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

  1. Tiffany Dal Santo
  2. Ying Sun
  3. Yin Wu
  4. Chen He
  5. Yutong Wang
  6. Xiaowen Jiang
  7. Kexin Li
  8. Olivia Bonardi
  9. Ankur Krishnan
  10. Jill T. Boruff
  11. Danielle B. Rice
  12. Sarah Markham
  13. Brooke Levis
  14. Marleine Azar
  15. Dipika Neupane
  16. Amina Tasleem
  17. Anneke Yao
  18. Ian Thombs-Vite
  19. Branka Agic
  20. Christine Fahim
  21. Michael S. Martin
  22. Sanjeev Sockalingam
  23. Gustavo Turecki
  24. Andrea Benedetti
  25. Brett D. Thombs

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Abstract

Women and gender-diverse individuals have faced disproportionate socioeconomic burden during COVID-19. There have been reports of greater negative mental health changes compared to men based on cross-sectional research that has not accounted for pre-COVID-19 differences. We compared mental health changes from pre-COVID-19 to during COVID-19 by sex or gender. MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), EMBASE (Ovid), Web of Science Core Collection: Citation Indexes, China National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science Framework Preprints (preprint server aggregator) were searched to August 30, 2021. Eligible studies included mental health symptom change data by sex or gender. 12 studies (10 unique cohorts) were included, all of which reported dichotomized sex or gender data. 9 cohorts reported results from March to June 2020, and 2 of these also reported on September or November to December 2020. One cohort included data pre-November 2020 data but did not provide dates. Continuous symptom change differences were not statistically significant for depression (standardized mean difference [SMD] = 0.12, 95% CI -0.09–0.33; 4 studies, 4,475 participants; I 2  = 69.0%) and stress (SMD = − 0.10, 95% CI -0.21–0.01; 4 studies, 1,533 participants; I 2  = 0.0%), but anxiety (SMD = 0.15, 95% CI 0.07–0.22; 4 studies, 4,344 participants; I 2  = 3.0%) and general mental health (SMD = 0.15, 95% CI 0.12–0.18; 3 studies, 15,692 participants; I 2  = 0.0%) worsened more among females/women than males/men. There were no significant differences in changes in proportions above cut-offs: anxiety (difference = − 0.05, 95% CI − 0.20–0.11; 1 study, 217 participants), depression (difference = 0.12, 95% CI -0.03–0.28; 1 study, 217 participants), general mental health (difference = − 0.03, 95% CI − 0.09–0.04; 3 studies, 18,985 participants; I 2  = 94.0%), stress (difference = 0.04, 95% CI − 0.10–0.17; 1 study, 217 participants). Mental health outcomes did not differ or were worse by small amounts among women than men during early COVID-19.

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  1. Version published to 10.1038/s41598-022-14746-1
  2. Version published to 10.1101/2021.06.28.21259384v2 on medRxiv
  3. ScreenIT

    SciScore for 10.1101/2021.06.28.21259384: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variableFor the present analysis, studies had to report mental health outcomes separately by sex (assignment based on external genitalia, usually at birth; e.g., female, male, intersex) or gender (socially constructed characteristics of roles and behaviours; e.g., woman, man, trans woman, trans man,
    RandomizationThen two reviewers independently evaluated titles and abstracts in random order; if either reviewer believed a study was potentially eligible, it underwent full-text review by two independent reviewers.
    Blindingnot detected.
    Power AnalysisYes: There is evidence that the authors conducted a sample size calculation to determine an adequate sample size OR the study was large enough (e.g., a large national survey) whereby a sample size calculation is not required.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    , PsycINFO (Ovid), CINAHL (EBSCO), EMBASE (Ovid), Web of Science Core Collection: Citation Indexes, China National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science Framework Preprints
    PsycINFO
    suggested: (PsycINFO, RRID:SCR_014799)
    EMBASE
    suggested: (EMBASE, RRID:SCR_001650)
    If not provided, we calculated it using Hedges’ g,31 as described by Borenstein et al.32 For each study, we then calculated a Hedges’ g difference in change between sex or gender groups with 95% CI.
    Hedges’
    suggested: None
    , RStudio Version 1.2.5042), using the metacont and metagen functions in the meta package.
    RStudio
    suggested: (RStudio, RRID:SCR_000432)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are limitations to consider. First, this review only included 11 studies from 9 cohorts, and many had limitations related to study sampling frames and recruitment methods, follow-up rates, and management of missing data. Second, heterogeneity was high for some meta-analyses. Third, there were not enough studies to attempt sub-group analyses by additional sociodemographic or other factors. Fourth, we did not identify any studies that compared results from gender-diverse individuals to other gender groups. In sum, we identified small sex- or gender-based differences for anxiety symptoms and general mental health, continuously measured, but other outcomes (continuous depression symptoms and stress; dichotomous anxiety symptoms, depression symptoms, general mental health, stress) were not different by sex or gender. These are aggregate results, though, and many individuals have certainly experienced negative mental health changes related to increased socioeconomic burden. Mental health changes should continue to be monitored in COVID-19, taking into consideration sex and gender, and studies should examine reasons for what appears to be resilience among many women despite facing disproportionate hardships in the pandemic.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2021.06.28.21259384v1 on medRxiv