State Variation in Anxiety and Depression During the COVID-19 Pandemic

Abstract

Background: Limited research has examined mental health outcomes related to regional differences in COVID response type and Medicaid expansion status in the United States. This is a salient concern as states in the southern U.S. consistently report the highest rates of COVID-19 transmission. State-level political ideologies are also associated with compliance with federal distancing orders and mask mandates. Furthermore, eight out of the twelve states that still have not expanded Medicaid coverage under the Affordable Care Act are in the south. Aims of the Study: The objectives of this study are to describe variation in mental health outcomes during the COVID-19 pandemic by differences in state-level supportive policies with a focus on Medicaid expansion status. This study also examines how employment status and health insurance coverage impact rates of generalized anxiety disorder and clinical depression. Methods: This repeated cross-sectional study analyzes data from the U.S. Census Bureau's COVID-19 Household Pulse Survey, a nationally representative survey of non-institutionalized adults aged 18 years and older. Our primary exposure variable is Medicaid expansion status. Our mental health outcomes of interest are: (1) generalized anxiety disorder using the GAD-2 criteria and (2) major depression based on the PHQ-2 screening instrument. Statistical analyses include testing demographic differences using chi-squared tests and multivariable logistic regression models to identify risk factors for frequent generalized anxiety disorder and clinical depression. Results: Our sample included 61,243 adults aged 18 years and older. The overall prevalence of generalized anxiety disorder and clinical depression are much higher than prior to the pandemic. The highest predictors of clinical depression and generalized anxiety disorder in the US population during the COVID-19 pandemic were age, sexual orientation, employment status, and family income. We did not find any statistically significant differences between living in a Medicaid expansion state versus a non-expansion state in terms of clinical depression and generalized anxiety disorder.