In a nationally representative probability survey of American adults taking place during the early phases of the COVID-19 response (April 2020), we found high levels of significant depressive symptoms and loneliness. Very frequent in-person social and sexual contacts during the time of COVID-19 restrictions in the last month were generally associated with lower prevalence of depression and loneliness, while remote contacts were not similarly protective. We also found that relationship tension due to COVID-19 spread and restrictions was strongly predictive of depression and loneliness. Our findings suggest that the COVID-19 spread and response has had a tremendous mental health impact on Americans.
We found that nearly one-third of Americans reported depressive symptoms in April 2020, notably much higher than previous estimates among American adults. From 2013 to 2016, the prevalence of major depression in a given 2 week period in US adults age 20 + years was 8%, nearly 4 times lower than our estimate [30]. Similarly, the mean loneliness score we found (4.4) was higher than prior estimates in three western European countries (3.5–3.7) [31], and the prevalence of loneliness we found in our general US population (Definition 1: 54%), is a similar magnitude as previously observed in older and elderly Americans (43–56%) [28, 29]. Patterns of higher depression prevalence among women, young adults, and people with lower incomes have been observed in previous studies [14, 30]. We also observed these gender, age, and socioeconomic patterns in our study, suggesting that while the magnitude of depression may be expanding during the time of COVID-19 spread and restrictions, the disproportionate burden continues to be felt in these populations.
The observed relationships between social and sexual connections and the outcomes of depression and loneliness are largely consistent with our understanding of the importance of human connection for mental health and well-being. Close touching in family interactions and among relationship partners has been associated with decreased heart rate, higher levels of oxytocin, and lower levels of cortisol [32, 33]; which, in turn could provide important mental health protections. These kinds of connections cannot easily be recreated with remote technology where direct touch is not possible, though some researchers have explored this through “huggable” and other similar communication devices [34]. We also know that common technical difficulties with video calls can cause misattributed negative feelings towards people on the call [35], perhaps contributing to the null effects we observed for remote connections and mental health outcomes. As the COVID-19 spread and response have dramatically limited access to many previously routine and familiar options for human connection, our findings are consistent with an explanation that the decreased frequency of social and sexual connections is contributing to poor mental health outcomes. In addition to limiting people’s social interactions, restrictions have also likely resulted in many people missing counseling or therapy appointments or other activities (e.g., exercise, massage, support group meetings, etc.) that may have been supportive of their mental health.
There are several other plausible explanations for the observed relationship between social and sexual connections and mental health outcomes. First, people who are struggling with poor mental health and feelings of isolation during COVID-19 restrictions may be reaching out more frequently for remote connections. As this was a cross-sectional study, our ability to infer temporality is limited. Future studies with a longitudinal design would be better able to disentangle the temporal relationships between social/sexual connections and mental health outcomes. Second, we used self-reported data for our key exposure and outcome assessments, with the potential for biased results. However, web-based surveys have shown to be effective modes to elicit sensitive sexual behaviors from study participants, alleviating some of the bias concern [36]. Similarly, our depression and loneliness scales are widely used in web-based surveys, are validated, and have good psychometric properties [24, 27]. However, their use could be complemented with clinical assessments in future studies. Relatedly, it is not yet known how these scales perform during times of social restrictions when daily lives have shifted so dramatically. It is possible that the wording of certain items (e.g., ‘How often do you feel isolated from others?’) may lose their discriminatory ability in times where isolation is essentially mandated. For this reason, we used a more conservative categorical definition of loneliness for our analyses than has been commonly used in prior studies. We also did not explore whether participants had run out of prescription medication supportive of their mental health or had missed counseling or therapy visits.
A key strength of this study is its external validity. Our findings are broadly representative of the US adult population during the early stages of the US COVID-19 response. However, these results may not hold during later phases of the COVID-19 response, or for countries outside of the US. Surveys should be conducted at frequent intervals and in other countries affected by COVID-19 to update our understanding of the changing mental health landscape across time and space.
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