Abstract
Markedly elevated adverse mental health symptoms were widely observed early in the coronavirus disease-2019 (COVID-19) pandemic. Unlike the U.S., where cross-sectional data indicate anxiety and depression symptoms have remained elevated, such symptoms reportedly declined in the U.K., according to analysis of repeated measures from a large-scale longitudinal study. However, nearly 40% of U.K. respondents (those who did not complete multiple follow-up surveys) were excluded from analysis, suggesting that survivorship bias might partially explain this discrepancy. We therefore sought to assess survivorship bias among participants in our longitudinal survey study as part of The COVID-19 Outbreak Public Evaluation (COPE) Initiative. Survivorship bias was assessed in 4039 U.S. respondents who completed surveys including the assessment of mental health as part of The COPE Initiative in April 2020 and were invited to complete follow-up surveys. Participants completed validated screening instruments for symptoms of anxiety, depression and insomnia. Survivorship bias was assessed for (1) demographic differences in follow-up survey participation, (2) differences in initial adverse mental health symptom prevalence adjusted for demographic factors and (3) differences in follow-up survey participation based on mental health experiences adjusted for demographic factors. Adjusting for demographics, individuals who completed only one or two out of four surveys had significantly higher prevalence of anxiety and depression symptoms in April 2020 (e.g. one-survey v. four-survey, anxiety symptoms, adjusted prevalence ratio [aPR]: 1.30, 95% confidence interval [CI]: 1.08-1.55, p = 0.0045; depression symptoms, aPR: 1.43, 95% CI: 1.17-1.75, p = 0.00052). Moreover, individuals who experienced incident anxiety or depression symptoms had significantly higher adjusted odds of not completing follow-up surveys (adjusted odds ratio [aOR]: 1.68, 95% CI: 1.22-2.31, p = 0.0015, aOR: 1.56, 95% CI: 1.15-2.12, p = 0.0046, respectively). Our findings reveal significant survivorship bias among longitudinal survey respondents, indicating that restricting analytic samples to only respondents who provide repeated assessments in longitudinal survey studies could lead to overly optimistic interpretations of mental health trends over time. Cross-sectional or planned missing data designs may provide more accurate estimates of population-level adverse mental health symptom prevalence than longitudinal surveys.
Highlights
IntroductionStudies have documented acutely elevated prevalence of adverse mental health symptoms during the early months of the coronavirus disease 2019 (COVID-19) pandemic compared with pre-pandemic data (CDC, 2020; Ettman et al, 2020; Li et al, 2020; Vindegaard and Benros, 2020; Wang et al, 2020; Pierce et al, 2020a; Bonati et al, 2021; Browning et al, 2021; Czeisler et al, 2021b)
We explored whether potential mental health survivorship bias could be explained by: (1) demographic differences in repeatedmeasures respondents; or (2) differences being within demographic subgroups
By race/ethnicity, non-Hispanic White and non-Hispanic Asian respondents had the lowest prevalence of one-survey respondents (33.4% and 32.3%, respectively) and highest prevalence of four-survey respondents (29.7% and 23.9%), whereas non-Hispanic Black and Latinx respondents had the highest prevalence of one-survey respondents (65.7% and 60.7%, respectively) and lowest prevalence of four-survey respondents (8.6% and 10.1%); p < 2.20 × 10−16
Summary
Studies have documented acutely elevated prevalence of adverse mental health symptoms during the early months of the coronavirus disease 2019 (COVID-19) pandemic compared with pre-pandemic data (CDC, 2020; Ettman et al, 2020; Li et al, 2020; Vindegaard and Benros, 2020; Wang et al, 2020; Pierce et al, 2020a; Bonati et al, 2021; Browning et al, 2021; Czeisler et al, 2021b). (Pierce et al, 2020a), and prevalence of anxiety and depression symptoms more than tripled in the United States (Czeisler et al, 2020; Ettman et al, 2020; Czeisler et al, 2021b). Analysis of longitudinal U.K. and U.S survey data suggested that those increased prevalence may have been transient, with anxiety and depression symptoms declining among participants who completed several follow-up measures between March or April and August 2020 (Fancourt et al, 2020; Riehm et al, 2021). Given that survivorship bias has not previously been reported to affect large-scale internet-based mental health surveys, this investigation may influence mental health surveillance study design and interpretation of ongoing studies and previously published papers
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