Mental illness and COVID-19 vaccination: a multinational investigation of observational & register-based data (preprint)

Background: Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Therefore, we aimed to investigate the association between mental illness and COVID-19 vaccination uptake, using data from five countries. Methods: Data from seven cohort studies (N=325,298), and the Swedish registers (8,080,234), were used to identify mental illness and COVID-19 vaccination uptake. Multivariable modified Poisson regression models were conducted to calculate the prevalence ratio (PR) and 95% CIs of vaccination uptake among individuals with v.s. without mental illness. Results from the cohort studies were pooled using random effects meta-analyses. Findings: Most of the meta-analyses performed using the COVIDMENT study population showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first (prevalence ratio [PR]: 0.98, 95% CI: 0.98-0.99, p<0.001) and second dose among individuals with mental illness; the reduction was however greater among those not using pyschiatric medication (PR: 0.91, 95% CI: 0.91-0.91, p<0.001). Conclusions: The high uptake of COVID-19 vaccination observed among individuals with most types of mental illness highlights the comprehensiveness of the vaccination campaign , however lower levels of vaccination uptake among subgroups of individuals with unmedicated mental illness warrants attention in future vaccination campaigns.

Mental illness and COVID-19 vaccination: a multinational investigation of observational & register-based data (preprint)

Background: Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Therefore, we aimed to investigate the association between mental illness and COVID-19 vaccination uptake, using data from five countries. Methods: Data from seven cohort studies (N=325,298), and the Swedish registers (8,080,234), were used to identify mental illness and COVID-19 vaccination uptake. Multivariable modified Poisson regression models were conducted to calculate the prevalence ratio (PR) and 95% CIs of vaccination uptake among individuals with v.s. without mental illness. Results from the cohort studies were pooled using random effects meta-analyses. Findings: Most of the meta-analyses performed using the COVIDMENT study population showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first (prevalence ratio [PR]: 0.98, 95% CI: 0.98-0.99, p<0.001) and second dose among individuals with mental illness; the reduction was however greater among those not using pyschiatric medication (PR: 0.91, 95% CI: 0.91-0.91, p<0.001). Conclusions: The high uptake of COVID-19 vaccination observed among individuals with most types of mental illness highlights the comprehensiveness of the vaccination campaign , however lower levels of vaccination uptake among subgroups of individuals with unmedicated mental illness warrants attention in future vaccination campaigns.

COVID-19 illness severity and 2-year prevalence of physical symptoms: an observational study in Iceland, Sweden, Norway and Denmark (preprint)

Background Persistence of physical symptoms after SARS-CoV-2 infection is a major public health concern, although evidence from large observational studies remain scarce. We aimed to assess the prevalence of physical symptoms in relation to acute illness severity up to more than 2-years after diagnosis of COVID-19. Methods This multinational study included 64 880 adult participants from Iceland, Sweden, Denmark, and Norway with self-reported data on COVID-19 and physical symptoms from April 2020 to August 2022. We compared the prevalence of 15 physical symptoms, measured by the Patient Health Questionnaire (PHQ-15), among individuals with or without a confirmed COVID-19 diagnosis, by acute illness severity, and by time since diagnosis. We additionally assessed the change in symptoms in a subset of Swedish adults with repeated measures, before and after COVID-19 diagnosis. Findings During up to 27 months of follow-up, 22 382 participants (34.5%) were diagnosed with COVID-19. Individuals who were diagnosed with COVID-19, compared to those not diagnosed, had an overall 37% higher prevalence of severe physical symptom burden (PHQ-15 score [≥] 15, adjusted prevalence ratio [PR] 1.37 [95% confidence interval [CI] 1.23-1.52]). The prevalence was associated with acute COVID-19 severity: individuals bedridden for seven days or longer presented with the highest prevalence (PR 2.25[1.85-2.74]), while individuals never bedridden presented with similar prevalence as individuals not diagnosed with COVID-19 (PR 0.92 [0.68-1.24]). The prevalence was statistically significantly elevated among individuals diagnosed with COVID-19 for eight of the fifteen measured symptoms: shortness of breath, chest pain, dizziness, heart racing, headaches, low energy/fatigue, trouble sleeping, and back pain. The analysis of repeated measurements rendered similar results as the main analysis. Interpretation These data suggest an elevated prevalence of some, but not all, physical symptoms during up to more than 2 years after diagnosis of COVID-19, particularly among individuals suffering a severe acute illness.

Elevated symptoms of depression and anxiety among family members and friends of critically ill COVID-19 patients - An observational study of five cohorts across four countries (preprint)

Background. Little is known regarding the mental health impact of having a significant person (family member and/or close friend) with COVID-19 of different severity. Methods. The study included five prospective cohorts from four countries (Iceland, Norway, Sweden, and the UK) with self-reported data on COVID-19 and symptoms of depression and anxiety during March 2020-March 2022. We calculated the prevalence ratio (PR) of depression and anxiety in relation to having a significant person with COVID-19 and performed a longitudinal analysis in the Swedish cohort to describe the temporal patterns of the results. Results. 162,237 and 168,783 individuals were included in the analysis of depression and anxiety, respectively, of whom 24,718 and 27,003 reported a significant person with COVID- 19. Overall, the PR was 1.07 (95% CI: 1.05-1.10) for depression and 1.08 (95% CI: 1.03-1.13) for anxiety among significant others of COVID-19 patients. The respective PRs for depression and anxiety were 1.04 (95% CI: 1.01-1.07) and 1.03 (95% CI: 0.98-1.07) if the significant person was never hospitalized, 1.15 (95% CI: 1.08-1.23) and 1.24 (95% CI: 1.14-1.34) if the patient was hospitalized, 1.42 (95% CI: 1.27-1.57) and 1.45 (95% CI: 1.31-1.60) if admitted to the ICU, and 1.34 (95% CI: 1.22-1.46) and 1.36 (95% CI: 1.22-1.51) if the significant person died. Individuals of hospitalized, ICU admitted, or deceased patients showed higher prevalence of depression and anxiety during the entire 12 months after the COVID-19 diagnosis of the significant person. Conclusions. Close friends and family members of critically ill COVID-19 patients show elevated prevalence of depression and anxiety throughout the first year after the diagnosis.

Mental health, gender, and care-seeking behavior during the COVID-19 pandemic in Sweden: An exploratory study (preprint)

Objective To explore the prevalence of care-seeking avoidance behavior in relation to gender and to describe the effect of (and potential interaction between) gender and care-seeking on mental health during the COVID-19 pandemic in Sweden. Methods We performed a cross-sectional study among 27,562 participants of the Omtanke2020 Study, using data collected at three time points concerning sociodemographic factors, mental health symptoms, and care-seeking behavior. Network analysis and prevalence ratios calculated from modified Poisson regressions were used to explore the relationship between gender, care-seeking behavior, and mental health symptoms (depression, anxiety, and COVID-19-related distress). Results In our study, women reported a higher prevalence of mental health symptoms and avoidance of care-seeking due to COVID-19, compared to men. At baseline and six months thereafter, female gender was positively associated with COVID-19-related distress and previous mental health diagnosis. At 12 months after baseline, female gender was positively associated with anxiety and avoidance of care-seeking for mental health. However, previous mental health diagnosis and care avoidance were more strongly associated with a higher prevalence of mental health symptoms among men, compared to women. Conclusion This study highlights gender differences in mental health outcomes and care-seeking behavior during the COVID-19 pandemic in Sweden.

Unravelling the link between sleep and mental health during the COVID-19 pandemic (preprint)

Background The emergence of COVID-19 brought unparalleled changes in people’s lifestyle, including sleep. We aimed to assess the bidirectional association between sleep quality and mental health and describe how sleep and mental health were affected in Sweden during the COVID-19 pandemic (between June 2020 and September 2021). Methods Data were obtained from the Omtanke2020 study. Participants who completed the baseline survey and 8 monthly follow-up surveys were included (N=9035). We described the distribution of sleep and mental health in the different Swedish regions using maps and over the study period with longitudinal graphs adjusting for sex, age, recruitment type (self-recruitment or invitation), and COVID-19 status. The inner relationships between mental health, sleep and covid infection were described through relative importance networks. Finally, we modelled how mental health affects sleep and vice versa using generalized estimating equations with different adjustments. Results Seasonal and north-south regional variations were found in sleep and mental health outcomes at baseline and attenuated over time. The seasonal variation of sleep and mental health correlated moderately with the incidence rate of COVID-19 in the sample. Networks indicate that the relationship between COVID-19 incidence and mental health varies over time. We observed a bidirectional relationship between sleep quality and quantity at baseline and mental health at follow-up and vice versa. Conclusion Sleep quality and quantity at baseline was associated with adverse symptom trajectories of mental health at follow-up, and vice versa, during the COVID-19 pandemic. There is also a weak relationship between COVID-19 incidence, sleep, and mental health.

Short-term improvement of mental health after a COVID-19 vaccination (preprint)

Abstract Importance: The role of COVID-19 vaccination on the mental health of the general population remains poorly understood. Objective: To assess the short-term change of depressive and anxiety symptoms in relation to COVID-19 vaccination among Swedish adults. Design: A prospective cohort study with monthly data collections on self-reported depressive and anxiety symptoms from December 2020 to October 2021 and COVID-19 vaccination from July to October 2021. Setting: The Omtanke2020 Study, Sweden. Participants: 7,925 participants of the Omtanke2020 study with complete data on depressive and anxiety symptoms and vaccination status. Intervention(s) or Exposure(s): Receiving the first or second dose of a COVID-19 vaccine. Main outcomes(s) and Measure(s): Binary measures of depression (PHQ-9, cut-off [≥] 10) and anxiety (GAD-7, cut-off [≥] 10) one month before the first dose, one month after the first dose, and, if applicable, one month after the second dose. For individuals not vaccinated or chose to not report vaccination status (unvaccinated individuals), we selected three monthly measures of PHQ-9 and GAD-7 with 2-month intervals in-between based on data availability. Results: 5,079 (64.1%) individuals received two doses of COVID-19 vaccine, 1,977 (24.9%) received one dose, 305 (3.9%) were not vaccinated, and 564 (7.1%) chose not to report vaccination status. There was a lower prevalence of depression and anxiety among vaccinated, compared with unvaccinated, individuals, especially after the second dose. Among individuals receiving two doses of vaccine, the prevalence of depression and anxiety was lower after both first (aRR=0.82, 95%CI 0.76-0.88 for depression; aRR=0.81, 95%CI 0.73-0.89 for anxiety) and second (aRR=0.79, 95%CI 0.73-0.85 for depression; aRR=0.73, 95%CI 0.66-0.81 for anxiety) dose, compared with before vaccination. Similar results were observed among individuals receiving only one dose (aRR=0.76, 95%CI 0.68-0.84 for depression; aRR=0.82, 95%CI 0.72-0.94 for anxiety, comparing after first dose to before vaccination). These results were independent of age, sex, recruitment type, body mass index, smoking, relationship status, history of psychiatric disorder, number of comorbidities, COVID-19 infection status, and seasonality. Conclusions and Relevance: We observed a positive short-term change in depressive and anxiety symptoms among adults receiving a COVID-19 vaccine in the current pandemic.

Acute COVID-19 severity and 16-month mental morbidity trajectories in patient populations of six nations (preprint)

BACKGROUND The aim of this multinational study was to assess the development of adverse mental health symptoms among individuals diagnosed with COVID-19 in the general population by acute infection severity up to 16 months after diagnosis. METHODS Participants consisted of 247 249 individuals from seven cohorts across six countries (Denmark, Estonia, Iceland, Norway, Scotland, and Sweden) recruited from April 2020 through August 2021. We used multivariable Poisson regression to contrast symptom-prevalence of depression, anxiety, COVID-19 related distress, and poor sleep quality among individuals with and without a diagnosis of COVID-19 at entry to respective cohorts by time (0-16 months) from diagnosis. We also applied generalised estimating equations (GEE) analysis to test differences in repeated measures of mental health symptoms before and after COVID-19 diagnosis among individuals ever diagnosed with COVID-19 over time. FINDINGS A total of 9979 individuals (4%) were diagnosed with COVID-19 during the study period and presented overall with a higher symptom burden of depression (prevalence ratio [PR] 1.18, 95% confidence interval [95% CI] 1.03-1.36) and poorer sleep quality (1.13, 1.03-1.24) but not with higher levels of symptoms of anxiety or COVID-19 related distress compared with individuals without a COVID-19 diagnosis. While the prevalence of depression and COVID-19 related distress attenuated with time, the trajectories varied significantly by COVID-19 acute infection severity. Individuals diagnosed with COVID-19 but never bedridden due to their illness were consistently at lower risks of depression and anxiety (PR 0.83, 95% CI 0.75-0.91 and 0.77, 0.63-0.94, respectively), while patients bedridden for more than 7 days were persistently at higher risks of symptoms of depression and anxiety (PR 1.61, 95% CI 1.27-2.05 and 1.43, 1.26-1.63, respectively) throughout the 16-month study period. CONCLUSION Acute infection severity is a key determinant of long-term mental morbidity among COVID-19 patients.

Mental health indicators in Sweden over a 12-month period during the COVID-19 pandemic (preprint)

Background The ongoing COVID-19 pandemic has had an unprecedented impact on the lives of people globally and is expected to have profound effects on mental health. Yet, self-reported large-scale online surveys on mental health are still relatively uncommon. Here we aim to describe the mental health burden experienced in Sweden using baseline data of the Omtanke2020 Study. Method Self-reported baseline data collected over a 12-month period (June 9, 2020-June 8, 2021) from the longitudinal online survey of the Omtanke2020 Study including 27,950 adults in Sweden. Participants were volunteers or actively recruited through existing cohorts and after providing informed consent responded to monthly online questionnaires on socio-demographics, mental and physical health, COVID-19 infection, and impact. Poisson regression was fitted to assess the relative risk of high mental health burden (depression, anxiety, and COVID-19 specific PTSD). Result The overall proportion of persons with high level of symptoms was 15.6%, 9.5% and 24.5% for depression, anxiety, and COVID-19 specific PTSD, respectively. Overall, 43.4% of the participants had significant, clinically relevant symptoms for at least one mental health outcome and 7.3% had significant symptoms for all three outcomes. We also observed differences in the prevalence of these symptoms across strata of sex, age, recruitment type, COVID-19 status, region, and seasonality. Conclusion While the proportion of persons with high mental health burden remains higher than in pre-pandemic publications, our estimates are lower than previously reported levels of depression, anxiety, and PTSD during the pandemic in Sweden and elsewhere.