Symptoms of Depression, Anxiety, Post-traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic

United States, March-April 2021

Jonathan Bryant-Genevier, PhD; Carol Y. Rao, ScD; Barbara Lopes-Cardozo, MD; Ahoua Kone, MPH; Charles Rose, PhD; Isabel Thomas, MPH; Diana Orquiola, MPH; Ruth Lynfield, MD; Dhara Shah, MPH; Lori Freeman, MBA; Scott Becker, MS; Amber Williams, MS; Deborah W. Gould, PhD; Hope Tiesman, PhD; Geremy Lloyd, MPH; Laura Hill, MSN; Ramona Byrkit, MPH


Morbidity and Mortality Weekly Report. 2021;70(26):947-952. 

In This Article

Abstract and Introduction


Increases in mental health conditions have been documented among the general population and health care workers since the start of the COVID-19 pandemic.[1–3] Public health workers might be at similar risk for negative mental health consequences because of the prolonged demand for responding to the pandemic and for implementing an unprecedented vaccination campaign. The extent of mental health conditions among public health workers during the COVID-19 pandemic, however, is uncertain. A 2014 survey estimated that there were nearly 250,000 state and local public health workers in the United States.[4] To evaluate mental health conditions among these workers, a nonprobability–based online survey was conducted during March 29–April 16, 2021, to assess symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation among public health workers in state, tribal, local, and territorial public health departments. Among 26,174 respondents, 53.0% reported symptoms of at least one mental health condition in the preceding 2 weeks, including depression (32.0%), anxiety (30.3%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms of a mental health condition was among respondents aged ≤29 years (range = 13.6%–47.4%) and transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages (range = 30.4%–65.5%). Public health workers who reported being unable to take time off from work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. Implementing prevention and control practices that eliminate, reduce, and manage factors that cause or contribute to public health workers' poor mental health might improve mental health outcomes during emergencies.

A nonprobability–based convenience sample of public health workers was invited to complete a self-administered, online, anonymous survey during March 29–April 16, 2021. All persons who worked at a state, tribal, local, or territorial health department for any length of time in 2020 were eligible to participate.* National public health membership associations emailed a link to the survey to all members (approximately 24,000), and supervisors were asked to cascade the survey to all workers within their organization; 26,174 public health workers responded to the survey. The survey included questions on traumatic events or stressors experienced since March 2020,§ demographics, workplace factors, and self-reported mental health symptoms, including depression, anxiety, PTSD, or suicidal ideation, in the past 2 weeks. Mental health symptoms were evaluated using the 9-item Patient Health Questionnaire (PHQ-9) for depression,[5] the 2-item General Anxiety Disorder (GAD-2) for anxiety,[6] the 6-item Impact of Event Scale (IES-6) for PTSD,[7] and one item of the PHQ-9 for suicidal ideation.** Prevalence of symptoms of mental health conditions and suicidal ideation were assessed by demographic characteristics and workplace factors.†† Univariate prevalence ratios were calculated using Poisson regression with 95% confidence intervals estimated using a robust standard error. Analyses were completed using RStudio software (version 1.2.1335; RStudio). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§

Overall, 53.0% of respondents reported symptoms of at least one adverse mental health condition in the preceding 2 weeks. Prevalences of symptoms of depression, anxiety, PTSD, and suicidal ideation were 32.0%, 30.3%, 36.8%, and 8.4%, respectively (Table 1). The highest prevalences of symptoms of a mental health condition or suicidal ideation were among respondents aged ≤29 years (range = 13.6%–47.4%), transgender or nonbinary persons of all ages (range = 30.4%–65.5%), and those who identified as multiple races (range = 12.1%–43.4%); prevalence of symptoms of PTSD was higher among respondents who had a postbaccalaureate graduate education (40.7%).

Most (92.6%) respondents reported working directly on COVID-19 response activities; the majority (59.2%) worked ≥41 hours in a typical week since March 2020. The prevalences of all four mental health outcomes and the severity of symptoms of depression or PTSD increased as the percentage of work time spent directly on COVID-19 response activities and number of work hours in a typical week increased (Table 1) (Figure). Public health workers who were unable to take time off from work when they needed were nearly twice as likely to report symptoms of an adverse mental health condition (prevalence ratio range = 1.84–1.93) as were those who could take time off. Among those not able to take time off from work (8,586), the most common reasons were concern about falling behind on work (64.4%), no work coverage (60.6%), and feeling guilty (59.0%); 18.2% reported that their employer did not allow time off from work. Needing mental health counseling/services in the last 4 weeks, but not receiving these services, was reported by nearly one in five (19.6%) respondents. Employee assistance programs were available to nearly two thirds (66.1%) of respondents but were accessed by only 11.7% of those respondents; 27.3% of all respondents did not know whether their employer offered an employee assistance program.


Distribution* of 9-item Patient Health Questionnaire scores for depression and 6-item Impact of Event Scale scores for post-traumatic stress disorder among state, tribal, local, and territorial public health worker respondents,§ by percentage of work time spent directly on COVID-19 response activities for the majority of 2020 (panels A, C), and hours worked in a typical week since March 2020 (panels B, D) — United States, March–April 2021
Abbreviations: IES-6 = 6-item Impact of Event Scale; PHQ-9 = 9-item Patient Health Questionnaire; PTSD = post-traumatic stress disorder.
*Upper and lower levels of boxes indicate 75th and 25th percentiles, respectively; horizontal line indicates median; whiskers indicate observation nearest to 1.5 × interquartile range.
Self-reported symptoms of depression or PTSD were evaluated; respondents who scored ≥10.0 out of 27 on the PHQ-9 for depression or ≥1.75 out of 4 on the IES-6 for PTSD were considered symptomatic for the respective conditions.
§Only public health worker respondents who completed all PHQ-9 items (n = 23,112) or all IES-6 items (n = 22,248) are included.

Respondents reported experiencing traumatic events or stressors since March 2020, including feeling overwhelmed by workload or family/work balance (72.0%), receiving job-related threats because of work (11.8%), and feeling bullied, threatened or harassed because of work (23.4%); 12.6% of respondents reported having received a diagnosis of COVID-19 (Table 2). Respondents who reported traumatic events or stressors, either personal or work-related, were more likely to report symptoms of PTSD than respondents who did not experience these events or stressors.

*Respondents who did not report working at a state, tribal, local, or territorial public health agency or department in 2020 were excluded from the analysis.
Membership associations that participated were the Association of Public Health Laboratories (APHL), the Association of State and Territorial Health Officials (ASTHO), the Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO).
§Respondents were asked if they had experienced specific traumatic events or stressors since March 2020, when COVID-19 was declared a pandemic; choices were yes/no/skip question.
Symptoms of depression, anxiety, and post-traumatic stress disorder were scored and categorized by severity according to thresholds established by these validated tools. Those who scored ≥10.0 out of 27 on the PHQ-9 for depression, ≥3.0 out of 6 on the GAD-2 for anxiety, or ≥1.75 out of 4 on the IES-6 for PTSD were considered symptomatic for the respective conditions.
**Respondents who indicated that they would be better off dead or thought of hurting themselves at any time in the past 2 weeks were categorized as experiencing suicidal ideation.
††Mental health outcome counts might not sum to total number of respondents because of missing data; counts for each category are those who answered all validated survey questions for that outcome.
§§45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.