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Cited by 93COVID-19 and Mental HealthSurvey Methodology and NonresponseMental Health Treatment and Access

Uncovering survivorship bias in longitudinal mental health surveys during the COVID-19 pandemic

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Czeisler, Mark É., Wiley, Joshua F., Czeisler, Charles A., Rajaratnam, Shantha M.W., Howard, Mark E.·2021·Epidemiology and Psychiatric Sciences
DOI 10.1017/s204579602100038xPMC PMC7872393

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Abstract

AIMS: Markedly elevated adverse mental health symptoms were widely observed early in the coronavirus disease-2019 (COVID-19) pandemic. Unlike the U.S., where cross-sectional data indicate anxiety and depression symptoms have remained elevated, such symptoms reportedly declined in the U.K., according to analysis of repeated measures from a large-scale longitudinal study. However, nearly 40% of U.K. respondents (those who did not complete multiple follow-up surveys) were excluded from analysis, suggesting that survivorship bias might partially explain this discrepancy. We therefore sought to assess survivorship bias among participants in our longitudinal survey study as part of The COVID-19 Outbreak Public Evaluation (COPE) Initiative. METHODS: Survivorship bias was assessed in 4039 U.S. respondents who completed surveys including the assessment of mental health as part of The COPE Initiative in April 2020 and were invited to complete follow-up surveys. Participants completed validated screening instruments for symptoms of anxiety, depression and insomnia. Survivorship bias was assessed for (1) demographic differences in follow-up survey participation, (2) differences in initial adverse mental health symptom prevalence adjusted for demographic factors and (3) differences in follow-up survey participation based on mental health experiences adjusted for demographic factors. RESULTS: Adjusting for demographics, individuals who completed only one or two out of four surveys had significantly higher prevalence of anxiety and depression symptoms in April 2020 (e.g. one-survey v. four-survey, anxiety symptoms, adjusted prevalence ratio [aPR]: 1.30, 95% confidence interval [CI]: 1.08-1.55, p = 0.0045; depression symptoms, aPR: 1.43, 95% CI: 1.17-1.75, p = 0.00052). Moreover, individuals who experienced incident anxiety or depression symptoms had significantly higher adjusted odds of not completing follow-up surveys (adjusted odds ratio [aOR]: 1.68, 95% CI: 1.22-2.31, p = 0.0015, aOR: 1.56, 95% CI: 1.15-2.12, p = 0.0046, respectively). CONCLUSIONS: Our findings reveal significant survivorship bias among longitudinal survey respondents, indicating that restricting analytic samples to only respondents who provide repeated assessments in longitudinal survey studies could lead to overly optimistic interpretations of mental health trends over time. Cross-sectional or planned missing data designs may provide more accurate estimates of population-level adverse mental health symptom prevalence than longitudinal surveys.

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  • Attrition may have led to higher retention of participants with more chronic, persistent insomnia symptoms rather than those with acute insomnia at baseline who subsequently remitted.

    “This may have led to higher retention of participants with more chronic, persistent insomnia symptoms, rather than those who experienced acute insomnia symptoms at baseline who subsequently remitted [32, 69].”

    From Insomnia is more likely to persist than remit after a time of stress and uncertainty: a longitudinal cohort study examining trajectories and predictors of insomnia symptoms (2024) · cites this paper as [69]

    The Results (page unavailable) report that follow-up participation was similar across insomnia-symptom groups, contrary to preferential retention of participants with persistent insomnia over those whose symptoms remitted. The paper also reports higher baseline insomnia prevalence among participants who completed only one survey than among those who completed all four. (LLM, conf=0.88)

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  • The sample may have demonstrated a survivorship bias, with very few participants with good sleep at baseline reporting deterioration of sleep over time.

    “Our sample may have also demonstrated a survivorship bias, with very few participants with good sleep at baseline reporting a deterioration of sleep over time [69].”

    From Insomnia is more likely to persist than remit after a time of stress and uncertainty: a longitudinal cohort study examining trajectories and predictors of insomnia symptoms (2024) · cites this paper as [69]

    The Results report survivorship bias associated with incident anxiety and depression symptoms, but say that follow-up participation was similar by insomnia symptoms. The paper therefore does not support the proposed sleep-specific explanation: that participants whose sleep deteriorated were less likely to remain in the sample. (LLM, conf=0.84)

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Research works printed but not linked: 1

  1. [30]Lumley T. “ Analysis of Complex Survey Samples.” Journal of Statistical Software, 9(1), 1– 19. R package version 2.2; 2004.

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Authors
Czeisler, M. É., Wiley, J. F., Czeisler, C. A., Rajaratnam, S. M. W., & Howard, M. E.
Affiliations
  • Brigham and Women's Hospital (US)
  • Monash University (AU)
  • The University of Melbourne (AU)
Corresponding author
Czeisler, Mark É.
ORCID
Venue
Epidemiology and Psychiatric Sciences
Publisher
Cambridge University Press (CUP)
Published
2021
Volume
30
Pages
e45-e45
ISSN
  • 2045-7960 (ISSN-L)
  • 2045-7979
DOI
10.1017/s204579602100038x
PMC
PMC7872393
OpenAlex
W3165179860
Cited by
90
References
52
Citations by year
2026: 23 · 2025: 17 · 2024: 9 · 2023: 10 · 2022: 21 · 2021: 9 · 2018: 1
FWCI
8.53
Type
journal article
Language
en
Open access
Licence
Locations
  • Epidemiology and Psychiatric Sciences (publishedVersion, cc-by)
  • medRxiv (acceptedVersion, cc-by-nd)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion, cc-by)
  • PubMed Central (submittedVersion, cc-by-nd)
Funders
  • Monash University
  • Kinghorn Foundation
  • National Institute on Aging (P01AG009975)
  • National Heart, Lung, and Blood Institute (U01HL111478)
Topics
  • Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
  • Social Sciences › Sociology and Political Science › Survey Methodology and Nonresponse
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
survivorship bias, mental health, anxiety symptoms, depressive symptoms, insomnia, COVID-19 pandemic, United States, United Kingdom comparison, sample selection bias

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