COVID-19 and mental health equity in the United States

The COVID-19 pandemic is likely to have profound mental health impacts that pervade racial, ethnic, and class lines in the United States. Past disasters and public health emergencies, however, suggest that socially disadvantaged groups (e.g., racial/ethnic minorities, people with low income) will experience more psychiatric morbidity related to the pandemic than socially advantaged groups [1]. The origins of these disparities are structural in nature. Historically produced arrangements of power and privilege provide socially advantaged groups with more resources to limit their exposure to, and cope with, stressors caused by disaster. Although racial/ethnic minorities have lower lifetime prevalence rates of mood and anxiety disorders than non-Hispanic whites in the United States [2], while low-income groups have higher rates [3], there are specific aspects of the COVID-19 pandemic that could cause it to have disproportionately adverse impacts on the mental health of racial/ethnic minorities as well as low-income populations.

This Commentary highlights two of these aspects—financial insecurity and grief—and depicts the COVID-19 pandemic from a mental health equity perspective. The goal is to orient future psychiatric research about mental health equity and COVID-19, and extend discourse about the disparate impacts of the pandemic [4] to the domain of mental health. I focus on Blacks, Hispanics, and low-income populations as socially disadvantaged groups because they represent large, and often overlapping, segments of the U.S. population that have been historically marginalized. I use the United States as a case study, but the issues identified are likely applicable to other developed countries with high levels of social and economic income inequality [5].

Stress resulting from COVID-19-related financial insecurity and inequity

The stress of financial insecurity is a well-established risk factor for psychiatric morbidity [5,6,7]. Sources of this stress include actual financial insecurity (e.g., unemployment, insufficient income to meet needs) as well as the perceived threat of financial insecurity (e.g., fear of job loss), with some evidence suggesting that the latter is more detrimental [6]. Furthermore, higher levels of income inequality within a society are associated with poorer population mental health, particularly among low-income segments of the population [5, 7]. The mental health sequel of the COVID-19 economic fallout are likely to be substantial, with one model suggesting that unemployment caused by the pandemic could result in 9570 additional suicides per year worldwide [8].

Socially disadvantaged groups have experienced the financial ramifications of the pandemic more immediately and severely than their socially advantaged counterparts. Data from the U.S. Bureau of Labor Statistics show that, between April 2019 and April 2020, the unemployment rate increased from 3.6 to 14.7 for the U.S. as a whole but from 11.5 to 31.2 among Blacks and from 3.7 to 16.7 among Latinos (https://bit.ly/2XMvayE, Tables A-1, A-2). Data that account for lost wages from reduced hours provide a more complete picture of the pandemic’s inequitable financial impacts. The Urban Institute’s Health Reform Monitoring Survey—a nationally representative survey conducted between March 25 and April 10, 2020 (N = 9000)—found that 57% of Hispanics reported lost jobs, reduced work hours, or reduced work-related income during the pandemic compared to 41% of Blacks and 38% of non-Hispanic whites (https://urbn.is/2XoKFht).

While theory and prior research suggest that inequities in COVID-19’s financial impact could translate into mental health disparities, nationally representative public opinion surveys provide some supporting—albeit preliminary and not peer-reviewed—evidence. A Kaiser Family Foundation Health Tracking Poll conducted between March 25 and March 30, 2020 (N = 1226) found that 54% of respondents who had lost their job or income because of the pandemic endorsed the statement that the virus has had a “negative impact on their mental health,” compared to 40% of those who did not lose their job or income (https://bit.ly/3gMhjkU). A Pew Research Center American Trends Panel survey conducted between March 19 and March 24, 2020 (N = 11,537) found that the proportion of respondents experiencing “high” psychological distress was substantially larger among respondents in the lower than upper income tertile (33% vs 17%) and among Hispanics (28%) and Blacks (26%) than Whites (22%) (https://pewrsr.ch/374YqFr). In sum, financial inequities that are magnified by the COVID-19 pandemic could disproportionately increase risk for mental health problems among socially disadvantaged groups.

Grief stemming from disparities in COVID-19 mortality

Unexpected death of a loved one is a risk factor for mental health problems [9, 10]. Analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions found that such death was independently associated with various psychiatric morbidities, and that risk increased with the number of unexpected deaths a person had experienced [9]. Unexpected death of a loved one was also most frequently rated as the worst traumatic event that respondents had experienced. Among bereaved individuals, the prevalence of prolonged grief disorder—which is characterized by persistent yearning and preoccupation with the deceased—is estimated to be nearly twice as high among African Americans than non-Hispanic whites [10].

Disparities in COVID-19 mortality rates could contribute to elevated grief and psychiatric morbidity among socially disadvantaged groups. As of May 27, 2020 aggregated data from 40 states that publicly report COVID-19 deaths by race/ethnicity indicate that the COVID-19 mortality rate is 2.4 times higher among African Americans (rate = 54.6 per 100,000) than non-Hispanic Whites (rate = 22.7 per 100,000) (https://bit.ly/3ctgUAc). As Yancy describes [4], racial/ethnic disparities in COVID-19 mortality are partially attributable to the fact that racial/ethnic minorities have elevated rates of chronic conditions (e.g., diabetes, cardiovascular disease) that are risk factors COVID-19 mortality. Although data on COVID-19 mortality are not currently available by income, lower-income groups in the United States also have higher rates of these conditions. For example, data from the National Health and Nutrition Examination Survey indicate that the prevalence of diabetes among adults over age 20 is 19.6% among people with annual income below the federal poverty level (FPL) compared to 10.3% among those with income ≥ 400% FPL (https://bit.ly/2yXg8Or). In sum, via COVID-19 mortality disparities, physical health disparities that preceded the pandemic could translate into mental health disparities that proceed the pandemic.

Conclusion

By no means does this Commentary provide an exhaustive review of factors that could cause the COVID-19 pandemic to have disproportionately adverse impacts on the mental health of socially disadvantaged groups. Other issues that could produce such disparities include, but are not limited to: heightened anxiety about acquiring the virus because of greater reliance on public transit, which is likely associated with higher risk of virus transmission; less access to broadband internet and smartphones that support audiovisual technologies which could help mitigate the effects of the pandemic by reducing social isolation and facilitating access to tele-mental health services; and virus-related discrimination which may be prevalent among Asian Americans.

The COVID-19 pandemic will be a focus of psychiatric research for the foreseeable future. If not informed by an equity perspective, such research may generate incomplete knowledge about how structural factors influence mental health risk and resilience during and after the pandemic. This information is important to ensuring that preparedness, response, and recovery efforts minimize disparities in psychiatric morbidity related to COVID-19 and future public health emergencies.