-item instrument with scores ranging between zero and 30, whereby higher scores indicate greater depression and scores of 12 or more have been validated against probable major depression.
The ALSPAC-young cohort measured pre-pandemic depression using the Short Mood and Feelings Questionnaire (SMFQ), a 13-item instrument with scores ranging from zero to 26.
Generation Scotland used the General Health Questionnaire (GHQ) – a 28-item instrument measuring somatic symptoms, and symptoms of anxiety, social dysfunction and depression. The authors used the Likert method to sum each sub-scale with seven items in each sub-scale. Scores ranged from zero to 21, with higher scores being indicative of participants’ experiencing the symptoms with greater frequency.
During the COVID-19 pandemic (April to May 2020), ALSPAC measured depression using the SMFQ. In the Generation Scotland cohort, depression was quantified using a 9-item tool – the Patient Health Questionnaire-9 (PHQ-9), with scores ranging from zero to 27.
In both the SMFQ and the PHQ-9, a higher score indicates more depressive symptoms. A score of 11 or greater on the SMFQ and 10 or higher on the PHQ-9 suggests probable depression.
Pre-pandemic anxiety in the ALSPAC-parent cohort was measured using the Spielberger Trait Anxiety Inventory – a 20 item instrument with scores ranging between 20 and 80, and higher scores being indicative of greater trait anxiety. Scores of 46 or greater have been validated as being predictive of moderate anxiety disorder.
For the ALSPAC-young and Generation Scotland cohorts, pre-pandemic anxiety was measured using the Generalised Anxiety Disorder Assessment-7 (GAD-7), a seven-item instrument with scores ranging from zero to 21 – with higher scores indicating greater severity of generalised anxiety disorder symptoms. A score of 10 or more on the GAD-7 is indicative of generalised anxiety disorder.
During the pandemic, both ALSPAC cohorts and Generation Scotland obtained anxiety scores using the GAD-7.
Pre-pandemic mental well-being was assessed in the ALSPAC-young cohort using the seven-item Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), with scores ranging between seven and 35. Here, a higher score corresponds to better mental well-being. A score of 17 or less is suggestive of poor mental well-being. Pre-pandemic well-being was not assessed in the ALSPAC-parent cohort or Generation Scotland.
Mental well-being during the COVID-19 pandemic in both ALSPAC cohorts and Generation Scotland was measured using the SWEMWBS.
Results identified a co-occurrence between the COVID-19 pandemic and an increase in adverse mental health, with the analysis also identifying specific groups that are at increased risk.
The ALSPAC-young cohort was used to quantify differences in depression, anxiety, and well-being before and during the COVID-19 pandemic as it was the only cohort with consistent measures at both assessment points.
The percentage of ALSPAC-young cohort members with probable anxiety disorder almost doubled, from 13% pre-pandemic to 24% during the pandemic. In the same sample, the prevalence of low well-being also increased, from 8% pre-pandemic to 13% during the pandemic.
In contrast, measures of depression amongst the ALSPAC-young cohort during the pandemic (18%) were lower than that pre-pandemic (24%) – although item-level analysis showed that scores on some items, including ‘no enjoyment’, ‘felt restless’, and ‘found it hard to think’, were higher during the pandemic.
Anxiety (GAD-7) scores and measures of lower well-being (SWEMWBS) were higher during the COVID-19 pandemic when compared to the most recent pre-pandemic assessment.
Analysis of ALSPAC-young, ALSPAC-parent and Generation Scotland, found that the prevalence of probable depression during the COVID-19 pandemic was highest for younger individuals (ages 18–40 years) and decreased with older age.
Moreover, the prevalence of anxiety and depression during the COVID-19 pandemic for the ALSPAC-young cohort was greater in women, those with existing mental or physical health conditions, and those experiencing socioeconomic adversity, even when controlling for pre-pandemic anxiety and depression.
Data from longitudinal studies provide an effective way of assessing the impact of the COVID-19 pandemic on mental health because they have existing information on mental health, that has been prospectively collected prior to the pandemic and which can be compared with the same, or similar measures collected during the pandemic. However, the use of similar, rather than identical measures in some of the studies makes assessing change within a single study challenging. Moreover, the use of different psychometric measures of anxiety and well-being across the different studies also makes comparison between the studies difficult. In addition, the time points at which the pre-pandemic data were collected were not aligned across studies. This difference in when the most recent pre-pandemic measurements were undertaken can have implications for the comparisons undertaken. Participants’ mental health as measured several years before the pandemic may not be indicative of their mental health immediately before it.
As with all longitudinal studies, participant attrition is an important consideration and those with greater mental health problems may be more likely to drop out of the study completely, affecting the findings by potentially underestimating the strength of the relationship between mental health and the pandemic.
An important challenge in cross-study research, highlighted in the example, is the fact that measurement strategies change over time within a study and often differ across studies. Such heterogeneity can sometimes be addressed through retrospective harmonisation techniques. Prospective methods in which studies come together and align their measurement approaches – as was done here with the measures recorded during the pandemic –brings advantages for cross-study comparisons but has implications for backwards comparability if different measures have previously used within individual studies. Prospective harmonisation therefore poses challenges around balancing measurement alignment within and between studies.
In this paper, the two studies, ALSPAC and Generation Scotland, used different measures of depression prior to the pandemic. The GHQ used in Generation Scotland operates on a Likert scale of scores ranging from zero to three, the ALSPAC-young cohort used the SMFQ which employs a three-point scale (‘0’ – not true, ‘1’ – sometimes true, and ‘2’ – true), and the ALSPAC-parents cohort used the EDPS which does not utilise a numeric response scale at all.
As part of the harmonisation process, the authors standardised continuous measures of depression and anxiety obtained before and during the COVID-19 pandemic to allow comparison of effect sizes across outcomes and cohorts in their analysis.
The advantage of such harmonisation effort was to facilitate the usage of data from different sources representing different regions of the UK, enhancing representativeness and allowing evaluation of the reproducibility of findings. Nonetheless, any effort to retrospectively harmonise data requires assumptions about the basis and process for such derivation work. It is important to utilise sensitivity analyses, as the current authors have done, to verify the suitability of such processing steps to the research question at hand.
By identifying who is at most risk of poor mental health during the pandemic, policymakers can target strategies at those in most need. The inclusion of a diverse group of stakeholders across different age cohorts and in different regions increases the relevance of the authors’ findings to policymaking.
It is beneficial to consider the measurement of depression, anxiety, and well-being as different important aspects of mental health. This distinction is reinforced through the research findings, which identify an increase in anxiety, particularly among the ALSPAC-young cohort, during the COVID-19 pandemic compared to their most recent pre-pandemic assessment. In contrast, the authors report an overall reduction in the prevalence of depression among the ALSPAC-young cohort (although higher scores were observed on some items on the SMFQ during the pandemic). By illustrating the importance and utility of pursuing a multi-faceted evaluation of mental health, this research underlines the necessity for policymakers and service providers to tailor interventions with recognition of the diverse needs of the population.
Kwong, A.S., Pearson, R.M., Adams, M.J., Northstone, K., Tilling, K., Smith, D., … & Timpson, N.J. (2021). Mental health before and during the COVID-19 pandemic in two longitudinal UK population cohorts. The British Journal of Psychiatry, 218(6), 334-343. https://doi.org/10.1192/bjp.2020.242
Skipper, M., Kaye, N. & O’Neill, D. (2021). Research Case Studies: The effect of the COVID-19 pandemic on mental health. CLOSER Learning Hub, London, UK: CLOSER.