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Income inequality in the USA has increased over the past four decades. Socioeconomic gaps in survival have also increased. Life expectancy has risen among middle-income and high-income Americans whereas it has stagnated among poor Americans and even declined in some demographic groups. Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution—ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans. Having missed out on decades of income growth and longevity gains, low-income Americans are increasingly left behind. Without interventions to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century health-poverty trap and the further widening and hardening of socioeconomic inequalities in health.

The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms. To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic. This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020. The COVID-19 pandemic and outcomes associated with the measures to mitigate it. Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20). A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]). These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

Posttraumatic Stress Disorder (PTSD) affects millions of people worldwide. While the relationship between direct exposure to traumatic events and PTSD is well-established, the influence of indirect trauma exposure on PTSD remains unclear. It is similarly unclear what role cumulative exposure to direct and indirect traumas play in the risk of PTSD. The study uses data from the Houston Trauma and Recovery Study, conducted on 2020-2021, and involved a random sampling of 1,167 individuals residing in Houston during Hurricane Harvey in 2017. Participants were asked about their experiences related to both Hurricane Harvey and the subsequent COVID-19 pandemic. Exposures were categorized as direct or indirect traumas, in line with the criteria delineated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Cumulative exposures were also calculated. Among participants, 12.6% were experiencing current PTSD. There were significant associations between both direct [OR = 3.18, 95% CI 1.85, 5.46] and indirect [OR = 1.91, 95% CI 1.05, 3.46] traumas related to Harvey, as well as direct [OR = 2.13, 95% CI 1.20, 3.77] and indirect [OR = 1.69, 95% CI 0.93, 3.09] traumas due to COVID and the risk of PTSD in fully adjusted models. Further, significant associations were found between the cumulative exposure to traumas from both Hurricane Harvey and COVID-19 and the risk of PTSD, considering both direct [OR = 2.53, 95% CI 1.36, 4.70] and indirect exposures [OR = 2.79, 95% CI 1.47, 5.28]. Our study offers support for connections between exposure to both direct and indirect traumas stemming from large-scale disasters and PTSD. Moreover, we show that cumulative exposures to multiple large-scale events increase the risk of PTSD. This highlights the importance of the consideration of a range of exposures as risks for PTSD, particularly in a time of compounding disasters and broad population exposures to these events.

Depression is a leading cause of disability in the U.S. across all race/ethnicity groups. While non-Hispanic Black and Hispanic persons have worse physical health on most indicators than non-Hispanic White persons, the literature on the association between race/ethnicity and rates of depression is mixed. Given unequal distribution of assets across racial/ethnic groups, it is possible that social and economic differences may explain differential rates of depression across race/ethnicity groups. Using National Health and Nutrition Examination Survey (NHANES) data from 2007-2016, we constructed a nationally representative sample of 26,382 adults over 18 years old (11,072 non-Hispanic White, 5,610 non-Hispanic Black, 6,981 Hispanic, and 2,719 Other race). We measured symptoms of depression using the Patient Health Questionnaire-9 (PHQ-9), with a score of 10 or more indicating probable depression. We identified three kinds of assets: financial assets (income), physical assets (home ownership), and social assets (marital status and education). We estimated the weighted prevalence of probable depression across race/ethnicity groups, odds ratios controlling for assets, and predicted probabilities of probable depression across race/ethnicity and asset groups. Three results contribute to our understanding of the differences in probable depression rates between race/ethnicity groups: 1) Non-Hispanic Black and Hispanic persons had a higher weighted prevalence of probable depression in the U.S. than non-Hispanic White persons. In models unadjusted for assets, non-Hispanic Black and Hispanic persons had 1.3 greater odds of probable depression than non-Hispanic White persons (p<0.01). 2) We found an inverse relation between assets and probable depression across all race-ethnicity groups. Also, non-Hispanic Black and Hispanic persons had fewer assets than non-Hispanic Whites. 3) When we controlled for assets, non-Hispanic Black and Hispanic persons had 0.8 times lower odds of probable depression than non-Hispanic White persons (p<0.05). Thus, when holding assets constant, minorities had better mental health than non-Hispanic White persons in the U.S. These three findings help to reconcile findings in the literature on race/ethnicity and depression. Given vastly unequal distribution of wealth in the U.S., it is not surprising that racial minorities, who hold fewer assets, would have an overall larger prevalence of mental illness, as seen in unadjusted estimates. Once assets are taken into account, Black and Hispanic persons appear to have better mental health than non-Hispanic White persons. Assets may explain much of the relation between race/ethnicity group and depression in the U.S. Future research should consider the role of assets in protecting against mental illness.

ObjectiveTo document the prevalence of anxiety disorders in the USA during the COVID-19 pandemic.DesignA cross-sectional analysis.SettingA nationally representative sample in the USA between 31 March and 13 April 2020.Participants1450 English-speaking adult participants in the AmeriSpeak Panel. AmeriSpeak is a probability-based panel designed to be representative of households in the USA.Main outcome measuresPrevalence of probable generalised anxiety disorder (GAD) using the GAD-7 and post-traumatic stress symptoms (PTSS) using the four-item PTSD (post-traumatic stress disorder) checklist. Both outcomes were stratified by demographics and COVID-19-related stressors.ResultsThe majority of participants were female (51.8%), non-Hispanic white (62.9%) and reported a household saving of $5000 or more. Those between 18 and 29 years old were the largest age group (38.1%) compared with 40–59 years (32.0%) and 60 years or more (29.9%). The prevalence of probable GAD was 10.9% (95% CI 9.1% to 13.2%) and the prevalence of PTSS was 21.7% (95% CI 19.1% to 24.6%). Among participants reporting five or more COVID-19-related stressors, the prevalence of probable GAD was 20.5% (95% CI 16.1% to 25.8%) and the prevalence of PTSS was 35.7% (95% CI 30.2% to 41.6%). Experiencing five or more COVID-19-related stressors was a predictor of both probable GAD (OR=4.5, 95% CI 2.3 to 8.8) and PTSS (OR=3.3, 95% CI 2.1 to 5.1).ConclusionsThe prevalence of probable anxiety disorders in the USA, as the COVID-19 pandemic and policies implemented to tackle it unfolded, is higher than estimates reported prior to the pandemic and estimates reported following other mass traumatic events. Exposure to COVID-19-related stressors is associated with higher prevalence of both probable GAD and PTSS, highlighting the role these stressors play in increasing the risk of developing anxiety disorders in the USA. Mitigation and recovery policies should take into account the mental health toll the pandemic had on the USA population.

The prevalence of depression in U.S. adults during the COVID-19 pandemic has been high overall and particularly high among persons with fewer assets. Building on previous work on assets and mental health, we document the burden of depression in groups based on income and savings during the first two years of the COVID-19 pandemic. Using a nationally representative, longitudinal panel study of U.S. adults (N = 1,271) collected in April-May 2020 (T1), April-May 2021 (T2), and April-May 2022 (T3), we estimated the adjusted odds of reporting probable depression at any time during the COVID-19 pandemic with generalized estimating equations (GEE). We explored probable depression—defined as a score of ≥10 on the Patient Health Questionnaire-9 (PHQ-9)—by four asset groups, defined by median income (≥ $65,000) and savings (≥$ 20,000) categories. The prevalence of probable depression was consistently high in Spring 2020, Spring 2021, and Spring 2022 with 27.9% of U.S. adults reporting probable depression in Spring 2022. We found that there were four distinct asset groups that experienced different depression trajectories over the COVID-19 pandemic. Low income-low savings asset groups had the highest level of probable depression across time, reporting 3.7 times the odds (95% CI: 2.6, 5.3) of probable depression at any time relative to high income-high savings asset groups. While probable depression stayed relatively stable across time for most groups, the low income-low savings group reported significantly higher levels of probable depression at T2, compared to T1, and the high income-low savings group reported significantly higher levels of probable depression at T3 than T1. The weighted average of probable depression across time was 42.9% for low income-low savings groups, 24.3% for high income-low savings groups, 19.4% for low income-high savings groups, and 14.0% for high income-high savings groups. Efforts to ameliorate both savings and income may be necessary to mitigate the mental health consequences of pandemics.

Purpose The Covid-19 pandemic has exacted a significant physical, financial, social, and emotional toll on populations throughout the world. This study aimed to document the association between pandemic stressors and mental health during the pandemic across countries that differ in cultural, geographic, economic, and demographic factors. Methods We administered an online survey randomly in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States from September 2020 to November 2020. This survey included questions on Covid-19-related stressors as well as the Patient Health Questionnaire-2 and the Primary Care PTSD Checklist to screen for depression and post-traumatic stress disorder (PTSD) symptoms, respectively. We performed bivariable and multivariable regression analyses to assess the prevalence and odds ratios of overall depression symptoms and probable PTSD and in relation to stressors across countries. Results Among 8754 respondents, 28.9% (95% CI 27.5–30.0%) experienced depression symptoms, and 5.1% (95% CI 4.5–6.0%) experienced probable PTSD. The highest prevalence of depression symptoms was in Egypt (41.3%, 95% CI 37.6–45.0%) and lowest in the United States (24.9%, 95% CI 22.3–27.7%). The highest prevalence of probable PTSD was in Brazil (7.3%, 95% CI 5.6–9.4%) and the lowest in China (1.2%, 95% CI 0.7–2.0%). Overall, experiencing six or more Covid-19-related stressors was associated with both depression symptoms (OR 1.90, 95% CI 1.46–2.48) and probable PTSD (OR 13.8, 95% CI 9.66–19.6). Conclusion The association between pandemic related stressors and the burden of adverse mental health indicators early in the Covid-19 pandemic transcended geographic, economic, cultural, and demographic differences between countries. The short-term and long-term impacts of the pandemic on mental health should be incorporated in efforts to tackle the consequences of Covid-19.

Depression is a common mental disorder that may comprise distinct, underlying symptom patterns over time. Associations between stressful life events throughout the civilian lifecourse—including during childhood—and adult depression have been documented in many populations, but are less commonly assessed in military samples. We identified different trajectories of depression symptoms across four years in a military cohort using latent class growth analysis, and investigated the relationship between these trajectories and two domains of civilian life experiences: childhood adversity (e.g., being mistreated during childhood) and more proximal stressful experiences (e.g., divorce). A four-group depression model was identified, including a symptom-free group (62%), an increasing symptom group (13%), a decreasing symptom group (16%), and a “chronic” symptom group (9%). Compared to the symptom-free group, soldiers with childhood adversity were more likely to be in the chronic depression, decreasing, and increasing symptom groups. Time-varying adult stressors had the largest effect on depression symptoms for the increasing symptom group compared to other groups, particularly in the last two years of follow-up. This study indicates the importance of considering events from throughout the lifecourse—not only those from deployment—when studying the mental health of servicemembers.

BackgroundCOVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic.MethodsBetween 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups.ResultsWe found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression.ConclusionPopulations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Substantial literature documents the impact of mass traumatic events on post-traumatic stress disorder (PTSD) in populations. However, the trajectory of PTSD in the US population during the pandemic and the association between assets, Covid-19 related stressors, and PTSD over time remains unclear. The Covid-19 and Life Stressors Impact on Mental Health and Well-Being (CLIMB) is a nationally representative, longitudinal panel of US adults in Spring 2020 ( N  = 1270), 2021 ( N  = 1182), and 2022 ( N  = 1091). Using the four-item PC-PTSD-4, we assessed the prevalence of probable PTSD in the US population over three years. Using generalized estimating equations (GEE) and logistic regression at each wave, we estimated associations of demographics, assets, and stressors with probable PTSD. Here we report that the overall prevalence of PTSD decreases from 22.2% in 2020 to 16.8% in 2022 ( p  = 0.02). Persons with household incomes below$20,000 report higher prevalence of probable PTSD compared to other income groups. The GEE model shows higher odds of probable PTSD among persons with household incomes below $ 20,000 (OR = 2.17 (95%CI: 1.35,3.50)) relative to $75,000 or more; and high stressor scores (OR = 2.33 (95%CI: 1.72,3.15)) compared to low stressor scores. High stressor scores are associated with higher odds of probable PTSD in 2020 (OR = 2.69 (95%CI: 1.56,4.66)), 2021 (OR = 4.58 (95%CI: 2.52,8.30)), and 2022 (OR = 3.89 (95%CI: 2.05,7.38)) compared to low stressor scores. This analysis highlights the pandemic’s prolonged influence on population mental health, particularly among persons with fewer economic assets and those experiencing more pandemic-related stressors. Reducing mental health disparities requires interventions to address inequities.