Generational, sex, and socioeconomic inequalities in mental and social wellbeing during the COVID-19 pandemic: prospective longitudinal observational study of five UK cohorts

Long term mortality trends in people with severe mental illnesses and how COVID-19, ethnicity and other chronic mental health comorbidities contributed: a retrospective cohort study

BACKGROUND

People with schizophrenia-spectrum and bipolar disorders (severe mental illnesses; 'SMI') experience excess mortality. Our aim was to explore longer-term trends in mortality, including the COVID-19 pandemic period, with a focus on additional vulnerabilities (psychiatric comorbidities and race/ ethnicity) in SMI.

METHODS

Retrospective cohort study using electronic health records from secondary mental healthcare, covering a UK region of 1.3 million people. Mortality trends spanning fourteen years, including the COVID-19 pandemic, were assessed in adults with clinician-ascribed ICD-10 diagnoses for schizophrenia-spectrum and bipolar disorders.

RESULTS

The sample comprised 22 361 people with SMI with median follow-up of 10.6 years. Standardized mortality ratios were more than double the population average pre-pandemic, increasing further during the pandemic, particularly in those with SMI and psychiatric comorbidities. Mortality risk increased steadily among people with SMI and comorbid depression, dementia, substance use disorders and anxiety over 13-years, increasing further during the pandemic. COVID-19 mortality was elevated in people with SMI and comorbid depression (sub-Hazard Ratio: 1.48 [95% CI 1.03-2.13]), dementia (sHR:1.96, 1.26-3.04) and learning disabilities (sHR:2.30, 1.30-4.06), compared to people with only SMI. COVID-19 mortality risk was similar for minority ethnic groups and White British people with SMI. Elevated all-cause mortality was evident in Black Caribbean (adjusted Rate Ratio: 1.40, 1.11-1.77) and Black African people with SMI (aRR: 1.59, 1.07-2.37) during the pandemic relative to earlier years.

CONCLUSIONS

Mortality has increased over time in people with SMI. The pandemic exacerbated pre-existing trends. Actionable solutions are needed which address wider social determinants and address disease silos.

Physical and mental health of 40,000 older women in England during the COVID-19 pandemic (2020-2021)

BACKGROUND

To assess factors associated with perceived changes in physical and mental health and with delays in seeking healthcare during the second and third COVID-19 lockdowns in England (2020-2021).

METHODS

An online survey of Million Women Study participants collected data on 44,523 women, mean age 76 (SD = 4), October 2020-May 2021. These data were linked to data collected prospectively on Million Women Study participants at recruitment in median year 1998 and at re-surveys in 2011-2013, as well as to hospital admission data from 2017-2019.

RESULTS

Of 40,821 participants with complete data on the outcomes of interest, 28% reported worse physical health and 26% worse mental health. After adjustment for age, region, education and survey period, poor/fair self-rated health (adjusted OR 2.71, 95% CI 2.52-2.91), having been told to shield (1.92, 1.79-2.05), obesity (2.17, 2.04-2.31) and other measures of poor health prior to the outbreak were all strongly related to worse physical health, as was being an informal carer (1.47, 1.38-1.56) and having a COVID-19 infection (1.64, 1.53-1.77). Depression (2.31, 2.06-2.58), poor/fair self-rated health (1.98, 1.84-2.13) and being an informal carer (1.69, 95% CI 1.58-1.80) were the factors most strongly related to worse mental health. Having poor/fair self-rated health (2.22, 2.05-2.40), obesity (1.58, 1.47-1.70) and being an informal carer (1.45, 1.34-1.56) were all strongly related to delaying seeking medical care. These associations remained essentially unchanged after exclusion of participants who had a COVID-19 infection.

CONCLUSIONS

In a large sample of older women in England, just over a quarter reported a deterioration in their physical and mental health during the national lockdowns. In addition to the expected effect of a COVID-19 infection on physical health, the groups who were most likely to report such a deterioration were those with pre-existing morbidity and those who were caring for others as informal carers.

Temporal dynamics of socioeconomic inequalities in depressive and anxiety symptoms during the COVID-19 pandemic: a scoping review

Background

The existence of socioeconomic inequalities in the prevalence of symptoms of depression and anxiety is widely acknowledged, and individuals from lower socioeconomic backgrounds tend to exhibit higher rates of symptoms. However, the direction in which the COVID-19 pandemic has influenced these disparities remains uncertain. We therefore aimed to systematically outline the available evidence on the temporal dynamics of socioeconomic inequalities in symptoms related to depression and anxiety during the COVID-19 pandemic across high-income countries.

Methods

A scoping review was conducted by searching the databases Embase, Scopus and PsycINFO. According to pre-defined eligibility criteria, two reviewers independently screened titles and abstracts as well as full texts of the compiled records. Data from the included studies were extracted using a standardised data-extraction form and analysed numerically and narratively. The scoping review followed the PRISMA-ScR guidelines.

Results

A total of 49 studies comprising 149 analyses of socioeconomic indicators in relation to symptoms of depression and anxiety were included. Despite heterogeneous study designs and results, there was a tendency of increasing (40.9%; n = 61) or persistent (38.2%; n = 57) inequality trends to the detriment of those in socially more disadvantaged positions. Increasing inequalities were most pronounced when income was used as a socioeconomic indicator. Groups with lower socioeconomic status appeared most vulnerable in the initial phase of the COVID-19 pandemic. Throughout the pandemic, dynamics were diverse, with persistent trends most frequently reported.

Conclusion

Overall, to the detriment of those with lower socioeconomic status, mental-health inequalities persisted or increased in most analyses. Continually monitoring socioeconomic inequalities over time is crucial, since this makes it possible to adapt prevention and intervention strategies to specific pandemic phases. Interventions targeting job security, income security and educational attainment could reduce mental-health inequalities. The results can contribute to preparedness plans for future pandemics and crises.

Extending intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to study individual longitudinal trajectories, with application to mental health in the UK

The intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) approach is gaining prominence in health sciences and beyond, as a robust quantitative method for identifying intersectional inequalities in a range of individual outcomes. However, it has so far not been applied to longitudinal data, despite the availability of such data, and growing recognition that intersectional social processes and determinants are not static, unchanging phenomena. Drawing on intersectionality and life course theories, we develop a longitudinal version of the intersectional MAIHDA approach, allowing the analysis not just of intersectional inequalities in static individual differences, but also of life course trajectories. We discuss the conceptualization of intersectional groups in this context: how they are changeable over the life course, appropriate treatment of generational differences, and relevance of the age-period-cohort identification problem. We illustrate the approach with a study of mental health using United Kingdom Household Longitudinal Study data (2009-2021). The results reveal important differences in trajectories between generations and intersectional strata, and show that trajectories are partly multiplicative but mostly additive in their intersectional inequalities. This article provides an important and much needed methodological contribution, enabling rigorous quantitative, longitudinal, intersectional analyses in social epidemiology and beyond.

A quantitative approach to the intersectional study of mental health inequalities during the COVID-19 pandemic in UK young adults

PURPOSE

Mental health inequalities across social identities/positions during the COVID-19 pandemic have been mostly reported independently from each other or in a limited way (e.g., at the intersection between age and sex or gender). We aim to provide an inclusive socio-demographic mapping of different mental health measures in the population using quantitative methods that are consistent with an intersectional perspective.

METHODS

Data included 8,588 participants from two British cohorts (born in 1990 and 2000-2002, respectively), collected in February/March 2021 (during the third UK nationwide lockdown). Measures of anxiety and depressive symptomatology, loneliness, and life satisfaction were analysed using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) models.

RESULTS

We found evidence of large mental health inequalities across intersectional strata. Large proportions of those inequalities were accounted for by the additive effects of the variables used to define the intersections, with some of the largest gaps associated with sexual orientation (with sexual minority groups showing substantially worse outcomes). Additional inequalities were found by cohort/generation, birth sex, racial/ethnic groups, and socioeconomic position. Intersectional effects were observed mostly in intersections defined by combinations of privileged and marginalised social identities/positions (e.g., lower-than-expected life satisfaction in South Asian men in their thirties from a sexual minority and a disadvantaged childhood social class).

CONCLUSION

We found substantial inequalities largely cutting across intersectional strata defined by multiple co-constituting social identities/positions. The large gaps found by sexual orientation extend the existing evidence that sexual minority groups were disproportionately affected by the pandemic. Study implications and limitations are discussed.