Objectives: Survey the prevalence of various stress-related factors among a sample of the US adult population over the course of 1 year to compare rates among those who reported ever receiving a positive COVID-19 test vs those who never received a positive test. Highlight the potential impact of these factors upon cognitive functioning during the COVID-19 pandemic.
Methods: A US census, age-balanced sample of adults was recruited through an online survey platform and participated in three waves of surveys. In each wave, roughly 3 months apart, participants, blinded to the survey sponsor, completed surveys with demographic information and questions regarding mental health, physical health, and environmental factors which have been linked to cognitive health. Participants were also asked whether they had ever received a positive COVID-19 test.
Results: A total of 4,905 respondents were included in the first wave, 3,940 were included in the second wave, and 3,157 respondents were included in the third wave. In the third wave of the survey the largest age group was those 30 to 39 years of age (33.7% of respondents; n=1,063/3,157). The majority of respondents reported that they had never tested positive for COVID-19 (87.2%; n=2,610/3,157). The rate of those who reported ever receiving a positive COVID-19 test result was 17.3% (n=547/3,157). Respondents who reported a positive test result were more likely to report experiencing anxious symptoms and depressive symptoms between the second and third surveys vs those who never received a positive test result (70.5% vs 47.5% and 66.5% vs 37.3%, respectively). Respondents who reported a positive test result were more likely to report receiving a formal diagnosis from a healthcare provider for a sleep-related disorder (53.7% vs 19.1%). Respondents who reported a positive test result were more likely to report experiencing “more” or “much more” concern vs those without a positive test result since the second survey in the following areas: affording housing (49.5% vs 25.3%); employment or potential job loss (33.6% vs 20.0%); and affording necessities like food and medicine (44.8% vs 27.6%).
Conclusions: Survey respondents who reported receiving a positive COVID-19 test result vs those who did not had a higher prevalence of stressors known to affect cognitive functioning, including anxiety, depression, sleep troubles, and concerns over issues recognized as social determinants of health. Routine neurocognitive assessment in clinical practice may be an important tool clinicians can use to track the long-term effects of the COVID-19 pandemic on overall cognitive health, allowing them to intervene as needed.
Cognitive Test, Cognition, Stress, COVID-19, Social Determinants of Health
The novel coronavirus (COVID-19), which first appeared in December 2019 in Wuhan, China, quickly spread across the globe, upending daily life for billions of people . Along with its well-documented physical effects, the uniquely global disruptive nature of the disease has taken a psychological toll as well [2,3]. Since its emergence, the COVID-19 pandemic has proven to be a multidimensional stressor, impacting social relationships, employment, the global economy, and other areas .
The near-global lockdowns of Spring of 2020, instituted to separate populations and slow the spread of the disease, resulted in widespread social isolation . In times of stress and upheaval, strong social connections are recommended by mental health experts as key to coping with stressful situations, but the social distancing recommended by governments removed these supports when they may have been needed most . However, the isolation recommended to preserve the physical health of populations has been shown to exacerbate existing or trigger new mental health conditions; it can lead to higher stress levels, increased depression and anxiety, and a rise in intimate partner violence [5-8]. Research has also shown during lockdown people engaged in more unhealthy lifestyle behaviors, such as increased smoking, alcohol consumption, and decreased physical activity, all of which resulted in increased stress .
In addition to lockdowns, uncertainty related to the pandemic contributed to greater psychological stress . Questions about how the disease was spread and when the pandemic would end led to feelings of vulnerability and a loss of control . Bombarded with a steady drumbeat of changing guidance, emerging facts, and misinformation, people who frequently searched for information about the disease showed greater levels of fear of the coronavirus . This perceived vulnerability to COVID-19 drove higher rates of social isolation, which in turn increased stress among populations .
The efforts to contain the COVID-19 pandemic in Spring 2020 also resulted in a dramatic increase in unemployment in the United States . In April of that year, the unemployment rate increased 10.3 percentage points to reach 14.7%, the highest rate since data began to be recorded in 1948 . In the month of April, the number of unemployed rose by 15.9 million to 23.1 million . The negative economic and employment impacts of the COVID-19 pandemic have concentrated on workers who were already in precarious positions: those in low-productivity industries, service jobs, and those in the “gig” economy [14,15]. The economic changes due to the pandemic are ongoing. In addition to the shock of immediate job loss, the COVID-19 pandemic has upended the way work is conducted in many industries, with asymmetric consequences across employment sectors . While remote work options may have changed the typical workday for the better for those in the information economy, automation instituted to minimize health risks may eliminate jobs for others . Employers may also move to short-term, informal work arrangements to address a changing environment, which may exacerbate the precariousness of workers . Even among those workers who continued to work throughout the pandemic, disruptions due to shuttered schools, daycare centers, and other organizations may negatively impact their productivity . The implications of these upheavals have already resulted in measurably higher stress and anxiety levels among those affected [8,10, and 16].
In addition to the psychological stressors felt across society, those whose health was directly impacted by a COVID-19 infection have shown higher levels of neurological and psychological sequelae, including anxiety, substance abuse disorders, and cognitive performance [3,18]. Though severity of disease has been correlated with a greater incidence of neurological and psychiatric outcomes, the risk of these diagnoses increased even for those whose disease did not require hospitalization [3,18].
The psychological impacts of the pandemic may have real consequences for cognitive health. Unhealthy lifestyle behaviors during lockdowns (e.g., alcohol consumption, smoking, and lack of physical activity) were shown to negatively impact cognitive function, while loneliness, a key result of lockdowns and isolation strategies, is a significant predictor of cognitive decline over time [9,19]. Anxiety, an increase in which has been seen during the pandemic, is linked to increased levels of cortical amyloid deposition, which are predictive of mild cognitive impairment [7,20]. Stressful situations cause the body to release glucocorticoids, a class of stress hormones that travel freely to the brain . Chronic exposure to elevated levels of glucocorticoids can impact cognitive function, a fact that may warrant greater vigilance on the part of clinicians as the pandemic continues .
Two years into the pandemic, the global response to COVID-19 has changed to reflect the tools available to fight the disease. Lockdowns have been lifted, the wearing of quality masks is common, and vaccines are now available. A longitudinal series of surveys, the first of which was conducted in Fall 2020, nearly one year in the pandemic, sought to gauge the prevalence of various stress-related factors over the course of one year among a sample of the US adult population. The objective of the survey detailed in this paper was to assess a difference between respondents who reported testing positive for the disease at any point and those who never reported a positive test result to better understand the potential impact of the pandemic on cognitive health.