Racial and Ethnic Disparities in the Mental Health Impact of the COVID-19 Pandemic in the United States: Analysis of 3 Million Americans from the National Health Interview Survey and Household Pulse Survey

Introduction

Since the first US case of coronavirus disease 2019 (COVID-19) was confirmed from samples taken on January 18, 2020 in Washington state,¹ there had been 67,903,759 confirmed COVID-19 cases and 853,230 deaths in the third year of the pandemic, January 18, 2022.² The pandemic has disproportionately affected racial and ethnic minorities and amplified health disparities. From March 2020 to January 2022, the cumulative COVID-19 hospitalization rate per 100,000 population was 1705.8 for American Indians and Alaska Natives (AIANs), 1248.0 for Black/African Americans, and 987.5 for Hispanic adults aged 25 years or older, compared with 670.6 for non-Hispanic White adults and 411.8 for Asians and Pacific Islanders.³ In 2020, the age-adjusted COVID-19 cumulative mortality rate per 100,000 population was 334.5 for AIANs, 237.9 for Black/African-Americans, 356.9 for Hawaiians and other Pacific Islanders, and 265.2 for Hispanic adults aged 25 years or older, compared with 116.4 for nonHispanic White adults and 110.9 for Asians.⁴

During the COVID-19 pandemic, people have experienced income losses, social isolation, reduced access to care, physical inactivity, food insecurity, and substance use, inducing physical and mental health problems.^5-12 Racial/ethnic minorities and low-income individuals in particular experienced disproportionately greater impacts of COVID-19 in terms of higher social and health inequities. For example, non-Hispanic Blacks, Hispanics, and the other/multiple-race group had 1.30, 1.22, and 1.35 times higher odds of job-related income losses in 2020 than non-Hispanic Whites after controlling for sociodemographic characteristics.⁵ Low-income adults had 5.54 and 2.18 times higher odds of being uninsured and delayed mental healthcare in 2020 than high-income adults.⁶ The prevalence of food insecurity in 2020 was higher for non-Hispanic Blacks (21.7%), Hispanics (17.2%), and non-Hispanic other races (8.8%) than non-Hispanic Whites (7.1%).¹³

Given such stark disparities in COVID-19 mortality and social determinants of health, racial and ethnic minorities might have experienced a disproportionately higher risk of mental health problems, but the available research has yielded heterogeneous findings on racial/ethnic mental health disparities. Some studies on mental health status during the early pandemic period found that racial/ethnic minorities, particularly Hispanics, were more likely to experience depression, anxiety, suicidal thoughts, or fear of COVID-19.^12,14-18 However, other studies found no statistically significant difference or, in fact, higher depression among non-Hispanics White adults.^8,19-22 Mixed findings on racial/ethnic disparities in mental health might have arisen from the use of different methods, study periods, or study locations.

There have also been studies comparing changes in mental health status from the baseline (prepandemic) among racial/ethnic groups, instead of only using mental health status during the pandemic.^15,23-26 Several studies found that the prevalence of psychological distress, including anxiety and depression, increased after the pandemic, but few studies have examined the differential effects of the pandemic by race and ethnicity.^15,23-26 One study found that non-Hispanic Blacks, Hispanics, and Asians experienced a significant change in screening positive for anxiety disorders between 2019 and 2020, compared with non-Hispanic Whites, and Asians showed the highest increase.²⁵ Other studies found that the increase in the prevalence of psychological distress was greater among Hispanics than any other racial/ethnic group, although the difference in the adjusted model was not statistically significant or unknown.^15,26 To extend the existing literature on the differential effects of the pandemic by race/ethnicity, we estimated mental health status before and during the pandemic by race/ethnicity using nationally representative datasets from 2019 to 2021.

Methods

Results

Higher proportions of non-Hispanic White and Asian adults with bachelor's and master's degrees or higher and annual household incomes of ≥$100,000, currently married, private insurance, and were homeowners or Northeast residents, compared with other racial/ethnic groups (data not shown).

During the COVID-19 pandemic, the adjusted predicted probabilities of having little interest in doing things increased from 3.29% in 2019 to 10.97% in 2020 and 11.28% in 2021, after controlling for sociodemographic characteristics (Table 1). The adjusted predicted probabilities of being depressed increased from 2.69% in 2019 to 11.00% in 2020 and 11.21% in 2021. The adjusted predicted probabilities of feeling anxious increased from 3.95% in 2019 to 18.35% in 2020 and 16.96% in 2021. The adjusted predicted probabilities of worrying increased from 4.18% in 2019 to 13.15% in 2020 and 12.61% in 2021. The adjusted mean PDI score increased from 87.52 in 2019 to 103.18 in 2020 and 101.13 in 2021.

All racial/ethnic groups showed worse mental health outcomes during the pandemic (Table 2). Non-Hispanic Whites experienced 3.57 times higher odds of having no interest, 4.39 times higher odds of depression, 5.43 times higher odds of anxiety, and 3.30 times higher odds of worrying in 2020 compared with the pre-pandemic period. In 2021, non-Hispanic Whites experienced higher odds of having no interest, depression, anxiety, and worrying by 3.66, 4.50, 4.83, and 3.14 times, respectively, compared with the pre-pandemic period. PDI for non-Hispanic Whites increased by 14.66 points in 2020 and 12.69 points in 2021, relative to the prepandemic period of 2019.

Non-Hispanic Blacks experienced 3.52 times higher odds of having no interest, 5.27 times higher odds of depression, 6.78 times higher odds of anxiety, and 3.99 times higher odds of worrying in 2020 than in 2019. In 2021, non-Hispanic Blacks experienced 3.76, 5.36, 6.74, and 3.80 times higher odds of having no interest, depression, anxiety, and worrying, respectively, compared with the pre-pandemic period. PDI for non-Hispanic Blacks increased by 16.26 points in 2020 and 14.21 in 2021, relative to the pre-pandemic period. Hispanics experienced 4.09 times higher odds of having no interest, 4.91 times higher odds of depression, 6.03 times higher odds of anxiety, and 3.93 times higher odds of worrying in 2020 than in 2019. In 2021, Hispanics experienced 4.18, 4.99, 5.53, and 3.80 times higher odds of having no interest, depression, anxiety, and worrying, respectively, compared with the pre-pandemic period. PDI for Hispanics increased by 17.81 points in 2020 and 15.70 points in 2021, relative to the pre-pandemic period.

Non-Hispanic Asians experienced 7.02 times higher odds of having no interest, 10.17 times higher odds of depression, 14.99 times higher odds of anxiety, and 10.68 times higher odds of worrying in 2020 than in 2019. In 2021, non-Hispanic Asians experienced 6.94, 9.87, 12.27, and 8.78 times higher odds of having no interest, depression, anxiety, and worrying, respectively, than in 2019. PDI for nonHispanic Asians increased by 16.70 points in 2020 and 13.89 points in 2021, relative to the pre-pandemic period. Non-Hispanic other races experienced 3.39 times higher odds of having no interest, 4.16 times higher odds of depression, 5.97 times higher odds of anxiety, and 3.26 times higher odds of worrying in 2020 than in 2019. In 2021, nonHispanic other races experienced 3.78, 4.60, 5.54, and 3.29 times higher odds of having no interest, depression, anxiety, and worrying, respectively, than in 2019. PDI for non-Hispanic other races increased by 17.98 points in 2020 and 16.90 points in 2021, relative to the pre-pandemic period.

Figure 1 shows marginal effects, which are the absolute difference in the adjusted average predicted probabilities (prevalence) between before and during the pandemic. The increase in the adjusted predicted prevalence of having no interest was higher for nonHispanic others, non-Hispanic Blacks, and Hispanics than non-Hispanic Whites in both 2020 and 2021 (Figure 1). The increase in the adjusted predicted prevalence of having depression was higher for nonHispanic others, non-Hispanic Blacks, Hispanics, and non-Hispanic Asians in 2020, than non-Hispanic Whites. The increase in the adjusted predicted prevalence of having anxiety was higher for non-Hispanic others and Hispanics than non-Hispanic Whites. The increase in the adjusted predicted prevalence of worrying was higher for all racial/ethnic minorities during the pandemic, compared with non-Hispanic Whites.

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Figure 1:

Changes in Adjusted Average Marginal Effects of the COVID-19 Pandemic on No Interest, Depression, Anxiety, and Worries During the Pandemic by Race/Ethnicity, US Adults Aged 18 years or Older AME=Average Marginal Effect; NHW= Non-Hispanic Whites; NHB=Non-Hispanic Blacks; NHA=Non-Hispanic Asians; NHO=Non-Hispanic other races. Marginal effects were estimated using logistic regression adjusted for age, sex, education, household income, marital status, employment status, insurance status, housing tenure, and region of residence.

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Discussion

Our study has shown findings generally consistent with previous studies that racial and ethnic minorities in the US have experienced disproportionately higher risks of psychological distress, including depression and anxiety, during the pandemic in 2020.^15,25,26 Our study found that non-Hispanic Blacks, Hispanics, non-Hispanic Asians were more likely to experience having no interest or depression in 2020 and 2021, compared with non-Hispanic Whites, except for having no interest in 2020 for non-Hispanic Blacks. The lower increase in the rate of depression and anxiety for non-Hispanic Blacks compared with non-Hispanic Whites in the previous study might arise from the difference in the study period. In fact, Twenge et al. found that non-Hispanic Blacks showed a higher increase in the rate of depression than nonHispanic Whites in Fall 2020, while Blacks had a lower increase in the rate of depression than Whites in Summer 2020.²⁵ This might be because of the potential lagged effect after the Black Lives Matter (BLM) movement had spread during the summer across the US.

We found that increases in the odds of psychological distress, including depression and anxiety, were disproportionately higher in racial/ethnic minorities during the pandemic, compared with non-Hispanic Whites, controlling for sociodemographic characteristics. This is an interesting and somewhat unexpected finding since previous studies found that non-Hispanic Asians were less likely to be influenced by financial hardships and non-Hispanic Blacks showed high levels of resilience during the pandemic.^5,8 This particular finding of our study might be partly explained by racism or xenophobia.^36-39 Since the BLM movement in many cities after the death of George Floyd in May 2020, Black Americans experienced 1.96 and 2.30-point increases in depression and anxiety associated with vicarious racism from May to July 2020.⁴⁰ Pre-existing xenophobia and anti-Asian sentiments might be activated with stigmatized terms or blame- rhetoric such as “Chinese virus” or “Kung flu,”^38,41 as the Chinese Government reported a cluster of cases of pneumonia in Wuhan, the first case of COVID-19.⁴² Asian Americans had experienced COVID-19 related racial discrimination, which has been shown to be associated with their depressive symptoms, anxiety, and worrying.^37,38,41

In our study, although non-Hispanic others showed the lowest increase in the odds of mental health symptoms, it should not be ignored that non-Hispanic others had the highest increase in the prevalence of all mental health symptoms (absolute difference) and had the highest level of mental health symptoms at baseline as well. Further studies should conduct subgroup analysis of the non-Hispanic other groups, which mostly consists of AIANs, Hawaiians and Pacific Islanders, and mixed races, to find reasons behind the highest prevalence of depression and anxiety. Given that AIANs have the highest rates of uninsurance, unemployment, poverty, and disability,⁴³ and the highest COVID- 19-related hospitalization and mortality,^3,4 there might have been an interaction effect between the pandemic and their socioeconomic and health conditions.

Considering our findings regarding the increase in the prevalence of depression and anxiety during the last two years and emerging new variants of coronavirus, the US might be faced with increased COVID-19-related mental healthcare needs. However, outpatient and inpatient visits or admission of mental healthcare services, group psychotherapy, or peer supporting meetings have been reduced for infection-control reasons or physical distancing requirements.⁴⁴ Moreover, racial and ethnic minorities are more likely to report that the pandemic has changed their mental healthcare access compared with non-Hispanic White.⁴⁵ To improve mental healthcare access during the pandemic, policymakers might consider home-based treatment or telehealth as an alternative to in-person care.⁴⁴ As a response to increasing demand for telehealth services, for example, the US government relaxed the rule related to the reimbursement for remote patient monitoring services for Medicare and Medicaid beneficiaries.⁴⁶ However, it should not be neglected that telehealth might have challenges related to internet access, privacy, data security, or overutilization, and might not be appropriate for certain populations such as older, under-educated, or low-income populations with difficulties in access to remote services, even exacerbating mental health disparities.⁴⁴

Conclusions and Implications for Translation

Using 2019 as a baseline, all racial/ethnic groups experienced a dramatic increase in rates of depression and anxiety in 2020. In 2021, the probability of experiencing depression and anxiety remained significantly high compared with 2019. All racial/ethnic minorities showed a higher increase in rates of depression and worries compared with non-Hispanic Whites. Non-Hispanic Blacks showed a higher increase in rates of all mental health outcomes compared with non-Hispanic Whites, except anxiety. Hispanics showed higher increases in all four measures compared with non-Hispanic Whites. Although non-Hispanic Asians had lower rates of all mental health symptoms than any other racial/ethnic group at the baseline in 2019, Asians showed the highest increases in the rates of depression and worries among all racial and ethnic groups. Non-Hispanic others showed the lowest relative changes but the highest prevalence for all four mental health symptoms before and during the pandemic.