key: cord-0819399-mgx2xdp0
authors: Le, Kien; Nguyen, My
title: The Psychological Burden of the COVID-19 Pandemic Severity
date: 2021-01-19
journal: Econ Hum Biol
DOI: 10.1016/j.ehb.2021.100979
sha: c9955a52d9833c8a1c7c937f1166bc5e7f8ab593
doc_id: 819399
cord_uid: mgx2xdp0

The alarming levels of spread and severity of COVID-19 have dominated global attention. In this time of crisis, there is an urgent need for studies identifying the linkages between the pandemic and social welfare. To help policymakers respond to the situation better, we investigate how the severity of the COVID-19 pandemic can condition people's psychological well-being. Employing the latest weekly panel data within an individual fixed effects framework, we uncover the damaging consequences of the COVID-19 severity, as measured by mortality rate, on the incidences of daily anxiety, worry, displeasure, and depression in the United States. Our work underlines the importance of public spending on mental health, both during and after the pandemic.

On March 11, 2020 , the World Health Organization (WHO) officially declared Coronavirus Disease 2019 (COVID-19) a pandemic posing a significant threat to humanity. The immediate consequences of COVID-19 have been felt all over the world, highlighted by more than 8 million confirmed cases and 440,000 deaths as of mid-June 2020. In the United States alone, the death toll has climbed above 120,000 and the number is still increasing by hundreds per day. In light of such a humanitarian crisis, it is critical for researchers and policymakers to understand the extent to which the pandemic alters people's health and wellbeing.

In this paper, we evaluate how the severity of the COVID-19 pandemic can condition the psychological well-being of Americans. The contribution of our study is two folds. First, we respond to the urgent need for science-backed research on the pandemic. Second, many prior studies on COVID-19, due to time limitation, are subject to the issue of endogeneity. Thus, to have convincing interpretations, our work employs the latest weekly panel data within an individual fixed effects framework to ensure the internal validity of our estimates. In particular, the use of weekly panel data in a short period of time can reduce the possibility of time-variant confounding factors, and the within-individual comparison approach can absorb the time-constant unobserved characteristics that could contaminate our estimates.

The severity of the pandemic can be linked to individuals' mental well-being through various channels. For example, as more people got infected and hospitalized, the risks of morbidity and mortality associated with COVID-19 contributed to the rising fear about one's own health and the health of their families. Besides, when the pandemic got more severe, the economy stumbled and individuals were brought to the brink of joblessness, which can psychologically aggravate individuals. Recently, there has been some evidence that COVID-19 is mentally devastating to individuals worldwide. Several observational studies report a high frequency of experiencing mental health symptoms for a sample of Chinese individuals at the initial stage of the pandemic (Wang et al., 2020; Xiao et al., 2020) . In Iran, disease prevalence and misinformation contributed to heightening stress and mental morbidity (Zandifar and Badrfam, 2020) . In the context of Japan, the outbreak triggered fear and panic behavior such as hoarding and stockpiling resources (Shigemura et al., 2020) .

The study utilizes all five current waves of the Household Pulse Survey Public Use File, which is released weekly focusing on American experiences during the COVID-19 pandemic.

We measure the pandemic severity by the state-level COVID-19 mortality rate. Given the shortage of testing capability in the early days, mortality rate is currently the best measure of the severity of the pandemic. Besides, Holingue et al. (2020) and Wolf et al. (2020) document that approximately 70% of Americans actively do online searching about COVID- 19 and have adequate knowledge about the pandemic. Therefore, it is expected that people may understand the severity of the pandemic via the mortality rate statistic.

Employing the individual fixed effects model, our study uncovers the detrimental consequences of the severity of the COVID-19 pandemic on psychological outcomes. Specifically, an increase of 0.01% in the number of weekly COVID-19 deaths per capita (mortality rate) makes individuals 3.9, 4.4, 4.5, and 3.2 percentage points more likely to experience anxiety, worry, displeasure, and depression on a daily basis, respectively. Taking the fractions of individuals who report daily anxiety, worry, displeasure, and depression as the benchmarks, the estimates correspond to 27%, 44%, 58%, and 41% increases, respectively. Overall, a 0.01% increase in the COVID-19 mortality rate makes individuals 8 percentage points more likely to exhibit at least one of the above-mentioned symptoms on a daily basis, corresponding to a 43% increase relative to the benchmark value. Furthermore, it is worth noting that our benchmarks are the proportions of individuals experiencing psychological issues daily during the pandemic, which are higher than the values in the pre-pandemic period. Therefore, our estimates represent the lower bounds of the psychological impacts of COVID-19 severity.

As the pandemic persists and evolves, not only more studies on the impacts of COVID-19 are needed, but quick and effective mitigation strategies are also required. Our work underlines 2 J o u r n a l P r e -p r o o f substantial psychological costs of the COVID-19 severity, thus calling for immediate responses from policymakers in the U.S. and beyond. Governments should not take public spending on mental health lightly, both during and after the pandemic. Monitoring psychological needs and delivering psychological support for the public should be an integral part of the general pandemic health care. Universal coverage of mental health services in healthcare systems could help mitigate the negative consequences of the pandemic severity. It is also important for health officials to have effective communication with the public about disease control and prevention in a timely manner to minimize fear and uncertainty.

The paper proceeds as follows. Section 2 provides a brief discussion of the data. Section 3 presents the empirical methodology. Section 4 discusses the estimating results. Section 5 concludes the study. . The COVID-19 mortality rate that he/she is exposed to, as measured by CM R, is the total number of people in California who have died as a result of COVID-19 a week from the survey start date (i.e. from April 17 to April 23), divided by California's population, and multiplied by 10,000. Figure A1 further provides a visual illustration of the variations in the overall mental health measure (the psychological distress indicator for having at least one of the following experiences: anxiety, worry, displeasure, and depression, on a daily basis) and

the COVID-19 mortality rate. Figure A1 consists of two maps in Panels A and B which give the overall mental health and mortality rate measures averaged across survey weeks for each state, respectively. The shade represents the severity of the pandemic and overall mental health (e.g. in Panel B, the pandemic is more severe in the darker shaded states).

To examine the extent to which the severity of the COVID-19 pandemic influences the mental health of individuals, we estimate the following model,

where the subscripts i, s, and w refers to the individual, state, and week of survey. The respectively. The vector X isw is a covariate of background characteristics at the individual level, including age, age squared, marital status, race, gender, occupational sector, and educational attainment. Finally, υ isw stands for the error term. Standard errors throughout the paper are clustered at the state-by-week level.

In the model given in equation (1), our identification hinges upon the variation in the exposure to the COVID-19 mortality rate across individuals within the same state. The variation is due to the timing of the survey if it is within state. However, such a between-individual comparison can bias our coefficient of interest if there exist individual-specific characteristics that are correlated with both mental health outcomes and the COVID-19 mortality rate in the state. For example, risk-averse people may temporarily migrate into a state where the outbreak is less severe. If such individuals also tend to take good care of their mental health, then the effects captured by α 1 in equation (1) will fail to deliver the causal interpretation.

To tackle these issues, we implement the individual fixed effects model where the identification comes from the within-individual variation in the exposure to the COVID-19 mortality rate in the state of residence at the time of survey, given by,

where θ i stands for individual fixed effects. Our coefficient of interest is now β 1 which 

The estimated impacts of the COVID-19 severity on mental health are reported in Tables 2   through 6 . First, Tables 2 through 5 present the results on the experiences of anxiety, worry, displeasure, and depression separately. Then, Table 6 Anxiety − Starting with Table 2 , we find that the pandemic severity exacerbates the levels of anxiety for individuals. As evident from Column 1, the number of new deaths due to COVID-19 is positively linked to the incidence of anxiety. A 0.01% increase in the mortality rate is associated with the rise in the probability of feeling anxious every day by 3 percentage points. With the introduction of the set of individual controls, the point estimates vary little, as shown in Column 2. The estimation results reported so far come from the variation in the exposure to COVID-19 mortality rate across individuals within the same state.

In Column 3, we make the within-individual comparison in the degree of exposure to the COVID-19 mortality rate. In other words, the individual fixed effects model allows us to see the change in the anxiety level within an individual as the pandemic gets more severe. Our individual fixed effects model suggests that a 0.01% increase in the number of weekly new deaths per capita raises the incidence of daily anxiety by 3.9 percentage points. Compared to the proportion of individuals experiencing anxiety every day in Table 1 , the effect on Daily

Anxiety implies an increase of approximately 27%. To show that our results are not driven by how we construct the variable Daily Anxiety, we repeat the exercise using the uncoded variable (Uncoded Anxiety) and report the results in Columns 4, 5, and 6. The conclusion remains the same. Worry − The estimated effects of the COVID-19 severity on worrying are provided in Table   3 . Overall, the pandemic severity aggravates individuals' psychological health by impeding their ability to control worry. According to the most parsimonious specifications, a 0.01% increase in the COVID-19 mortality rate in the individual's residence state makes him/her 2.5 percentage points more likely to be worried on a daily basis (Column 1). According to the estimate reported in Column 2, the impacts of the COVID-19 mortality rate on the incidence of worry remain virtually unchanged with the inclusion of individual characteristics.

Moving to Column 3, the within-individual estimate is both statistically and economically significant. A 0.01% increase in the COVID-19 mortality rate is associated with the rise in the incidence of daily worry by 4.4 percentage points. Taking the fraction of individuals who report daily worry as the benchmark (Table 1) , the estimate implies the average increase of 44%. As shown in Columns 4, 5, and 6, using the raw measure of worry as the outcome variable tells us the same story. The severity of the COVID-19 pandemic is positively linked to the frequency of worry. Displeasure − We report the estimated effects of the pandemic severity on displeasure in Depression − We proceed to the relationship between COVID-19 severity and depression.

Overall, the estimates shown in Table 5 suggest that a high COVID-19 mortality rate provokes To ensure the internal validity of our estimates for the relationship between COVID-19 mortality rate and depression, we adopt the individual fixed effects model. Evident from Column 3, the individual is 3.2 percentage points more likely to feel depressed and hopeless every day in response to a 0.01% increase in the COVID-19 mortality rate in his/her residence state. Compared to the proportion of individuals reporting daily depression, this effect implies an average increase of 41%. As for the uncoded measure of depression, a higher COVID-19 mortality rate is also positively associated with the frequency of depression, thus keeping our conclusion unchanged. four symptoms is enough to be considered psychologically affected.

The estimated effects of the pandemic severity on the probability of experiencing psychological distress are reported in Table 6 . The results show that the more severe the pandemic becomes, Our most extensive specification in Column 3 suggests that a 0.01% increase in the number 

It is also of interest to explore the heterogeneous impacts of the severity of COVID-19 along the lines of temporal, political, racial, and gender dimensions. The results from the heterogeneity exercises are provided in Table 7 . For each panel in Table 7 , each column represents a separate regression and the column heading indicates the dimension of heterogeneity. The dependent variable in all regression is the overall mental health measure, Psychological Distress, which is an indicator for whether the individual has at least one of the four negative psychological experiences (anxiety, worry, displeasure, depression) on a daily basis. All estimates come from the most extensive specification (the specification in Column 3 of Table 6 ). First, we want to explore if there are heterogeneous impacts between the upswing and the downswing of the pandemic wave. Taking the first week as the reference week, the upswing and the downswing of the pandemic consist of weeks with higher and lower COVID-19 mortality rate than that of the first week, respectively. The results reported in the first two columns of Panel A in Table 7 show that the psychological consequences of the COVID-19

severity are larger during the upswing of the pandemic wave.

Next, we proceed to examine the heterogeneity along the line of political affiliations by categorizing the US states into red and blue states. Since red and blue states may differ in the way of handling the pandemic, we expect the impacts also differ. The results are 

In this section, we want to test if the impacts of pandemic severity are affected by the death of George Floyd on May 25th. The results from the most extensive specification are presented in 

So far, we have provided evidence that the severity of the COVID-19 pandemic proxied by the about disease control and prevention should be conducted effectively to minimize fear and uncertainty. It is also essential for the government to control the dissemination of non-official information which could create unnecessary anxiety and panic (Johal, 2009 ).

We utilize five weekly rounds of the Household Pulse Survey Public Use File to quantify the psychological impacts of the COVID-19 pandemic severity in the U.S. The severity of the pandemic is proxied by the state-level COVID-19 mortality rate. Our identification strategy hinges upon the within-individual comparison in a short period of time and the individual fixed effects model absorbs the individual-specific time-invariant unobserved characteristics that could contaminate our estimates.

We uncover the detrimental repercussions of the COVID-19 mortality rate on psychological

outcomes. An increase of 0.01% in the number of weekly COVID-19 deaths per capita (mortality rate) makes individuals 3.9, 4.4, 4.5, and 3.2 percentage points more likely to feel anxious, worried, displeased, and depressed on a daily basis, respectively. Taking the fractions of individuals reporting such feelings as our benchmark, these estimates imply the average increases in the incidences of daily anxiety, worry, displeasure, and depression by 27%, 44%, 58%, and 41%, respectively. Overall, individuals are also 8 percentage points more inclined to have at least one of those experiences on a daily basis, corresponding to a 43% increase relative to the benchmark value. 

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) surveys, respectively. The All Column indicates the weighted average (by sample size) of mortality rates across weeks. Figure A1: COVID-19 Mortality Rate and Mental Health (a) Panel A: Psychological Distress (b) Panel B: Mortality Rate Note: The figure illustrates the variations in average measures of psychological distress (Panel A) and COVID-19 mortality rate (Panel B) across states. Psychological Distress is an indicator for having at least one of the following experiences (anxiety, worry, displeasure, and depression) on a daily basis