RESUMO
ImportanceWomen and gender-diverse individuals have faced disproportionate socioeconomic burden during COVID-19. There have been reports that this has translated into greater negative changes in mental health, but this has been based on cross-sectional research that has not accounted for pre-COVID-19 differences. ObjectiveTo compare mental health symptom changes since pre-COVID-19 by sex or gender. Data SourcesMEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv, and Open Science Framework (December 31, 2019 to August 30, 2021). Study SelectionEligible studies compared mental health symptom changes from pre-COVID-19 to COVID-19 by sex or gender. Data Extraction and SynthesisData was extracted by a single reviewer with validation by a second reviewer. Adequacy of study methods and reporting was assessed using an adapted version of the Joanna Briggs Institute Checklist for Prevalence Studies. A restricted maximum-likelihood random-effects meta-analyses was conducted. Main Outcomes and MeasuresAnxiety symptoms, depression symptoms, general mental health, and stress measured continuously or dichotomously. Results12 studies (10 unique cohorts) were included. All compared females or women to males or men; none included gender-diverse individuals. Continuous symptom change differences were not statistically significant for depression (standardized mean difference [SMD]= 0.12, 95% CI -0.09 to 0.33; 4 studies, 4,475 participants; I2=69.0%) and stress (SMD= - 0.10, 95% CI -0.21 to 0.01; 4 studies, 1,533 participants; I2=0.0%), but anxiety (SMD= 0.15, 95% CI 0.07 to 0.22; 4 studies, 4,344 participants; I2=3.0%) and general mental health (SMD= 0.15, 95% CI 0.12 to 0.18; 3 studies, 15,692 participants; I2=0.0%) worsened more among females or women than males or men during COVID-19. There were no significant differences in changes in proportion above a cut-off: anxiety (difference= -0.05, 95% CI -0.20 to 0.11; 1 study, 217 participants), depression (difference= 0.12, 95% CI -0.03 to 0.28; 1 study, 217 participants), general mental health (difference= -0.03, 95% CI -0.09 to 0.04; 3 studies, 18,985 participants; I2=94.0%), stress (difference= 0.04, 95% CI -0.10 to 0.17; 1 study, 217 participants). Conclusion and RelevanceMental health outcomes did not differ or were worse by amounts below thresholds for clinical significance for women compared to men. RegistrationPROSPERO (CRD42020179703). KEY MESSAGESO_ST_ABSQuestionC_ST_ABSDid mental health symptoms worsen more for females or women than males or men in COVID-19? FindingsWe reviewed almost 65,000 citations and identified 12 studies that provided data to directly compare mental health symptom changes from pre-COVID-19 to during COVID-19 for females or women versus males or men. Statistically significant, but small, sex- or gender-based differences were found in 2 of 8 mental health outcomes. MeaningMental health changes among females or women were not significantly different from males or men for most outcomes, and differences that were identified were small and less than minimally important difference thresholds.
RESUMO
BackgroundScalable interventions to address COVID-19 mental health are needed. Our objective was to assess effects of mental health interventions for community-based children, adolescents, and adults. MethodsWe searched 9 databases (2 Chinese-language) from December 31, 2019 to March 22, 2021. We included randomised controlled trials with non-hospitalised, non-quarantined participants of interventions to address COVID-19 mental health challenges. We synthesized results descriptively but did not pool quantitatively due to substantial heterogeneity of populations and interventions and concerns about risk of bias. FindingsWe identified 9 eligible trials, including 3 well-conducted, well-reported trials that tested interventions designed specifically for COVID-19 mental health challenges, plus 6 trials of standard interventions (e.g., individual or group therapy, expressive writing, mindfulness recordings) minimally adapted for COVID-19, all with risk of bias concerns. Among the 3 COVID-19-specific intervention trials, one (N = 670) found that a self-guided, internet-based cognitive-behavioural intervention targeting dysfunctional COVID-19 worry significantly reduced COVID-19 anxiety (standardized mean difference [SMD] 0.74, 95% CI 0.58 to 0.90) and depression symptoms (SMD 0.38, 95% CI 0.22 to 0.55) in Swedish general population participants. A lay-delivered telephone intervention for homebound older adults in the United States (N = 240) and a peer-moderated education and support intervention for people with a rare autoimmune condition from 12 countries (N = 172) significantly improved anxiety (SMD 0.35, 95% CI 0.09 to 0.60; SMD 0.31, 95% CI 0.03 to 0.58) and depressive symptoms (SMD 0.31, 95% CI 0.05 to 0.56; SMD 0.31, 95% CI 0.07 to 0.55) 6-weeks post-intervention, but these were not significant immediately post-intervention. No trials in children or adolescents were identified. InterpretationInternet-based programs for the general population and lay-or peer-delivered interventions for vulnerable groups may be effective, scalable options for public mental health in COVID-19. More well-conducted trials, including for children and adolescents, are needed. FundingCanadian Institutes of Health Research (CMS-171703; MS1-173070); McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund (R2-42). RegistrationPROSPERO (CRD42020179703); registered on April 17, 2020. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched for systematic reviews of randomised controlled trials of interventions to address mental health challenges in COVID-19. We used searches from our living systematic review, which were not limited by study design and reviewed citations through April 29, 2021 from MEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science Framework Preprints (preprint server aggregator). We identified 4 systematic reviews of interventions for COVID-19 mental health with search dates between April and September 2020. None, however, included evidence from any completed randomised controlled trials on mental health interventions for community-based children, adolescents, or adults during COVID-19. Added value of this studyOur systematic review is the only living systematic review on COVID-19 community-based mental health interventions registered in PROSPERO and, to the best of our knowledge, the first systematic review to synthesize evidence on completed randomised controlled trials of COVID-19 mental health interventions. The sheer volume of evidence being published in COVID-19 poses a barrier to effective synthesis and policy response. We reviewed over 45,000 citations in any language and distilled this to 9 verified eligible community-based trials. Of these, there were 3 well-conducted trials of interventions designed specifically to be scalable to address challenges of public mental health in COVID-19. One trial showed that internet-based cognitive behavioural therapy in the Swedish general population (N = 670) reduced COVID-19 anxiety and symptoms of depression. Trials that tested a lay-delivered telephone support intervention for homebound older adults in the United States (N = 240) and a peer-moderated group intervention for people with a rare autoimmune condition from 12 countries (N = 172) also found that they improved mental health outcomes, although not all outcomes were statistically significant. Implications of all the available evidenceEffective, scalable, and feasibly delivered mental health interventions are needed for the general public and vulnerable groups as lockdown restrictions continue, even intermittently, and because COVID-19 mental health implications will likely persist beyond the pandemic. Although we identified only 3 high-quality trials, they demonstrated approaches that can be feasibly adopted to meet the needs of adults in the general public and vulnerable groups. The successful internet-based cognitive behavioural therapy intervention was made available to the Swedish general public free-of-charge following testing and suggests that online tools tailored for specific concerns in COVID-19 may represent an efficient way of addressing public mental health. Two lay-and peer-delivered interventions, consistent with pre-COVID-19 evidence, suggest that low-intensity, non-professionally delivered, support-oriented approaches can be leveraged among vulnerable groups. The absence of trials of interventions for children and adolescents underlines the need for evidence on scalable strategies for this population, including school-based approaches.
