Population-level Mental Health Research Articles

Mental health of the Pacific Island Nation communities: What the rest in the world can contribute to and learn from?

Creating Futures initiative has established a network of mental health professionals, researchers, and community members from the Pacific Island Nations (PIN), Australia, and New Zealand to address the growing challenges of mental health conditions compounded by the climate change crisis. The enormous amount of work done in Global Mental Health can be particularly helpful to improve population-level mental health. However, translation of this evidence base into practice poses several challenges. This perspective paper discusses the role of local culture and health systems context in determining the feasibility and acceptability of implementing and scaling up evidence-based interventions designed in an American-European context. The paper also advocates development (and evaluation) of mental health interventions in the PIN communities particularly and Global South generally and exporting these interventions to the rest of the world. COVID-19 crisis underlined the role of global cooperation as well as national level 'self-reliance'. In this post COVID-19 world, it will be desirable for the mental health community to cooperate and collaborate to scale up evidence-based interventions through rigorous contextualization and at the same time main-stream mental health interventions developed in the Global South by incorporating them in the Global Mental Health discourse.

Neighborhood-Level Social Determinants of Health and Adolescent Mental Health

ObjectiveMental health diagnoses among adolescents are increasing in prevalence. Existing literature considers associations between individual-level social determinants of health (SDOH) and adolescent mental health. Neighborhood-level SDOH can have a substantial impact on health. This paper examines associations between neighborhood-level SDOH and mental health diagnoses of anxiety, depression, and suicidal ideation among hospitalized adolescents. MethodsWe used 2018 and 2019 Texas Inpatient Discharge Public Use Data Files linked to the zip-code level Child Opportunity Index 2.0, a composite measure of subdomains which characterize neighborhood-level SDOH, to examine rates of mental health diagnoses and associations with patient characteristics across opportunity level quintiles. ResultsThe sample included 50,011 adolescents ages 10–19 admitted to the hospital with the mental health diagnoses anxiety, depression, and/or suicide. Most had a single diagnosis; anxiety (12.9%), depression (37.5%), or suicide (13.0%). Hospitalized adolescents 10–14 years old were a plurality (44.2%) of the sample. Most adolescents were White (64.2%) and non-Hispanic (67.4%) and lived in rural areas (29.6%). Adolescents from racial minority populations and those in rural communities with mental health diagnoses had lower opportunity-levels. Higher opportunity levels were associated with greater odds of having an anxiety or suicide diagnosis while a depression diagnosis was associated with a lower opportunity-level. ConclusionsThere are significant differences in adolescent mental health diagnoses associated with neighborhood opportunity-level. While all adolescents can benefit from mental health education, screening, and early interventions, additional resources tailored to neighborhood-level opportunity may prove a more meaningful way to improve population-level mental health outcomes.

The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis.

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

Generational differences in mental health trends in the twenty-first century.

Given the observed deterioration in mental health among Australians over the past decade, this study investigates to what extent this differs in people born in different decades-i.e., possible birth cohort differences in the mental health of Australians. Using 20 y of data from a large, nationally representative panel survey (N = 27,572), we find strong evidence that cohort effects are driving the increase in population-level mental ill-health. Deteriorating mental health is particularly pronounced among people born in the 1990s and seen to a lesser extent among the 1980s cohort. There is little evidence that mental health is worsening with age for people born prior to the 1980s. The findings from this study highlight that it is the poorer mental health of Millennials that is driving the apparent deterioration in population-level mental health. Understanding the context and changes in society that have differentially affected younger people may inform efforts to ameliorate this trend and prevent it continuing for emerging cohorts.

Exposure to green and blue spaces and depression in older adults: Findings from the EPIPorto cohort

Abstract Background Portugal is amongst the European countries with the largest share of older adults and highest prevalence of depression. Natural environments may play an important role promoting population-level mental health. We investigated the associations between the exposure to green and blue spaces and depression among older adults from Porto (Portugal) and the mediation role of social interactions and physical exercise. Methods This study included data from the fourth wave (2017) of the EPIPorto cohort, which included only participants aged ≥60. The presence of depressive symptoms was measured using the Geriatric Depression Scale (GDS). Using the residential locations, we computed the Normalized Difference Vegetation Index (NDVI), and the shortest distance to the nearest urban green space and blue space. We fitted crude and adjusted negative binomial regression models. Associations were expressed using relative risks (RR) and 95% intervals (95% CI). We used structural equation modelling to assess mediation. Results We included 639 participants, from which 27.2% presented depression (GDS ≥5). In the adjusted models, we found statistically significant associations between having more NDVI within 50 and 100 meters and lower GDS (RR = 0.78 [95%CI 0.65-0.94] and RR = 0.81 [95%CI 0.67-0.97], respectively). Most of the association between NDVI and the GDS was direct, being only slightly mediated by the time spent with family, although both the direct and indirect effects did not reach statistical significance. No significant associations with the remaining variables of exposure were identified. Conclusions We observed a direct association between living in areas with more vegetation and less depressive symptoms in older adults in Porto. Key messages • Our results suggest that the provision of green space may be an effective strategy to promote mental health in late life.

Shared genetic architecture between mental health and the brain functional connectome in the UK Biobank

Psychiatric disorders are complex clinical conditions with large heterogeneity and overlap in symptoms, genetic liability and brain imaging abnormalities. Building on a dimensional conceptualization of mental health, previous studies have reported genetic overlap between psychiatric disorders and population-level mental health, and between psychiatric disorders and brain functional connectivity. Here, in 30,701 participants aged 45–82 from the UK Biobank we map the genetic associations between self-reported mental health and resting-state fMRI-based measures of brain network function. Multivariate Omnibus Statistical Test revealed 10 genetic loci associated with population-level mental symptoms. Next, conjunctional FDR identified 23 shared genetic variants between these symptom profiles and fMRI-based brain network measures. Functional annotation implicated genes involved in brain structure and function, in particular related to synaptic processes such as axonal growth (e.g. NGFR and RHOA). These findings provide further genetic evidence of an association between brain function and mental health traits in the population.

Evaluating the Impact of Mask Mandates and Political Party Affiliation on Mental Health Internet Search Behavior in the United States During the COVID-19 Pandemic: Generalized Additive Mixed Model Framework.

The impacts of the COVID-19 pandemic on mental health worldwide and in the United States have been well documented. However, there is limited research examining the long-term effects of the pandemic on mental health, particularly in relation to pervasive policies such as statewide mask mandates and political party affiliation. The goal of this study was to examine whether statewide mask mandates and political party affiliations yielded differential changes in mental health symptoms across the United States by leveraging state-specific internet search query data. This study leveraged Google search queries from March 24, 2020, to March 29, 2021, in each of the 50 states in the United States. Of the 50 states, 39 implemented statewide mask mandates-with 16 of these states being Republican-to combat the spread of COVID-19. This study investigated whether mask mandates were associated differentially with mental health in states with and without mandates by exploring variations in mental health search queries across the United States. In addition, political party affiliation was examined as a potential covariate to determine whether mask mandates had differential associations with mental health in Republican and Democratic states. Generalized additive mixed models were implemented to model associations among mask mandates, political party affiliation, and mental health search volume for up to 7 months following the implementation of a mask mandate. The results of generalized additive mixed models revealed that search volume for "restless" significantly increased following a mask mandate across all states, whereas the search volume for "irritable" and "anxiety" increased and decreased, respectively, following a mandate for Republican states in comparison with Democratic states. Most mental health search terms did not exhibit significant changes in search volume in relation to mask mandate implementation. These findings suggest that mask mandates were associated nonlinearly with significant changes in mental health search behavior, with the most notable associations occurring in anxiety-related search terms. Therefore, policy makers should consider monitoring and providing additional support for these mental health symptoms following the implementation of public health-related mandates such as mask mandates. Nevertheless, these results do not provide evidence for an overwhelming impact of mask mandates on population-level mental health in the United States.

Inequalities in Access to Mental Health Treatment by Australian Youths During the COVID-19 Pandemic.

The authors aimed to evaluate changes in use of government-subsidized primary mental health services, through the Medicare Benefits Schedule (MBS), by young people during the first year of the COVID-19 pandemic in Australia and whether changes were associated with age, sex, socioeconomic status, and residence in particular geographical areas. Interrupted time-series analyses were conducted by using quarterly mental health MBS service data (all young people ages 12-25 years, 2015-2020) for individual Statistical Area Level 3 areas across Australia. The data captured >22.4 million service records. Meta-analysis and meta-regression models estimated the pandemic interruption effect at the national level and delineated factors influencing these estimates. Compared with expected prepandemic trends, a 6.2% (95% CI=5.3%-7.2%) increase was noted for all young people in use of MBS mental health services in 2020. Substantial differences were found between age and sex subgroups, with a higher increase among females and young people ages 18-25. A decreasing trend was observed for males ages 18-25 (3.5% reduction, 95% CI=2.5%-4.5%). The interruption effect was strongly associated with socioeconomic status. Service uptake increased in areas of high socioeconomic status, with smaller or limited uptake in areas of low socioeconomic status. During 2020, young people's use of primary mental health services increased overall. However, increases were inequitably distributed and relatively low, compared with increases in population-level mental health burden. Policy makers should address barriers to primary care access for young people, particularly for young males and those from socioeconomically disadvantaged backgrounds.

Introduction: Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project

In this article, we introduce the SSM-MH Special Issue “Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project,” which presents findings from the Pandemic Journaling Project (PJP). PJP is an online journaling platform and mixed-methods research study created in May 2020 to provide ordinary people around the world an opportunity to chronicle the impact of the COVID-19 pandemic in their lives—for themselves and for posterity. The essays in this collection demonstrate how journaling via an online platform can help illuminate experiences of mental wellbeing and distress, with important implications for both research and clinical practice. We begin by introducing the Pandemic Journaling Project and describing our procedures for generating the data subsets analyzed in the papers collected here. We then outline the principal interventions of the special issue as a whole, introduce the papers, and identify a number of cross-cutting themes and broader contributions. Finally, we point toward key questions for future research and therapeutic practice by highlighting the three-fold value of online journaling as a research method, a therapeutic strategy, and a tool for advancing social justice. We focus in particular on how this innovative methodological approach holds promise as both a modality for psychotherapeutic intervention and a form of grassroots collaborative ethnography. We suggest that our methods create new opportunities for confronting the impact of pandemics and other large-scale events that generate radical social change and affect population-level mental health.

Language-agnostic deep learning framework for automatic monitoring of population-level mental health from social networks

In many countries, mental health issues are among the most serious public health concerns. National mental health statistics are frequently collected from reported patient cases or government-sponsored surveys, which have restricted coverage, frequency, and timeliness. Many domains of study, including public healthcare and biomedical informatics, have recently adopted social media data as a feasible real-time alternative to traditional methods of gathering representative information at the population level in a variety of contexts. However, because of the limits of fundamental natural language processing tools and labeled corpora in countries with limited natural language resources, such as Thailand, implementing social media systems to monitor mental health signals could be challenging. This paper presents LAPoMM, a novel framework for monitoring real-time mental health indicators from social media data without using labeled datasets in low-resource languages. Specifically, we use cross-lingual methods to train language-agnostic models and validate our framework by examining cross-correlations between the aggregate predicted mental signals and real-world administrative data from Thailand’s Department of Mental Health, which includes monthly depression patients and reported cases of suicidal attempts. A combination of a language-agnostic representation and a deep learning classification model outperforms all other cross-lingual techniques for recognizing various mental signals in tweets, such as emotions, sentiments, and suicidal tendencies. The correlation analyses discover a strong positive relationship between actual depression cases and the predicted negative sentiment signals as well as suicide attempts and negative signals (e.g., fear, sadness, and disgust) and suicidal tendency. These findings establish the effectiveness of our proposed framework and its potential applications in monitoring population-level mental health using large-scale social media data. Furthermore, because the language-agnostic model utilized in the methodology is capable of supporting a wide range of languages, the proposed LAPoMM framework can be easily generalized for analogous applications in other countries with limited language resources.

Comparing population-level mental health of UK workers before and during the COVID-19 pandemic: a longitudinal study using Understanding Society

ObjectivesThe COVID-19 pandemic has substantially affected workers’ mental health. We investigated changes in UK workers’ mental health by industry, socioeconomic class and occupation and differential effects by UK country of...

Applied Mindfulness for Physician Wellbeing: A Prospective Qualitative Study Protocol.

BackgroundPhysician burnout has significant adverse impacts on the wellbeing of individual physicians, and by extension the healthcare delivery systems of which they are part. Mindfulness is consistently cited as a pragmatic approach to effectively address burnout and enhance physician wellbeing. However, very few empirical studies have been published on Mindfulness Based Interventions (MBIs) for physicians. Moreover, the majority of these studies have been quantitative, leaving a gap in understanding the practical application of mindfulness in the context of physicians' daily lives.ObjectivesThis paper outlines the rationale, development and design of a novel prospective qualitative study examining the acceptability, feasibility, and pragmatic application of a mindfulness intervention for physician wellness.MethodsThe study will be conducted in three groups of at least 8 practicing physicians from a broad range of medical specialties at a tertiary care hospital in a large urban center in Eastern Canada. The intervention will consist of an innovative program based on the teachings of internationally renowned scholar and Zen Master Thích Nhãt Hạnh. It will include 5 weekly 2-h mindfulness sessions delivered by two health providers trained in mindfulness and in the teachings of Thich Nhat Hanh. The primary outcome measure will be an in-depth Thematic Analysis of post-program semi-structured interviews. Field data will also be collected through participant observation. The study will be theoretically grounded within the interpretive paradigm utilizing “the Mechanisms of Mindfulness Theory”. An external advisory committee formed by four senior members of Thích Nhãt Hạnh's community will provide guidance across all phases of the study.DiscussionOur innovative approach provides a new framework to further understand the mechanisms by which mindfulness interventions can impact physician wellbeing, and by extension their patients, colleagues, and broader healthcare systems. Through a clear articulation of the rigorous application of accepted procedures and standards used in our protocol, this paper seeks to provide a roadmap for other researchers who wish to develop further studies in this area. Lessons learned in the preparation and conduction of this study can be applied to other healthcare contexts including non-physician health provider wellbeing, clinical care, and population-level mental health.

Suicidal Risk and Adverse Social Outcomes in Adulthood Associated with Child and Adolescent Mental Disorders

ObjectiveThe life course of children and adolescents with mental disorders is an important area of investigation, yet it remains understudied. This study provides a first-ever comprehensive examination of the relationship between child and adolescent mental disorders and subsequent suicidal and adverse social outcomes in early adulthood using population-based data. MethodsDe-identified administrative databases were used to create a birth cohort of 60,838 residents of Manitoba born between April 1980 to March 1985 who were followed until March 2015. Unadjusted and adjusted hazard ratios (aHRs) and odds ratios (aORs) were calculated to determine associations between physician-diagnosed mental disorders in childhood or adolescence and a range of adverse early adulthood (ages 18 to 35) outcomes. ResultsDiagnoses of mood/anxiety disorders, attention-deficit hyperactivity disorder, substance use disorder, conduct disorder, psychotic disorder, personality disorders in childhood or adolescence were associated with having the same diagnoses in adulthood. These mental disorder diagnoses in childhood/adolescence were strongly associated with an increased risk of suicidal behaviors and adverse adult social outcomes in adulthood. Similarly, suicide attempts in adolescence conferred an increased risk in adulthood of suicide death (aHR: 3.6; 95% confidence interval [CI]: 1.9-6.9), suicide attempts (aHR: 6.2; CI: 5.0–7.6), social housing use (aHR: 1.7; CI 1.4–2.1), income assistance (aHR: 1.8; CI 1.6–2.1), criminal accusation (aHR: 2.2; CI 2.0–2.5), criminal victimization (aHR:2.5; CI 2.2–2.7), and not completing high school (aOR: 3.1; CI: 2.5–3.9). ConclusionMental disorders diagnosed in childhood and adolescence are important risk factors not only for mental disorders in adulthood but also for a range of early adult adversity. These findings provide an evidence-based prognosis of children's long-term well-being and a rationale for ensuring timely access to mental health services. Better population-level mental health promotion and early intervention for children and adolescents with mental disorders are promising for improving future adult outcomes.

Analysis of mental and physical disorders associated with COVID-19 in online health forums: a natural language processing study

ObjectivesOnline health forums provide rich and untapped real-time data on population health. Through novel data extraction and natural language processing (NLP) techniques, we characterise the evolution of mental and physical...

A Text Messaging Intervention (StayWell at Home) to Counteract Depression and Anxiety During COVID-19 Social Distancing: Pre-Post Study.

BackgroundSocial distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19–related depression and anxiety symptoms among people who speak English and Spanish in the United States.ObjectiveThis paper describes the changes in StayWell participants’ anxiety and depression levels after 60 days of exposure to skills-based SMS text messages.MethodsWe used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Questionnaire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used 2-tailed paired t tests to detect changes in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later.ResultsThe analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of –1.72 (95% CI –2.35 to –1.09) in PHQ-8 scores and –0.48 (95% CI –0.71 to –0.25) in GAD-2 scores. These improvements translated to an 18.5% and 17.2% reduction in mean PHQ-8 and GAD-2 scores, respectively.ConclusionsStayWell is an accessible, low-intensity population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health.Trial RegistrationClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599International Registered Report Identifier (IRRID)RR2-10.2196/23592

16.3 Alterations in Google Search Volume of Common Child and Adolescent Psychiatric Diagnoses During the COVID-19 Pandemic in the United States: A Time Series Analysis

Researchers have analyzed monthly Google search volumes (MGSVs) to determine the possible impact of the COVID-19 pandemic on population-level mental health. To our knowledge, no study has examined MGSVs as a potential correlate of the mental health of children and adolescents. We searched for aberrances in MGSVs of common child and adolescent psychiatry diagnoses during the pandemic in comparison to MGSVs forecasted from the prepandemic data.

Symbolic disempowerment and Donald Trump's 2016 presidential election: Mental health responses among Latinx and white populations

The 2016 election of United States (U.S.) President Donald Trump was a political event that may have affected population-level mental health. A prominent theme in the Trump election was anti-immigrant policy that contributed to a racist and xenophobic sociopolitical climate. Applying a symbolic dis/empowerment framework, this study examines whether there was an effect of the Trump election on the mental health of the U.S. population that differed by race/ethnicity, language of interview, and state-level support for Trump or Clinton. We used data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System 2011–2018 to examine trends in poor mental health days in the five months after the U.S Presidential election (November 2016 to March 2017) compared to all other survey months. We conducted difference-in-differences analyses using negative binomial regression models to examine the effect of the five post-election months on the rate of poor mental health days, comparing six population categories: 1) non-Latinx white populations in Trump states, 2) non-Latinx white populations in Clinton states, 3) English-speaking Latinx populations in Trump states, 4) English-speaking Latinx populations in Clinton states, 5) Spanish-speaking Latinx populations in Trump states, and 6) Spanish-speaking Latinx populations in Clinton states. White populations in Clinton states reported more poor mental health days in response to the five months post-election period compared to white populations in Trump states. English-speaking Latinx people living in Trump states experienced higher than expected poor mental health days in November 2016 and February 2017. Spanish-speaking Latinx people, by contrast, reported fewer poor mental health days in the post-election period. The 2016 U.S. presidential election preceded population-level changes in mental health that support a symbolic dis/empowerment framework. We discuss possible explanations and the mental health implications for future major political events.

Reddit Users' Experiences of Suicidal Thoughts During the COVID-19 Pandemic: A Qualitative Analysis of r/Covid19_support Posts.

Background: The COVID-19 pandemic is having considerable impacts on population-level mental health, with research illustrating an increased prevalence in suicidal thoughts due to pandemic stressors. While the drivers of suicidal thoughts amid the pandemic are poorly understood, qualitative research holds great potential for expanding upon projections from pre-pandemic work and nuancing emerging epidemiological data. Despite calls for qualitative inquiry, there is a paucity of qualitative research examining experiences of suicidality related to COVID-19. The use of publicly available data from social media offers timely and pertinent information into ongoing pandemic-related mental health, including individual experiences of suicidal thoughts.Objective: To examine how Reddit users within the r/COVID19_support community describe their experiences of suicidal thoughts amid the COVID-19 pandemic.Methods: This study draws on online posts from within r/COVID19_support that describe users' suicidal thoughts during and related to the COVID-19 pandemic. Data were collected from creation of this subreddit on February 12, 2020 until December 31, 2020. A qualitative thematic analysis was conducted to generate themes reflecting users' experiences of suicidal thoughts.Results: A total of 83 posts from 57 users were included in the analysis. Posts described a range of users' lived and living experiences of suicidal thoughts related to the pandemic, including deterioration in mental health and complex emotions associated with suicidal thinking. Reddit users situated their experiences of suicidal thoughts within various pandemic stressors: social isolation, employment and finances, virus exposure and COVID-19 illness, uncertain timeline of the pandemic, news and social media, pre-existing mental health conditions, and lack of access to mental health resources. Some users described individual coping strategies and supports used in attempt to manage suicidal thoughts, however these were recognized as insufficient for addressing the multilevel stressors of the pandemic.Conclusions: Multiple and intersecting stressors have contributed to individuals' experiences of suicidal thoughts amid the COVID-19 pandemic, requiring thoughtful and complex public health responses. While ongoing challenges exist with self-disclosure of mental health challenges on social media, Reddit and other online platforms may offer a space for users to share suicidal thoughts and discuss potential coping strategies.

Patterns of mental health problems before and after easing COVID-19 restrictions: Evidence from a 105248-subject survey in general population in China.

The COVID-19 pandemic has alarming implications for individual and population level mental health. Although the future of COVID-19 is unknown at present, more countries or regions start to ease restrictions. The findings from this study have provided the empirical evidence of prevalence and patterns of mental disorders in Chinese general population before and after easing most COVID-19 restrictions, and information of the factors associated with these patterns. A cross-sectional population-based online survey was carried out from February to March 2020 in the general population across all provinces in China. The 12-item General Health Questionnaire (GHQ-12) was incorporated in the survey. Latent class analyses were performed to investigate the patterns of mental disorders and multinomial logistic regressions were used to examine how individual and regional risk factors can predict mental disorder patterns. Four distinctive patterns of mental health were revealed in the general population. After the ease of most COVID-19 restrictions, the prevalence of high risk of mental disorders decreased from 25.8% to 20.9% and prevalence of being high risk of unhappiness and loss of confidence decreased from 10.1% to 8.1%. However, the prevalence of stressed, social dysfunction and unhappy were consistently high before and after easing restrictions. Several regional factors, such as case mortality rate and healthcare resources, were associated with mental health status. Of note, healthcare workers were less likely to have mental disorders, compared to other professionals and students. The dynamic management of mental health and psychosocial well-being is as important as that of physical health both before and after the ease of COVID-19 restrictions. Our findings may help in mental health interventions in other countries and regions while easing COVID-19 restrictions.

Perceived Stress During the First Wave of COVID-19 Outbreak: Results From Nationwide Cross-Sectional Study in Estonia.

Objective: To study the population-level mental health responses during the first wave of coronavirus disease 2019 (COVID-19) outbreak in Estonia and analyze its socio-demographic, behavioral, and health-related variations among general population.Methods: This study used nationally representative data on 4,606 individuals, aged 18–79 years from a rapid-response cross-sectional survey conducted in April 2020. Point prevalence and mutually adjusted prevalence rate ratios for perceived stress from log-binomial regression analysis were presented for socio-demographic, behavioral, and health-related variables.Results: This study found that 52.2% of population aged 18–79 reported elevated stress levels in relation to COVID-19 outbreak. Higher levels of perceived stress were found in women, in younger age groups, in Estonians, and in those with higher self-perceived infection risk, presence of respiratory symptoms, and less than optimal health, according to self-reports.Conclusion: Although, the potential long-term health effects of the current crisis are yet unknown, the alarmingly high stress levels among people indicate that the COVID-19 pandemic might have had a widespread effect on people's mental health.