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Abstract

Communities of color in the United States have been disproportionately impacted by the COVID-19 pandemic. Studies exploring the mental health implications of these disparities have only just begun to emerge. The purpose of this study is to better understand mental health concerns and test whether social determinants of health and COVID-19-related experiences influence these concerns. In April 2020, we launched a community-based survey for adults across the United States. A total of 341 respondents completed the survey, which included questions about demographics, depression, social isolation, work environment, and preexisting mental health conditions. We generated matched controls by adding county data from the Robert Wood Johnson Foundation to our survey. Chi square, Pearson product-moment correlation, point biserial correlation, and logistic regression were estimated. Our analysis revealed that respondents who identified as Latinx, Latin@, or Hispanic were 10 times more likely to meet the threshold score for depression. Similarly, individuals with prior mental health conditions and those who expressed feelings of social isolation due to COVID-19 were 3 times more likely to meet the threshold score for depression. These results confirm our hypothesis that communities of color will likely experience disproportionate mental health impacts of COVID-19—specifically, the mental health sequela that emerge from exposure, cumulative burden, and social isolation. We discuss the implications for expanding access and quality of health and mental health services to address current inequities.

Introduction

The covid-19 pandemic has exposed hundreds of millions of individuals to job loss and severe financial uncertainty, increased loneliness due to social isolation, and increased health-related fears and anxiety about postpandemic life.^1-3 Research from other pandemics, such as severe acute respiratory syndrome, H1N1, and Ebola, have documented poor mental health outcomes among affected communities.^4,5 There is concern that mental health symptoms from the COVID-19 pandemic may persist for many years, especially among those who recovered from COVID-19, patients who were hospitalized, and frontline workers.^6-11 The risk of long-lasting or more severe mental health effects may increase among communities of color and those with preexisting mental health problems and mental health symptoms as a result of the pandemic.

Mental health may also play an important role in the spread of COVID-19. After the Ebola outbreak, depression and posttraumatic stress symptoms were associated with higher-risk behaviors, whereas anxiety was associated with more preventive behaviors.⁴ These findings suggest a potential protective effect of mild anxiety, such as increased social distancing, handwashing, cleaning, and mask wearing. The loneliness induced by the preventive measures of quarantine and isolation, however, can have negative mental health consequences.^2,12,13 Additionally, financial and household strain could increase many of these long-lasting mental health effects.^5,14,15 Preexisting mental health problems become exacerbated during a pandemic¹⁶ and increased life concerns may leave some individuals particularly vulnerable to COVID-19-related stressors.¹⁷

Mental Health Disparities

The mental health implications resulting from the ongoing COVID-19 pandemic are still to be determined, but existing research suggests the outlook is concerning.¹⁶ This is worrisome given that global mental health disparities already existed.^18-20 Mental health disparities occur when the need for services outweighs the availability, and when both need and access are determined by factors such as socioeconomic status. Approximately 11% of the US population reports having symptoms of anxiety, 5% having symptoms of depression, and more than 20% being affected by some type of mental health problem; however, not enough services are available to meet the need.^21,22 This is an even larger problem in parts of the world where mental health services are nonexistent or severely limited.¹⁸ Social inequalities in health insurance coverage, provider and service access, and income levels are systemic, macro-level contributors to mental health disparities.^23-25 These social determinants of health play a large role, not only in mental and physical healthcare but also in overall wellbeing and quality of life.^26-28

Among the most discussed social determinants of mental health disparities and COVID-19 rates are race and ethnicity, with communities of color having greater risk of morbidity and mortality.^29-32 The COVID-19-related death rate is disproportionately high in communities of color, possibly because of preexisting health disparities that leave these groups medically vulnerable.^33,34 Millet et al³⁵ highlighted mental health disparities in Black communities, adding to the concern that disparities in the effects of COVID-19 are due to underlying comorbidities. Sneed et al³⁶ found that African Americans in Michigan, in addition to being disproportionately affected by COVID-19 mortality, received less mental health treatment but had more fears about contracting the virus and being hospitalized. Of the general population with a mental health diagnosis, only 31% of African Americans received mental health treatment, compared with 48% of White participants.³⁶ In a national study of COVID-19 mortality with over 100,000 data points, Selden and Berdahl³⁷ found that Black adults had higher rates of comorbidity and were more likely to work in the healthcare industry compared with White adults, and that both Black and Hispanic participants were less likely to work from home compared with White participants. Researchers have underscored the need to better understand and develop policy aimed at correcting these disparities.³⁸

Literature on health disparities, disasters, and pandemics suggests that the overlap of stressors—such as physical health, work-related issues, and problems with access to care during the COVID-19 pandemic—presents a worrisome outlook for mental health.^5,39,40 Further, a clear link exists between such stressors and chronic health conditions.^41,42 Disproportionate rates of cumulative trauma exposure can also be found within resource-constrained and communities of color, in addition to disparities related to outcomes of stress and trauma.⁴³ Building upon this linkage, the model of allostatic load—an individual's accumulated burden of stress—suggests that increases in stress biomarkers are related to negative health outcomes.⁴⁴ Further, acute stressors coupled with historical stressors and trauma (eg, discrimination, oppression) are linked to negative health outcomes.⁴⁵ With comorbidities underlying many of the COVID-19 racial and ethnic disparities, concerns about behavioral health equity can be linked to an intersectionality of risk for Black, African American, Latinx, Latin@, and Hispanic populations.⁴⁶ The purpose of this study is to better understand early patterns of mental health problems related to the COVID-19 pandemic and to test whether social determinants of health and COVID-19-related experience influence these patterns.

Method

The study began on April 9, 2020, and ran through May 3, 2020, which was a critical period from lockdown to phased reopening for many states. This study was part of a larger study to better understand behavioral health needs during the COVID-19 pandemic. Study respondents were recruited via the Tulane University School of Social Work website and media promotion, using an anonymous survey through Qualtrics. The only limiting eligibility factors were age (adults aged 18 years or older) and ability to access the survey through Qualtrics. Respondents received a welcome letter and gave consent to participate virtually via the online survey. Respondents were informed that they could skip any questions or stop at any time. There was no monetary compensation. Study protocol was approved by Tulane University Institutional Review Board.

Measures

Respondents completed a brief survey that included a measure of mental health depression (Patient Health Questionnaire 2)⁴⁷ and basic demographic information (age, gender, race and ethnicity, education, income, zip code). Respondents were asked whether they had worked from home, participated in emergency services, and experienced social isolation as a result of COVID-19, and whether they had preexisting mental health concerns. To assess geographic differences in health disparities before the pandemic, the following county-level statistics were accessed from the Robert Wood Johnson Foundation's Better Data for Better Health collection⁴⁸ and matched to respondents' zip codes: number of respondents without health insurance, number of mental healthcare providers, number of respondents unemployed, and percentage of respondents in fair or poor health. We used county-level COVID-19 rates from the US Centers for Disease Control and Prevention COVID Data Tracker.⁴⁹

Sample

The total number of people who completed the survey was 341, the majority (82%) of whom were White. Each participant who identified as non-White was matched with corresponding non-Hispanic White cases. Matching variables were zip code, age (±10 years), gender, and having symptoms of depression. The subsample resulted in 118 respondents—66 (56%) non-Hispanic White respondents and 52 (44%) respondents of color. Independent t tests and chi-square tests revealed no group differences on the matching variables (gender, zip code, age, depression).

Respondents

The respondents represented many states including Louisiana (55%), California (9%), Illinois (7%), Georgia (5%), Mississippi (5%), New York (4%), Florida (4%), Texas (4%), Iowa (3%), Arizona (2%), and Tennessee (1%). The mean age was 40 years; 90 (76%) of respondents identified as female, 23 (19%) as male, 3 (3%) as nonbinary, and 2 (2%) as unreported. Respondents were allowed to select multiple racial/ethnic identities: 70% identified as White; 20% identified as Black or African American; 13% identified as Latinx, Latin@, or Hispanic; 6% identified as Asian; 2% identified as American Indian or Native American; and 2% identified as other or multiple identities. The most frequent category for income in 2019 was $60,000 to $69,999. All respondents had at least a high school education (17%), 77% had a 4-year or professional degree, and 6% had a doctorate degree. The majority of respondents (62%) were married or cohabitating, 31% were single, and 7% were divorced or separated.

Results

Chi-square analyses were conducted to assess associations among dichotomous study variables and depression. Results revealed that Latinx, Latin@, and Hispanic respondents (χ² = 7.21, P = .007), those with prior mental health problems (χ² = 10.07, P = .002), and those reporting social isolation (χ² = 12.22, P = .001) were more likely to meet the threshold score for depression, whereas Black or African American respondents were less likely to meet the threshold for depression (χ² = 5.21, P = .022). No other significant associations were revealed (Table 1).

Table 1.

Chi-Square Associations Between Study Variables and Depression

Variables	Depression
	Score <3	Score ≥3^a	Total n (%)	χ²	P Value
	(n = 45)	(n = 73)
	n (%)	n (%)
Latin@, Latinx, or Hispanic	1 (2.2)	14 (19.2)	15 (12.7)	7.21	.007
Black or African American	14 (31.1)	10 (13.7)	24 (20.3)	5.21	.022
Prior mental health problems	8 (17.8)	34 (46.6)	42 (35.6)	10.07	.002
Participated in response	10 (22.2)	12 (16.4)	22 (18.6)	0.614	.433
Work from home	26 (57.8)	49 (67.1)	75 (63.6)	1.05	.306
Experience social isolation	26 (57.8)	63 (86.3)	89 (75.4)	12.22	.001
COVID-19 suspected count	7 (15.6)	12 (16.4)	19 (16.1)	0.016	.899

A score of ≥3 indicates likely depression.

Pearson product-moment correlations were conducted to assess associations among the study variables. Results and descriptive statistics are presented in Table 2. Younger respondents lived in communities with higher percentages of people in fair and poor health (r = -0.34) and had lower income (r = 0.59). As income increased, respondents tended to live in communities with more mental healthcare providers (r = 0.19), lower percentages of people in fair or poor health (r = -0.31), and higher unemployment (r = 0.20). As the number of mental healthcare providers increased in a community, the percentage of those in fair and poor health decreased (r = -0.29), the number of people uninsured increased (r = 0.62), and the number of COVID-19 cases increased (r = 0.60). As the number of people unemployed in a community increased, the percentage of those in fair or poor health decreased (r = -0.20), and the number of COVID-19 cases (r = 0.57), uninsured (r = 0.90), and mental healthcare providers (r = 0.84) increased.

Table 2.

Pearson Product-Moment Correlations Among Study Variables

	Min^a	Max	M	SD	Income	Age	PHQ2	COVID-19	% Health	Uninsured	Mental Health
Income in 2019	1	12	6.8	3.7
Age	20	61	40.0	11.6	0.59^**
Depression (PHQ2)	2	8	4.0	1.7	-0.13	-0.11
COVID-19 rates	68	215,000	1,1020.3	2,4662.8	0.10	0.02	0.18
% fair or poor health	11	27	18.1	3.3	-0.31^**	-0.34^**	0.19^*	-0.129
Number uninsured	1,510	90,8742	9,4531.2	19,1030.5	0.163	0.09	0.18	0.43^**	-0.110
Number mental health providers	16	3,4521	3,006.2	4,501.2	0.19^*	0.11	-0.01	0.62^**	-0.29^**	0.60^**
Number unemployed	447	23,9829	19,186.0	3,2272.8	0.20^*	0.11	0.13	0.57^**	-0.20^*	0.90^**	0.84^**

Income 1 (minimum): <$10,000; Income 12 (maximum): >$150,000; Median: 7 ($60,000 to $69,999).

Statistical significance is bolded; ^*P < .05, ^**P < .01.

Abbreviations: M, mean; PHQ2, Patient Health Questionnaire 2; SD, standard deviation.

Point biserial correlations were conducted (see Table 3) and revealed weak to moderate association. As age (r = -0.25) and income (r = -0.20) increased, respondents were less likely to have prior mental health problems. Individuals who reported social isolation lived in communities with higher percentages of people in fair or poor health (r = 0.20) and were younger (r = -0.25). Respondents who worked from home due to COVID-19 lived in communities with higher numbers of people who were uninsured (r = .19), higher COVID-19 rates (r = 0.20), and higher unemployment (r = 0.19). Respondents identifying as Latinx, Latin@, or Hispanic lived in communities with higher rates of COVID-19 (r = 0.19), and those identifying as Black or African American lived in communities with higher percentages of people in fair or poor health (r = 0.24).

Table 3.

Point Biserial Correlation Coefficients

	Prior Mental Health Problems	Latinx, Latin@, or Hispanic	Black or African American	COVID-19 Response	Work from Home	Social Isolation	COVID-19 Suspected
Income 2019	-0.200^*	-0.143	-0.112	-0.159	0.095	-0.150	-0.057
Age	-0.251^**	-0.119	-0.091	-0.084	0.114	-0.246^**	-0.129
COVID-19 rates	0.132	0.194^*	-0.108	-0.032	0.201^*	0.054	-0.070
% fair or poor health	0.060	0.058	0.239^**	-0.081	0.149	0.198^*	0.013
Number uninsured	0.065	0.049	0.028	-0.088	0.188^*	0.033	0.005
Number mental health providers	0.115	-0.015	-0.126	-0.046	0.174	-0.081	-0.019
Number unemployed	0.078	0.029	-0.059	-0.068	0.191^*	-0.004	-0.021

Note: Statistical significance is bolded; ^*P < .05, ^**P < .01.

A binary logistic regression was conducted to assess variables that classify depression cutoff scores (a score of ≥3 indicates likely depression). Forward stepwise conditional modeling, where only significant variables are added to the model, was used to account for limited power. Results of the beginning block predicted 58% of cases and the overall model was significant (χ²₂ = 11.18, P = .004, Nagelkerke R² = 0.054). The overall model of Block 2 predicted an additional 11% (69% total variance) of cases; the overall model was significant (χ²₁ = 33.15, P = .001, Nagelkerke R² = 0.337). Beta coefficients are presented in Table 4, where in the final block respondents identifying as Latinx, Latin@, and Hispanic were 10 times more likely to meet the threshold score for depression. Respondents who reported feeling socially isolated or having prior mental health problems were 3 times more likely to meet the threshold for depression.

Table 4.

Binary Logistic Regression Beta Coefficients Classifying Depression

Block/Step	Predictor Variables	β	SE	Wald	P Value	Exp(β)	95% CI
Block 1: χ² (df 1) = 4.69, P = .03, Nagelkerke R² = 0.125
Step 1	% fair or poor health	.13	0.06	4.41	.04	1.14	1.01-1.29
Step 2	COVID-19	.00	0.00	3.35	.07	1.00	1.00-1.00
Step 2	% fair or poor health	.15	0.06	5.69	.02	1.16	1.03-1.32
Block 2: χ² (df 3) = 21.97, P = .004, Nagelkerke R² = 0.282
Step 1	COVID-19	.00	0.00	3.27	.07	1.00	1.00-1.00
	% fair or poor health	.13	0.07	3.56	.06	1.14	1.00-1.30
	Social isolation	1.51	0.49	9.51	.00	4.54	1.74-11.86
Step 2	COVID-19	.00	0.00	3.48	.06	1.00	1.00-1.00
	% fair or poor health	.12	0.07	3.24	.07	1.13	0.99-1.29
	Prior mental health problems	1.14	0.50	5.29	.02	3.12	1.18-8.25
	Social isolation	1.30	0.50	6.70	.01	3.67	1.37-9.82
Step 3	COVID-19	.00	0.00	3.48	.06	1.00	1.00-1.00
	% fair or poor health	.13	0.07	3.38	.07	1.13	0.99-1.30
	Latinx, Latin@, or Hispanic	2.33	1.16	4.07	.04	10.30	1.07-99.31
	Prior mental health problems	1.12	0.51	4.81	.03	3.07	1.13-8.36
	Social isolation	1.36	0.52	6.84	.01	3.89	1.41-10.77

Note: Forward selection was used. Criterion variable = A score of ≥3 indicates depression. Variables not included in the final step of the model: Black or African American (P = .06); income (P = .291); participated in response or emergency services (P = .237); COVID-19 rates (P = .042); number of mental healthcare providers (P = .159); number unemployed (P = .143); work from home (P = .737); COVID-19 suspected (P = .448).

Abbreviations: CI, confidence interval; SE, standard error.

Discussion

COVID-19 continues to be a global crisis, with the number of cases increasing in many countries worldwide including much of the United States.⁵⁰ The prolonged nature of the COVID-19 pandemic, the social ramifications from social distancing, financial impacts, and physical health concerns are creating a toll on social emotional functioning.^16,51,52 Mental health symptoms as a result of the pandemic may decrease over time, but some people are likely to experience long-lasting or more severe mental health impacts, especially those with fewer resources and more life stressors.^5,6,53 The purpose of this study was to better understand early patterns of mental health problems related to the COVID-19 pandemic and to test whether social determinants of health and COVID-19–related experience influence these patterns. Our findings suggest that preexisting mental health disparities, social isolation due to COVID-19, and identifying as people of color increased the likeliness of depression.

Disparities

Social determinants of health also highlight disparities that will likely exacerbate long-term mental health consequences of the COVID-19 pandemic. This study revealed that younger respondents and those with less income lived in communities with a higher percentage of people in fair and poor health and were more likely to have prior mental health problems. Our findings are consistent with other studies that explored the impact of age, gender, and socioeconomic status on mental health in the context of COVID-19,⁵⁴ as well as studies that demonstrated links between income inequality and mental health disparities.²⁵ Our findings linking mental and physical health are consistent with previous research suggesting that stress proliferation and allostasis lead to physiological problems.^44,45,55 We found that respondents with higher depression scores also lived in communities with a higher percentage of people in fair and poor health. At the community level, we found that the presence of fewer mental healthcare providers was consistent with higher percentages of people in fair or poor health.

Our study found that respondents with prior mental health problems were 3 times more likely to meet the threshold score for depression during the COVID-19 pandemic. This is consistent with much of the literature on postdisaster recovery, suggesting that preexisting mental health problems lead to more somber recovery prognoses.^56,57 Respondents in our study who worked from home due to COVID-19 also lived in communities with higher numbers of people who were uninsured and with higher COVID-19 rates; this is unsurprising as COVID-19 rates indicate more restrictive environments⁵⁸ and poorer communities. We found population-level COVID-19 mental health disparities related to the pandemic, with high correlations to factors including higher unemployment rates, fewer mental healthcare providers, higher numbers of people uninsured, and higher numbers of COVID-19 cases. The combined stressors of COVID-19-related unemployment, inequities around insurance benefits, and a shortage of mental healthcare providers create additional burdens on an already strained healthcare system and suggest a worrisome outlook for overall population wellbeing.^{1,18,22-24,27,28}

Social Isolation

Social isolation is a stressor of particular concern during the COVID-19 pandemic. Individuals in our study who reported social isolation due to COVID-19 were younger, more likely to meet the threshold score for depression, and lived in communities with higher percentages of people in fair or poor health. A vast amount of previous research has found that social support plays an important role in recovery from disasters.^11,15,59-61 Previous research, together with our findings, suggests that social isolation is likely to increase the negative mental health effects of the COVID-19 pandemic.^13,62 The American Psychological Association has noted the continued importance of social support as a COVID-19 response, and our results support the need to strengthen social support efforts in communities with existing health disparities.⁶³

Race and Ethnicity

It has been suggested that the disproportionate COVID-19 mortality in communities of color is likely due to preexisting health disparities.^30,33,64 Findings from our study show that disparities are not limited to physical health. Respondents in our study identifying as Latinx, Latin@, or Hispanic were over 10 times more likely to have increased symptoms of depression and were more likely to live in communities with higher rates of COVID-19. This is concerning given that before the pandemic, communities of color were less likely to receive mental health treatment.⁶⁵ In Latinx, Latin@, and Hispanic communities in particular, less than half of those with depressive disorders received treatment.²³ Respondents who identified as Black or African American were less likely than Latinx, Latin@, or Hispanic respondents to meet the threshold score for depression, but they were more likely to live in communities with higher percentages of people in fair or poor health, which demonstrates the importance of underlying comorbidities contributing to disparities in the effects of COVID-19. Other research suggests that almost 60% of African Americans who needed mental health treatment did not receive care.²³ Yoon et al⁶⁶ identified racial discrimination due to age and national origin as a contributing factor to depressive symptoms. Together, these findings suggest that the burden of prepandemic disparities in access to mental health services may further compound the deleterious mental health effects of the COVID-19 pandemic.

Findings from our study provide insight into COVID-19 mental health problems and potential mental health disparities, with some limitations. The small subsample size (118 respondents) limits the thoroughness of statistical tests, the generalizability of the results, and the ability to draw inferences. Given the limited external validity, results can be generalized only for study respondents, specifically college graduates from Louisiana with a median income of $60,000. Future studies are needed to understand whether our results hold for other populations. Caution should also be given to inferences about the role of race and ethnicity, due to the lack of representation. Larger studies on this topic are needed for better representation. Future studies should further investigate preexisting health disparities, daily functioning, and social support patterns. While the current study is limited, we expect similar patterns of associations to hold and likely strengthen with a larger and more diverse sample. In addition, we propose associations, including hierarchical (cross-level) associations, that future research should consider and test with larger samples.

Conclusion

COVID-19 has disproportionately affected communities of color. Our findings further elucidate the importance of preexisting health disparities and negative mental health impacts. Mental health disparities and their impact on overall health and wellbeing deserve increased attention. Future healthcare models and service delivery systems must address both present and past disparities. Mental health equity is the right to access preventive and treatment services regardless of race or geographic location.⁶⁷ Given the increased stressors associated with the COVID-19 pandemic, along with other stressors experienced during the year 2020, such as civil unrest and election anxiety, mental health equity should be a top priority for recovery plans. However, given the strained healthcare system, methods should be integrated into pandemic healthcare response.⁵¹ One way to accomplish this and reduce health disparities is with patient-centered medical homes,⁶⁸ which have been noted as an effective policy strategy to increase healthcare access postdisaster.^69,70 In addition to integrated services, culturally appropriate “E-mental health” education models that use internet platforms are a promising way to increase treatment access and possibly address social isolation, as telehealth becomes better accepted due to the social distancing requirements of COVID-19.^16,71,72

Access alone may not reduce mental health disparities. Collaborative efforts should focus on preferred treatment and modalities for communities of color and those with preexisting conditions.^73-75 The COVID-19 pandemic has created unprecedented mental health impacts that are yet unknown, despite existing research that suggests mental health should be of primary concern in strategizing the global response. Our pilot data strongly suggests that mental health disparities will be exacerbated due to COVID-19, especially for communities of color, communities in areas with existing health disparities, those with preexisting mental health problems, and those experiencing social isolation. Our findings are in line with literature regarding health disparities in communities of color. This study is the first step in documenting mental health disparities during COVID-19 using quantitative data. While the culmination of this pandemic is still unknown, addressing mental health disparities now is crucial to ensuring the best possible outcomes in wellbeing for everyone.

Footnotes

Acknowledgments

The authors would like to acknowledge the National Institute of Minority Health Disparities for funding the Dillard University Minority Health and Health Disparities Research Center as well as the collaboration and support from Tulane University ByWater Institute and Empowering Change Task Force at Tulane University School of Social Work.

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COVID-19 Mental Health Disparities

Abstract

Introduction

Mental Health Disparities

Method

Measures

Sample

Respondents

Results

Discussion

Disparities

Social Isolation

Race and Ethnicity

Conclusion

Footnotes

Acknowledgments

References