The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented levels of movement restriction, job losses, and economic uncertainty in the United States and around the world (1). Concerns regarding illness, death, and the death of loved ones may be compounded by financial uncertainty, as reports of mass unemployment with variable international governmental responses circulate (2).

Mental health outcomes have been associated with pandemics in the past (3–5). While there has been a rapid response to the COVID-19 pandemic in terms of nonpharmaceutical interventions, vaccine development, and medical support, little comprehensive planning has been performed to predict and respond to the possible mental health crisis that could emerge from the pandemic, and the only data available on general public responses to the pandemic are in Chinese populations (6, 7). A recent study in the UK population included a set of two surveys of the general public, although their focus was on prioritization of concerns rather than estimating the prevalence of mental health outcomes (8). These data are echoed by research suggesting that healthcare workers have a significant burden of mental health challenges in the face of COVID-19 and highlighting the potential psychological effects of quarantine (9, 10). Moreover, pandemics and other natural disasters may disproportionately affect those with underlying mental illness, the elderly, and healthcare workers (11–14). Loneliness can be exacerbated by the COVID-19 pandemic through several mechanisms and may be associated with other mental health outcomes (15, 16). Time spent outdoors may also be associated with better mental health in the pandemic context, particularly if this time is spent exercising, a benefit that may be more pronounced for women than men (17). Time spent outdoors in general may also be associated with improved positive affect and decreased negative emotions based on a UK study (18). A recent position paper issued a call to action for high-quality population-level data to assess the mental health burden in the context of the present pandemic (8), and it is possible that the uptake of nonpharmaceutical interventions is affected by mental health outcomes given the role of behavioral considerations in their implementation (19, 20).

We therefore sought to investigate the prevalence of anxiety and depression in the general US population in the context of the early COVID-19 pandemic and explore associations of these mental health outcomes with loneliness (of particular concern given enhanced social distancing and isolation), health status, socioeconomic status, residence size, time spent outdoors, and other baseline demographic characteristics. These baseline characteristics were chosen given their potential relevance for developing future risk models and their potential modifiability. A better understanding of the prevalence of these mental health outcomes and their putative risk factors may help guide public policy, research, and interventions.

In this first study of general US population mental health during the COVID-19 pandemic, we found high baseline levels of both anxiety and depression, independent of living under a shelter-in-place or stay-at-home order. More than half (52.1%) of the respondents had at least mild anxiety, and 47.3% of the subjects had at least mild depressive symptoms. This high burden of mental health concerns in the general population in the pandemic context suggests the need for further study and consideration for intervention. That said, the prevalence of mental health outcomes is fairly high in the US population at baseline, where estimates have suggested the prevalence of anxiety and depression is on the order of 19% and 24%, respectively (28, 29).

We found that respondents who identify as Black were less likely to meet the criteria for anxiety on both univariate and adjusted analyses and less likely to meet the criteria for depression on adjusted analyses. Those who identified as Asian had decreased odds of meeting both anxiety and depression on fully adjusted analyses. This finding suggests the need for further study, although they echo prepandemic research that has suggested a lower prevalence of self-reported anxiety in respondents who identify as Black (30–32). Estimates regarding the prevalence of depression vary, with some studies suggesting a higher prevalence among minorities and others pointing to a lower prevalence among racial minorities (33–36). Further research is needed to determine whether this finding is a result of confounding or chance or is replicable.

Living in a larger home was associated with a reduced risk of both anxiety and depression; this effect was seen despite the lack of any association between anxiety or depression and household income and persisted when including income and number of household members in a multivariable model. Similarly, we found that increased time spent outdoors correlated with a reduction in depression (but not anxiety) risk, and those who spent more than an hour a day outdoors had approximately half the risk of depression as those who spent no time outdoors. This association of depression with time outdoors echoes prior research on associations with time spent outdoors and its impact on mental health (37, 38). Our finding that both larger living space and increased time spent outdoors correlate with a reduction in mental health burden may have actionable implications for public health initiatives and decisions regarding access to outdoor recreation areas during stay-at-home or shelter-in-place orders.

History of hospitalization, a rough measure of overall health status, was associated with an increased risk of both anxiety and depression. This effect persisted even when controlling for age and history of anxiety and depression, respectively, suggesting that those with a poorer health status may be at increased risk of adverse mental health outcomes in the context of the COVID-19 pandemic.

Media consumption was not associated with the presence of anxiety or depression. Similarly, we did not detect significant associations between likelihood of meeting the criteria for anxiety or depression and household income or religiosity on adjusted multivariable analyses.

Notably, we found that fewer than half of the respondents had no anxiety; that is, more than half of the subjects reported a level of anxiety that would at least be classified as mild. Conversely, 13.4% of the subjects demonstrated severe anxiety, a higher proportion than has been reported even in healthcare workers responding to pandemic COVID-19 (9). Our finding that 23.6% of the subjects met the criteria for depression using the PHQ-9 echoes earlier pooled data that suggested a prevalence of 24.6% for depression using this scale, although this pooled estimate from 44 studies may overestimate the baseline prevalence of depression due to the inherent limitations of the PHQ-9 (29). The heterogeneity of baseline measures of depression as measured by the PHQ-9 has also been reported in assessments of outpatients (39).

Loneliness is an established risk factor for both anxiety and depression (26, 40), and we found an ~5- to 10-fold increase in odds of anxiety and depression, respectively, with being in the highest loneliness quartile. That said, there may be a tautological relationship between loneliness and depression, and this should be considered when evaluating the relationship between these variables (41). As with those living in smaller homes with minimal access to the outdoors, loneliness can be seen as an independent risk factor for anxiety or depression in the context of the COVID-19 pandemic.

This study has several limitations. First, as with any survey-based research, its generalizability may be limited. We used Prolific Academic for survey distribution in order to maximize our generalizability to the general US population by using an age-, sex-, and race-stratified survey panel design with a large and validated sampling frame. As with any survey data, however, the sample willing to participate may not fully reflect the population of interest, and stratifying by these variables does not guarantee that the sample population reflects the general population in any other way. Second, our study took place during the early phase of the COVID-19 pandemic, when shelter-in-place and stay-at-home orders were only just beginning. If anything, however, this underestimates the prevalence of anxiety and depression as these outcomes would only be expected to increase as restrictions persist and highlights that even the anticipation of such restrictions may present a stressor. Third, as with any survey study, response bias and social desirability bias may play a role, although the anonymous survey design may help mitigate these concerns. Fourth, while our study relied on validated scales wherever possible, some survey questions were the product of pilot testing alone, and therefore their methodology—although consistent with the survey development literature—has not been fully vetted. Fifth, our selection of independent variables was not exhaustive, and other important variables, such as sleep (42), family stress (43), underlying mental health diseases (44), and others, may be important confounders. Finally, and importantly, this cross-sectional study that lacks a comparator group cannot establish causation; therefore, we do not know whether the associations we describe are truly clinical risk factors.

In this first study of mental health outcomes in the US population during the COVID-19 pandemic, we found high rates of depression and anxiety, with the most profound mental health effects in women, those with a history of hospitalization over the past 2 years, those who were most lonely, and those living in smaller homes, and (for depression) those spending the least time outdoors. These findings may be considered in future public health efforts and in developing national and international pandemic responses.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Ascension Health IRB. The patients/participants provided their written informed consent to participate in this study.

BK and JK: study conception, design, writing, statistics. JK: oversight. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.