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Mental Distress in the United States at the Beginning of the COVID-19 Pandemic Calliope Holingue, PhD, MPH, Luther G. Kalb, PhD, Kira E. Riehm, MSc, Daniel Bennett, PhD, Arie Kapteyn, PhD, Cindy B. Veldhuis, PhD, Renee M. Johnson, PhD, MPH, M. Daniele Fallin, PhD, Frauke Kreuter, PhD, Elizabeth A. Stuart, PhD, and Johannes Thrul, PhD Objectives. To assess the impact of the COVID-19 pandemic on mental distress in US adults. Methods. Participants were 5065 adults from the Understanding America Study, a probability-based Internet panel representative of the US adult population. The main exposure was survey completion date (March 10–16, 2020). The outcome was mental distress measured via the 4-item version of the Patient Health Questionnaire. Results.Among stateswith 50 ormore COVID-19 cases as ofMarch 10, each additional day was significantly associated with an 11% increase in the odds of moving up a category of distress (odds ratio = 1.11; 95% confidence interval = 1.01, 1.21; P = .02). Perceptions about the likelihood of getting infected, death from the virus, and steps taken to avoid infecting others were associated with increased mental distress in the model that included all states. Individuals with higher consumption of alcohol or cannabis or with history of depressive symptomswere at significantly higher risk for mental distress. Conclusions. These data suggest that as the COVID-19 pandemic continues, mental distress may continue to increase and should be regularly monitored. Specific populations are at high risk for mental distress, particularly those with preexisting depressive symp- toms. (Am J Public Health. 2020;110:1628–1634. https://doi.org/10.2105/AJPH. 2020.305857) See also Cable, p. 1595. The United States has entered a newhistorical phase with the rapid spread of the novel coronavirus SARS-CoV-2 and deaths from COVID-19. Data from China suggest that the mental health impacts of COVID-19 are severe.1 Thus far, there are little data on the mental health impact of the pandemic in the United States. This infor- mation is critical, as there is a robust literature on how public health crises, such as SARS or natural disasters, can lead to mental health challenges, including symptoms of acute stress, loneliness, anxiety, and depression.2 Social distancing recommendations may further increase the likelihood of mental health symptoms, because isolation is known to have detrimental mental health effects.3 Early findings from China indicate the serious mental health impact of the COVID-19 pandemic. In one survey with 1210 participants conducted in January and February 2020, 54% rated the psychological impact of the COVID-19 pandemic as moderate to severe, 29% reported moderate- to-severe anxiety symptoms, 17% reported moderate-to-severe depressive symptoms, and 8% reported moderate-to-severe stress levels.1 Another survey with 52 730 respon- dents in January and February 2020 reported that almost 35% of the sample experienced psychological distress.4 This study also found regional differences in psychological distress, with respondents from Hubei province, the epicenter of the COVID-19 pandemic, reporting significantly higher distress. Moreover, people with preexisting mental disorders could be more heavily affected by the COVID-19 pandemic, including possi- ble relapse or exacerbation of psychiatric conditions.5 There are marked mental health disparities in the United States that are likely to be exacerbated by this pandemic. For example, serious mental distress is more common in women and in those who are uninsured and is often comorbid with chronic somatic con- ditions.6 In addition, those in higher income brackets have lower rates of serious mental distress.6 Existing research has linked eco- nomic hardship with the incidence7 and progression8 of mental disorders. Difficulty withfinances not only contributes to stress but also is a leading barrier to receiving mental health and substance use disorder treatment.9 The COVID-19 pandemic has become intertwined with an economic crisis and has resulted in widespread job loss and economic downturn.10 Information is needed to un- derstand how shifting labormarket outcomes, secondary to the COVID-19 pandemic, are potentially exacerbating mental health dis- parities across the United States. Research from China has already demonstrated that college students whose families had less stable incomes were at increased risk of mental distress because of COVID-19.11 ABOUT THE AUTHORS Calliope Holingue and Luther G. Kalb are with the Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD.Kira E.Riehm,ReneeM. Johnson,M.Daniele Fallin, ElizabethA. Stuart, and JohannesThrul are with theDepartment of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Daniel Bennett and Arie Kapteyn are with the Center for Economic and Social Research, University of Southern California, Los Angeles. Cindy B. Veldhuis is with the School of Nursing, Columbia University, New York, NY. Frauke Kreuter is with the Maryland Population Research Center, University of Maryland, College Park. Correspondence should be sent to Calliope Holingue, MPH, PhD, Office 3050A, Kennedy Krieger Institute, 1750 E Fairmount Ave, Baltimore, MD 21231 (e-mail: holingue@kennedykrieger.org). Reprints can be ordered at http://www.ajph .org by clicking on the “Reprints” link. This article was accepted June 21, 2020. https://doi.org/10.2105/AJPH.2020.305857 1628 Research Peer Reviewed Holingue et al. AJPH November 2020, Vol 110, No. 11 AJPH COVID-19 https://doi.org/10.2105/AJPH.2020.305857 https://doi.org/10.2105/AJPH.2020.305857 mailto:holingue@kennedykrieger.org http://www.ajph.org http://www.ajph.org https://doi.org/10.2105/AJPH.2020.305857 The social isolation, financial hardship, and fear associatedwithCOVID-19 could present a perfect storm for public mental health in the United States. Data are needed to track the impact of the COVID-19 pandemic on mental health, including identifying those in greatest need, to serve as evidence-based information for the public and to marshal resources across local, state, and federal agencies. The current study addresses this need by examining predictors of mental distress in a nationally representative house- hold panel during a period of rapid spread of COVID-19 in the United States. METHODS Data for this project came from the Understanding America Study (UAS), a probability-based Internet panel recruited via postal mailings. Eligible participants were selected based on a random selection of ad- dresses drawn from the post office delivery sequence files via a commercial vendor.12 The initial panel intake survey includes an age screening; eligible individuals are all adults aged 18 years and older in the contacted household. The UAS panel consists currently of 11 nationally representative sample batches, rolled into the panel between 2014 and 2019. The current analysis used early release (March 17, 2020) data from the UAS 230 wave, which was fielded betweenMarch 10 andMarch 16.Thisweek of data collection paralleled the declaration of COVID-19 as a pandemic by theWorldHealthOrganization, of a national emergency by the president of theUnited States, and the beginning of school and work closures and social distancing recommendations. All active respondents of the UAS were selected for participation, except Spanish speakers. As such, this survey was made available to 8502 UAS participants. Of the 8502 invited participants, 5325 completed the survey and were counted as respondents (overall response rate of 63%). Of those who were not counted as respondents, 89 started the survey without completing, and 3088 did not start the survey. Survey weights for UAS account for probabilities of sample selection and align- ment to Current Population Survey bench- marks, along socioeconomic dimensions, gender (male or female), race and ethnicity (White, Black, other, Hispanic), age (18–39, 40–49, 50–59, and ‡ 60 years), education (high school or less, some college, or bach- elor’s degree or more), Census regions (Northeast, Midwest, South, or West), and fraction of Native Americans. The reference population considered for the weights is the US population of adults aged 18 years and older. More information about UAS can be found at https://uasdata.usc.edu/index.php, and specific information about the UAS 230 survey is at https://uasdata.usc.edu/page/ COVID-19+Corona+Virus.Weused survey weights in all analyses. Measures Mental distress and substance use. The pri- mary outcome measure of interest was the 4-item version of the Patient Health Ques- tionnaire (PHQ-4), which has been validated in the general population.13 This measure asks about the frequency of being bothered by feelings of nervousness, worry, depression, and loss of interest over the past 2 weeks. Response options include not at all (0), several days (1), more than half the days (2), and nearly every day (3). The total score is determined by add- ing the scores of each of the 4 items. Scores are categorized as normal (0–2), mild (3–5), moderate (6–8), or severe (9–12). A score of 3 or higher for the first 2 items suggests anxiety, while a score of 3 or higher on the last 2 items suggests depression.14 In an earlier wave of data collection, participants completed the 8-item version of the Center for Epidemio- logic Studies–Depression Scale (CES-D 8).15 We used the number of symptoms a respon- dent previously endorsed as occurring “much of the time” in the past week as a measure of historical depressive symptoms. The most re- cent CES-D 8 was used for participants who had multiple CES-D 8 scores from previous waves (49% of sample had CES-D 8 score from June 2019, 32% from June 2017, and 19% from May 2015). COVID-19 items. Respondents were asked to provide their best estimate of the chance (0%–100%) that they would become infected with COVID-19 in the next 3 months and that they would die if infected. We classified individuals as having a per- ception of 0%, 1% to 50%, or greater than 50% for both of these questions. We used the category of 0% as the reference group because these variables were zero-inflated. Participants were also asked whether they had “taken any steps to stay away from other people to avoid infecting them.” Response options were yes, no, and unsure. The survey start date (between March 10 and March 16) was used to assess whether calendar time was associated with mental distress. Other variables. Sociodemographic factors included gender (female or male), age (years), race/ethnicity (White, American Indian or Alaska Native, Asian, Black or African American, Hawaiian or Pacific Is- lander, Hispanic or Latino, or multiracial), education (high-school degree or below, attended some college or received a 2-year degree, bachelor’s degree, or graduate de- gree), marital status (married, never married, separated or divorced, or widowed); house- hold income (< $20 000, $20 000–$39 999, $40 000–$59 999, $60 000–$99 999, or ‡ $100 000), and currently have a job (yes or no). lastly, participants were asked to estimate the number of days on which they consumed alcohol and number of days on which they consumed cannabis, both over the past week. high- and low-count states. we classified states according towhether they had a high or low count of confirmed cases of covid-19 as of march 10, 2020, the first $20="" 000,="" $20="" 000–$39="" 999,="" $40="" 000–$59="" 999,="" $60="" 000–$99="" 999,="" or="" ‡="" $100="" 000),="" and="" currently="" have="" a="" job="" (yes="" or="" no).="" lastly,="" participants="" were="" asked="" to="" estimate="" the="" number="" of="" days="" on="" which="" they="" consumed="" alcohol="" and="" number="" of="" days="" on="" which="" they="" consumed="" cannabis,="" both="" over="" the="" past="" week.="" high-="" and="" low-count="" states.="" we="" classified="" states="" according="" towhether="" they="" had="" a="" high="" or="" low="" count="" of="" confirmed="" cases="" of="" covid-19="" as="" of="" march="" 10,="" 2020,="" the="">