COVID-19 Infection among Family and Friends: The Psychological Impact on Non-Infected Persons

Abstract

Little is known about the mental health impact of having a family member or friend infected with COVID-19. Thus, the purpose of this study was to conduct a comprehensive national assessment of the psychological impact of COVID-19 infection, hospitalization, or death among family members and friends. A multi-item valid and reliable questionnaire was deployed online to recruit adults in the U.S. A total of 2797 adult Americans without a history of COVID-19 infection participated in the study and reported that they had a family member or friend infected with (54%), hospitalized due to (48%), or die (36%) of COVID-19 infection. Symptoms of depression, anxiety, or both (i.e., psychological distress) were statistically significantly higher among those who had family members/friends infected, hospitalized, or die due to COVID-19. Also, this study found that the greater the number of family members/friends affected by COVID-19, or the more severe the COVID-19 infection outcome (i.e., hospitalization vs. death), the higher the odds of symptoms of depression, anxiety, or both. There is an urgent need to develop educational interventions and implement policy measures that address the growing mental health needs of this subgroup of the population that was not infected but indirectly affected by COVID-19 infections among social networks

Full text

Citation: Khubchandani, J.; Sharma,
S.; Webb, F.J.; Wiblishauser, M.J.;
Sharma, M. COVID-19 Infection
among Family and Friends: The
Psychological Impact on Non-
Infected Persons. Brain Sci. 2022,12,
1123. https://doi.org/10.3390/
brainsci12091123
Academic Editor: Domenico De
Berardis
Received: 4 August 2022
Accepted: 21 August 2022
Published: 24 August 2022
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brain
sciences
Article
COVID-19 Infection among Family and Friends: The
Psychological Impact on Non-Infected Persons
Jagdish Khubchandani 1, * , Sushil Sharma 2, Fern J. Webb 3, Michael J. Wiblishauser 4and Manoj Sharma 5
1College of Health, Education & Social Transformation, New Mexico State University,
Las Cruces, NM 88003, USA
2Provost Office, Texas A&M University Texarkana, Texarkana, TX 75503, USA
3College of Medicine, University of Florida, Jacksonville, FL 32209, USA
4School of Education, Health Professions & Human Development, University of Houston-Victoria,
Victoria, TX 77901, USA
5School of Public Health, University of Nevada, Las Vegas, NV 89119, USA
*Correspondence: jagdish@nmsu.edu
Abstract:
Little is known about the mental health impact of having a family member or friend infected
with COVID-19. Thus, the purpose of this study was to conduct a comprehensive national assessment
of the psychological impact of COVID-19 infection, hospitalization, or death among family members
and friends. A multi-item valid and reliable questionnaire was deployed online to recruit adults in
the U.S. A total of 2797 adult Americans without a history of COVID-19 infection participated in the
study and reported that they had a family member or friend infected with (54%), hospitalized due to
(48%), or die (36%) of COVID-19 infection. Symptoms of depression, anxiety, or both (i.e., psychologi-
cal distress) were statistically significantly higher among those who had family members/friends
infected, hospitalized, or die due to COVID-19. Also, this study found that the greater the number of
family members/friends affected by COVID-19, or the more severe the
COVID-19
infection outcome
(i.e., hospitalization vs. death), the higher the odds of symptoms of depression, anxiety, or both.
There is an urgent need to develop educational interventions and implement policy measures that
address the growing mental health needs of this subgroup of the population that was not infected
but indirectly affected by COVID-19 infections among social networks.
Keywords: COVID-19; pandemic; infection; depression; anxiety; stress; psychiatry
1. Introduction
The COVID-19 pandemic has caused major upheavals for societies and individuals.
By July 2022, more than six million individuals died of COVID-19 infections and more than
550 million were infected worldwide [
1
]. Beyond the direct health impact of COVID-19
via infections, hospitalizations, and deaths, many other population health problems and
risky health behaviors have been extensively explored and reported in the literature during
the pandemic [
2
–
7
]. Among the most prominent public health issues explored during the
COVID-19 pandemic, mental health problems have been reported extensively across regions
and populations. For example, a global review from the early stages of the pandemic found
that the prevalence of depression, anxiety, and distress symptoms worldwide were 28.18%,
29.57%, and 25.18%, respectively. In contrast, another review of data from the first year
of the pandemic suggested that the prevalence of depression, anxiety, and distress was
31.4%, 31.9%, and 41.1%, respectively, indicating sharp increases [
8
,
9
]. Several reviews also
focused on special populations. For instance, a review of healthcare workers (HCWs) with
data till April 2020 found the prevalence of depression and anxiety to be 24.1% and 28.6%,
respectively. In contrast, another review of HCWs with data till November 2020 found the
prevalence of anxiety and depression to be 40% and 37%, respectively [
10
,
11
]. Across all
these studies and reviews from various regions and populations, it was noted that the rates
Brain Sci. 2022,12, 1123. https://doi.org/10.3390/brainsci12091123 https://www.mdpi.com/journal/brainsci

Brain Sci. 2022,12, 1123 2 of 12
of psychological problems among individuals worldwide increased substantially during
the pandemic [7–11].
A plethora of reasons have been cited for the increase in psychological distress and
poor mental health during the COVID-19 pandemic. These findings could be attributed
to a variety of factors such as personality type and pre-pandemic mental health status,
level of control over life, working conditions, household wealth, community resources,
social support, COVID-19-related fears and worries, and above all, resilience [
12
–
15
]. For
example, an investigation with more than 15,000 European adults earlier in the pandemic
explored resilience and found that good stress response and positive appraisal, specifi-
cally of the consequences of the COVID-19 crisis, were strong predictors of good mental
health. For others, however, since the beginning of the pandemic, stress and associated
maladaptive coping resulted in various health risk behaviors and problems. Subsequently,
within the first year of the COVID-19 pandemic [
13
–
15
], prolonged lockdowns and social
distancing, isolation and boredom, job insecurity and financial problems, uncertainty re-
lated to the future, and worries and fear were the most common factors cited for poor
mental health [
6
–
9
,
12
–
14
]. More recently, misinformation and rumors, internet addiction
or excessive social and mass media consumption, work-life imbalance or altered family
responsibilities, occupational losses or changes, food insecurity and material deprivation,
the stigma of infection or becoming infected with COVID-19, fear of COVID-19 infection,
and prevailing social and political upheaval have also been explored with regards to mental
health during the pandemic [14–19].
Despite the extant literature on psychological distress during the pandemic, little is
known about the psychological impact of COVID-19 infections among family and friends.
Thus, the purpose of this investigation was to assess the psychological health of a national
random sample of adult Americans who were not infected with COVID-19 but had family
members or friends infected with COVID-19 virus. Specifically, we aimed to investigate the
proportion of individuals who had a family member or friend infected/hospitalized/die
due to COVID-19, the prevalence of symptoms of depression and anxiety, and the differ-
ences in the burden of anxiety and depression symptoms based on whether or not someone
had a family member or friend infected/hospitalized/die due to COVID-19.
2. Methods
A multi-component valid and reliable questionnaire was deployed via Amazon mTurk
and emails to social networks and community organizations across the United States
from June-September 2021 [
12
,
13
,
15
,
17
]. To estimate the required sample size, an a pri-
ori power analysis was conducted. Based on the total population of adults in the USA
(
n=≈250 million
), 99% confidence levels, and a conservative 3% margin of error, a total of
1844 participants were needed for the study (assuming that half of them knew someone
who was infected, hospitalized, or died of COVID-19). A total of 2797 adult Americans
participated in this study (exceeding the required sample size) [
12
,
15
]. A comprehensive
literature review was conducted to compile a draft survey with face validity. This initial
survey draft was reviewed by a panel of experts (n= 3) to ensure content validity. Based
on the feedback of the experts, several changes were made to the draft to create the final
questionnaire [
15
–
20
]. The final survey consisted of three major sections (i.e., questions
on COVID-19 infection, psychological distress, and sociodemographic information of the
study participants). To screen for potential participants, we asked the study participants
if they had ever tested positive for COVID-19 infection (with response options ‘yes’ vs.
‘no’). Only those who never tested positive for COVID-19 infection or never had COVID-19
infection were included in this study.
The study participants were asked if they knew someone (i.e., family members or
friends) who tested positive for COVID-19, was hospitalized due to COVID-19 or died due
to COVID-19 infection. The response options for these questions were: ‘yes, one person’; ‘yes,
more than one person’; or ‘no, I do not know anyone’ (infected with, hospitalized for, died due
to COVID-19). The internal consistency reliability was computed for these three COVID-19

Brain Sci. 2022,12, 1123 3 of 12
infection-related questions and was found to be high (Cronbach alpha = 0.86). Next, using
the reliable and valid Patient Health Questionnaire-4 (PHQ-4) we assessed symptoms
of anxiety (GAD-2), depression (PHQ-2), or both (PHQ-4) in the study sample [
17
–
20
].
Internal consistency reliability for the PHQ-4 components was computed and found to
be reasonable (GAD-2 alpha = 0.74; PHQ-2 alpha = 0.72; PHQ-4 alpha = 0.83). In the
last section of the survey, study participants were asked about their sociodemographic
characteristics. IRB approval was sought before data collection for the study.
Data were analyzed using IBM SPSS 26 software. In the primary approach, we com-
puted descriptive statistics (i.e., frequencies and percentages) to delineate the sociodemo-
graphic characteristics of the study population and the distribution of COVID-19 infection,
hospitalizations, and deaths in the social networks of the study participants. Subsequently,
Chi-square tests were conducted to assess group differences in symptoms of anxiety, de-
pression, or both (psychological distress) based on sociodemographic characteristics and
COVID-19 infection among friends and family members. Finally, a multiple regression
analysis was conducted to explore the relationship between COVID-19 infection among
family members/friends and psychological distress. Depression, anxiety, or symptoms
of both, were the outcome variables while COVID-19 among family members/friends
was treated as the predictor variables (where the ‘no’ infection, hospitalization, or death
groups were used as comparison groups). Adjusted odds ratios (AOR with 95% confidence
intervals) were computed for the probability of psychological distress based on COVID-19
among family/friends. Statistical significance was set at p< 0.05.
3. Results
A total of 2797 adult Americans without COVID-19 infection history participated in
the study where the majority (>50%) were male, 18–35 years old, married, with children
at home, White, employed full-time, college graduates, with incomes
≤
$60,000, and
urban dwellers (Table 1). With regards to the psychological outcomes, almost a third or
more of the study participants reported anxiety symptoms (33%), depression symptoms
(43%), or symptoms of both anxiety and depression (psychological distress; 32%) (Table 1).
These symptoms differed statistically significantly by demographic characteristics and the
prevalence of these symptoms was highest for 18–35-year-olds, married individuals, those
with children at home, college degree holders, those with incomes
≤
$60,000, or living in
rural areas. White individuals were most likely to have anxiety symptoms (38%) while
Hispanics were more likely to have depression symptoms (54%). Those working full-time
were more likely to have anxiety symptoms (34%) while part-time employed persons were
more likely to have depression symptoms (45%) (Table 1).
Table 1.
Background Characteristics of Study Participants Stratified by Anxiety and Depression
Symptoms.
Total Anxiety Symptoms Depression
Symptoms
Psychological
Distress
Variable N (%) N (%) N (%) N (%)
All Participants 2797 (100) 928 (33) 1198 (43) 899 (32)
Sex
Male 1688 (60) 573 (34) 733 (43) 557 (33)
Female 1109 (40) 355 (32) 465 (42) 342 (31)
Age Group
18–25 years 420 (15) 153 (36) * 200 (48) * 155 (37) *
26–35 years 1416 (50) 470 (33) 611 (43) 456 (32)
36–45 years 604 (22) 194 (32) 260 (43) 185 (31)
46–59 years 245 (9) 86 (35) 97 (40) 77 (31)
≥60 years 112 (4) 25 (22) 30 (27) 26 (23)

Brain Sci. 2022,12, 1123 4 of 12
Table 1. Cont.
Total Anxiety Symptoms Depression
Symptoms
Psychological
Distress
Variable N (%) N (%) N (%) N (%)
Marital Status
Single/never married 791 (28) 269 (34) 330 (42) 264 (33) *
Married 1650 (59) 561 (34) 726 (44) 545 (33)
Engaged/living with a partner
184 (7) 54 (29) 74 (40) 52 (28)
Divorced/separated 133 (5) 32 (24) 52 (39) 26 (20)
Other (e.g., widow) 39 (2) 12 (31) 16 (41) 12 (31)
Children at home
Yes 1649 (59) 600 (36) * 769 (47) * 582 (35) *
No 1148 (41) 328 (29) 429 (37) 317 (28)
Race/Ethnicity
White 1591 (57) 606 (38) * 728 (46) 603 (38) *
Black 467 (17) 134 (29) 186 (40) 129 (28)
Asian 202 (7) 49 (24) 58 (29) 44 (22)
Multiracial 252 (9) 37 (15) 99 (39) 31 (12)
Other race 285 (10) 102 (36) 127 (45) 92 (32)
Hispanic 1141 (41) 418 (37) 617 (54) * 409 (36)
Education
≤High school 282 (10) 95 (34) 103 (37) 92 (33)
Some college 800 (29) 228 (29) 303 (38) 209 (26)
Bachelor’s degree 1332 (48) 476 (36) * 624 (47) * 465 (35)
≥Master’s degree 383 (13) 129 (34) 168 (44) 133 (35) *
Employment Status
Full-time 2137 (76) 736 (34) * 922 (43) 724 (34) *
Part-time 477 (17) 140 (29) 215 (45) * 132 (28)
Not employed 183 (7) 52 (28) 61 (33) 43 (24)
Annual Household Income
0–$60,000 1555 (56) 597 (38) * 734 (47) * 574 (37) *
≥$60,001 1242 (44) 331 (27) 464 (37) 325 (26)
Location
Rural 487 (17) 188 (39) * 237 (49) * 174 (36) *
Urban 1608 (58) 554 (35) 732 (46) 541 (34)
Suburban 702 (25) 186 (27) 229 (33) 184 (26)
* Indicates p< 0.05. N(%) Indicates frequencies and percentages. Psychological distress indicates symptoms of
both depression and anxiety.
When asked about COVID-19 infection among family members and friends, 16% knew
one person and 38% knew more than one COVID-19 infected person (Table 2). Similarly,
20% knew one person and 28% knew more than one person hospitalized due to
COVID-19
infection. More than a third (36%) of participants had at least one family member or
friend die due to COVID-19 infection. Individuals who had a family member/friend
infected, hospitalized, or die due to COVID-19 infection had statistically significantly
higher rates of anxiety, depression, or symptoms of both (Table 2). Compared to those who
did not have a family member/friend affected by COVID-19 infections, knowing even one
COVID-19
affected person increased the rate of psychological distress, and having more
than one family member/friend affected by COVID-19 infection further increased the rate
of psychological distress among study participants (Table 2).

Brain Sci. 2022,12, 1123 5 of 12
Table 2.
COVID-19 Infection Among Family/Friends Stratified by Anxiety and Depression Symptoms.
Total Anxiety
Symptoms
Depression
Symptoms
Psychological
Distress
Variable N (%) N (%) N (%) N (%)
Family Members/Friends Infected with COVID-19
No 1284 (46) 333 (26) 525 (41) 321 (25)
Yes, one person 460 (16) 173 (38) 211 (46) 170 (37)
Yes, more than one person 1053 (38) 422 (40) * 462 (44) 408 (39) *
Family Members/Friends Hospitalized due to COVID-19
No 1455 (52) 363 (25) 555 (38) 337 (23)
Yes, one person 561 (20) 211 (38) 250 (45) 206 (37)
Yes, more than one person 781 (28) 354 (45) * 393 (50) * 356 (46) *
Family Members/Friends Died due to COVID-19
No 1773 (64) 460 (26) 670 (38) 433 (24)
Yes, one person 485 (17) 193 (40) 230 (47) 190 (39)
Yes, more than one person 539 (19) 275 (51) * 298 (55) * 276 (51) *
* Indicates p< 0.05. N(%) Indicates frequencies and percentages. Psychological distress = symptoms of both
depression and anxiety.
Multiple logistic regression analyses were conducted to assess the association between
psychological distress and having a family member/friend who was infected, hospitalized,
or die due to COVID-19 infection (Table 3). Those who did not know anyone who was
infected, hospitalized, or die due to COVID-19 were the comparison group in the logistic
regression. Despite adjustment for sociodemographic characteristics, individuals who re-
ported having family members/friends infected, hospitalized, or die due to COVID-19 were
statistically significantly more likely to report psychological distress. For anxiety symptoms,
knowing one infected person [AOR = 1.70 (95% CI = 1.34–2.15)] or more than one infected
person [AOR = 2.14 (95% CI = 1.78–2.58)] increased the risk of these symptoms. Similarly,
knowing one hospitalized person [AOR = 1.74 (
95% CI = 1.40–2.16)
] or more than one hos-
pitalized person [AOR = 2.54 (95% CI = 2.10–3.09)], significantly increased the risk of anxiety
symptoms. Having one person die due to COVID-19 [
AOR = 1.81
(
95% CI = 1.45–2.26
)] or
more than one person die due to COVID-19 [AOR = 2.93 (
95% CI = 2.38–3.60
)] significantly
increased the risk of anxiety symptoms. For depression symptoms, knowing one infected
person [AOR = 1.30 (95% CI = 1.03–1.63)] or more than one infected person [
AOR= 1.33
(
95% CI
= 1.11–1.59)] increased the risk of these symptoms. Similarly, knowing one hos-
pitalized person [AOR = 1.28 (95% CI = 1.04–1.59)] or more than one hospitalized person
[
AOR = 1.72
(95% CI = 1.43–2.07)], significantly increased the risk of depression symp-
toms. Having one family member/friend die due to COVID-19 infection [
AOR = 1.48
(
95% CI = 1.19–1.83)
] or more than one family member/friend die due to COVID-19 in-
fection [AOR = 2.06 (95% CI = 1.68–2.53)] significantly increased the risk of depression
symptoms. Symptoms of both depression and anxiety (i.e., psychological distress) statisti-
cally significantly increased with having one or more than one family member or friend
infected, hospitalized, or die due to COVID-19 (Table 3). In the final approach, the entire
study population of non-infected adult Americans was grouped into two categories based
on whether or not they had a family member/friend infected, hospitalized, or die due to
COVID-19 (no vs. yes and ‘no’ was the comparison group; Table 3). Compared to those
who did not have a family member/friend infected, hospitalized, or die of COVID-19,
those who had one or more known person who was affected with COVID-19 infection were
statistically significantly more likely to have depression symptoms, anxiety symptoms, or
symptoms of both anxiety and depression.

Brain Sci. 2022,12, 1123 6 of 12
Table 3.
Multiple Regression to Predict Depression/Anxiety Symptoms Based on COVID-19 Infection
Among Family/Friends.
Predictor (3 Categories)
Anxiety
Symptoms
Depression
Symptoms
Psychological
Distress
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Family Members/Friends Infected with COVID-19
No Ref Ref Ref
Yes, one person 1.70 (1.34–2.15) * 1.30 (1.03–1.63) * 1.73 (1.36–2.21) *
Yes, more than one person 2.14 (1.78–2.58) ** 1.33 (1.11–1.59) * 2.12 (1.75–2.56) **
Family Members/Friends Hospitalized due to COVID-19
No Ref Ref Ref
Yes, one person 1.74 (1.40–2.16) * 1.28 (1.04–1.59) * 1.85 (1.48–2.31) *
Yes, more than one person 2.54 (2.10–3.09) ** 1.72 (1.43–2.07) * 2.84 (2.34–3.45) **
Family Members/Friends Died due to COVID-19
No Ref Ref Ref
Yes, one person 1.81 (1.45–2.26) * 1.48 (1.19–1.83) * 1.93 (1.54–2.40) *
Yes, more than one person 2.93 (2.38–3.60) ** 2.06 (1.68–2.53) ** 3.22 (2.61–3.96) **
Predictor (2 Categories = No & Yes)
Anxiety
Symptoms
Depression
Symptoms
Psychological
Distress
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Family Members/Friends Infected with COVID-19
No Ref Ref Ref
Yes, one or more than one 1.90 (1.60–2.25) ** 1.28 (1.08–1.53) ** 1.86 (1.54–2.25) **
Family Members/Friends Hospitalized due to COVID-19
No Ref Ref Ref
Yes, one or more than one 2.00 (1.77–2.07) ** 1.44 (1.26–1.71) ** 2.25 (1.90–2.70) **
Family Members/Friends Died due to COVID-19
No Ref Ref Ref
Yes, one or more than one 2.27 (1.90–2.71) ** 1.76 (1.48–2.08) ** 2.46 (2.07–2.93) **
* Indicates p< 0.05. ** Indicates p< 0.01. AOR = adjusted odds ratios. 95% CI = confidence intervals. The binary
outcomes were depression, anxiety, and moderate to severe psychological distress (yes vs. no). The predictor
variable was COVID-19 infection, hospitalization, or death among family and friends (No was comparison group;
Ref. OR = 1). Multiple regression analyses show the odds of various psychological outcomes after adjusting for
the demographic characteristics from Table 1.
4. Discussion
By August 2022, more than 95 million Americans were infected and more than a mil-
lion died due to COVID-19 infection [
1
,
21
]. In this national study, 54% of the participants
reported having a family member/friend infected with COVID-19 and 48% knew a person
who was hospitalized due to COVID-19. These findings indicate the rampant spread of the
virus across communities nationwide and the impact of this pandemic on the entire popula-
tion, including those not infected. For example, having at least one family member/friend
infected, hospitalized, or die from COVID-19 was found to be associated with an increased
risk of anxiety or depression symptoms or both anxiety and depression (psychological
distress). Also, the relationship between having a family member/friend infected, hos-
pitalized, or die from COVID-19 and psychological distress had a dose-response pattern;
the higher the number of family members/friends affected by COVID-19, the greater the
odds of having symptoms of psychological distress among non-infected adult Americans.
Furthermore, the odds of psychological distress symptoms increased in a graded manner
among study participants based on the severity of COVID-19-related outcomes among
family members/friends (i.e., odds of psychological distress increased from infection to
hospitalization to death of a family member/friend due to COVID-19).
Compared to those who did not know anyone who was infected, those who knew one
or more infected persons were statistically significantly more likely to have symptoms of

Brain Sci. 2022,12, 1123 7 of 12
both depression and anxiety (25% vs. 37% vs. 39%). The fear of getting infected by someone
in the social networks, having a family member/friend in quarantine, uncertainty about
the outcome of infection among family members/friends, work-family disruption, and
stress due to the illness of a member in the social network could have led to the higher risk
of anxiety and depression symptoms among non-infected individuals [
7
–
9
,
12
,
18
,
22
–
24
].
Similarly, compared to those who did not have a family member/friend hospitalized due
to COVID-19 infection, those who had one or more family members/friends hospitalized
due to COVID-19 were more likely to have symptoms of both depression and anxiety (23%
vs. 37% vs. 46%). Recent studies suggest that hospitalized COVID-19 patients and their
relatives may have a nearly equal prevalence of psychological distress. Also, the rates of
psychological distress were found to be higher in relatives of COVID-19 intensive care
patients than relatives of intensive care patients who had other health problems [
23
–
27
].
There are a myriad of reasons postulated for psychological distress, such as caregiver
burden, uncertainty about infection outcomes in family members, fear of death of a dear
one, not being supported by healthcare facilities and providers, communication-related
challenges with medical providers and other family members, lack of social connections and
support, financial concerns, added household responsibilities, and inability to see/meet
COVID-19 infected family members (especially, if they are in an intensive care unit) [
23
–
29
].
Unfortunately, healthcare workers who took care of COVID-19 patients have also been
shown to suffer similar or nearly the same levels of psychological distress [10,11].
An additional key finding in this national study was that more than a third (36%) of
the participants had a family member/friend die due to COVID-19 infection. Compared
to those who did not have a family member/friend die due to COVID-19, those who had
one or more than one person die were significantly more likely to have symptoms of both
depression and anxiety (24% vs. 39% vs. 51%). Studies before the pandemic established
the relationship between sudden deaths in the family, bereavement, prolonged grief, and
multidimensional psychological distress [
29
–
32
]. The COVID-19 pandemic has created
unprecedented circumstances with mass bereavement, inability to see loved ones before
death, overwhelming stress and fear, disruption of rituals/traditions, unusual management
of dead bodies and funerals (to contain infection), unexpected life changes or alterations in
family responsibilities and caregiving, losing a head of the household or income earners,
multiple infected members in the household, and lack of emotional and social support for
families who have lost a family member due to COVID-19 infection [
28
–
33
]. Unsurprisingly,
the highest odds of psychological distress were observed among those who lost more than
one family member or friend due to COVID-19 [AOR = 3.22 (95% CI = 2.61–3.96)].
Findings from our study provide significant information about the mental status
of the general population throughout the United States during the COVID-19 pandemic
(especially of those who had family members/friends/relatives hospitalized or die due
to COVID-19 infection). For example, a back-of-the-envelope calculation suggests that
by August 2022, there were approximately 200+ million Americans without a confirmed
COVID-19 infection [
1
,
21
]. Based on our national survey findings, approximately half of
the non-infected Americans had a family member/friend infected or hospitalized due to
COVID-19 (equating to roughly 100 million people) and another third lost a family mem-
ber/friend due to COVID-19 infection (equating to roughly 70 million people). Considering
our study results, even if a third of these people now have new onset of symptoms of
anxiety or depression due to COVID-19-related hospitalizations and death in the social
networks, the estimated number of additional Americans with these symptoms would
easily exceed 25 million people (in addition to more than 50 million who had a diagnosable
mental illness before the pandemic) [
3
,
12
,
15
,
20
]. Experts estimate that without urgent
interventions, the burden of mental disorders, associated disability, and loss of productivity
will continue to increase in the U.S. due to the pandemic, and for each additional person
needing mental healthcare (e.g., had a family member die due to COVID-19), the total
cost could run into trillions of dollars [
3
,
12
,
19
]. The results of our national assessment
indicate an urgent need to prioritize the exploration and implementation of multipronged

Brain Sci. 2022,12, 1123 8 of 12
interventions for mental health promotion that are customized to families, close relatives,
and friends of those individuals who were hospitalized for or died due to COVID-19.
The United States has suffered some of the worst outbreaks of COVID-19 infections
during the pandemic and profound upheaval across the nation. In response, federal and
statewide efforts are underway to increase awareness about mental illness and the impor-
tance of obtaining help for psychological stress (e.g., online resources from government
agencies) [
34
,
35
]. Additional initiatives and interventions are being explored by regional
professional organizations, community-based agencies, worksites, and schools [
33
,
34
,
36
,
37
].
Experts have also made recommendations on bereavement services, grief counseling, cop-
ing with stress during public health emergencies, trauma-informed approaches to public
mental health promotion, and best practices for healthcare workers who deal with psycho-
logical distress among patients and their relatives [
23
–
32
,
38
–
40
]. However, there remains a
lack of coordinated national programs across countries to provide direct consumer services
to address mental health problems during the COVID-19 pandemic. The need for the
development and provision of mental health care-related programs designed to engage
large population groups from various settings continues to increase, in part as a result of
the ongoing COVID-19 pandemic. Two major areas of research need greater resources and
attention. First, future research should focus on the scalability, reach, and impact of existing
initiatives and interventions to determine the extent to which they mitigate psychological
distress among those who have been affected by COVID-19 directly and indirectly. Second,
innovations using technology should be explored to provide a wider array of population
mental health promotion services [7,9,18,37,38].
In light of the burden of mental health problems nationally and globally, public
health practitioners need to address this issue at both the educational level and policy
level [
39
–
45
]. The major challenges that can be addressed through public health education
interventions are improving communication with health care providers, enhancing com-
munication within the social networks of individuals affected by COVID-19, enhancing the
comprehension of medical information, promoting health literacy, providing information
on grief/bereavement counseling and related services, reducing stigma around mental
health problems and help-seeking, promoting stress management strategies, advertising
resources available to the general public, and sensitizing people on the risk factors for poor
mental health [
42
–
45
]. For policy-level interventions, there is an urgent need to allocate
greater funding for mental health promotion interventions and strengthening the physi-
cal infrastructure and social services. For example, public policy initiatives should help
increase community capacity for COVID-19 prevention and mental health promotion, re-
sources for community mental health surveillance, mental health promotion interventions
in healthcare systems, mental health related training and professional development for com-
munity health workers, workplace incentives and practices for physical and mental health
promotion, support for schools/colleges to provide healthy lifestyle interventions and men-
tal health/case management services, suicide prevention and awareness campaigns, group
and family based interventions (e.g., problem solving, coping, etc.), creating pipelines
of linguistically and culturally competent mental healthcare providers, primary care and
community-based screening services and gatekeeping efforts, web-based interventions
to promote sleep hygiene and stress management, community based strategies to reduce
substance use and promote healthier lifestyles (e.g., exercise), social services/benefits for
those who are most at risk (e.g., those who lost an income earner), telehealth and tech-
nology investments, and assistance with the deployment of community-based activities
and services (e.g., phone lines, support groups, social/mass media channels, counseling
sessions, bereavement support, funeral services, etc.) [37–47].
Most of the existing studies before this national assessment had critical limitations
[23–33]
.
First, most of the existing studies were from hospital or healthcare facility-based samples
of family members of infected/hospitalized patients. Second, these studies were mostly
regional with small sample sizes. Third, the majority of the studies were outside the
United States and were not population-based random samples. Fourth, the studies did

Brain Sci. 2022,12, 1123 9 of 12
not delineate the number of family members/friends infected, hospitalized, or dead due
to COVID-19 (we used a scale of 0, 1, or more than 1 to assess the graded impact on
psychological distress). Finally, earlier studies did not assess the psychological impact of
COVID-19 infections among non-infected family members or friends [23–33].
Limitations and Future Directions
Despite our attempt to address the aforementioned limitations of previous studies, the
results of our study are restricted by all the threats to validity and reliability inherent to
survey study design (e.g., reliance on self-reported behaviors, recall bias in participants,
and the inability to establish cause-and-effect relationships). Another threat to validity is
the nature of the sample (e.g., limited to those with internet connection or understanding
of online surveys). Since the beginning of the COVID-19 pandemic, the United States has
experienced several very distinct waves of infection surge. It could be possible that with
each wave the psychological status or morbidity and mortality in social networks could
have changed. We could not correlate the impact of such waves on psychological symptoms
and COVID-19-related morbidity and mortality in social networks due to the cross-sectional
nature of this one-time survey study. Also, we did not ascertain nuances such as the time
since the death of a family member/friend or the duration of hospitalization of a family
member/friend due to COVID-19; these details could have an impact on the level of
psychological distress (i.e., temporal sequence of events and duration of distress).
Additional and longitudinal studies with larger samples of those who have had
family members or friends hospitalized or die due to COVID-19 infection are warranted to
understand the true and long-term burden of grief, worries, other mental health problems
(e.g., PTSD), and psychological distress among adults and children affected. In addition,
among those who had a family member or friend directly affected by COVID-19, future
studies should also examine in community settings any confounders such as pre-existing
mental illness, family structure, household wealth and resources, access to and usage
of mental healthcare, social support, and relationship with those who were hospitalized
or died due to COVID-19 [
19
,
23
–
26
]. An examination of such variables would provide
precise and critical insights into the nature and extent of psychological problems among
those who had a family member or friend infected with COVID-19. Finally, in addition to
the aforementioned education and policy interventions, professional organizations and
government agencies should increase funding for mental health research. As COVID-
19 continues to disrupt the social and economic fabric of societies along with impacting
the physical and mental health of the public, such funding is much needed and will
be critical for our understanding of COVID-19-related fear, trauma, neurobiological and
cognitive changes, and resilience. Such research initiatives will help design evidence-based
interventions for rehabilitation, healing, and providing solutions for population mental
health problems that have become rampant due to the ongoing COVID-19 assault [
46
–
48
].
5. Conclusions
In this national assessment, a large proportion of American people without a history
of COVID-19 infection reported having a family member or friend infected, hospitalized,
or die due to COVID-19 infection. These individuals were significantly more likely to
have symptoms of psychological distress compared to those who did not have family
members or friends infected with COVID-19. Family members, friends, and relatives of
those affected by COVID-19 through infection, hospitalization, or death suffer from a higher
level of anxiety and depression symptoms. There is an urgent need to develop educational
interventions and implement policy measures that address the growing mental health
needs and provide the necessary support to, this subgroup of the population not infected
but indirectly affected by COVID-19 infections.

Brain Sci. 2022,12, 1123 10 of 12
Author Contributions:
Conceptualization/methodology: J.K. and S.S.; data collection, J.K., S.S.,
M.J.W. and F.J.W.; formal analysis, J.K. and M.J.W.; writing—original draft preparation, S.S., M.J.W.,
F.J.W. and M.S.; writing—review and editing, M.S., M.J.W. and F.J.W.; project administration, J.K. and
S.S. All authors have read and agreed to the published version of the manuscript.
Funding: No external funding was received for this study.
Institutional Review Board Statement:
The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Institutional Review Board of Ball State University.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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