Older adults have been especially impacted by the coronavirus pandemic, as they are at higher risk of serious illness if infected and account for 80 percent of all COVID-related deaths. Current public health guidelines recommend older adults limit in-person social interactions as much as possible. While this is effective in limiting exposure to disease, it contributes to social isolation and loneliness.

Not surprisingly, the coronavirus pandemic and resulting economic downturn have taken a toll on the mental health of adults of all ages in the U.S. In July, a majority of U.S. adults 18 and older (53%) said that worry and stress related to coronavirus has had a negative impact on their mental health, up from 39% in May, according to a recent KFF tracking poll. Similarly, among older adults (ages 65 and older), close to half (46%) in July said that worry and stress related to coronavirus has had a negative impact on their mental health, up from 31% in May.

Previous KFF research has found the share of adults reporting anxiety or depression has increased since the start of the coronavirus pandemic, with four in ten adults age 18 and older (40%) reporting symptoms of anxiety or depression in July. Younger adults were significantly more likely than older adults to report anxiety or depression. Even so, the effect of the coronavirus pandemic on the mental health of older adults is important to consider, particularly because of the increased rates of social isolation, loneliness, and bereavement that older adults may face due to the pandemic. Former U.S. Surgeon General Vivek Murthy has brought attention to the association between loneliness and the absence of social connections and worse physical and mental health, including anxiety and depression (Dr. Murthy serves on the KFF Board of Trustees). Among older adults specifically, extensive research has documented the connection between loneliness and increased risk of premature death, dementia, stroke, depression, anxiety, and suicide.

This analysis builds on prior research by estimating the share of older adults reporting anxiety or depression using the Census Bureau’s Household Pulse Survey. The survey was conducted in March 2020 through August 2020, and includes differences in reported rates of anxiety or depression by demographic groups. All differences reported in the text are statistically significant (see Methods for additional details).

Findings

Overall, one in four (24%) adults ages 65 and older reported anxiety or depression in August 2020, a rate which has been relatively constant since the pandemic started in March. This rate is substantially higher than the one in 10 (11%) older adults with Medicare who reported depression or anxiety in 2018 (based on the 2018 Medicare Current Beneficiary Survey) (Figure 1). However, consistent with other KFF analysis, our analysis finds that older adults reported anxiety or depression in August 2020 at a lower rate than younger adults under the age of 65 (24% vs. 40%).

Rates of anxiety or depression among older adults in August 2020 were higher among those who are female, Hispanic, low income, in relatively poor health, who live alone, or who have experienced recent loss of employment income in their household. More specifically (Table 1):

  • A larger share of older women than older men reported anxiety or depression – 28% versus 20%.
  • A larger share of adults ages 65-74 (26%) reported feelings of anxiety or depression compared to adults ages 80 and older (19%)
  • Older Hispanic adults reported anxiety or depression at higher rates (33%) than older non-Hispanic White adults (23%), non-Hispanic Black adults (26%) and non-Hispanic Asian adults (17%).
  • More than one in three (37%) older adults with household incomes under $25,000 reported anxiety or depression, almost twice the rate (20%) among older adults with household incomes exceeding $100,000 annually.
  • While almost half (48%) of older adults in poor or fair self-reported health reported anxiety or depression, the share drops to 24% of those in good self-reported health and 14% of those in excellent or very good self-reported health.
  • A slightly larger share of older adults who live alone reported anxiety or depression compared to older adults who did not live alone (27% vs. 24%).
  • A larger share of older adults who said that they or someone in their household lost employment income since March 2020 reported anxiety or depression compared to those who were not living in a household that lost employment income (34% vs. 21%, respectively).
Discussion

Amid the ongoing coronavirus pandemic, our analysis finds rates of depression and anxiety are high among adults ages 65 and older relative to rates in 2018, with one in four reporting anxiety or depression during most weeks since the onset of the pandemic – an increase from one in ten older adults who reported anxiety or depression in 2018. Compared to younger adults, however, a smaller share of older adults reported anxiety and depression in August 2020, a finding that is consistent with prior KFF analysis. This difference is likely the result of many factors: younger adults are more likely to be unemployed than older adults, and research shows that job loss is associated with increased depression, anxiety, distress, and low self-esteem. Moreover, adults under the age of 65 who are parents may feel additional stress related to childcare and remote learning.

Cultural, racial, and generational differences in conceptualizing and reporting mental health issues likely impact the extent to which people of different ages do or do not identify and report depression and anxiety. For older adults in particular, depression is often misconstrued as a normal part of the aging process and thus may go unrecognized and untreated. Increased rates of anxiety and depression among older adults during the pandemic may be compounded by existing barriers to mental health treatment, particularly among people of color or those of low socioeconomic status who may experience more difficulty accessing mental health care or who may face more pronounced stigma surrounding mental health issues. Data used in this analysis exclude older adults in long-term care facilities; however, in light of the impact of coronavirus on these facilities, this population may be especially vulnerable to adverse mental health effects, and warrants further investigation.

Although cost sharing for mental health care is now equivalent to cost sharing for general medical outpatient services under the Medicare Part B benefit, mental health care may still be unaffordable for older adults. This may be particularly true for the 6 million Medicare beneficiaries in traditional Medicare who do not have supplemental coverage to help cover their cost sharing, and for rising number of  beneficiaries in Medicare Advantage plans who would face cost-sharing requirements for mental health services, potentially subject to advance plan approval. Additionally, finding a provider can be difficult for older adults because providers may limit their number of patients with Medicare, due to lower reimbursement rates compared to private insurance. Psychiatrists, for example, are the most likely of any physician specialty to opt out of Medicare.

In response to the coronavirus pandemic, legislative and regulatory changes have been made to expand access to Medicare coverage of telehealth services for traditional Medicare beneficiaries during the coronavirus public health emergency, including for mental health services. It is currently unknown if expanded access to mental health services via telehealth will continue once the public health emergency has expired.

The coronavirus pandemic has continued to spread across the country, and there is growing concern about the increased risk of spread during the fall and winter months. Older adults face the challenge of mitigating risk while avoiding loneliness and isolation which can lead to poor mental health. Our analysis adds to a growing body of literature about the stark effects that the coronavirus pandemic has had on the mental health of people.

This work was supported in part by Well Being Trust. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

 

Methods
This analysis uses the 2018 Survey file from the Centers for Medicare & Medicaid Services Medicare Current Beneficiary Survey (MCBS) and the Census Bureau’s Household Pulse Survey March to August 2020 (with specific demographic comparisons using the most recent data, August 19-31, 2020) to estimate the share of adults age 65 and older who report symptoms of anxiety or depression.

The MCBS is a nationally-representative survey of Medicare beneficiaries. Our analysis uses the 2018 MCBS to provide a baseline estimate of mental health of adults age 65 and older prior to the coronavirus pandemic; we did not include adults under age 65 with Medicare coverage. The 2020 Household Pulse Survey is a nationally-representative survey conducted by the U.S. Census Bureau, and is designed to understand how the coronavirus pandemic has affected many facets of American life, including mental health and well-being. Using the Pulse survey data, we analyzed self-reported rates of anxiety and depression among adults ages 65 and older. We did not use Medicare coverage status in the Household Pulse Survey due to the unreliability of self-reported coverage indicators in survey data.

Both the MCBS and the Household Pulse Survey ask respondents to report the frequency of anxiety and depression symptoms using the two-item Patient Health Questionnaire depression module (PHQ-2) and the 2-item Generalized Anxiety Disorder Scale (GAD-2). However, the Household Pulse Survey instrument asks about symptoms of anxiety or depression experienced over the last seven days, whereas the MCBS asks about the last two weeks; the latter timeframe is used in a clinical setting when administering either of these screening tools. Both of these questionnaires have been clinically validated and are considered diagnostic of clinically significant symptoms of depression (PHQ-2) or anxiety (GAD-2) with high levels of sensitivity and specificity. For each of the two questions of each scale, respondent answers are assigned a numerical value: not at all = 0, several days = 1, more than half the days = 2, and nearly every day = 3. Answers to both scales were added together and respondents with a value of three or greater were considered to have anxiety or depression in this analysis, consistent with diagnostic cut points for probable depression or anxiety when using these scales in a clinical setting. This follows a similar analysis published by the National Center for Health Statistics. Our analysis of the MCBS and Household Pulse Survey excludes respondents who have missing values for either scale. Using the Household Pulse Survey, we analyzed the share of older adults who report anxiety or depression across all weeks of the survey, but we report demographic differences using the most current data (August 19-31, 2020).

Our analysis of both the MCBS and the Household Pulse Survey used respective survey weights to account for the complex sampling design of the surveys. All reported differences in the share of adults reporting anxiety and depression in the text are statistically significant. Results from all statistical tests were reported with p<0.05 considered statistically significant.

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