Criticism of COVID Psychological Tsunami: It May Be Inflated
Many studies of low-quality and relaxed peer review were rushed into print.
Posted Nov 06, 2020
News outlets and science journals have published many predictions of an approaching mental health pandemic related to the psychological stress of dealing with the COVID-19 infection epidemic. Tsunami has been a favorite word. One headline by a BBC health reporter claimed “Psychiatrists fear 'tsunami' of mental illness after lockdown” (Roxby 2020). Even highly-respected researchers in JAMA said “a wave of devastation is imminent” that will overwhelm the mental health system (Simon et al., 2020).
The claims seem to be accepted with little pushback. Are these predictions true, or is this misinformation, hype, or low-quality science?
What Does the Research Say?
This blog post is focused on adults in the general population. Future posts will explore the research on children, healthcare workers, infected survivors, and patients with pre-existing psychiatric disorders.
Dozens of research studies have already been published on the mental health status of the general population. I read 34 of them. The studies were from China, Germany, Hong Kong, India, Ireland, Italy, Mexico, Spain, Taiwan, Turkey, and the United States. More are being published every week. I gave up trying to read them all, but it probably doesn’t matter, because nearly all of them used the same methods. They just keep repeating the same type of research in different countries.
For anxiety, the average percentage of the general population who scored above validated cutoffs on anxiety measures from 19 studies was 28% (ranging from 8.3% to 70.8%). Prior to COVID-19, the average in the general population was 18.1% according to the Anxiety and Depression Association of America (ADAA 10/18/2020).
For depression, the average percentage who score above validated cutoffs on depression measures for 14 studies was 23% (ranging from 6.2% to 48.3%). Prior to COVID-19, the average in the general population was 7.1% according to the National Institute of Mental Health (NIMH 10/18/2020a).
For posttraumatic stress disorder (PTSD), the average percentage who score above validated cutoffs on PTSD measures for three studies was 13% (ranging from 7.6% to 15.8%). The pre-COVID average in the general population was 6.8% (NIMH 10/18/2020b).
Overall, if we are to believe these studies, the rate of anxiety disorders has increased by more than 50%, the rate of depression has tripled, and the rate of PTSD has doubled all in the space of less than six months.
Can We Believe the Evidence?
Is any of this really true? I ask this with all sincerity out of concern for those dealing with the psychological stress from COVID-19 but also out of concern about the hype machine revved up about a so-called mental health “tsunami.” We have seen hyped claims turn out to be false in the past.
When I look at these studies, there are obvious problems. First, all studies were based on self-administered questionnaires. No studies used interviews by trained researchers. Individuals often give inaccurate answers on self-administered questionnaires because they misunderstand questions, overlay their own idiosyncratic interpretations, or give answers they want the research to show.
Second, all respondents self-selected to participate. Individuals with problems are more likely to participate in research studies. For obvious reasons, those with problems find the research more worthy of their valuable time. This skews the research to look like there are more problems than there really are.
Third, nearly all studies were cross-sectional. Few of the studies had a prospective longitudinal component of examining individuals before they experienced the COVID-19 pandemic. For example, the base rate of anxiety in the U.S. is 18.1%. The average rate of anxiety from COVID-19 studies was 29% by my calculation. If you subtract the 18.1% who already had anxiety prior to COVID-19 from 29%, does that mean the increase in anxiety is only 11%? Does an 11% increase constitute a psychological pandemic?
Fourth, one study that included a longitudinal component gives a completely different picture. Researchers measured problems in eight waves of data with over 5,000 individuals from March through June 2020 (Daly and Robinson, 2020). Distress increased in April but then gradually decreased to levels that existed prior to COVID-19!
Fifth, all studies measured symptoms only. None of the studies measured functional impairment. It has long been a consensus that functional impairment must be present to count individuals as having problems. Symptoms without impairment traditionally are not considered disorders.
Sixth, many studies from non-English speaking countries contained many grammar errors. These were not minor errors. Here is the first sentence of the abstract of one article published in PLOS ONE, “Huge citizens expose to social media during a novel coronavirus disease (COVID-19) outbroke in Wuhan, China.” (Gao et al., 2020). Many journals relaxed both their peer-review process and their in-house editing process, a topic we will re-visit in a later post, which makes me distrust this entire article and many others.
The editors of the Journal of Psychosomatic Research were so concerned about “the large number and rapid publication of studies of variable quality,” that they launched a living systematic review website (Thombs et al., 2020). They hoped an expert voice could help separate the informative evidence from the misleading evidence. As of 9/12/20, they had sifted through 697 studies and included the outcome results for 91 studies of symptom assessments (The DEPRESSD Project 10/18/20). Then they stopped reviewing this category because the methodology was so poor and so difficult to keep up to date! (They are still updating the review for two other categories). To be clear, they launched a massive effort to review psychological studies and then abandoned it because the studies were of poor quality.
What It Means
There are many individuals who feel psychologically stressed more than usual because of the pandemic. However, most of these probably do not extend into impairment of function or require clinical intervention.
Science has taken center stage during the COVID-19 pandemic for a variety of reasons. The credibility of science and some scientists have been questioned. There is good psychiatric and psychological science, there is bad, politically-biased science, and there is a lot of grey area in between. We have not seen much of the good science yet. To make hyperbolic claims of a tsunami or crisis that will overwhelm the mental health system are unprecedented and extraordinary claims. The research data for those claims however are not yet extraordinary.
ADAA (10/18/2020), Anxiety and Depression Association of America. Facts & Statistics. https://adaa.org/about-adaa/press-room/facts-statistics. Accessed 10/18/20.
Daly M, Robinson E (2020). Psychological distress and adaptation to the COVID-19 crisis in the United States Michael Daly a,*, Eric Robinson. Journal of Psychiatric Research https://doi.org/10.1016/j.jpsychires.2020.10.035
Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, et al. (2020) Mental health problems and social media exposure during COVID-19 outbreak. PLoS ONE 15(4): e0231924. https://doi.org/10.1371/journal.pone.0231924
NIMH (10/18/2020a). Major Depression. https://www.nimh.nih.gov/health/statistics/major-depression.shtml. Accessed 10/18/20.
NIMH (10/18/2020b). Posttraumatic Stress Disorder (PTSD). https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml. Accessed 10/18/20.
Roxby P (May 16, 2020). Psychiatrists fear ‘tsunami’ of mental illness after lockdown. BBC News. https://www.bbc.com/news/health-52676981. Accessed 11/4/20.
Simon NM, Saxe GN, Marmar, CR (early online October 12, 2020). Mental Health Disorders Related to COVID-19–Related Deaths. JAMA. 2020;324(15):1493-1494. doi:10.1001/jama.2020.19632
The DEPRESSD Project (2020 10 18). Living Systematic Review of Mental Health in COVID-19. https://www.depressd.ca/covid-19-mental-health. Accessed 10/18/20.
Thombs BD et al., (2020). Curating evidence on mental health during COVID-19: A living systematic review. Journal of Psychosomatic Research 133. https://doi.org/10.1016/j.jpsychores.2020.110113.