Mental health outcomes during COVID-19: A scoping review & recommendations for geriatrics research

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Introduction

In addition to being at greater risk for severe illness and fatality during infectious outbreaks, older adults are also vulnerable to mental and physical health risks due to increased social isolation. Studies on the mental health effects of the COVID-19 pandemic are rapidly emerging, with reviews focused on the prevalence of psychiatric symptoms in patients infected with COVID-19, healthcare workers, or mixed samples of healthcare workers, patient populations, and community-dwelling individuals. However, recent reviews of mental health during COVID-19 have failed to focus on findings in the geriatric population. This review provides a scope of the current literature on the prevalence of psychiatric symptoms in the general population, with a geriatric lens, by examining older adults’ representation across studies and the pandemic’s impact on older adults’ mental health.

Methods

The PRISMA Extension for Scoping Reviews Checklist was used as the methodological framework to conduct the review. A review of the literature on the topic was conducted through PubMed and https://www.medrxiv.org/ from January 1st, 2020 to June 1st, 2020. Studies were included if they (i) focused on mental health outcomes during the COVID-19 pandemic, (ii) used validated measures of psychological or psychiatric symptomatology; (iii) included samples of the general population or in which they comprised the majority; (iv) reported quantitative outcomes of prevalence (expressed as the percentage of participants that exceed the cut-off for normal on the measures). Excluded were (i) opinion papers or commentaries without prevalence data; (ii) studies that reported qualitative data or population means only; (iii) studies with samples of primarily healthcare workers (i.e., the entire or >50% of the sample were healthcare workers), (iv) studies with patient samples such as those with confirmed or probable COVID-19 infection, clinic or hospitalized patients, or pregnant women. Fifty-six full-text articles were included in the review, with 33 published articles and 23 pre-print articles.

Results

Cross-sectional designs were employed by all 56 studies that met the inclusion criteria. The results pooled across the studies showed that 1 in 3 individuals across all age groups endorses post-traumatic stress symptoms, while approximately 30% experience depression, anxiety, and overall stress. Amongst available data in older adults 60 years of age or older, anxiety rates were comparable to the overall population (30.2%), while the prevalence of depression was higher, with nearly 1 in 3 older adults experiencing clinically significant depression symptoms. Effects of age on mental health outcomes are mixed, with several studies showing that the risk or severity of psychiatric symptoms may be lower in older adults. In contrast, others show the opposite pattern or no effect of age.

The current literature on mental health outcomes during the COVID-19 pandemic has two important methodological limitations. The first is that the cross-sectional design in all reviewed studies does not permit firm conclusions regarding whether the current reported prevalence rates can be attributed to the onset of the pandemic or whether they represent a change from baseline. A second limitation is that all studies reviewed typically assessed mental health outcomes using self-report measures completed by anonymous responders in online surveys. No studies included follow-up assessments, and none conducted clinical or psychiatric interviews to confirm the presence of clinically significant psychiatric symptomatology or to establish a diagnosis. Self-report measures are used as screening tools in psychological research, but there are limitations to relying on scale scores to establish clinical significance.

Conclusions

Overall, nearly 1 in 3 individuals have experienced negative effects on mental health during COVID-19, a figure that exceeds rates reported in front-line healthcare workers. Paradoxically, some studies report that older age may be a protective factor against psychiatric symptoms, but this is based on a limited number of studies. Our main recommendations for future research include: (i) the use of longitudinal study designs to permit assessment of change in mental health and to yield more definitive conclusions regarding the impact of the pandemic on mental health, and (ii) ensuring a wider representation of older adults through the use of methods, other than online survey platforms, to assess mental health. More high-quality data is needed to understand the pandemic’s effects on the general population’s mental health, which can inform public health and social policy decisions aimed at alleviating these burdens during the pandemic.

Funding

The study was funded by the Ontario Ministry of Health and Long-Term Care Alternative Funding Plan. The funders had no role in the design of the study, analysis, or preparation of the manuscript.

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