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Recent research has shown that the impacts of the COVID-19 pandemic and social isolation on people’s mental health are quite extensive, but there are limited studies on the effects of the pandemic on patients with mental health disorders.
The objective of this study was to assess the negative impacts of the COVID-19 pandemic on individuals who have previously sought treatment for a mental health disorder.
This study uses the newly developed Epidemic-Pandemic Impacts Inventory (EPII) survey. This tool was designed to assess tangible impacts of epidemics and pandemics across personal and social life domains. From November 9, 2020, to February 18, 2021, a total of 245 adults recruited from a mental health clinic completed the consent form and responded to the survey link from the Siyan Clinical Corporation and Siyan Clinical Research practices located in Santa Rosa, California, USA.
We found that the least affected age group included individuals aged 75 years or older. This was followed closely by the 65- to 75-year-old age group. People with children under the age of 18 years also reported both more negative indicators associated with the pandemic and more positive indicators compared to those without children at home. Gender queer, nonconforming, and transgender individuals may also be at higher risk for more negative impacts associated with the pandemic. When respondents were assessed with regard to their mental health diagnosis, no differences were noted. Substance use also increased during the pandemic.
In conclusion, the data collected here may serve as foundational research in the prevention, care, and treatment of mental health disorders during pandemics such as COVID-19. Populations such as those with previously diagnosed mental health disorders are particularly at risk for negative effects of pandemic-related stressors such as social isolation, especially if they have children in the household, are part of a younger age group, or have substance use disorder. Gender may also be a factor. Further, the EPII survey may prove to be a useful tool in understanding these effects. Overall, these data may be a critical step toward understanding the effects of the COVID-19 pandemic on populations with a mental health diagnosis, which may aid mental health practitioners in understanding the consequences of pandemics on their patients’ overall well-being.
ClinicalTrials.gov NCT04568135; https://clinicaltrials.gov/ct2/show/NCT04568135
The World Health Organization announced that the COVID-19 outbreak had become a global pandemic on March 11, 2020. One year later, approximately 29.5 million people within the United States alone had been infected with the COVID-19 virus [
Research published since the height of the COVID-19 pandemic demonstrates the deleterious effects of this event on psychological well-being. One cross-sectional study conducted across 34 hospitals in China demonstrated that among health care workers exposed to COVID-19, women, nurses, those in Wuhan, and frontline health care workers have a high risk of developing negative mental health outcomes and may need psychological support or interventions [
The effects of COVID-19 have been far-reaching beyond China, however, and the impact of the virus has been felt across the globe. Within the United States, a survey conducted during the last week of March 2020 showed that 72% of Americans felt that their lives were impacted by the outbreak, a 32% increase from the survey conducted only 2 weeks earlier [
The primary goal of this study was to describe the impacts of COVID-19 on a population of residents in the United States who had previously sought psychiatric services at the Siyan Clinical Corporation and Siyan Clinical Research practices located in Santa Rosa, California. Our objective was to assess the impact of the current COVID-19 pandemic on participants with previously diagnosed psychiatric disorders to identify areas of needed support and services. We were interested in whether or not there were any differences in the impact of the COVID-19 pandemic based on features such as age, gender, and mental health diagnosis. The data collected may serve as foundational research in the prevention, care, and treatment of mental health disorders during pandemics such as COVID-19. We also used a newly developed tool, the Epidemic-Pandemic Impacts Inventory (EPII) survey, to assess tangible impacts of epidemics and pandemics across personal and social life domains.
Approximately 3500 adult patients in the Siyan Clinical Corporation and Siyan Clinical Research practices (Santa Rosa, California, USA) were invited to participate in a one-time anonymous survey to assess tangible impacts of epidemics and pandemics across personal and social life domains. Siyan staff derived a list of patients from the Siyan electronic health record system who met eligibility criteria and sent an email inviting them to participate in the survey, explaining the purpose of the survey, how Siyan will use the survey results, and how the survey will be administered. Interested patients signed and returned an informed consent form (ICF) and then received a link to the online survey. A total of 326 patients out of 3500 completed the consent form and received the survey link from Siyan, for a response rate of 9.3%. Of these 326 patients, a total of 245 people responded from November 9, 2020, to February 18, 2021, for a completion rate of 75.2% among those who had completed the consent form. Patients received a US $10 eGift card from Starbucks upon completion of the survey.
These procedures were reviewed by the Advarra Institutional Review Board (IRB) and informed consent was obtained from all participants. The protocol, ICFs, principal investigator curriculum vitae, and all subject-facing and recruitment materials were submitted to the Advarra IRB for review in June 2020. A notice of intent was sent to the authors of the EPII survey prior to IRB submission. The ICF collection process was outlined in the approved protocol and most patients signed the ICFs via Adobe Sign. The data were collected through an approved process utilizing the Alchemer cloud-based integrated feedback platform. In September 2020, the protocol was determined to be IRB exempt by Advarra. This study was conducted using ethical principles derived from international guidelines including the Declaration of Helsinki and the Council for International Organizations of Medical Sciences International Ethical Guidelines.
This study was reviewed and published on ClinicalTrials.gov (NCT04568135) on September 29, 2020.
The EPII is a newly developed, 92-item tool designed to determine the impacts of epidemics and pandemics in personal and social life domains developed by Grasso and colleagues [
A participant had to meet the following criteria to be eligible to participate in this study:
Voluntarily agreed to participate in the study under their own free will and was willing and able to agree to an e-ICF indicating that he or she understood the purpose of the study, he or she understood the procedures that were required for the study, and that he or she was willing to participate in the study.
Was female or male and between the ages of 18 and 80 years, inclusive, at the time of consent.
Was receiving or had previously received psychiatric services from Siyan Clinical Corporation and/or Siyan Clinical Research practices.
Was capable of understanding and complying with study requirements.
Had agreed to the e-ICF. No study-related procedures would be performed before the participant had agreed to the consent letter.
A participant who met any of the following criteria were excluded from this study:
Had a known diagnosis of dementia.
Was under the age of 18 years or over the age of 80 years.
Following the analytic approach taken in a preliminary report [
Sociodemographic characteristics of the sample.
Variable | Respondents (N=245), n (%) | |
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18 to 24 | 25 (10.2) |
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25 to 34 | 39 (15.9) |
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35 to 44 | 57 (23.3) |
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45 to 54 | 40 (16.3) |
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55 to 64 | 47 (19.2) |
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65 to 74 | 24 (9.8) |
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75 or older | 13 (5.3) |
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Female | 187 (76.3) |
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Male | 52 (21.2) |
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Other (gender queer, nonconforming, or transgender) | 6 (2.4) |
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American Indian or Alaska Native | 7 (2.1) |
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Asian | 5 (2.0) |
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Black or African American | 5 (2.0) |
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Hispanic or Latino | 24 (9.8) |
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White | 207 (84.5) |
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Other | 6 (2.4) |
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Undisclosed | 9 (3.7) |
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Less than high school | 3 (1.2) |
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Graduated high school | 20 (8.2) |
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Trade or technical school | 8 (3.3) |
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Some college, no degree | 62 (25.3) |
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Associate degree | 34 (13.9) |
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Bachelor's degree | 74 (30.2) |
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Advanced degree (master's degree, PhD, or MD) | 43 (17.6) |
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Undisclosed | 1 (0.4) |
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Yes | 80 (32.7) |
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No | 162 (66.1) |
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Undisclosed | 3 (1.2) |
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Employed, full time | 98 (40.0) |
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Employed, part time | 35 (14.3) |
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Unemployed, disabled | 22 (9.0) |
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Unemployed, looking for work | 19 (7.8) |
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Unemployed, not looking for work | 6 (2.4) |
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Unemployed, retired | 32 (13.1) |
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Unemployed, volunteer work | 1 (0.4) |
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Other—write in | 29 (11.8) |
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Undisclosed | 3 (1.2) |
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Anxiety disorders | 187 (76.3) |
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Eating disorders | 50 (20.4) |
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Mood disorders | 187 (76.3) |
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Personality disorders | 8 (3.3) |
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Psychotic disorders | 2 (0.8) |
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Substance abuse disorders | 29 (11.8) |
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Trauma-related disorders | 75 (30.6) |
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Other | 19 (7.8) |
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Undisclosed | 7 (2.9) |
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Divorced | 33 (13.5) |
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Married or domestic partner | 135 (55.1) |
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Separated | 7 (2.9) |
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Single or never married | 58 (23.7) |
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Widowed | 9 (3.7) |
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Other | 1 (0.4) |
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Undisclosed | 1 (0.4) |
On average, respondents selected
Overall, there was a significant effect of age (
Average number of negative indicators by age. Respondents who were 75 years of age or older reported the lowest number of negative indicators (mean 14.92) on the Epidemic-Pandemic Impacts Inventory. The 65- to 75-year-old respondents reported the next lowest number of negative indicators (mean 18.08). Results are shown as mean (displayed on the bars) ± standard error of the mean (whiskers).
We also analyzed the reported number of negative and positive indicators as a function of gender. In a one-way ANOVA analysis, the average negative indicators trended toward significance between men, women, and other gender queer, nonconforming, or transgender individuals (
Negative (A) and positive (B) indicators were analyzed as a function of gender. Gender queer, nonconforming, and transgender individuals reported more negative indicators than men and women, on average. Results are reported as mean (displayed on the bars) ± standard error of the mean (whiskers).
An additional topic of interest was whether there would be any differences between respondents who completed the survey before, during, or after the stay-at-home order. Time frames aligned with the dates when the California regional stay-at-home order was implemented (December 3, 2020) and lifted (January 25, 2021). Therefore, the time frames before, during, and after the stay-at-home order were defined as follows, and surveys were aggregated along these dates:
Pre–stay-at-home order: surveys completed before December 3, 2020.
During stay-at-home order: surveys completed from December 4, 2020, to January 25, 2021.
Post–stay-at-home order: surveys completed on January 26, 2021, or after.
It is relevant to note that the sample size for the pre–stay-at-home order group was much smaller (n=17) than that of the during stay-at-home order group (n=135) and the post–stay-at-home order group (n=93). There were minimal differences across groups: the average number of negative indicators was 22.53 (SD 7.04) for the pre–stay-at-home order group, 23.3 (SD 8.93) for the during stay-at-home order group, and 22.54 (SD 8.83) for the post–stay-at-home order group (
Respondents with children under 18 years living at home (n=80) reported a significantly higher number of overall negative impacts (mean 27.84, SD 8.20), on average, compared to respondents without children under 18 years living at home (n=162) (mean 20.57, SD 7.95) (
Average number of negative indicators (A) and positive indicators (B) as a function of having children living at home. Respondents with children under 18 years of age living at home (n=80) reported higher numbers of overall negative and positive impacts compared to respondents without children under 18 years of age living at home (n=162). Results are shown as mean (displayed on the bars) ± standard error of the mean (whiskers).
The
About one-third (86/245, 35.1%) of the respondents reported an increase in the use of alcohol or substances.
The most prevailing
Average number of negative indicators as a function of mental health diagnosis. Results are shown as mean (displayed on the bars) ± standard error of the mean (whiskers).
The most reported indicator in
Top five positive indicators. The most reported indicator in positive change was "More appreciative of things usually taken for granted," followed by "More quality time with family or friends in person or from a distance".
The most impacted indicators.
Subcategory and survey itemsa | Respondents (N=245), n (%)b | |
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Increase in workload or work responsibilities. | 121 (49.4) |
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Had to continue to work even though in close contact with people who might be infected (eg, customers, patients, and coworkers) | 113 (46.1) |
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Had a child in the home who could not go to school | 91 (37.1) |
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Adult unable to go to school or training for weeks or had to withdraw | 48 (19.6) |
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Increase in verbal arguments or conflict with a partner or spouse | 94 (38.4) |
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Had to spend a lot more time taking care of a family member | 68 (27.8) |
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Family celebrations canceled or restricted | 235 (95.9) |
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Separated from family or close friends | 218 (89.0) |
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Unable to pay important bills like rent or utilities | 43 (17.6) |
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Difficulty getting places due to less access to public transportation or concerns about safety | 33 (13.5) |
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Spent more time on screens and devices (eg, looking at phone, playing video games, and watching TV) | 228 (93.1) |
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Increase in mental health problems or symptoms (eg, mood, anxiety, and stress) | 223 (91.0) |
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More time sitting down or being sedentary | 227 (92.7) |
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Less physical activity or exercise | 206 (84.1) |
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Isolated or quarantined due to possible exposure to this disease | 134 (54.7) |
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Limited physical closeness with child or loved one due to concerns of infection | 130 (53.1) |
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Death of close friend or family member from this disease | 41 (16.7) |
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Had symptoms of this disease but was never tested | 18 (7.3) |
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More appreciative of things usually taken for granted | 192 (78.4) |
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More quality time with family or friends in person or from a distance (eg, on the phone, email, social media, video conferencing, and online gaming) | 141 (57.6) |
aThe top two indicators in each subcategory with the highest percentage of respondents reporting yes, me or yes, person in home are listed.
bValues reported are the number of respondents combined who answered yes, me or yes, person in home.
Overall, in this study, we showed that people who have previously sought mental health treatment reported many negative indicators associated with the COVID-19 pandemic. The least affected age groups included individuals who were 75 years or older and 65 to 75 years old. People with children under the age of 18 years living in the household also reported both more negative indicators and more positive indicators than those without minors living in the home. A marginal effect of gender was noted, but these results should be carefully interpreted, as the sample was not absolutely representative of the population. No effect of mental health diagnosis was noted. Furthermore, this study demonstrates the utility of Grasso and colleagues’ [
The results of this study are largely in line with other recent findings. For instance, other survey-based research during the COVID-19 pandemic has also shown that older adults appeared to have a more optimistic outlook and better mental health during the early stages of the pandemic [
Our finding that people with minor children living at home experienced more negative indicators is also in line with other recent studies. For example, one survey of parents in the United States during the pandemic found that 27% of parents reported worsening mental health for themselves, and 14% reported worsening behavioral health for their children; further, this worsening of mental health for parents occurred alongside worsening behavioral health for children in nearly 10% of families, among whom 48% reported loss of regular child care, 16% reported change in insurance status, and 11% reported worsening food security due to the pandemic [
Other researchers have also observed, such as we did, that substance use increased during the COVID-19 pandemic, as did other negative mental health outcomes. In one survey of Americans, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%) [
The data collected here may serve as foundational research in the prevention, care, and treatment of mental health disorders during pandemics such as COVID-19. Dissemination of this new tool, the EPII survey, may be a useful way of measuring the impacts of epidemic- and pandemic-level events not only in this country, but across the world. Understanding how individuals, particularly those individuals at risk due to mental illness, are impacted by events such as COVID-19 may be helpful for determining ways to mitigate the effects of this stress. Further dissemination of this knowledge could be achieved through additional papers, such as this one, that utilize the EPII and presentations or posters at mental health conferences. Without a doubt, more can be done.
In conclusion, we found that people with children under the age of 18 years were most affected by the pandemic. Older age also seemed to be associated with fewer indications of experiencing negative impacts of COVID-19. Gender queer, nonconforming, and transgender individuals may also be at higher risk for negative impacts of COVID-19. No effect of mental health diagnosis was noted. Substance use also tended to increase during the pandemic. Finally, the EPII survey can indeed assess tangible impacts of epidemics and pandemics across personal and social life domains, and it may be a useful tool for future studies that aim to examine the impact of stressful situations on at-risk populations.
analysis of variance
Epidemic-Pandemic Impacts Inventory
informed consent form
Institutional Review Board
not applicable
Substance Abuse and Mental Health Services Administration
standard error of the mean
This research was funded, in part, by a grant from SAMHSA (Substance Abuse and Mental Health Services Administration) Emergency Response for Suicide Prevention (grant 5 H79 TI081478-03).
None declared.