Systematic review of mental health symptom changes by sex or gender in early-COVID-19 compared to pre-pandemic

Abstract

ABSTRACT Importance Women and gender-diverse individuals have faced disproportionate socioeconomic burden during COVID-19. There have been reports that this has translated into greater negative changes in mental health, but this has been based on cross-sectional research that has not accounted for pre-COVID-19 differences. Objective To compare mental health symptom changes since pre-COVID-19 by sex or gender. Data Sources MEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv, and Open Science Framework (December 31, 2019 to August 30, 2021). Study Selection Eligible studies compared mental health symptom changes from pre-COVID-19 to COVID-19 by sex or gender. Data Extraction and Synthesis Data was extracted by a single reviewer with validation by a second reviewer. Adequacy of study methods and reporting was assessed using an adapted version of the Joanna Briggs Institute Checklist for Prevalence Studies. A restricted maximum-likelihood random-effects meta-analyses was conducted. Main Outcomes and Measures Anxiety symptoms, depression symptoms, general mental health, and stress measured continuously or dichotomously. Results 12 studies (10 unique cohorts) were included. All compared females or women to males or men; none included gender-diverse individuals. Continuous symptom change differences were not statistically significant for depression (standardized mean difference [SMD]= 0.12, 95% CI -0.09 to 0.33; 4 studies, 4,475 participants; I 2 =69.0%) and stress (SMD= - 0.10, 95% CI -0.21 to 0.01; 4 studies, 1,533 participants; I 2 =0.0%), but anxiety (SMD= 0.15, 95% CI 0.07 to 0.22; 4 studies, 4,344 participants; I 2 =3.0%) and general mental health (SMD= 0.15, 95% CI 0.12 to 0.18; 3 studies, 15,692 participants; I 2 =0.0%) worsened more among females or women than males or men during COVID-19. There were no significant differences in changes in proportion above a cut-off: anxiety (difference= -0.05, 95% CI -0.20 to 0.11; 1 study, 217 participants), depression (difference= 0.12, 95% CI -0.03 to 0.28; 1 study, 217 participants), general mental health (difference= -0.03, 95% CI -0.09 to 0.04; 3 studies, 18,985 participants; I 2 =94.0%), stress (difference= 0.04, 95% CI -0.10 to 0.17; 1 study, 217 participants). Conclusion and Relevance Mental health outcomes did not differ or were worse by amounts below thresholds for clinical significance for women compared to men. Registration PROSPERO (CRD42020179703). KEY MESSAGES Question Did mental health symptoms worsen more for females or women than males or men in COVID-19? Findings We reviewed almost 65,000 citations and identified 12 studies that provided data to directly compare mental health symptom changes from pre-COVID-19 to during COVID-19 for females or women versus males or men. Statistically significant, but small, sex- or gender-based differences were found in 2 of 8 mental health outcomes. Meaning Mental health changes among females or women were not significantly different from males or men for most outcomes, and differences that were identified were small and less than minimally important difference thresholds.

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