Impact of the COVID-19 pandemic on mental health, relationship satisfaction, and socioeconomic status: United States

1 Introduction

The coronavirus disease 2019 (COVID-19) pandemic has had widespread effects on public health, social relatoinships, and economic stability. While its effects have lessened over time, mortality rates continue to remain higher than those of seasonal influenza [1]. Experts agree that future pandemics are inevitable, underscoring the need for improved prevention, preparedness, and crisis management [2]. Research emphasizes that to better handle future crises, it is critical to invest in healthcare, ensure robust governance, and advance technological solutions that can enhance community resilience and response efforts [3]. Understanding the pandemic’s impact on social relationships, income, work, education, and health is essential for shaping policies and public health interventions that will strengthen future crises response.

The pandemic and the implementation of prevention measures (e.g., social distancing and isolation) have impacted social relationships, income, work/school interactions, and health [4]. Social distancing and financial concerns can impact mental health by promoting feelings of isolation, hopelessness, and anxiety [5]. Wang et al. [6] found that one in three adults among the global population experienced psychological distress during the COVID-19 pandemic, often as a result of coping with emotional responses during the pandemic and related prevention measures implemented [7,8,9]. Furthermore, the pandemic has presented significant characteristics of a traumatic event, including prolonged exposure to the social stressor, unpredictability, and threat to health or life [10]. Individuals who experience trauma have a higher likelihood of developing adverse mental or behavioral health conditions, such as substance use, depressive or anxiety disorders, impairment in daily and/or social functioning, and physical conditions [11]. Given this increased risk of mental health concerns, early access to mental health services is critical to prevent the progression of these issues and avoid negative outcomes related to social, occupational, and educational functioning.

Several factors have been proposed to influence the relationship between the pandemic and mental health outcomes, including social relationships and socioeconomic status (SES). SES reflects the extent to which individuals hold socially and economically valued resources [12]. While social relationships can serve as protective factors against deleterious post-traumatic responses, the relationships can also be strained during major stressful events [13,14]. Social support theory [15] suggests that social support – whether emotional, instrumental, or informational – can buffer individuals against the adverse effects of stress, including those caused by the pandemic. The social determinants of health theory suggests that social and economic conditions, including SES and social relationships, significantly shape individuals’ health outcomes, especially during crises like the pandemic [16]. For example, Luk et al. [17] highlighted the intersection of race/ethnicity, socio-economic status, and mental health during the pandemic, emphasizing the need for culturally sensitive interventions to address medical mistrust and improve engagement with mental health and addiction treatment, especially among racial/ethnic minorities and those with a history of alcohol use disorder (AUD). Additionally, Kim et al. [18] found that both minimal changes and complete disruptions in daily life during the pandemic were linked to higher rates of depression and suicidal thoughts. Unexpectedly, positive changes like increased income or improved work conditions were also associated with worse mental health outcomes, likely due to added stress and burnout, especially among frontline workers [18]. Other research also highlights significant mental health challenges following the pandemic, with elevated rates of depression, anxiety, and stress strongly associated with lower quality of life [19]. Key risk factors included older age, marital status, unemployment, excessive social media use, smoking, and the loss of family members to COVID-19 [19].

Relationship satisfaction refers to an individual’s overall evaluation of their social relationships, including emotional support, communication, and fulfillment [20,21,22]. Satisfaction among social relationships has been found to be positively correlated with psychological well-being, and the disruption of these relationships during crises, such as the pandemic, can significantly exacerbate mental health challenges [23]. Conversely, a lack of social support during a health crisis may increase feelings of loneliness and isolation, leading to poorer mental health outcomes [24]. Relationship satisfaction may be impacted by factors such as SES [25,26,27,28]. Social relationships, particularly during times of crisis, serve both as protective factors and as sources of stress, depending on the context [23,29]. The disruption of social relationships during the pandemic has highlighted the vital role of social support in fostering mental health resilience, making it essential to understand how this disruption interacts with SES factors to identify pathways to resilience [23]. Given that social relationships can be affected by crises, which in turn impacts mental health outcomes, it is important to understand whether and how relationships mediate the association between the pandemic and mental health.

During the pandemic restrictions, requests for substance use service significantly decreased, likely due to reduced social opportunities and access to treatment, while requests for mental health-services increased, reflecting heightened psychological distress from isolation, fear, and financial challenges [30]. After restrictions were lifted, requests for substance use services rose, requests for alcohol services resumed their pre-pandemic decline, and mental health-related continued to decrease [30]. Ogeil et al. [31] found that pandemics and disasters, including lockdowns, contributed to increased alcohol consumption and related harms, particularly among those with pre-existing mental health conditions. This placed additional strain on emergency services, leading to significant rises in alcohol-related issues for those with comorbid conditions. Similarly, while youth alcohol consumption decreased overall, particularly among social drinkers, it increased among high-risk users, highlighting the need to address high-risk drinking in disaster planning and to intervene early to reduce the global burden of alcohol consumption [32].

Since the early stages of the pandemic, vulnerable populations have been disproportionately impacted by COVID-19 [33]. Vulnerable populations are identified based on factors, such as financial strains, place of residence, race and ethnicity, age, and chronic health conditions [34]. Individuals from racial/ethnic minoritized groups, with low SES or who have pre-existing mental health conditions, are more likely to face barriers in accessing community health resources, including COVID-19 testing/treatment and mental health services [33,35,36,37]. These barriers increase the likelihood of experiencing poor mental health outcomes [38]. A systematic review that examined the prevalence of psychological distress among participants from 19 countries found individuals residing in areas of lower SES strata to be associated with higher odds of depression and anxiety during the COVID-19 pandemic [6].

While much is known about the individual impacts of relationship satisfaction and SES on mental health during past global health emergencies, no studies have simultaneously explored these factors as mediators and moderators within the context of the pandemic [39].

2 Methodology

3 Results

Distributions of the variables included in the analysis are presented in Table 1.

Covariate associations are presented in the supplementary data. Female-identifying respondents experienced more negative mental health outcomes (anxiety, β = 0.12, p < 0.0001; depression, β = 0.08, p = 0.0029; psychological distress, β = 0.11, p < 0.0001). People with more children (β = 0.10, p = 0.0001) and better living conditions (β = −0.22, p < 0.0001) reported more relationship satisfaction.

Our hypothesis was mediated moderation. That is, as the pandemic endured, relationships became strained, resulting in exacerbated problems with mental health, especially for persons from low SES backgrounds. A conceptual diagram of the analysis is presented in Figure 1. Tests of the total mediated effect are reported in Table 2 (full model results are available in the supplemental material). There was no mediation.

Figure 1

Analysis framework.

Across all outcomes, all tests of mediated moderation were nonsignificant (p > 0.05), with total mediated effects close to zero. When examining individual path coefficients, this was likely because there were not large changes in relationship satisfaction during the pandemic (p = 0.2482). Relationship satisfaction increased slightly during the pandemic, though only a small amount (β = 0.05). Meaningful associations were identified between relationship satisfaction and mental health outcomes (anxiety, depression, and psychological distress, p < 0.0001). Respondents who reported greater relationship satisfaction tended toward moderately better mental health outcomes (anxiety, β = −0.13; depression, β = −0.18; psychological distress, β = −0.16). The association between relationship satisfaction and drinking evidenced marginal non-significance (p = 0.0938, β = 0.04, a small effect). There was some evidence of moderation by SES. While most respondents did not show large changes in average levels of the outcome variables going into the pandemic (|β| < 0.05, p > 0.05), this was not the case for respondents in low SES areas for depression (p = 0.0015) and psychological distress outcomes (p = 0.0015). Specifically, participants from low-income areas showed increases in depression (β = −0.09) and psychological distress (β = −0.12) as the pandemic bore on.

4 Discussion

The pandemic disrupted daily life, affecting living conditions, social relationships, and income, which in turn impacted mental health [49]. This study explored whether relationship satisfaction and SES influenced the link between the pandemic and mental health outcomes (depression, anxiety, substance use, and psychological distress). While no direct effects of the pandemic on mental health or relationship satisfaction were found, relationship satisfaction was found to correlate with anxiety, depression, and psychological distress. A small non-significant mediation effect emerged for alcohol use, with higher relationship satisfaction associated with slightly increased alcohol consumption. SES did not moderate the pandemic’s impact on substance use and anxiety, but did for depression and psycholigical distress. These findings underscore the complexity of pandemic-related stressors, suggesting that while direct pandemic effects were not observed, social and economic factors continued to influence individuals’ mental health and substance use patterns.

Specifically, participants from low-income areas tended toward faster increases in depression and psychological distress as the pandemic continued. This finding was consistent with global research findings, which found individuals residing in areas of lower SES strata to be associated with higher odds of psychological distress (e.g., depression) during the pandemic [6]. Limited research has focused on the impact of the pandemic on psychological distress among individuals with low SES. This study highlights the need to better understand how economic hardship contributes to emotional and cognitive coping challenges, particularly in crisis situations. Individuals facing financial strain may have access to resources, such as mental health services, which can limit opportunities to learn adaptive coping mechanisms. This lack of resources may increase their vulnerability to emotional distres, maladaptive coping mechanisms, and long-term psychological consequences. Results suggest the importance of not only mobilizing outreach for financially vulnerable communities, but doing so in a timely manner to mitigate the effects of the pandemic, particularly in areas with limited access to mental health services.

Whereas prior studies have provided support for separate pathways examined in this study, the current study examined a well-powered, single model in its entirety with all paths included. Although most studies found that individuals were more likely to report declines in relationship satisfaction during stressful external events [50,51,52], several studies found that relationship satisfaction increased for some individuals during the pandemic [51]. The current study did not find a significant association between days into the pandemic and relationship satisfaction, which may explain the lack of mediating effect found for relationship satisfaction. This suggests that the impact of the pandemic on relationships may be more individualized, with some relationships strengthening due to increased time together, while others may deteriorate under stress. Future research should explore the factors that determine whether relationship satisfaction improves or declines in times of crisis.

As stated earlier, individuals with higher relationship satisfaction were more likely to report experiencing better mental health outcomes. Several studies have found evidence for the influence of relationship satisfaction on mental health outcomes during external stressful events [13,14,51,53]. Findings in the current study are consistent with prior literature demonstrating an association between intimate relationship satisfaction and mental health [13]. Since past studies have examined relationship satisfaction with respect to intimate relationships and this study measured relationship satisfaction more broadly (i.e., any relationship), this finding is particularly noteworthy. This indicates that support from any type of close relationship – whether romantic, familial, or platonic – may serve as a protective factor against mental health deterioration. Future interventions should consider utilizing social support networks beyond intimate partners during crises.

Participants with better relationship satisfaction tended to use slightly more alcohol during the pandemic (marginal effects). Participants on average were found to increase their drinking days per month by 28% from before to during the pandemic. Our finding that alcohol consumption increased during the pandemic aligns with studies conducted within the United States, as well as the United Kingdom and Ireland [54,55]. A large review of drinking during the pandemic [56] suggested increased drinking was associated with restricted social rewards and the ability to drink in isolation, thus avoiding judgment from others; however, the current study suggests a more nuanced approach may be needed to fully understand the association between alcohol, the pandemic, and mediating social relationships (i.e., relationship satisfaction may offer rewards and mitigate isolation). While relationship satisfaction is typically protective of mental health, it may not necessarily lead to reduced alcohol consumption. Instead, individuals with strong social bonds may engage in drinking as a shared activity, using alcohol as a way to connect or manage stress together [57]. This highlights the need for targeted messaging about alcohol use in social contexts, particularly during crises.

As noted above, SES moderated the relationship between the pandemic and mental health outcomes (i.e., depression and psychological distress). Specifically, individuals with low SES were more likely to experience increased symptoms of depression and psychological distress as the pandemic progressed. Similar to this finding, prior research has found that individuals who experienced income instability during the pandemic were more likely to report higher rates of depression and other adverse mental health outcomes compared to individuals not experiencing income instability [58]. This may be explained by the lack of control and increased distressful emotions that individuals with low SES may experience due to external stressors [59]. This suggests that economic disparities not only impact financial security but also shape individuals’ emotional resilience. Given that those with lower SES may face higher chronic stress and reduced access to mental health care, policies addressing financial relief and accessible mental health interventions should be prioritized in future crisis responses.

This study also found that respondents with more children and better living conditions were more likely to report experiencing more relationship satisfaction. Consistent with this finding, prior research found parent–child relationships to be positively impacted by having more than one child during the pandemic [60]. This suggests that having multiple children may provide built-in socialization opportunities that ease parental stress, while better living conditions may buffer against pandemic-related relationship strain. Future studies should explore how housing and family dynamics interact to shape well-being during the times of crisis.

5 Conclusion