Comparison of Mental Health Symptoms Prior to and During COVID-19: Evidence from a Systematic Review and Meta-analysis of 134 Cohorts

Abstract

Objectives: The rapid pace, high volume, and limited quality of mental health evidence that has been generated during COVID-19 poses a barrier to understanding mental health outcomes. We sought to summarize results from studies that compared mental health outcomes during COVID-19 to outcomes assessed prior to COVID-19 in the same cohort in the general population and in other groups for which data have been reported. Design: Living systematic review. Data Sources: MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), EMBASE (Ovid), Web of Science Core Collection: Citation Indexes, China National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science Framework Preprints (preprint server aggregator). Eligibility criteria for selecting studies: For this report, we included studies that compared general mental health, anxiety symptoms, or depression symptoms, assessed January 1, 2020 or later, to the same outcomes collected between January 1, 2018 and December 31, 2019. Any population was eligible. We required ≥ 90% of participants pre-COVID-19 and during COVID-19 to be the same or the use of statistical methods to address missing data. For population groups with continuous outcomes for at least two studies in an outcome domain, we conducted restricted maximum-likelihood random-effects meta-analyses. Worse COVID-19 mental health outcomes are reported as positive. Risk of bias of included studies was assessed using an adapted version of the Joanna Briggs Institute Checklist for Prevalence Studies. Results: As of April 11, 2022, we had reviewed 94,411 unique titles and abstracts and identified 137 unique eligible studies with data from 134 cohorts. Almost all studies were from high-income (105, 77%) or upper-middle income (28, 20%) countries. Among adult general population studies, we did not find changes in general mental health (standardized mean difference of change [SMD change = 0.11, 95% CI -0.00 to 0.22) or anxiety symptoms (SMD change = 0.05, 95% CI -0.04 to 0.13), but depression symptoms worsened minimally (SMD change = 0.12, 95% CI 0.01 to 0.24). Among women or females, mental health symptoms worsened by minimal to small amounts in general mental health (SMD change = 0.22, 95% CI 0.08 to 0.35), anxiety symptoms (SMD change = 0.20, 95% CI 0.12 to 0.29), and depression symptoms (SMD change = 0.22, 95% CI 0.05 to 0.40). Of 27 other analyses across outcome domains, among subgroups other than women or females, 5 analyses suggested minimal or small amounts of symptom worsening, and 2 suggested minimal or small symptom improvements. No other subgroup experienced statistically significant changes across outcome domains. In the 3 studies with data from March to April 2020 and later in 2020, symptoms either were unchanged from pre-COVID-19 at both time points or increased initially then returned to pre-COVID-19 levels. Heterogeneity measured by the I 2 statistic was high (e.g., > 80%) for most analyses, and there was concerning risk of bias in most studies. Conclusions: High risk of bias in many studies and substantial heterogeneity suggest that point estimates should be interpreted cautiously. Nonetheless, there was general consistency across analyses in that most symptom change estimates were close to zero and not statistically significant, and changes that were identified were of minimal to small magnitudes. There were, however, small negative changes for women or females in all domains. It is possible that gaps in data have not allowed identification of changes in some vulnerable groups. Continued updating is needed as evidence accrues. Funding: Canadian Institutes of Health Research (CMS-171703; MS1-173070; GA4-177758; WI2-179944); McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund (R2-42). Registration: PROSPERO (CRD42020179703); registered on April 17, 2020.