Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

COVID-19 Pandemic: Stress, Anxiety, and Depression Levels Highest amongst Indigenous Peoples in Alberta

COVID-19 Pandemic: Stress, Anxiety, and Depression Levels Highest amongst Indigenous Peoples in... behavioral sciences Article COVID-19 Pandemic: Stress, Anxiety, and Depression Levels Highest amongst Indigenous Peoples in Alberta 1 , 2 1 1 , 2 2 1 , 3 Mobolaji A. Lawal , Reham Shalaby , Chidi Chima , Wesley Vuong , Marianne Hrabok , 2 2 1 1 , 2 , April Gusnowski , Shireen Surood , Andrew J. Greenshaw and Vincent I. O. Agyapong * Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B, Canada; mobolaji@ualberta.ca (M.A.L.); rshalaby@ualberta.ca (R.S.); Chidi.Chima@albertahealthservices.ca (C.C.); marianne.hrabok1@ucalgary.ca (M.H.); andy.greenshaw@ualberta.ca (A.J.G.) Addiction and Mental Health, Alberta Health Services, Edmonton, AB T5K 2J5, Canada; Wesley.Vuong@albertahealthservices.ca (W.V.); April.Gusnowski@albertahealthservices.ca (A.G.); shireen.surood@albertahealthservices.ca (S.S.) Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada * Correspondence: agyapong@ualberta.ca; Tel.: +1-780-215-7771; Fax: +1-780-743-3896 Abstract: This study explores differences in stress, anxiety, and depression experienced by different ethnic groups during the COVID-19 pandemic. This was a cross-sectional online survey of subscribers of the COVID-19 Text4Hope text messaging program in Alberta. Stress, anxiety, and depression were measured among Caucasian, Indigenous, Asian, and other ethnic groups using the Perceived Stress Scale (PSS)-10, Generalized Anxiety Disorder (GAD)-7, and Patient Health Questionnaire Citation: Lawal, M.A.; Shalaby, R.; (PHQ)-9 scales, respectively. The burden of depression and stress were significantly higher in Chima, C.; Vuong, W.; Hrabok, M.; Indigenous populations than in both Caucasian and Asian ethnic groups. The mean difference Gusnowski, A.; Surood, S.; between Indigenous and Caucasian for PHQ-9 scores was 1.79, 95% CI of 0.74 to 2.84, p < 0.01 and for Greenshaw, A.J.; Agyapong, V.I.O. PSS-10 it was 1.92, 95% CI of 0.86 to 2.98, p < 0.01). The mean difference between Indigenous and COVID-19 Pandemic: Stress, Anxiety, Asian for PHQ-9 scores was 1.76, 95% CI of 0.34 to 3.19, p = 0.01 and for PSS-10 it was 2.02, 95% CI and Depression Levels Highest of 0.63 to 3.41, p < 0.01. However, Indigenous participant burden of anxiety was only significantly amongst Indigenous Peoples in higher than Asian participants’ (mean difference for GAD-7 was 1.91, 95% CI of 0.65 to 3.18, p < 0.01). Alberta. Behav. Sci. 2021, 11, 115. Indigenous people in Alberta have higher burden of mental illnesses during the COVID-19 pandemic. https://doi.org/10.3390/bs11090115 These findings are helpful for service planning and delivery. Academic Editors: Andy Smith and Keywords: COVID-19; mobile phones; text; anxiety; depression; stress; psychological distress; Scott D. Lane pandemic; ethnic groups; Indigenous people Received: 7 May 2021 Accepted: 20 August 2021 Published: 24 August 2021 1. Introduction Publisher’s Note: MDPI stays neutral Several studies have reported increased or high levels of psychological distress and with regard to jurisdictional claims in perceived mental illnesses in different populations during a pandemic or epidemic of published maps and institutional affil- a disease [1–10] and during mass disasters [11–13]. By early 2020, the Chinese Center iations. for Disease Control and Prevention investigated clusters of patients with pneumonia of unknown etiology in Wuhan, leading to the isolation of a novel coronavirus (2019- nCoV) [14]. The World Health Organization (WHO) declared a global pandemic [15] on 11 March 2020 and by July, there were around 10 million coronavirus disease (COVID-19) Copyright: © 2021 by the authors. cases and approximately 510,000 COVID-related deaths. Canada reported about 104,000 Licensee MDPI, Basel, Switzerland. COVID cases with approximately 8600 related deaths in the same period [16]. This article is an open access article The WHO has reported that one in four people will suffer mental or neurological distributed under the terms and disorders [17]. The 2017 Global Burden of Disease Study revealed that, depressive disorders conditions of the Creative Commons and anxiety disorders were the third and eighth leading causes of years lived with disability Attribution (CC BY) license (https:// (YLDs), respectively [18,19]. In Canada, mental health and substance use disorders are creativecommons.org/licenses/by/ the second leading cause of YLDs. Around 20% of Canadian residents experience mental 4.0/). Behav. Sci. 2021, 11, 115. https://doi.org/10.3390/bs11090115 https://www.mdpi.com/journal/behavsci Behav. Sci. 2021, 11, 115 2 of 13 illness each year, most frequently mood and anxiety disorders [20]. Suicide can occur in psychotic and affective disorders but it is a core symptom of depressive disorder [21] and around 4000 deaths by suicide occur in Canada annually [22]. The total annual cost of mental illnesses to the Canadian economy was estimated at $51 billion (CAD) in 2008 with a projected increase to $2.5 trillion (CAD) by 2041 [20]. Indigenous peoples are a diverse set of communities living across Canada, comprising First Nations, Métis, and Inuit populations [23]. Indigenous peoples constituted 4.9% of the population of Canada in 2016 [24]. Collectively, Indigenous peoples carry the highest burden of physical and mental illnesses in Canada [25–31], a trend that extends to other countries with Indigenous populations [32–37]. However, one study reported similar prevalence of depression and anxiety for Indigenous and non-Indigenous populations in the Canadian province of British Columbia [38]. Additionally, a systematic review and meta-analysis study that combined studies of Indigenous people of the Americas reported significantly lower lifetime prevalent rates of generalized anxiety, panic, and all depressive disorders in Indigenous populations. However, post-traumatic stress disorder (PTSD) and social phobia were significantly higher relative to the non-Indigenous population [39]. Despite these findings, the overwhelming majority of studies [25–36] and a United Nations report [37] agreed that the burdens of physical and of mental illnesses are generally higher in Indigenous peoples compared to non-Indigenous populations. Worldwide, suicide rates among Indigenous peoples are generally significantly higher than in non-Indigenous populations [40]. In a 2019 Canadian study, relative to non- Indigenous persons, the suicide rate among Inuit peoples was nine times higher; three times higher among First Nations peoples; and two times higher among Métis peoples [41]. However, suicide rates varied by First Nations Band, with a reported suicide rate of zero about 60% of bands. In addition, suicide rates were highest in people aged 15–24 years among First Nations males and Inuit males and females [41]. The reasons for the dispropor- tionately higher burden of physical and mental illnesses among the Canadian Indigenous populations is attributable to social determinants of health (e.g., education, housing, so- cioeconomic status, access to services, etc.). Indigenous peoples often experience inequities that predispose them to experience poorer health outcomes compared to non-Indigenous populations [42–44]. The Truth and Reconciliation Commission of Canada report detailed intergenerational trauma inflicted upon Indigenous peoples from the imposition of the residential school system and the Indian Act in Canada over several decades [45]. Numerous studies, using standardized questionnaires, have reported high levels of psychological distress, anxiety, and depression due to the COVID-19 pandemic [1–10,46,47]. The prevalence of anxiety and depression, as measured by different standardized ques- tionnaires, varied widely during the COVID-19 pandemic. For depression, the prevalence ranged from 14.6% to 53.8% during the COVID-19 pandemic [1,2,4,6,9,46], in excess of expected worldwide prevalence of 2% to 6% in 2017 [48]. Reported prevalence for anxiety during the COVID-19 pandemic range from 8.3% to 50.3% [1,2,4,6,8–10,46], also far higher expected worldwide prevalence of 2.5% to 7% in 2017 [48]. For stress during the COVID-19 pandemic, estimated prevalence ranges from 7.6% to 53.8% [2,5,8,9,47]. These worldwide prevalence for anxiety disorders and depression used for comparison were gleaned from a combination of survey-, medical- and epidemiological data, and meta-regression modelling in cases where raw data is missing [48]. Different studies reported variable epidemio- logical risk factors that are significantly associated with increased prevalence of anxiety, depression, and stress, measured by standardized questionnaires, during the COVID-19 pandemic in different populations [1–7,9,10,46]. Risk factors positively associated with depression in these studies included age 21–40 years [4,10], female gender [2,9], alcohol use [10], negative affect, detachment, an acquaintance infected with COVID-19, prior medical problems, stressful situations [2], spe- cific physical health symptoms, poor self-rated health status [9], being close to the epicenter of the outbreak [10], being quarantined or affected by quarantine [3,46], financial burden due to massive quarantine [6], and spending more time exposed to COVID-19 related Behav. Sci. 2021, 11, 115 3 of 13 news [6]. Risk factors reported to be significantly associated with increased prevalence of anxiety included age 20–46 years [1,2,4,10], female gender [2,9], negative affect, detachment, stressful situations, prior medical problems [2], family members infected with COVID- 19 [2,10], being infected with COVID-19 [10], specific physical health symptoms, poor self-rated health status and student status [9], quarantine or affected by quarantine [7,46], financial burden due to massive quarantine [6], perceived impact of COVID-19 [7], and time spent exposed to COVID-19 related news information [6,10]. Most factors that are positively associated with anxiety and depression during the COVID-19 pandemic may also bey associated with stress. These include age 20–46 years [1,2,10], female gender [2,5,9], negative affect, detachment, having an acquaintance infected with COVID-19 [2], higher educational level, migrant status, being close to the epicenter of a COVID-19 outbreak [5], quarantined or affected by quarantine [46], student status, specific physical health symptoms, and poor self-rated health status [9]. Despite the positive association of these factors with anxiety, depression, and stress during the COVID-19 pandemic some studies reported no such relationship for several of these factors. For instance, gender had no effect on anxiety and depression in two of these studies [1,7]. However, in a global report of anxiety disorder and depression estimates, females were reported to have higher prevalence of depression compared to males (4.1% versus 2.7%, respectively). In the same report, females had higher prevalence of anxiety disorders than males (4.7% versus 2.8%, respectively) [48]. In that report, median estimates for prevalence of depression and anxiety were higher in females for all the countries considered. Given the generally greater burden of health among Indigenous peoples in Canada, in the absence of published detailed mental health studies addressing this inequity, we hypothesized that perceived stress, anxiety, and depression, measured by standardized instruments, would be higher for among Indigenous persons relative to other ethnic groups. Text4Hope is a texting service that delivers once-daily supportive messages to support individuals’ mental health during the COVID-19 pandemic. Text messages were based on cognitive-behavioral therapy concepts and developed by mental health professionals (i.e., psychiatrists, psychologists, and mental health therapists). The program offers mental health support, aims to ameliorate pandemic-related negative thoughts and feelings, and help individuals to develop healthy coping and resiliency skills [49]. The program was modeled after the Text4Mood [50] and Text4Support [51] mental health texting services provided to people in Alberta, Canada. Ultimately, such services are evidence-based, clini- cally relevant, and cost-effective interventions applied as a therapeutic alliance to mental healthcare services for individuals with depressive and drug use disorders [52–55]. The aim of this program is to close the psychological treatment gap experienced in healthcare systems during the COVID-19 pandemic. The aim of this study was to determine the burden of anxiety, depression, and stress in relation to ethnicity for Text4Hope subscribers who completed the baseline survey. 2. Materials and Methods A cross-sectional survey was used to explore mean differences in perceived stress, anx- iety, and depression symptom scores among the various ethnic groupings for Text4Hope subscribers who completed the baseline survey. This study explored each participant’s demographic characteristics (gender, age, level of education, employment status, rela- tionship status, and housing status) and stratified them by their self-identified ethnicity (Caucasian, Indigenous, Asian, and Other). The mean scores, standard deviations, and standard errors from the Perceived Stress Scale (PSS)-10 [56], Generalized Anxiety Disorder (GAD)-7 [57], and Patient Health Questionnaire (PHQ)-9 [58] for self-reported symptoms of stress, anxiety, and depression, respectively, were stratified by ethnicity. The PSS is a 10-item validated self-report questionnaire (with an associated Cronbach’s alpha of >0.70) which is used to assess the level of stress in the previous month. Each item on the scale is scored between 0 (never) to 5 (very often). Higher scores on the scale indicate higher levels of stress. The GAD-7 is a 7-item validated questionnaire (associated with a Cronbach’s Behav. Sci. 2021, 11, 115 4 of 13 alpha of 0.92) which is used to assess the self-reported levels of anxiety in respondents in the two weeks prior to assessment. Each item on the scale is scored between 0 (not at all) to 4 (nearly everyday). Higher scores on the scale indicate higher levels of anxiety. The PHQ-9 is a 9-item validated instrument (associated with a Cronbach’s alpha of 0.89) which used to diagnose and measure the severity of depression in general medical and mental health settings. Each of the 9 questionnaire items is scored between 0 (not at all) to 3 (nearly every day). Higher scores on the scale indicate higher levels of depression. The mean scores for stress, anxiety, and depression were compared among the ethnic groups and their differences were calculated using appropriate statistical methods to determine the mean differences and a 95% confidence interval in their PSS-10, GAD-7, and PHQ-9 scores. These mean differences and their 95% confidence interval depict the burden of anxiety, depression, and stress for each ethnic group relative to the other ethnic groups. 2.1. Recruitment The study recruitment procedures and sample size estimations have been described earlier [59–62]. In summary, Text4Hope was launched by AHS on 23 March 2020. The program’s aim was to send daily supportive text messages to help support Albertans dealing with mental health concerns due to the COVID-19 pandemic. An online survey link was sent to self-subscribers and requested demographic information including gender, age, ethnicity, education, relationship status, employment status, type of employment, housing status, isolation status, and clinical characteristics of stress, anxiety, depression and obsessive-compulsive symptoms. Clinical characteristics were assessed using validated scales for self-reported symptoms, including the PSS-10, GAD-7, and PHQ-9. Participant consent was implied by submission of subscribers’ survey responses. Ethical approval for the research study was obtained through the University of Alberta Health Research Ethics Board (Pro00086163). Data was collected between 24 March 2020 and 4 May 2020. 2.2. Statistical Methods Data analysis was undertaken using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 26 (IBM Corp., Armonk, NY., USA). Demographic char- acteristics of respondents were summarized in absolute numbers and percentages, by ethnic category. A one-way analysis of variance (One-Way ANOVA) with two tailed signif- icance (p < 0.05) was used to assess statistical differences between the ethnic groups for corresponding mean scores on the PSS-10, GAD-7, and PHQ-9. For variables that did not violate the assumptions of homogeneity of variance in the mean scores on the ANOVA test, we performed a Turkey’s post hoc test to determine if there were statistically signifi- cant differences in the mean scores of the various clinical measures between the different ethnic groups. For variables which violated the homogeneity of variance assumption, we determined if there were statistically significant differences for the mean scores for the various clinical measures between the different ethnic groupings using the Welch F test and a Games–Howell post-hoc test (as these tests do not require groups to exhibit homogeneity of error variance). 3. Results 3.1. Demographic Characteristics of Respondents Of the 44,992 subscribers who joined Text4Hope in the first 6 weeks, 8267 responded to the online survey invitation, yielding a 19.4% response rate. Of the 8267 respondents, 6685 (81.0%) identified as Caucasian, 302 (3.7%) identified as Indigenous, 407 (4.9%) identified as Asian, 756 (9.2%) identified as belonging to “Other” ethnic groups, and 103 (1.2%) did not identify their ethnicity. The other demographic characteristics of the respondents are displayed in Table 1. Behav. Sci. 2021, 11, 115 5 of 13 Table 1. Demographic characteristics of respondents by self-reported ethnicity. Caucasian Indigenous Asian Other Overall Variables N (%) N (%) N (%) N (%) N (%) Gender Male 751 (76.5) 32 (3.3) 93 (9.5) 105 (10.7) 981 (12.0) Female 5884 (83.1) 263 (3.7) 312 (4.4) 620 (8.8) 7079 (86.9) Other 50 (55.6) 7 (7.8) 2 (2.2) 31 (34.4) 90 (1.1) Age 25 646 (71.3) 47 (5.2) 88 (7.9) 125 (13.8) 906 (11.1) 26–40 2355 (80.4) 124 (4.2) 188 (6.4) 261 (8.9) 2928 (36.6) 41–60 2905 (85.1) 111 (3.3) 113 (3.3) 283 (8.3) 3412 (42.7) >60 673 (89.5) 13 (1.7) 10 (1.3) 56 (7.4) 752 (9.4) Education Less than High School Diploma 214 (65.2) 35 (10.7) 17 (5.2) 62 (18.9) 328 (4.0) High School Diploma 621 (77.7) 50 (6.3) 21 (2.6) 106 (13.3) 798 (9.8) Post-Secondary Education 5815 (83.9) 212 (3.1) 388 (5.2) 547 (7.9) 6932 (85.1) Other Education 35 (38.9) 4 (4.4) 8 (8.9) 43 (47.8) 90 (1.1) Employment Status Employed 4970 (83.4) 196 (3.3) 300 (5.0) 490 (8.2) 5956 (73.1) Unemployed 744 (78.2) 66 (6.9) 34 (3.6) 107 (11.3) 951 (11.7) Retired 498 (89.9) 8 (1.4) 6 (1.1) 42 (7.6) 554 (6.8) Students 310 (68.4) 25 (5.5) 53 (11.7) 65 (14.3) 453 (5.6) Other 161 (68.8) 7 (3.0) 12 (5.5) 54 (23.1) 234 (2.9) Relationship Status Married/Cohabiting/Partnered 4820 (83.5) 178 (3.1) 276 (4.8) 499 (8.6) 5773 (70.9) Separated/Divorced 533 (86.7) 25 (4.1) 14 (2.3) 43 (7.0) 615 (7.5) Widowed 117 (88.6) 4 (3.0) 1 (0.8) 10 (7.6) 132 (1.6) Single 1167 (76.0) 90 (5.9) 110 (7.2) 168 (10.9) 1535 (18.8) Other 47 (50.5) 5 (5.4) 3 (3.2) 38 (40.9) 93 (1.1) Housing Status Own Home 4532 (86.3) 123 (2.3) 197 (3.8) 401 (7.6) 5243 (65.7) Living with Family 533 (67.6) 43 (5.5) 99 (12.6) 113 (14.3) 788 (9.8) Renting 1466 (78.0) 123 (6.5) 93 (4.9) 197 (10.5) 1879 (23.5) Other 39 (48.1) 6 (7.4) 6 (7.4) 30 (7.0) 81 (1.0) In Table 1, the majority of respondents identified as female (n = 7079, 86.9%), aged between 26 and 60 years (n = 6340, 79.3%), had post-secondary education (n = 6932, 85.1%), were employed (n = 5956, 73.1%), were married, cohabiting, or partnered (n = 5773, 70.9%), and owned their own home (n = 5243, 65.7%). 3.2. Association between Ethnic Categories and Prevalence of Perceived Stress, Likely GAD, and Likely MDD The data displayed in Table 2 illustrate prevalence rates for clinically meaningful stress, anxiety, and depression. These data suggest the prevalence of moderate to high stress, likely Generalized Anxiety Disorder (GAD), and likely Major Depressive Disorder (MDD) were highest in respondents that identified as Indigenous. The mean score for all respondents (n = 7589) on the PSS-10 was 20.79 (SD = 6.83). For the PHQ-9 scale, the mean score for all the respondents (n = 7082) was 9.43 (SD = 6.29) and for the GAD-7 scale, the mean score for all respondents (n = 6944) was 9.68 (SD = 5.87). Chi square analysis revealed significant association between the prevalence of likely stress and depression and the ethnicity of the participants, but not for the likely anxiety symptoms. Behav. Sci. 2021, 11, 115 6 of 13 Table 2. Association between ethnic categories and prevalence of perceived stress, likely GAD, and likely MDD. Variable Ethnic Categories Caucasian Indigenous Asian Other Total Prevalence N (%) N (%) N (%) N (%) N (%) Perceived Stress Moderate or High Stress 5593 (85.2) 279 (92.1) 329 (86.1) 618 (88.0) Chi square value 14.71 6819 (85.7) p-value <0.01 Effect Size (Phi) 0.04 Generalized Anxiety Disorder (GAD) GAD likely 2848 (47.1) 144 (51.8) 137 (41.6) 296 (44.7) Chisquare value 6.4 3425 (47.1) p-value 0.09 Effect Size (Phi) 0.03 Major Depressive Disorder (MDD) MDD likely 2695 (43.7) 149 (52.8) 149 (44.2) 305 (47.5) Chi Square value 11.8 3298 (44.4) p-value 0.01 Effect Size (Phi) 0.04 a b c Moderate or High Stress defined as PSS-10 score  14; Likely GAD defined as GAD-7 score  10; Likely MDD defined as PHQ-9 score  10. Table 3 presents the means and standard deviations for each of the PSS-10, PHQ-9, and GAD-7 scales by ethnicity groups. Table 3. Descriptive illustration of mean scores of GAD-7, PHQ-9 and PSS-10 scales by ethnic group. 95% Confidence Interval for Mean Variables N Mean Std. Deviation Std. Error Minimum Maximum Lower Bound Upper Bound Caucasian 5750 9.69 5.83 0.08 9.54 9.84 0 21 Indigenous 262 10.56 5.91 0.37 9.84 11.28 0 21 GAD-7 Total Asian 307 8.65 5.96 0.34 7.98 9.32 0 21 Score Other 595 9.75 5.99 0.25 9.26 10.23 0 21 Total 6914 9.68 5.86 0.07 9.54 9.82 0 21 Caucasian 5859 9.30 6.19 0.08 9.15 9.46 0 27 Indigenous 266 11.10 6.50 0.40 10.31 11.88 0 27 PHQ-9 Total Asian 315 9.33 6.82 0.38 8.58 10.09 0 27 Score Other 612 10.04 6.71 0.27 9.51 10.57 0 27 Total 7052 9.44 6.29 0.08 9.29 9.58 0 27 Caucasian 6243 20.65 6.83 0.09 20.48 20.82 0 40 Indigenous 286 22.56 6.36 0.38 21.82 23.30 8 40 PSS-10 Total Asian 359 20.55 6.78 0.36 19.84 21.25 2 39 Score Other 668 21.51 6.91 0.27 20.99 22.04 1 40 Total 7556 20.79 6.83 0.08 20.64 20.94 0 40 Table 3 suggests that respondents that self-identified as Indigenous had the highest mean scores on the PSS-10, PHQ-9, and GAD-7 scales, while respondents that self-identified as Caucasian or Asian had fairly similar mean scores on the PSS-10 and PHQ-9 but not the GAD-7 scales. Behav. Sci. 2021, 11, 115 7 of 13 Table 4 represents the results of One-Way ANOVA comparing sums of squares between and within ethic groups for the PSS-10, PHQ-9, and GAD-7 scales. Table 4. ANOVA comparing sums of squares between and within ethnic groups. Variables Sum of Squares Df Mean Square F Sig. Between Groups 533.18 3 177.73 5.183 <0.01 Within Groups 236,941.86 6910 34.29 GAD-7 Total Score Total 237,475.03 6913 Between Groups 1061.60 3 353.87 8.984 <0.01 PHQ-9 Total Score Within Groups 277,609.70 7048 39.39 Total 278,671.30 7051 Between Groups 1397.14 3 465.71 10.013 <0.01 PSS-10 Within Groups 351,233.05 7552 46.51 Total Score Total 352,630.20 7555 Table 4 suggests that there were statistically significant differences between and within ethnic groups for scores on the PSS-10 (F = 10.013, p < 0.001), the PHQ-9 (F = 8.98, p < 0.001), and the GAD-7 (F = 5.18, p < 0.001). The Levene Statistic test of homogeneity of variances suggested no violation of the assumption of equality of means for the PSS-10 and the GAD-7 (p > 0.05) and so we ran the Turkey’s post-hoc test to determine statistically significant differences in the mean scores between the different ethnic groups as presented in Table 5 But in contrast, the Levene Statistic test of homogeneity of variances indicated a violation of the assumption of homogeneity of error variance for the PHQ-9 scores (p < 0.05). Consequently, we ran a Welch F test and a Games-Howell post-hoc test to determine statistically significant differences between mean scores on the PHQ-9 between the different ethnic groups. The Welch F test was statistically significant which confirms that the differences between the groups in terms of their mean PHQ-9 scores are statistically significant. The results of the Games–Howell post-hoc test is as presented in Table 5. Table 5. Tukey HSD and Games-Howell post-hoc multiple comparisons. 95% Confidence Interval Dependent Mean Ethnicity Ethnicity Sig. Std. Error Lower Upper Difference Variable Bound Bound Asian 1.04 * 0.34 0.01 0.16 1.92 Caucasian Other 0.06 0.25 0.99 0.71 0.59 Asian 1.91 * 0.49 <0.01 0.65 3.18 GAD-7 Indigenous Caucasian 0.87 0.37 0.09 0.08 1.82 Total Score Other 0.82 0.43 0.24 0.30 1.93 Asian Other 1.10 * 0.41 0.04 2.16 0.04 Asian 0.10 0.37 0.99 0.85 1.05 Caucasian Other 0.87 * 0.28 0.01 1.58 0.15 Asian 2.02 * 0.54 <0.01 0.63 3.41 PSS-10 Indigenous Caucasian 1.92 * 0.41 <0.01 0.86 2.98 Total Score Other 1.05 0.48 0.13 0.19 2.29 Asian Other 0.97 0.45 0.13 2.11 0.18 Caucasian Asian 0.03 0.39 0.99 1.04 0.99 Other 0.74 * 0.28 0.05 1.46 0.01 Indigenous Asian 1.76 * 0.55 0.01 0.34 3.19 PHQ-9 Indigenous Caucasian 1.79 * 0.41 <0.01 0.74 2.84 Total Score Other 1.06 0.48 0.126 0.18 2.30 Asian Other 0.71 0.47 0.44 1.92 0.51 a b Tukey HSD post hoc multiple comparison; Games-Howell post hoc multiple comparison; * The mean difference is significant at the 0.05 level. Behav. Sci. 2021, 11, 115 8 of 13 Table 5 suggests that respondents who self-identified as Indigenous had signifi- cantly higher mean scores on the GAD-7 compared to respondents that self-identified as Asian (Mean Difference = 1.91, 95% CI = 0.65–3.18 and p < 0.01) but not respon- dents that self-identified as Caucasian (p > 0.05) or “Other” ethnic groups (p > 0.05). On the other hand, respondents that identified as Caucasian had significantly higher mean scores on the GAD-7 compared to respondents that identified as Asian (Mean Difference = 1.04, 95% CI = 0.16–1.92, p = 0.01) but not respondents that identified as “Other” ethnic groups (p > 0.05). However, respondents that identified as Asian had significantly lower mean scores on the GAD-7 compared to respondents that identified as “Other” (Mean Difference= 1.10, 95% CI= 2.16 to 0.04, p < 0.05). Table 5 also suggests that respondents that identified as Indigenous had higher mean scores on the PSS-10 than both respondents that identified as Caucasian (Mean Difference = 1.92, 95% CI = 0.86–2.98, p < 0.01) or Asian (Mean Difference = 2.02, 95% CI = 0.63–3.41, p < 0.01) but not respondents that identified as “Other” ethnic groups (p = 0.13). There were no statistically significant differences in the mean scores between respondents that identified as Caucasian or Asian for the mean PSS-10 scores (p > 0.05). However, respondents that identified as Caucasian had significantly lower mean scores on the PSS-10 compared to respondents that identified as “Other” ethnic groups (Mean Difference = 0.87, 95% CI = 1.58 to 0.15, p < 0.05). Table 5 suggests that respondents that identified as Indigenous had significantly higher mean scores on the PHQ-9 compared to respondents that identified as Asian (Mean Difference =1.76, 95% CI = 0.34–3.19 and p < 0.05) or Caucasian (Mean Difference = 1.79, 95% CI = 0.74–2.84, p < 0.01), but not those who identified as “Other” ethnic groups (p > 0.05). On the other hand, respondents that identified as Caucasian had significantly lower mean scores on the PHQ-9 compared to respondents that identified as “Other” ethnic groups (Mean Difference = 0.74, 95% CI = 1.46–0.01, p = 0.05). 4. Discussion To our knowledge, this is the first study to examine how depression, anxiety, and stress symptoms vary among ethnic groups in Canada during the COVID-19 pandemic. The demographics of our study population suggest that the demographic profile of subscribers of the Text4Hope program and Text4Mood programs [50] are comparable. Our study found that respondents identifying as Indigenous reported higher levels of depression, anxiety, and stress than other ethnic groups in Alberta, Canada as measured by the PHQ-9, GAD-7, and PSS-10, respectively. Persons who identified as Caucasian or Asian reported similar levels of depression and stress, but respondents that identified as Caucasian reported more anxiety than respondents that identified as Asian. However, the significantly lower mean GAD-7 score reported by respondents that identified as Asian, compared to other ethnic groups, is not surprising given that in a global study of anxiety disorders, Asian people had lower prevalence of anxiety disorders (2% to 4%) compared to the rest of the world (4% to 6%), with the exception of some countries in South America, Eastern Europe, and Finland with similar prevalence of anxiety disorders [48]. Overall, the prevalence of distress was high, which is consistent with previous research. For example, significant stress was reported by over 90% of respondents that identified as Indigenous, and significant anxiety and depression were reported by over 50%. High rates of anxiety, depression, and stress found in this study are consistent with previous research showing high levels of population-level distress during the pandemic [1,2,4,6,8–10,46], with rates grossly elevated compared to pre-COVID-19 estimates [48]. For instance, the prevalence of significant anxiety symptoms in our study of 47.1%, was similar to the rates re- ported in different studies across the world during the COVID-19 pandemic [1,2,4,6,8–10,46], yet is much higher than an estimated global pre-COVID-19 rate in 2017 of 2.5% to 7% for anxiety [48]. The COVID-19 pandemic has likely accentuated pre-existing differences in the burden of mental health. For example, although a higher burden of mental health conditions among Indigenous peoples compared to non-Indigenous people in Canada was reported Behav. Sci. 2021, 11, 115 9 of 13 prior to the pandemic [29–31,63–65], as well as in other countries with Indigenous popu- lations [35,36,40], it is likely that COVID-19 has placed additional stressors on this group. The reasons for the disproportionately higher burden of physical and mental illnesses among Indigenous peoples may include inequalities related to social determinants of health (e.g., education, housing, socioeconomic status, access to services, etc.), which can place Indigenous peoples at greater risk of poorer health outcomes compared to non- Indigenous populations [42–44]. This pattern of data likely stems from broad societal events; for example, in Canada, Indigenous people have experienced intergenerational trauma related to the Residential School System and the Government of Canada’s Indian Act over decades [45]. It has been documented that natural disasters and public health crises exaggerate pre-existing social inequities, and our findings are consistent with this. Our study has several limitations, including a lack of baseline data on the stress, anxiety, and depression levels immediately prior to the COVID-19 pandemic and related restrictions, limiting direct pre- and post-COVID-19 comparisons. Second, the response rate in our study of 19.4% was low. However, our sample size was greater than the sample size of 3693 needed for prevalence rates estimates for stress, anxiety, and depression in our overall sample of 44,992 subscribers or the 4200-sample size needed for prevalence rate estimates in the entire Alberta population with a confidence interval of 99% and a 2% margin of error. Third, our study likely evidences selection bias given the rather low response rate; specifically, it is possible that non-respondents may differ in a systematic way compared to respondents. For example, they may be more (or less) affected by the pandemic or may have limitations in literacy or English fluency. Similarly, our study has some limited generalizability. The respondents that self-identified as Indigenous in our study represented 3.7% of our sample, lower than estimated proportion of the Indigenous population in Canada (4.9%) [24]. Furthermore, the vast majority of our respondents identified as female (86.9%), which is an overrepresentation in our study relative to Canadian population estimates of 50.3% [66]. This may likely increase the prevalence of perceived anxiety and depression in our study population given that females reportedly have higher prevalence of anxiety disorders and depression in all the countries considered in a global study [48]. Finally, although the ANOVA analysis allowed for comparison of the stress, anxiety, and depression levels between all the ethnic groups as a strength, it did not take into account potential confounding factors such as gender, age, relationship status, employment status, and education status, which is a limitation as ethnicity is likely to be one of several key factors upon which vulnerability to mental health effects of COVID-19 would be based. In addition, other social determinants of health, along with co-morbid physical health conditions, are known to play a significant role in increasing vulnerability in times of crisis [11]. Any interventions aimed at mitigating mental health effects of COVID-19 must therefore take of all these various factors into account. 5. Conclusions The results of our study indicate that stress, anxiety, and depression levels are high in the general population during the COVID-19 pandemic, and are significantly associated with specific risk factors, such as Indigenous ethnicity. These results suggest a need for population-level mental health support, with enhanced psychological intervention for specific groups, such as Indigenous persons. Future studies should consider using a prospective study design in randomly selected participants from the general population with participants screened by trained clinicians for the presence of depression, anxiety, and stress using standardized objective assessment instruments. This will minimize recall bias and ensure that study findings are generalizable to the entire population. Despite several limitations, this study provides useful data about the mental health ethnicity correlates of the COVID-19 pandemic. These findings are important for govern- ment and healthcare planning to determine the nature and quality of services required to address mental health challenges arising during this pandemic, as well as future pan- demics that enforce public health measures. Specifically, planning for and implementing Behav. Sci. 2021, 11, 115 10 of 13 virtual care programs as well as supportive text messages is a relatively low-cost and easily scalable means of supporting individuals during public health crises [53,67–70], especially appropriate for supporting persons at additional risk of negative outcomes [52,54,55]. Author Contributions: Conceptualization, V.I.O.A.; data curation: R.S., W.V., A.G., S.S. and V.I.O.A.; methodology: R.S., A.J.G. and V.I.O.A.; supervision: V.I.O.A. and S.S.; writing—original draft: M.A.L., V.I.O.A. and R.S.; writing—review and editing: M.A.L., R.S., C.C., W.V., M.H., A.G., S.S., A.J.G. and V.I.O.A. All authors have read and agreed to the published version of the manuscript. Funding: This study was supported by grants from the Mental Health Foundation, the Calgary Health Trust, the University Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation, and the Alberta Cancer Foundation. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or the decision to submit the results for publication. Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the University of Alberta Health Research Ethics Board (protocol code Pro00086163 approved on 18 March 2020). Participant consent was implied by submission of subscribers’ survey responses. Informed Consent Statement: Informed consent was implied if subscribers completed the online sur- vey and submitted responses, as approved by the University of Alberta Health Research Ethics Board. Data Availability Statement: The data that support the findings of this study are available from the corresponding author, V.I.O.A., upon reasonable request. Acknowledgments: Support for the project was received from Alberta Health Services and the University of Alberta. Conflicts of Interest: The authors declare no conflict of interest. References 1. Ahmed, M.Z.; Ahmed, O.; Aibao, Z.; Hanbin, S.; Siyu, L.; Ahmad, A. Epidemic of COVID-19 in China and associated Psychological Problems. Asian J. Psychiatry 2020, 51, 102092. [CrossRef] 2. Mazza, C.; Ricci, E.; Biondi, S.; Colasanti, M.; Ferracuti, S.; Napoli, C.; Roma, P. A Nationwide Survey of Psychological Distress among Italian People during the COVID-19 Pandemic: Immediate Psychological Responses and Associated Factors. Int. J. Environ. Res. Public Health 2020, 17, 3165. [CrossRef] 3. Zhang, J.; Lu, H.; Zeng, H.; Zhang, S.; Du, Q.; Jiang, T.; Du, B. The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav. Immun. 2020, 87, 49–50. [CrossRef] 4. Huang, Y.; Zhao, N. Chinese mental health burden during the COVID-19 pandemic. Asian J. Psychiatry 2020, 51, 102052. [CrossRef] 5. Qiu, J.; Shen, B.; Zhao, M.; Wang, Z.; Xie, B.; Xu, Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen. Psychiatry 2020, 33, e100213. [CrossRef] 6. Li, J.; Yang, Z.; Qiu, H.; Wang, Y.; Jian, L.; Ji, J.; Li, K. Anxiety and depression among general population in China at the peak of the COVID-19 epidemic. World Psychiatry 2020, 19, 249–250. [CrossRef] 7. Tull, M.T.; Edmonds, K.A.; Scamaldo, K.M.; Richmond, J.R.; Rose, J.P.; Gratz, K.L. Psychological Outcomes Associated with Stay-at-Home Orders and the Perceived Impact of COVID-19 on Daily Life. Psychiatry Res. 2020, 289, 113098. [CrossRef] 8. Madani, A.; Boutebal, S.E.; Bryant, C.R. The Psychological Impact of Confinement Linked to the Coronavirus Epidemic COVID-19 in Algeria. Int. J. Environ. Res. Public Health 2020, 17, 3604. [CrossRef] 9. Wang, C.; Pan, R.; Wan, X.; Tan, Y.; Xu, L.; Ho, C.S.; Ho, R.C. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int. J. Environ. Res. Public Health 2020, 17, 1729. [CrossRef] 10. Moghanibashi-Mansourieh, A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J. Psychiatry 2020, 51, 102076. [CrossRef] 11. Moosavi, S.; Nwaka, B.; Akinjise, I.; Corbett, S.E.; Chue, P.; Greenshaw, A.J.; Silverstone, P.H.; Li, X.M.; Agyapong, V.I.O. Mental Health Effects in Primary Care Patients 18 Months After a Major Wildfire in Fort McMurray: Risk Increased by Social Demographic Issues, Clinical Antecedents, and Degree of Fire Exposure. Front. Psychiatry 2019, 10, 683. [CrossRef] [PubMed] 12. Harada, N.; Shigemura, J.; Tanichi, M.; Kawaida, K.; Takahashi, S.; Yasukata, F. Mental health and psychological impacts from the 2011 Great East Japan Earthquake Disaster: A systematic literature review. Disaster Mil. Med. 2015, 1, 17. [CrossRef] 13. McKinzie, A.E. In their own words: Disaster and emotion, suffering, and mental health. Int. J. Qual. Stud. Health Well-Being 2018, 13, 1440108. [CrossRef] [PubMed] Behav. Sci. 2021, 11, 115 11 of 13 14. Zhu, N.; Zhang, D.; Wang, W.; Li, X.; Yang, B.; Song, J.; Zhao, X.; Huang, B.; Shi, W.; Lu, R.; et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N. Engl. J. Med. 2020, 382, 727–733. [CrossRef] 15. World Health Organization Timeline of WHO’s Response to COVID-19. Available online: https://www.who.int/news-room/ detail/29-06-2020-covidtimeline (accessed on 2 July 2020). 16. World Health Organization Coronavirus Disease (COVID-19) Situation Report—163. Available online: https://www.who.int/ docs/default-source/coronaviruse/situation-reports/20200701-covid-19-sitrep-163.pdf?sfvrsn=c202f05b_2 (accessed on 1 July 2020). 17. World Health Organization Mental Disorders Affect One in Four People. Available online: https://www.who.int/whr/2001 /media_centre/press_release/en/#:~{}:text=Geneva%2C%204%20October%E2%80%94%20One%20in,ill%2Dhealth%20and% 20disability%20worldwide (accessed on 1 July 2020). 18. Disease, G.B.D.; Injury, I.; Prevalence, C. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018, 392, 1789–1858. 19. Lang, J.J.; Alam, S.; Cahill, L.E.; Drucker, A.M.; Gotay, C.; Kayibanda, J.F.; Kozloff, N.; Mate, K.K.V.; Patten, S.B.; Orpana, H.M. Global Burden of Disease Study trends for Canada from 1990 to 2016. CMAJ 2018, 190, E1296–E1304. [CrossRef] 20. Smetanin, P.; Stiff, D.; Briante, C.; Adair, C.E.; Ahmad, S.; Khan, M. The Life and Economic Impact of Major Mental Illnesses in Canada: 2011 to 2041. Risk Analytica, on Behalf of the Mental Health Commission of Canada 2011; Mental Health Commission of Canada, Ed.; Risk Analytica: Toronto, ON, Canada, 2011; pp. 116–122. 21. American Psychiatric Association. Depressive Disorders. In Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013; pp. 155–188. 22. Government of Canada Suicide in Canada: Key Statistics (Infographic). Available online: https://www.canada.ca/en/public- health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html (accessed on 2 July 2020). 23. Statistics Canada Indigenous Peoples in Canada: First Nations People, Métis and Inuit. Available online: https://www12.statcan. gc.ca/nhs-enm/2011/as-sa/99-011-x/99-011-x2011001-eng.pdf (accessed on 1 July 2020). 24. Statistics Canada First Nations People, Metis and Inuit in Canada: Diverse and Growing Populations. Available online: https://www150.statcan.gc.ca/n1/en/pub/89-659-x/89-659-x2018001-eng.pdf?st=W7cSG4EI (accessed on 5 July 2020). 25. MacMillan, H.L.; MacMillan, A.B.; Offord, D.R.; Dingle, J.L. Indigenous health. CMAJ 1996, 155, 1569–1578. 26. Carriere, G.; Bougie, E.; Kohen, D.; Rotermann, M.; Sanmartin, C. Acute care hospitalization by Indigenous identity, Canada, 2006 through 2008. Health Rep. 2016, 27, 3–11. 27. Park, J.; Tjepkema, M.; Goedhuis, N.; Pennock, J. Avoidable mortality among First Nations adults in Canada: A cohort analysis. Health Rep. 2015, 26, 10–16. 28. Ospina, M.B.; Voaklander, D.C.; Stickland, M.K.; King, M.; Senthilselvan, A.; Rowe, B.H. Prevalence of asthma and chronic obstructive pulmonary disease in Indigenous and non-Indigenous populations: A systematic review and meta-analysis of epidemiological studies. Can. Respir. J. 2012, 19, 355–360. [CrossRef] 29. Kielland, N.; Simeone, T. Current Issues in Mental Health in Canada: The Mental Health of First Nations and Inuit Communi- ties. Available online: https://lop.parl.ca/staticfiles/PublicWebsite/Home/ResearchPublications/InBriefs/PDF/2014-02-e.pdf (accessed on 5 July 2020). 30. Canada, G.O. The Mental Health and Well-Being of Indigenous Peoples in Canada. In The Human Face of Mental Health and Mental Illness in Canada 2006; Government of Canada: Ottawa, ON, Canada, 2006; pp. 159–179. 31. Lavoie, J.G.; Ward, A.; Wong, S.T.; Ibrahim, N.; Morton, D.; O’Neil, J.D.; Green, M. Hospitalization for mental health related ambulatory care sensitive conditions: What are the trends for First Nations in British Columbia? Int. J. Equity Health 2018, 17, 156. [CrossRef] [PubMed] 32. Pulver, L.J.; Haswell, M.R.; Ring, I.; Waldon, J.; Clark, W.; Whetung, V.; Kinnon, D.; Graham, C.; Chino, M.; LaValley, J.; et al. Indigenous Health—Australia, Canada, Aotearoa, New Zealand and the United States—Laying Claim to a Future that Embraces Health for Us All; Background Paper, 33; World Health Organisation: Geneva, Switzerland, 2010. 33. IHS Special Diabetes Program for Indians | 2014 Report to Congress Changing the Course of Diabetes: Turning Hope into Reality. 2014. Available online: https://www.nihb.org/sdpi/docs/05022016/SDPI_2014_Report_to_Congress.pdf (accessed on 20 December 2000). 34. National Center for Chronic Disease Prevention and Health Promotion in Centers for Disease Control and Prevention Native Americans with Diabetes. Available online: https://www.cdc.gov/vitalsigns/aian-diabetes/index.html (accessed on 1 July 2020). 35. Nasir, B.F.; Toombs, M.R.; Kondalsamy-Chennakesavan, S.; Kisely, S.; Gill, N.S.; Black, E.; Hayman, N.; Ranmuthugala, G.; Beccaria, G.; Ostini, R.; et al. Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: A cross-sectional study. BMJ Open 2018, 8, e020196. [CrossRef] 36. McNamara, B.J.; Banks, E.; Gubhaju, L.; Joshy, G.; Williamson, A.; Raphael, B.; Eades, S. Factors relating to high psychological distress in Indigenous Australians and their contribution to Indigenous-non-Indigenous disparities. Aust. N. Z. J. Public Health 2018, 42, 145–152. [CrossRef] Behav. Sci. 2021, 11, 115 12 of 13 37. United Nations Department of Economic and Social Affairs State of the World’s Indigenous Peoples. Available online: https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/03/The-State-of-The- Worlds-Indigenous-Peoples-WEB.pdf (accessed on 5 July 2020). 38. Thommasen, H.V.; Baggaley, E.; Thommasen, C.; Zhang, W. Prevalence of depression and prescriptions for antidepressants, Bella Coola Valley, 2001. Can. J. Psychiatry 2005, 50, 346–352. [CrossRef] [PubMed] 39. Kisely, S.; Alichniewicz, K.K.; Black, E.B.; Siskind, D.; Spurling, G.; Toombs, M. The prevalence of depression and anxiety disorders in indigenous people of the Americas: A systematic review and meta-analysis. J. Psychiatr. Res. 2017, 84, 137–152. [CrossRef] [PubMed] 40. Pollock, N.J.; Naicker, K.; Loro, A.; Mulay, S.; Colman, I. Global incidence of suicide among Indigenous peoples: A systematic review. BMC Med. 2018, 16, 145. [CrossRef] [PubMed] 41. Kumar, M.B.; Tjepkema, M. Suicide among First Nations people, Métis and Inuit (2011–2016): Findings from the 2011 Canadian Census Health and Environment Cohort (CanCHEC). Available online: https://www150.statcan.gc.ca/n1/en/pub/99-011-x/99 -011-x2019001-eng.pdf?st=8IX6ph_l (accessed on 5 July 2020). 42. Willows, N.; Veugelers, P.; Raine, K.; Kuhle, S. Associations between household food insecurity and health outcomes in the Indigenous population (excluding reserves). Health Rep. 2011, 22, 15–20. 43. Kim, P.J. Social Determinants of Health Inequities in Indigenous Canadians Through a Life Course Approach to Colonialism and the Residential School System. Health Equity 2019, 3, 378–381. [CrossRef] 44. Kaspar, V. The lifetime effect of residential school attendance on indigenous health status. Am. J. Public Health 2014, 104, 2184–2190. [CrossRef] 45. Truth and Reconciliation Commission of Canada Honouring the Truth, Reconciling for the Future Summary of the Final Report of the Truth and Reconciliation Commission of Canada. Available online: http://nctr.ca/assets/reports/Final%20Reports/ Executive_Summary_English_Web.pdf (accessed on 2 July 2020). 46. Lei, L.; Huang, X.; Zhang, S.; Yang, J.; Yang, L.; Xu, M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine during the COVID-19 Epidemic in Southwestern China. Med. Sci. Monit. 2020, 26, e924609. [CrossRef] 47. Zhang, Y.; Ma, Z.F. Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2020, 17, 2381. [CrossRef] 48. Ritchie, H.; Roser, M.; Mental Health Published online at OurworldInData.org. Our World in Data 2018. Available online: https:/ourworldindata.org/mental-health (accessed on 20 December 2000). 49. Agyapong, V.I.O. Coronavirus Disease 2019 Pandemic: Health System and Community Response to a Text Message (Text4Hope) Program Supporting Mental Health in Alberta. Disaster Med. Public Health Prep. 2020, 22, 1–5. [CrossRef] [PubMed] 50. Agyapong, V.I.; Mrklas, K.; Juhas, M.; Omeje, J.; Ohinmaa, A.; Dursun, S.M.; Greenshaw, A.J. Cross-sectional survey evaluating Text4Mood: Mobile health program to reduce psychological treatment gap in mental healthcare in Alberta through daily supportive text messages. BMC Psychiatry 2016, 16, 378. [CrossRef] [PubMed] 51. Urichuk, L.; Hrabok, M.; Hay, K.; Spurvey, P.; Sosdjan, D.; Knox, M.; Fu, A.; Surood, S.; Brown, R.; Coulombe, J.; et al. Enhancing peer support experience for patients discharged from acute psychiatric care: Protocol for a randomised controlled pilot trial. BMJ Open 2018, 8, e022433. [CrossRef] [PubMed] 52. Agyapong, V.I.O.; Juhás, M.; Ohinmaa, A.; Omeje, J.; Mrklas, K.; Suen, V.Y.M.; Dursun, S.M.; Greenshaw, A.J. Randomized controlled pilot trial of supportive text messages for patients with depression. BMC Psychiatry 2017, 17, 286. [CrossRef] [PubMed] 53. Agyapong, V.I.; Ahern, S.; McLoughlin, D.M.; Farren, C.K. Supportive text messaging for depression and comorbid alcohol use disorder: Single-blind randomised trial. J. Affect Disord. 2012, 141, 168–176. [CrossRef] [PubMed] 54. Agyapong, V.I.O.; Juhas, M.; Mrklas, K.; Hrabok, M.; Omeje, J.; Gladue, I.; Kozak, J.; Leslie, M.; Chue, P.; Greenshaw, A.J. Randomized controlled pilot trial of supportive text messaging for alcohol use disorder patients. J. Subst. Abus. Treat. 2018, 94, 74–80. [CrossRef] 55. Hartnett, D.; Murphy, E.; Kehoe, E.; Agyapong, V.; McLoughlin, D.M.; Farren, C. Supportive text messages for patients with alcohol use disorder and a comorbid depression: A protocol for a single-blind randomised controlled aftercare trial. BMJ Open 2017, 7, e013587. [CrossRef] 56. Cohen, S.; Kamarck, T.; Mermelstein, R. A Global Measure of Perceived Stress. J. Health Soc. Behav. 1983, 24, 385–396. [CrossRef] 57. Spitzer, R.L.; Kroenke, K.; Williams, J.B.; Löwe, B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch. Intern. Med. 2006, 166, 1092–1097. [CrossRef] 58. Kroenke, K.; Spitzer, R.L.; Williams, J.B. The PHQ-9: Validity of a brief depression severity measure. J. Gen. Intern. Med. 2001, 16, 606–613. [CrossRef] 59. Agyapong, V.I.O.; Hrabok, M.; Vuong, W.; Gusnowski, A.; Shalaby, R.; Mrklas, K.; Li, D.; Urichuk, L.; Snaterse, M.; Surood, S.; et al. Closing the Psychological Treatment Gap During the COVID-19 Pandemic With a Supportive Text Messaging Program: Protocol for Implementation and Evaluation. JMIR Res. Protoc. 2020, 9, e19292. [CrossRef] 60. Mrklas, K.; Shalaby, R.; Hrabok, M.; Gusnowski, A.; Vuong, W.; Surood, S.; Urichuk, L.; Li, D.; Li, X.-M.; Greenshaw, A.J.; et al. COVID-19 pandemic: Prevalence of Perceived Stress, Anxiety, Depression, and Obsessive-Compulsive Symptoms vary among Healthcare and non-Healthcare Workers in Alberta. JMIR Ment. Health 2020. [CrossRef] [PubMed] Behav. Sci. 2021, 11, 115 13 of 13 61. Abba-Aji, A.; Li, D.; Hrabok, M.; Shalaby, R.; Gusnowski, A.; Vuong, W.; Surood, S.; Nkire, N.; Li, X.M.; Greenshaw, A.J.; et al. COVID-19 Pandemic and Mental Health: Prevalence and Correlates of New-Onset Obsessive-Compulsive Symptoms in a Canadian Province. Int. J. Environ. Res. Public Health 2020, 17, 6986. [CrossRef] [PubMed] 62. Nwachukwu, I.; Nkire, N.; Shalaby, R.; Hrabok, M.; Vuong, W.; Gusnowski, A.; Surood, S.; Urichuk, L.; Greenshaw, A.J.; Agyapong, V.I.O. COVID-19 Pandemic: Age-Related Differences in Measures of Stress, Anxiety and Depression in Canada. Int. J. Environ. Res. Public Health 2020, 17, 6366. [CrossRef] [PubMed] 63. Statista Canadian Aboriginal’s Life Stress Perception 2007–2014, by Indigenous Identity. Available online: https://www.statista. com/statistics/817337/perceived-life-stress-among-aboriginals-canada-by-aboriginal-identity/ (accessed on 1 July 2020). 64. Statista Share of Canadian Aboriginals with a Mood Disorder 2007–2014, by Indigenous Identity. Available online: https: //www.statista.com/statistics/817334/mood-disorders-among-aboriginals-canada-by-aboriginal-identity/ (accessed on 4 July 2020). 65. Cardinal, J.; Schopflocher, D.; Svenson, L.; Morrison, K.; Laing, L. First Nations in Alberta: A Focus on Health Service Use. Edmonton: Alberta Health and Wellness. 2004. Available online: https://open.alberta.ca/dataset/212381eb-ba02-49c8-82d0-279 50a9a16df/resource/43a8b731-3937-41f1-b52e-06bba2e0b613/download/First-Nation-Service-Use-2004.pdf (accessed on 1 July 2020). 66. Statistics Canada Table 17-10-0005-01 Population Estimates on 1 July by Age and Sex. Available online: https://www150.statcan. gc.ca/t1/tbl1/en/tv.action?pid=1710000501 (accessed on 2 July 2020). 67. Agyapong, V.I.O.; Milnes, J.; McLoughlin, D.M.; Farren, C.K. Perception of patients with alcohol use disorder and comorbid depression about the usefulness of supportive text messages. Technol. Health Care 2013, 21, 31–39. [CrossRef] [PubMed] 68. Agyapong, V. Mobile Phone Text Message Interventions in Psychiatry—What are the Possibilities? Curr. Psychiatry Rev. 2011, 7, 50–56. [CrossRef] 69. Agyapong, V.I.O.; McLoughlin, D.M.; Farren, C.K. Six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder. J. Affect. Disord. 2013, 151, 100–104. [CrossRef] [PubMed] 70. Agyapong, V.I.O.; Mrklas, K.; Suen, V.Y.M.; Rose, M.S.; Jahn, M.; Gladue, I.; Kozak, J.; Leslie, M.; Dursun, S.; Ohinmaa, A.; et al. Supportive Text Messages to Reduce Mood Symptoms and Problem Drinking in Patients With Primary Depression or Alcohol Use Disorder: Protocol for an Implementation Research Study. JMIR Res. Protoc. 2015, 4, e55. [CrossRef] http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Behavioral Sciences Multidisciplinary Digital Publishing Institute

COVID-19 Pandemic: Stress, Anxiety, and Depression Levels Highest amongst Indigenous Peoples in Alberta

Loading next page...
 
/lp/multidisciplinary-digital-publishing-institute/covid-19-pandemic-stress-anxiety-and-depression-levels-highest-amongst-nvFKyhtiXt
Publisher
Multidisciplinary Digital Publishing Institute
Copyright
© 1996-2021 MDPI (Basel, Switzerland) unless otherwise stated Disclaimer The statements, opinions and data contained in the journals are solely those of the individual authors and contributors and not of the publisher and the editor(s). MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Terms and Conditions Privacy Policy
ISSN
2076-328X
DOI
10.3390/bs11090115
Publisher site
See Article on Publisher Site

Abstract

behavioral sciences Article COVID-19 Pandemic: Stress, Anxiety, and Depression Levels Highest amongst Indigenous Peoples in Alberta 1 , 2 1 1 , 2 2 1 , 3 Mobolaji A. Lawal , Reham Shalaby , Chidi Chima , Wesley Vuong , Marianne Hrabok , 2 2 1 1 , 2 , April Gusnowski , Shireen Surood , Andrew J. Greenshaw and Vincent I. O. Agyapong * Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B, Canada; mobolaji@ualberta.ca (M.A.L.); rshalaby@ualberta.ca (R.S.); Chidi.Chima@albertahealthservices.ca (C.C.); marianne.hrabok1@ucalgary.ca (M.H.); andy.greenshaw@ualberta.ca (A.J.G.) Addiction and Mental Health, Alberta Health Services, Edmonton, AB T5K 2J5, Canada; Wesley.Vuong@albertahealthservices.ca (W.V.); April.Gusnowski@albertahealthservices.ca (A.G.); shireen.surood@albertahealthservices.ca (S.S.) Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada * Correspondence: agyapong@ualberta.ca; Tel.: +1-780-215-7771; Fax: +1-780-743-3896 Abstract: This study explores differences in stress, anxiety, and depression experienced by different ethnic groups during the COVID-19 pandemic. This was a cross-sectional online survey of subscribers of the COVID-19 Text4Hope text messaging program in Alberta. Stress, anxiety, and depression were measured among Caucasian, Indigenous, Asian, and other ethnic groups using the Perceived Stress Scale (PSS)-10, Generalized Anxiety Disorder (GAD)-7, and Patient Health Questionnaire Citation: Lawal, M.A.; Shalaby, R.; (PHQ)-9 scales, respectively. The burden of depression and stress were significantly higher in Chima, C.; Vuong, W.; Hrabok, M.; Indigenous populations than in both Caucasian and Asian ethnic groups. The mean difference Gusnowski, A.; Surood, S.; between Indigenous and Caucasian for PHQ-9 scores was 1.79, 95% CI of 0.74 to 2.84, p < 0.01 and for Greenshaw, A.J.; Agyapong, V.I.O. PSS-10 it was 1.92, 95% CI of 0.86 to 2.98, p < 0.01). The mean difference between Indigenous and COVID-19 Pandemic: Stress, Anxiety, Asian for PHQ-9 scores was 1.76, 95% CI of 0.34 to 3.19, p = 0.01 and for PSS-10 it was 2.02, 95% CI and Depression Levels Highest of 0.63 to 3.41, p < 0.01. However, Indigenous participant burden of anxiety was only significantly amongst Indigenous Peoples in higher than Asian participants’ (mean difference for GAD-7 was 1.91, 95% CI of 0.65 to 3.18, p < 0.01). Alberta. Behav. Sci. 2021, 11, 115. Indigenous people in Alberta have higher burden of mental illnesses during the COVID-19 pandemic. https://doi.org/10.3390/bs11090115 These findings are helpful for service planning and delivery. Academic Editors: Andy Smith and Keywords: COVID-19; mobile phones; text; anxiety; depression; stress; psychological distress; Scott D. Lane pandemic; ethnic groups; Indigenous people Received: 7 May 2021 Accepted: 20 August 2021 Published: 24 August 2021 1. Introduction Publisher’s Note: MDPI stays neutral Several studies have reported increased or high levels of psychological distress and with regard to jurisdictional claims in perceived mental illnesses in different populations during a pandemic or epidemic of published maps and institutional affil- a disease [1–10] and during mass disasters [11–13]. By early 2020, the Chinese Center iations. for Disease Control and Prevention investigated clusters of patients with pneumonia of unknown etiology in Wuhan, leading to the isolation of a novel coronavirus (2019- nCoV) [14]. The World Health Organization (WHO) declared a global pandemic [15] on 11 March 2020 and by July, there were around 10 million coronavirus disease (COVID-19) Copyright: © 2021 by the authors. cases and approximately 510,000 COVID-related deaths. Canada reported about 104,000 Licensee MDPI, Basel, Switzerland. COVID cases with approximately 8600 related deaths in the same period [16]. This article is an open access article The WHO has reported that one in four people will suffer mental or neurological distributed under the terms and disorders [17]. The 2017 Global Burden of Disease Study revealed that, depressive disorders conditions of the Creative Commons and anxiety disorders were the third and eighth leading causes of years lived with disability Attribution (CC BY) license (https:// (YLDs), respectively [18,19]. In Canada, mental health and substance use disorders are creativecommons.org/licenses/by/ the second leading cause of YLDs. Around 20% of Canadian residents experience mental 4.0/). Behav. Sci. 2021, 11, 115. https://doi.org/10.3390/bs11090115 https://www.mdpi.com/journal/behavsci Behav. Sci. 2021, 11, 115 2 of 13 illness each year, most frequently mood and anxiety disorders [20]. Suicide can occur in psychotic and affective disorders but it is a core symptom of depressive disorder [21] and around 4000 deaths by suicide occur in Canada annually [22]. The total annual cost of mental illnesses to the Canadian economy was estimated at $51 billion (CAD) in 2008 with a projected increase to $2.5 trillion (CAD) by 2041 [20]. Indigenous peoples are a diverse set of communities living across Canada, comprising First Nations, Métis, and Inuit populations [23]. Indigenous peoples constituted 4.9% of the population of Canada in 2016 [24]. Collectively, Indigenous peoples carry the highest burden of physical and mental illnesses in Canada [25–31], a trend that extends to other countries with Indigenous populations [32–37]. However, one study reported similar prevalence of depression and anxiety for Indigenous and non-Indigenous populations in the Canadian province of British Columbia [38]. Additionally, a systematic review and meta-analysis study that combined studies of Indigenous people of the Americas reported significantly lower lifetime prevalent rates of generalized anxiety, panic, and all depressive disorders in Indigenous populations. However, post-traumatic stress disorder (PTSD) and social phobia were significantly higher relative to the non-Indigenous population [39]. Despite these findings, the overwhelming majority of studies [25–36] and a United Nations report [37] agreed that the burdens of physical and of mental illnesses are generally higher in Indigenous peoples compared to non-Indigenous populations. Worldwide, suicide rates among Indigenous peoples are generally significantly higher than in non-Indigenous populations [40]. In a 2019 Canadian study, relative to non- Indigenous persons, the suicide rate among Inuit peoples was nine times higher; three times higher among First Nations peoples; and two times higher among Métis peoples [41]. However, suicide rates varied by First Nations Band, with a reported suicide rate of zero about 60% of bands. In addition, suicide rates were highest in people aged 15–24 years among First Nations males and Inuit males and females [41]. The reasons for the dispropor- tionately higher burden of physical and mental illnesses among the Canadian Indigenous populations is attributable to social determinants of health (e.g., education, housing, so- cioeconomic status, access to services, etc.). Indigenous peoples often experience inequities that predispose them to experience poorer health outcomes compared to non-Indigenous populations [42–44]. The Truth and Reconciliation Commission of Canada report detailed intergenerational trauma inflicted upon Indigenous peoples from the imposition of the residential school system and the Indian Act in Canada over several decades [45]. Numerous studies, using standardized questionnaires, have reported high levels of psychological distress, anxiety, and depression due to the COVID-19 pandemic [1–10,46,47]. The prevalence of anxiety and depression, as measured by different standardized ques- tionnaires, varied widely during the COVID-19 pandemic. For depression, the prevalence ranged from 14.6% to 53.8% during the COVID-19 pandemic [1,2,4,6,9,46], in excess of expected worldwide prevalence of 2% to 6% in 2017 [48]. Reported prevalence for anxiety during the COVID-19 pandemic range from 8.3% to 50.3% [1,2,4,6,8–10,46], also far higher expected worldwide prevalence of 2.5% to 7% in 2017 [48]. For stress during the COVID-19 pandemic, estimated prevalence ranges from 7.6% to 53.8% [2,5,8,9,47]. These worldwide prevalence for anxiety disorders and depression used for comparison were gleaned from a combination of survey-, medical- and epidemiological data, and meta-regression modelling in cases where raw data is missing [48]. Different studies reported variable epidemio- logical risk factors that are significantly associated with increased prevalence of anxiety, depression, and stress, measured by standardized questionnaires, during the COVID-19 pandemic in different populations [1–7,9,10,46]. Risk factors positively associated with depression in these studies included age 21–40 years [4,10], female gender [2,9], alcohol use [10], negative affect, detachment, an acquaintance infected with COVID-19, prior medical problems, stressful situations [2], spe- cific physical health symptoms, poor self-rated health status [9], being close to the epicenter of the outbreak [10], being quarantined or affected by quarantine [3,46], financial burden due to massive quarantine [6], and spending more time exposed to COVID-19 related Behav. Sci. 2021, 11, 115 3 of 13 news [6]. Risk factors reported to be significantly associated with increased prevalence of anxiety included age 20–46 years [1,2,4,10], female gender [2,9], negative affect, detachment, stressful situations, prior medical problems [2], family members infected with COVID- 19 [2,10], being infected with COVID-19 [10], specific physical health symptoms, poor self-rated health status and student status [9], quarantine or affected by quarantine [7,46], financial burden due to massive quarantine [6], perceived impact of COVID-19 [7], and time spent exposed to COVID-19 related news information [6,10]. Most factors that are positively associated with anxiety and depression during the COVID-19 pandemic may also bey associated with stress. These include age 20–46 years [1,2,10], female gender [2,5,9], negative affect, detachment, having an acquaintance infected with COVID-19 [2], higher educational level, migrant status, being close to the epicenter of a COVID-19 outbreak [5], quarantined or affected by quarantine [46], student status, specific physical health symptoms, and poor self-rated health status [9]. Despite the positive association of these factors with anxiety, depression, and stress during the COVID-19 pandemic some studies reported no such relationship for several of these factors. For instance, gender had no effect on anxiety and depression in two of these studies [1,7]. However, in a global report of anxiety disorder and depression estimates, females were reported to have higher prevalence of depression compared to males (4.1% versus 2.7%, respectively). In the same report, females had higher prevalence of anxiety disorders than males (4.7% versus 2.8%, respectively) [48]. In that report, median estimates for prevalence of depression and anxiety were higher in females for all the countries considered. Given the generally greater burden of health among Indigenous peoples in Canada, in the absence of published detailed mental health studies addressing this inequity, we hypothesized that perceived stress, anxiety, and depression, measured by standardized instruments, would be higher for among Indigenous persons relative to other ethnic groups. Text4Hope is a texting service that delivers once-daily supportive messages to support individuals’ mental health during the COVID-19 pandemic. Text messages were based on cognitive-behavioral therapy concepts and developed by mental health professionals (i.e., psychiatrists, psychologists, and mental health therapists). The program offers mental health support, aims to ameliorate pandemic-related negative thoughts and feelings, and help individuals to develop healthy coping and resiliency skills [49]. The program was modeled after the Text4Mood [50] and Text4Support [51] mental health texting services provided to people in Alberta, Canada. Ultimately, such services are evidence-based, clini- cally relevant, and cost-effective interventions applied as a therapeutic alliance to mental healthcare services for individuals with depressive and drug use disorders [52–55]. The aim of this program is to close the psychological treatment gap experienced in healthcare systems during the COVID-19 pandemic. The aim of this study was to determine the burden of anxiety, depression, and stress in relation to ethnicity for Text4Hope subscribers who completed the baseline survey. 2. Materials and Methods A cross-sectional survey was used to explore mean differences in perceived stress, anx- iety, and depression symptom scores among the various ethnic groupings for Text4Hope subscribers who completed the baseline survey. This study explored each participant’s demographic characteristics (gender, age, level of education, employment status, rela- tionship status, and housing status) and stratified them by their self-identified ethnicity (Caucasian, Indigenous, Asian, and Other). The mean scores, standard deviations, and standard errors from the Perceived Stress Scale (PSS)-10 [56], Generalized Anxiety Disorder (GAD)-7 [57], and Patient Health Questionnaire (PHQ)-9 [58] for self-reported symptoms of stress, anxiety, and depression, respectively, were stratified by ethnicity. The PSS is a 10-item validated self-report questionnaire (with an associated Cronbach’s alpha of >0.70) which is used to assess the level of stress in the previous month. Each item on the scale is scored between 0 (never) to 5 (very often). Higher scores on the scale indicate higher levels of stress. The GAD-7 is a 7-item validated questionnaire (associated with a Cronbach’s Behav. Sci. 2021, 11, 115 4 of 13 alpha of 0.92) which is used to assess the self-reported levels of anxiety in respondents in the two weeks prior to assessment. Each item on the scale is scored between 0 (not at all) to 4 (nearly everyday). Higher scores on the scale indicate higher levels of anxiety. The PHQ-9 is a 9-item validated instrument (associated with a Cronbach’s alpha of 0.89) which used to diagnose and measure the severity of depression in general medical and mental health settings. Each of the 9 questionnaire items is scored between 0 (not at all) to 3 (nearly every day). Higher scores on the scale indicate higher levels of depression. The mean scores for stress, anxiety, and depression were compared among the ethnic groups and their differences were calculated using appropriate statistical methods to determine the mean differences and a 95% confidence interval in their PSS-10, GAD-7, and PHQ-9 scores. These mean differences and their 95% confidence interval depict the burden of anxiety, depression, and stress for each ethnic group relative to the other ethnic groups. 2.1. Recruitment The study recruitment procedures and sample size estimations have been described earlier [59–62]. In summary, Text4Hope was launched by AHS on 23 March 2020. The program’s aim was to send daily supportive text messages to help support Albertans dealing with mental health concerns due to the COVID-19 pandemic. An online survey link was sent to self-subscribers and requested demographic information including gender, age, ethnicity, education, relationship status, employment status, type of employment, housing status, isolation status, and clinical characteristics of stress, anxiety, depression and obsessive-compulsive symptoms. Clinical characteristics were assessed using validated scales for self-reported symptoms, including the PSS-10, GAD-7, and PHQ-9. Participant consent was implied by submission of subscribers’ survey responses. Ethical approval for the research study was obtained through the University of Alberta Health Research Ethics Board (Pro00086163). Data was collected between 24 March 2020 and 4 May 2020. 2.2. Statistical Methods Data analysis was undertaken using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 26 (IBM Corp., Armonk, NY., USA). Demographic char- acteristics of respondents were summarized in absolute numbers and percentages, by ethnic category. A one-way analysis of variance (One-Way ANOVA) with two tailed signif- icance (p < 0.05) was used to assess statistical differences between the ethnic groups for corresponding mean scores on the PSS-10, GAD-7, and PHQ-9. For variables that did not violate the assumptions of homogeneity of variance in the mean scores on the ANOVA test, we performed a Turkey’s post hoc test to determine if there were statistically signifi- cant differences in the mean scores of the various clinical measures between the different ethnic groups. For variables which violated the homogeneity of variance assumption, we determined if there were statistically significant differences for the mean scores for the various clinical measures between the different ethnic groupings using the Welch F test and a Games–Howell post-hoc test (as these tests do not require groups to exhibit homogeneity of error variance). 3. Results 3.1. Demographic Characteristics of Respondents Of the 44,992 subscribers who joined Text4Hope in the first 6 weeks, 8267 responded to the online survey invitation, yielding a 19.4% response rate. Of the 8267 respondents, 6685 (81.0%) identified as Caucasian, 302 (3.7%) identified as Indigenous, 407 (4.9%) identified as Asian, 756 (9.2%) identified as belonging to “Other” ethnic groups, and 103 (1.2%) did not identify their ethnicity. The other demographic characteristics of the respondents are displayed in Table 1. Behav. Sci. 2021, 11, 115 5 of 13 Table 1. Demographic characteristics of respondents by self-reported ethnicity. Caucasian Indigenous Asian Other Overall Variables N (%) N (%) N (%) N (%) N (%) Gender Male 751 (76.5) 32 (3.3) 93 (9.5) 105 (10.7) 981 (12.0) Female 5884 (83.1) 263 (3.7) 312 (4.4) 620 (8.8) 7079 (86.9) Other 50 (55.6) 7 (7.8) 2 (2.2) 31 (34.4) 90 (1.1) Age 25 646 (71.3) 47 (5.2) 88 (7.9) 125 (13.8) 906 (11.1) 26–40 2355 (80.4) 124 (4.2) 188 (6.4) 261 (8.9) 2928 (36.6) 41–60 2905 (85.1) 111 (3.3) 113 (3.3) 283 (8.3) 3412 (42.7) >60 673 (89.5) 13 (1.7) 10 (1.3) 56 (7.4) 752 (9.4) Education Less than High School Diploma 214 (65.2) 35 (10.7) 17 (5.2) 62 (18.9) 328 (4.0) High School Diploma 621 (77.7) 50 (6.3) 21 (2.6) 106 (13.3) 798 (9.8) Post-Secondary Education 5815 (83.9) 212 (3.1) 388 (5.2) 547 (7.9) 6932 (85.1) Other Education 35 (38.9) 4 (4.4) 8 (8.9) 43 (47.8) 90 (1.1) Employment Status Employed 4970 (83.4) 196 (3.3) 300 (5.0) 490 (8.2) 5956 (73.1) Unemployed 744 (78.2) 66 (6.9) 34 (3.6) 107 (11.3) 951 (11.7) Retired 498 (89.9) 8 (1.4) 6 (1.1) 42 (7.6) 554 (6.8) Students 310 (68.4) 25 (5.5) 53 (11.7) 65 (14.3) 453 (5.6) Other 161 (68.8) 7 (3.0) 12 (5.5) 54 (23.1) 234 (2.9) Relationship Status Married/Cohabiting/Partnered 4820 (83.5) 178 (3.1) 276 (4.8) 499 (8.6) 5773 (70.9) Separated/Divorced 533 (86.7) 25 (4.1) 14 (2.3) 43 (7.0) 615 (7.5) Widowed 117 (88.6) 4 (3.0) 1 (0.8) 10 (7.6) 132 (1.6) Single 1167 (76.0) 90 (5.9) 110 (7.2) 168 (10.9) 1535 (18.8) Other 47 (50.5) 5 (5.4) 3 (3.2) 38 (40.9) 93 (1.1) Housing Status Own Home 4532 (86.3) 123 (2.3) 197 (3.8) 401 (7.6) 5243 (65.7) Living with Family 533 (67.6) 43 (5.5) 99 (12.6) 113 (14.3) 788 (9.8) Renting 1466 (78.0) 123 (6.5) 93 (4.9) 197 (10.5) 1879 (23.5) Other 39 (48.1) 6 (7.4) 6 (7.4) 30 (7.0) 81 (1.0) In Table 1, the majority of respondents identified as female (n = 7079, 86.9%), aged between 26 and 60 years (n = 6340, 79.3%), had post-secondary education (n = 6932, 85.1%), were employed (n = 5956, 73.1%), were married, cohabiting, or partnered (n = 5773, 70.9%), and owned their own home (n = 5243, 65.7%). 3.2. Association between Ethnic Categories and Prevalence of Perceived Stress, Likely GAD, and Likely MDD The data displayed in Table 2 illustrate prevalence rates for clinically meaningful stress, anxiety, and depression. These data suggest the prevalence of moderate to high stress, likely Generalized Anxiety Disorder (GAD), and likely Major Depressive Disorder (MDD) were highest in respondents that identified as Indigenous. The mean score for all respondents (n = 7589) on the PSS-10 was 20.79 (SD = 6.83). For the PHQ-9 scale, the mean score for all the respondents (n = 7082) was 9.43 (SD = 6.29) and for the GAD-7 scale, the mean score for all respondents (n = 6944) was 9.68 (SD = 5.87). Chi square analysis revealed significant association between the prevalence of likely stress and depression and the ethnicity of the participants, but not for the likely anxiety symptoms. Behav. Sci. 2021, 11, 115 6 of 13 Table 2. Association between ethnic categories and prevalence of perceived stress, likely GAD, and likely MDD. Variable Ethnic Categories Caucasian Indigenous Asian Other Total Prevalence N (%) N (%) N (%) N (%) N (%) Perceived Stress Moderate or High Stress 5593 (85.2) 279 (92.1) 329 (86.1) 618 (88.0) Chi square value 14.71 6819 (85.7) p-value <0.01 Effect Size (Phi) 0.04 Generalized Anxiety Disorder (GAD) GAD likely 2848 (47.1) 144 (51.8) 137 (41.6) 296 (44.7) Chisquare value 6.4 3425 (47.1) p-value 0.09 Effect Size (Phi) 0.03 Major Depressive Disorder (MDD) MDD likely 2695 (43.7) 149 (52.8) 149 (44.2) 305 (47.5) Chi Square value 11.8 3298 (44.4) p-value 0.01 Effect Size (Phi) 0.04 a b c Moderate or High Stress defined as PSS-10 score  14; Likely GAD defined as GAD-7 score  10; Likely MDD defined as PHQ-9 score  10. Table 3 presents the means and standard deviations for each of the PSS-10, PHQ-9, and GAD-7 scales by ethnicity groups. Table 3. Descriptive illustration of mean scores of GAD-7, PHQ-9 and PSS-10 scales by ethnic group. 95% Confidence Interval for Mean Variables N Mean Std. Deviation Std. Error Minimum Maximum Lower Bound Upper Bound Caucasian 5750 9.69 5.83 0.08 9.54 9.84 0 21 Indigenous 262 10.56 5.91 0.37 9.84 11.28 0 21 GAD-7 Total Asian 307 8.65 5.96 0.34 7.98 9.32 0 21 Score Other 595 9.75 5.99 0.25 9.26 10.23 0 21 Total 6914 9.68 5.86 0.07 9.54 9.82 0 21 Caucasian 5859 9.30 6.19 0.08 9.15 9.46 0 27 Indigenous 266 11.10 6.50 0.40 10.31 11.88 0 27 PHQ-9 Total Asian 315 9.33 6.82 0.38 8.58 10.09 0 27 Score Other 612 10.04 6.71 0.27 9.51 10.57 0 27 Total 7052 9.44 6.29 0.08 9.29 9.58 0 27 Caucasian 6243 20.65 6.83 0.09 20.48 20.82 0 40 Indigenous 286 22.56 6.36 0.38 21.82 23.30 8 40 PSS-10 Total Asian 359 20.55 6.78 0.36 19.84 21.25 2 39 Score Other 668 21.51 6.91 0.27 20.99 22.04 1 40 Total 7556 20.79 6.83 0.08 20.64 20.94 0 40 Table 3 suggests that respondents that self-identified as Indigenous had the highest mean scores on the PSS-10, PHQ-9, and GAD-7 scales, while respondents that self-identified as Caucasian or Asian had fairly similar mean scores on the PSS-10 and PHQ-9 but not the GAD-7 scales. Behav. Sci. 2021, 11, 115 7 of 13 Table 4 represents the results of One-Way ANOVA comparing sums of squares between and within ethic groups for the PSS-10, PHQ-9, and GAD-7 scales. Table 4. ANOVA comparing sums of squares between and within ethnic groups. Variables Sum of Squares Df Mean Square F Sig. Between Groups 533.18 3 177.73 5.183 <0.01 Within Groups 236,941.86 6910 34.29 GAD-7 Total Score Total 237,475.03 6913 Between Groups 1061.60 3 353.87 8.984 <0.01 PHQ-9 Total Score Within Groups 277,609.70 7048 39.39 Total 278,671.30 7051 Between Groups 1397.14 3 465.71 10.013 <0.01 PSS-10 Within Groups 351,233.05 7552 46.51 Total Score Total 352,630.20 7555 Table 4 suggests that there were statistically significant differences between and within ethnic groups for scores on the PSS-10 (F = 10.013, p < 0.001), the PHQ-9 (F = 8.98, p < 0.001), and the GAD-7 (F = 5.18, p < 0.001). The Levene Statistic test of homogeneity of variances suggested no violation of the assumption of equality of means for the PSS-10 and the GAD-7 (p > 0.05) and so we ran the Turkey’s post-hoc test to determine statistically significant differences in the mean scores between the different ethnic groups as presented in Table 5 But in contrast, the Levene Statistic test of homogeneity of variances indicated a violation of the assumption of homogeneity of error variance for the PHQ-9 scores (p < 0.05). Consequently, we ran a Welch F test and a Games-Howell post-hoc test to determine statistically significant differences between mean scores on the PHQ-9 between the different ethnic groups. The Welch F test was statistically significant which confirms that the differences between the groups in terms of their mean PHQ-9 scores are statistically significant. The results of the Games–Howell post-hoc test is as presented in Table 5. Table 5. Tukey HSD and Games-Howell post-hoc multiple comparisons. 95% Confidence Interval Dependent Mean Ethnicity Ethnicity Sig. Std. Error Lower Upper Difference Variable Bound Bound Asian 1.04 * 0.34 0.01 0.16 1.92 Caucasian Other 0.06 0.25 0.99 0.71 0.59 Asian 1.91 * 0.49 <0.01 0.65 3.18 GAD-7 Indigenous Caucasian 0.87 0.37 0.09 0.08 1.82 Total Score Other 0.82 0.43 0.24 0.30 1.93 Asian Other 1.10 * 0.41 0.04 2.16 0.04 Asian 0.10 0.37 0.99 0.85 1.05 Caucasian Other 0.87 * 0.28 0.01 1.58 0.15 Asian 2.02 * 0.54 <0.01 0.63 3.41 PSS-10 Indigenous Caucasian 1.92 * 0.41 <0.01 0.86 2.98 Total Score Other 1.05 0.48 0.13 0.19 2.29 Asian Other 0.97 0.45 0.13 2.11 0.18 Caucasian Asian 0.03 0.39 0.99 1.04 0.99 Other 0.74 * 0.28 0.05 1.46 0.01 Indigenous Asian 1.76 * 0.55 0.01 0.34 3.19 PHQ-9 Indigenous Caucasian 1.79 * 0.41 <0.01 0.74 2.84 Total Score Other 1.06 0.48 0.126 0.18 2.30 Asian Other 0.71 0.47 0.44 1.92 0.51 a b Tukey HSD post hoc multiple comparison; Games-Howell post hoc multiple comparison; * The mean difference is significant at the 0.05 level. Behav. Sci. 2021, 11, 115 8 of 13 Table 5 suggests that respondents who self-identified as Indigenous had signifi- cantly higher mean scores on the GAD-7 compared to respondents that self-identified as Asian (Mean Difference = 1.91, 95% CI = 0.65–3.18 and p < 0.01) but not respon- dents that self-identified as Caucasian (p > 0.05) or “Other” ethnic groups (p > 0.05). On the other hand, respondents that identified as Caucasian had significantly higher mean scores on the GAD-7 compared to respondents that identified as Asian (Mean Difference = 1.04, 95% CI = 0.16–1.92, p = 0.01) but not respondents that identified as “Other” ethnic groups (p > 0.05). However, respondents that identified as Asian had significantly lower mean scores on the GAD-7 compared to respondents that identified as “Other” (Mean Difference= 1.10, 95% CI= 2.16 to 0.04, p < 0.05). Table 5 also suggests that respondents that identified as Indigenous had higher mean scores on the PSS-10 than both respondents that identified as Caucasian (Mean Difference = 1.92, 95% CI = 0.86–2.98, p < 0.01) or Asian (Mean Difference = 2.02, 95% CI = 0.63–3.41, p < 0.01) but not respondents that identified as “Other” ethnic groups (p = 0.13). There were no statistically significant differences in the mean scores between respondents that identified as Caucasian or Asian for the mean PSS-10 scores (p > 0.05). However, respondents that identified as Caucasian had significantly lower mean scores on the PSS-10 compared to respondents that identified as “Other” ethnic groups (Mean Difference = 0.87, 95% CI = 1.58 to 0.15, p < 0.05). Table 5 suggests that respondents that identified as Indigenous had significantly higher mean scores on the PHQ-9 compared to respondents that identified as Asian (Mean Difference =1.76, 95% CI = 0.34–3.19 and p < 0.05) or Caucasian (Mean Difference = 1.79, 95% CI = 0.74–2.84, p < 0.01), but not those who identified as “Other” ethnic groups (p > 0.05). On the other hand, respondents that identified as Caucasian had significantly lower mean scores on the PHQ-9 compared to respondents that identified as “Other” ethnic groups (Mean Difference = 0.74, 95% CI = 1.46–0.01, p = 0.05). 4. Discussion To our knowledge, this is the first study to examine how depression, anxiety, and stress symptoms vary among ethnic groups in Canada during the COVID-19 pandemic. The demographics of our study population suggest that the demographic profile of subscribers of the Text4Hope program and Text4Mood programs [50] are comparable. Our study found that respondents identifying as Indigenous reported higher levels of depression, anxiety, and stress than other ethnic groups in Alberta, Canada as measured by the PHQ-9, GAD-7, and PSS-10, respectively. Persons who identified as Caucasian or Asian reported similar levels of depression and stress, but respondents that identified as Caucasian reported more anxiety than respondents that identified as Asian. However, the significantly lower mean GAD-7 score reported by respondents that identified as Asian, compared to other ethnic groups, is not surprising given that in a global study of anxiety disorders, Asian people had lower prevalence of anxiety disorders (2% to 4%) compared to the rest of the world (4% to 6%), with the exception of some countries in South America, Eastern Europe, and Finland with similar prevalence of anxiety disorders [48]. Overall, the prevalence of distress was high, which is consistent with previous research. For example, significant stress was reported by over 90% of respondents that identified as Indigenous, and significant anxiety and depression were reported by over 50%. High rates of anxiety, depression, and stress found in this study are consistent with previous research showing high levels of population-level distress during the pandemic [1,2,4,6,8–10,46], with rates grossly elevated compared to pre-COVID-19 estimates [48]. For instance, the prevalence of significant anxiety symptoms in our study of 47.1%, was similar to the rates re- ported in different studies across the world during the COVID-19 pandemic [1,2,4,6,8–10,46], yet is much higher than an estimated global pre-COVID-19 rate in 2017 of 2.5% to 7% for anxiety [48]. The COVID-19 pandemic has likely accentuated pre-existing differences in the burden of mental health. For example, although a higher burden of mental health conditions among Indigenous peoples compared to non-Indigenous people in Canada was reported Behav. Sci. 2021, 11, 115 9 of 13 prior to the pandemic [29–31,63–65], as well as in other countries with Indigenous popu- lations [35,36,40], it is likely that COVID-19 has placed additional stressors on this group. The reasons for the disproportionately higher burden of physical and mental illnesses among Indigenous peoples may include inequalities related to social determinants of health (e.g., education, housing, socioeconomic status, access to services, etc.), which can place Indigenous peoples at greater risk of poorer health outcomes compared to non- Indigenous populations [42–44]. This pattern of data likely stems from broad societal events; for example, in Canada, Indigenous people have experienced intergenerational trauma related to the Residential School System and the Government of Canada’s Indian Act over decades [45]. It has been documented that natural disasters and public health crises exaggerate pre-existing social inequities, and our findings are consistent with this. Our study has several limitations, including a lack of baseline data on the stress, anxiety, and depression levels immediately prior to the COVID-19 pandemic and related restrictions, limiting direct pre- and post-COVID-19 comparisons. Second, the response rate in our study of 19.4% was low. However, our sample size was greater than the sample size of 3693 needed for prevalence rates estimates for stress, anxiety, and depression in our overall sample of 44,992 subscribers or the 4200-sample size needed for prevalence rate estimates in the entire Alberta population with a confidence interval of 99% and a 2% margin of error. Third, our study likely evidences selection bias given the rather low response rate; specifically, it is possible that non-respondents may differ in a systematic way compared to respondents. For example, they may be more (or less) affected by the pandemic or may have limitations in literacy or English fluency. Similarly, our study has some limited generalizability. The respondents that self-identified as Indigenous in our study represented 3.7% of our sample, lower than estimated proportion of the Indigenous population in Canada (4.9%) [24]. Furthermore, the vast majority of our respondents identified as female (86.9%), which is an overrepresentation in our study relative to Canadian population estimates of 50.3% [66]. This may likely increase the prevalence of perceived anxiety and depression in our study population given that females reportedly have higher prevalence of anxiety disorders and depression in all the countries considered in a global study [48]. Finally, although the ANOVA analysis allowed for comparison of the stress, anxiety, and depression levels between all the ethnic groups as a strength, it did not take into account potential confounding factors such as gender, age, relationship status, employment status, and education status, which is a limitation as ethnicity is likely to be one of several key factors upon which vulnerability to mental health effects of COVID-19 would be based. In addition, other social determinants of health, along with co-morbid physical health conditions, are known to play a significant role in increasing vulnerability in times of crisis [11]. Any interventions aimed at mitigating mental health effects of COVID-19 must therefore take of all these various factors into account. 5. Conclusions The results of our study indicate that stress, anxiety, and depression levels are high in the general population during the COVID-19 pandemic, and are significantly associated with specific risk factors, such as Indigenous ethnicity. These results suggest a need for population-level mental health support, with enhanced psychological intervention for specific groups, such as Indigenous persons. Future studies should consider using a prospective study design in randomly selected participants from the general population with participants screened by trained clinicians for the presence of depression, anxiety, and stress using standardized objective assessment instruments. This will minimize recall bias and ensure that study findings are generalizable to the entire population. Despite several limitations, this study provides useful data about the mental health ethnicity correlates of the COVID-19 pandemic. These findings are important for govern- ment and healthcare planning to determine the nature and quality of services required to address mental health challenges arising during this pandemic, as well as future pan- demics that enforce public health measures. Specifically, planning for and implementing Behav. Sci. 2021, 11, 115 10 of 13 virtual care programs as well as supportive text messages is a relatively low-cost and easily scalable means of supporting individuals during public health crises [53,67–70], especially appropriate for supporting persons at additional risk of negative outcomes [52,54,55]. Author Contributions: Conceptualization, V.I.O.A.; data curation: R.S., W.V., A.G., S.S. and V.I.O.A.; methodology: R.S., A.J.G. and V.I.O.A.; supervision: V.I.O.A. and S.S.; writing—original draft: M.A.L., V.I.O.A. and R.S.; writing—review and editing: M.A.L., R.S., C.C., W.V., M.H., A.G., S.S., A.J.G. and V.I.O.A. All authors have read and agreed to the published version of the manuscript. Funding: This study was supported by grants from the Mental Health Foundation, the Calgary Health Trust, the University Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation, and the Alberta Cancer Foundation. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or the decision to submit the results for publication. Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the University of Alberta Health Research Ethics Board (protocol code Pro00086163 approved on 18 March 2020). Participant consent was implied by submission of subscribers’ survey responses. Informed Consent Statement: Informed consent was implied if subscribers completed the online sur- vey and submitted responses, as approved by the University of Alberta Health Research Ethics Board. Data Availability Statement: The data that support the findings of this study are available from the corresponding author, V.I.O.A., upon reasonable request. Acknowledgments: Support for the project was received from Alberta Health Services and the University of Alberta. Conflicts of Interest: The authors declare no conflict of interest. References 1. Ahmed, M.Z.; Ahmed, O.; Aibao, Z.; Hanbin, S.; Siyu, L.; Ahmad, A. Epidemic of COVID-19 in China and associated Psychological Problems. Asian J. Psychiatry 2020, 51, 102092. [CrossRef] 2. Mazza, C.; Ricci, E.; Biondi, S.; Colasanti, M.; Ferracuti, S.; Napoli, C.; Roma, P. A Nationwide Survey of Psychological Distress among Italian People during the COVID-19 Pandemic: Immediate Psychological Responses and Associated Factors. Int. J. Environ. Res. Public Health 2020, 17, 3165. [CrossRef] 3. Zhang, J.; Lu, H.; Zeng, H.; Zhang, S.; Du, Q.; Jiang, T.; Du, B. The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav. Immun. 2020, 87, 49–50. [CrossRef] 4. Huang, Y.; Zhao, N. Chinese mental health burden during the COVID-19 pandemic. Asian J. Psychiatry 2020, 51, 102052. [CrossRef] 5. Qiu, J.; Shen, B.; Zhao, M.; Wang, Z.; Xie, B.; Xu, Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen. Psychiatry 2020, 33, e100213. [CrossRef] 6. Li, J.; Yang, Z.; Qiu, H.; Wang, Y.; Jian, L.; Ji, J.; Li, K. Anxiety and depression among general population in China at the peak of the COVID-19 epidemic. World Psychiatry 2020, 19, 249–250. [CrossRef] 7. Tull, M.T.; Edmonds, K.A.; Scamaldo, K.M.; Richmond, J.R.; Rose, J.P.; Gratz, K.L. Psychological Outcomes Associated with Stay-at-Home Orders and the Perceived Impact of COVID-19 on Daily Life. Psychiatry Res. 2020, 289, 113098. [CrossRef] 8. Madani, A.; Boutebal, S.E.; Bryant, C.R. The Psychological Impact of Confinement Linked to the Coronavirus Epidemic COVID-19 in Algeria. Int. J. Environ. Res. Public Health 2020, 17, 3604. [CrossRef] 9. Wang, C.; Pan, R.; Wan, X.; Tan, Y.; Xu, L.; Ho, C.S.; Ho, R.C. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int. J. Environ. Res. Public Health 2020, 17, 1729. [CrossRef] 10. Moghanibashi-Mansourieh, A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J. Psychiatry 2020, 51, 102076. [CrossRef] 11. Moosavi, S.; Nwaka, B.; Akinjise, I.; Corbett, S.E.; Chue, P.; Greenshaw, A.J.; Silverstone, P.H.; Li, X.M.; Agyapong, V.I.O. Mental Health Effects in Primary Care Patients 18 Months After a Major Wildfire in Fort McMurray: Risk Increased by Social Demographic Issues, Clinical Antecedents, and Degree of Fire Exposure. Front. Psychiatry 2019, 10, 683. [CrossRef] [PubMed] 12. Harada, N.; Shigemura, J.; Tanichi, M.; Kawaida, K.; Takahashi, S.; Yasukata, F. Mental health and psychological impacts from the 2011 Great East Japan Earthquake Disaster: A systematic literature review. Disaster Mil. Med. 2015, 1, 17. [CrossRef] 13. McKinzie, A.E. In their own words: Disaster and emotion, suffering, and mental health. Int. J. Qual. Stud. Health Well-Being 2018, 13, 1440108. [CrossRef] [PubMed] Behav. Sci. 2021, 11, 115 11 of 13 14. Zhu, N.; Zhang, D.; Wang, W.; Li, X.; Yang, B.; Song, J.; Zhao, X.; Huang, B.; Shi, W.; Lu, R.; et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N. Engl. J. Med. 2020, 382, 727–733. [CrossRef] 15. World Health Organization Timeline of WHO’s Response to COVID-19. Available online: https://www.who.int/news-room/ detail/29-06-2020-covidtimeline (accessed on 2 July 2020). 16. World Health Organization Coronavirus Disease (COVID-19) Situation Report—163. Available online: https://www.who.int/ docs/default-source/coronaviruse/situation-reports/20200701-covid-19-sitrep-163.pdf?sfvrsn=c202f05b_2 (accessed on 1 July 2020). 17. World Health Organization Mental Disorders Affect One in Four People. Available online: https://www.who.int/whr/2001 /media_centre/press_release/en/#:~{}:text=Geneva%2C%204%20October%E2%80%94%20One%20in,ill%2Dhealth%20and% 20disability%20worldwide (accessed on 1 July 2020). 18. Disease, G.B.D.; Injury, I.; Prevalence, C. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018, 392, 1789–1858. 19. Lang, J.J.; Alam, S.; Cahill, L.E.; Drucker, A.M.; Gotay, C.; Kayibanda, J.F.; Kozloff, N.; Mate, K.K.V.; Patten, S.B.; Orpana, H.M. Global Burden of Disease Study trends for Canada from 1990 to 2016. CMAJ 2018, 190, E1296–E1304. [CrossRef] 20. Smetanin, P.; Stiff, D.; Briante, C.; Adair, C.E.; Ahmad, S.; Khan, M. The Life and Economic Impact of Major Mental Illnesses in Canada: 2011 to 2041. Risk Analytica, on Behalf of the Mental Health Commission of Canada 2011; Mental Health Commission of Canada, Ed.; Risk Analytica: Toronto, ON, Canada, 2011; pp. 116–122. 21. American Psychiatric Association. Depressive Disorders. In Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013; pp. 155–188. 22. Government of Canada Suicide in Canada: Key Statistics (Infographic). Available online: https://www.canada.ca/en/public- health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html (accessed on 2 July 2020). 23. Statistics Canada Indigenous Peoples in Canada: First Nations People, Métis and Inuit. Available online: https://www12.statcan. gc.ca/nhs-enm/2011/as-sa/99-011-x/99-011-x2011001-eng.pdf (accessed on 1 July 2020). 24. Statistics Canada First Nations People, Metis and Inuit in Canada: Diverse and Growing Populations. Available online: https://www150.statcan.gc.ca/n1/en/pub/89-659-x/89-659-x2018001-eng.pdf?st=W7cSG4EI (accessed on 5 July 2020). 25. MacMillan, H.L.; MacMillan, A.B.; Offord, D.R.; Dingle, J.L. Indigenous health. CMAJ 1996, 155, 1569–1578. 26. Carriere, G.; Bougie, E.; Kohen, D.; Rotermann, M.; Sanmartin, C. Acute care hospitalization by Indigenous identity, Canada, 2006 through 2008. Health Rep. 2016, 27, 3–11. 27. Park, J.; Tjepkema, M.; Goedhuis, N.; Pennock, J. Avoidable mortality among First Nations adults in Canada: A cohort analysis. Health Rep. 2015, 26, 10–16. 28. Ospina, M.B.; Voaklander, D.C.; Stickland, M.K.; King, M.; Senthilselvan, A.; Rowe, B.H. Prevalence of asthma and chronic obstructive pulmonary disease in Indigenous and non-Indigenous populations: A systematic review and meta-analysis of epidemiological studies. Can. Respir. J. 2012, 19, 355–360. [CrossRef] 29. Kielland, N.; Simeone, T. Current Issues in Mental Health in Canada: The Mental Health of First Nations and Inuit Communi- ties. Available online: https://lop.parl.ca/staticfiles/PublicWebsite/Home/ResearchPublications/InBriefs/PDF/2014-02-e.pdf (accessed on 5 July 2020). 30. Canada, G.O. The Mental Health and Well-Being of Indigenous Peoples in Canada. In The Human Face of Mental Health and Mental Illness in Canada 2006; Government of Canada: Ottawa, ON, Canada, 2006; pp. 159–179. 31. Lavoie, J.G.; Ward, A.; Wong, S.T.; Ibrahim, N.; Morton, D.; O’Neil, J.D.; Green, M. Hospitalization for mental health related ambulatory care sensitive conditions: What are the trends for First Nations in British Columbia? Int. J. Equity Health 2018, 17, 156. [CrossRef] [PubMed] 32. Pulver, L.J.; Haswell, M.R.; Ring, I.; Waldon, J.; Clark, W.; Whetung, V.; Kinnon, D.; Graham, C.; Chino, M.; LaValley, J.; et al. Indigenous Health—Australia, Canada, Aotearoa, New Zealand and the United States—Laying Claim to a Future that Embraces Health for Us All; Background Paper, 33; World Health Organisation: Geneva, Switzerland, 2010. 33. IHS Special Diabetes Program for Indians | 2014 Report to Congress Changing the Course of Diabetes: Turning Hope into Reality. 2014. Available online: https://www.nihb.org/sdpi/docs/05022016/SDPI_2014_Report_to_Congress.pdf (accessed on 20 December 2000). 34. National Center for Chronic Disease Prevention and Health Promotion in Centers for Disease Control and Prevention Native Americans with Diabetes. Available online: https://www.cdc.gov/vitalsigns/aian-diabetes/index.html (accessed on 1 July 2020). 35. Nasir, B.F.; Toombs, M.R.; Kondalsamy-Chennakesavan, S.; Kisely, S.; Gill, N.S.; Black, E.; Hayman, N.; Ranmuthugala, G.; Beccaria, G.; Ostini, R.; et al. Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: A cross-sectional study. BMJ Open 2018, 8, e020196. [CrossRef] 36. McNamara, B.J.; Banks, E.; Gubhaju, L.; Joshy, G.; Williamson, A.; Raphael, B.; Eades, S. Factors relating to high psychological distress in Indigenous Australians and their contribution to Indigenous-non-Indigenous disparities. Aust. N. Z. J. Public Health 2018, 42, 145–152. [CrossRef] Behav. Sci. 2021, 11, 115 12 of 13 37. United Nations Department of Economic and Social Affairs State of the World’s Indigenous Peoples. Available online: https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/03/The-State-of-The- Worlds-Indigenous-Peoples-WEB.pdf (accessed on 5 July 2020). 38. Thommasen, H.V.; Baggaley, E.; Thommasen, C.; Zhang, W. Prevalence of depression and prescriptions for antidepressants, Bella Coola Valley, 2001. Can. J. Psychiatry 2005, 50, 346–352. [CrossRef] [PubMed] 39. Kisely, S.; Alichniewicz, K.K.; Black, E.B.; Siskind, D.; Spurling, G.; Toombs, M. The prevalence of depression and anxiety disorders in indigenous people of the Americas: A systematic review and meta-analysis. J. Psychiatr. Res. 2017, 84, 137–152. [CrossRef] [PubMed] 40. Pollock, N.J.; Naicker, K.; Loro, A.; Mulay, S.; Colman, I. Global incidence of suicide among Indigenous peoples: A systematic review. BMC Med. 2018, 16, 145. [CrossRef] [PubMed] 41. Kumar, M.B.; Tjepkema, M. Suicide among First Nations people, Métis and Inuit (2011–2016): Findings from the 2011 Canadian Census Health and Environment Cohort (CanCHEC). Available online: https://www150.statcan.gc.ca/n1/en/pub/99-011-x/99 -011-x2019001-eng.pdf?st=8IX6ph_l (accessed on 5 July 2020). 42. Willows, N.; Veugelers, P.; Raine, K.; Kuhle, S. Associations between household food insecurity and health outcomes in the Indigenous population (excluding reserves). Health Rep. 2011, 22, 15–20. 43. Kim, P.J. Social Determinants of Health Inequities in Indigenous Canadians Through a Life Course Approach to Colonialism and the Residential School System. Health Equity 2019, 3, 378–381. [CrossRef] 44. Kaspar, V. The lifetime effect of residential school attendance on indigenous health status. Am. J. Public Health 2014, 104, 2184–2190. [CrossRef] 45. Truth and Reconciliation Commission of Canada Honouring the Truth, Reconciling for the Future Summary of the Final Report of the Truth and Reconciliation Commission of Canada. Available online: http://nctr.ca/assets/reports/Final%20Reports/ Executive_Summary_English_Web.pdf (accessed on 2 July 2020). 46. Lei, L.; Huang, X.; Zhang, S.; Yang, J.; Yang, L.; Xu, M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine during the COVID-19 Epidemic in Southwestern China. Med. Sci. Monit. 2020, 26, e924609. [CrossRef] 47. Zhang, Y.; Ma, Z.F. Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2020, 17, 2381. [CrossRef] 48. Ritchie, H.; Roser, M.; Mental Health Published online at OurworldInData.org. Our World in Data 2018. Available online: https:/ourworldindata.org/mental-health (accessed on 20 December 2000). 49. Agyapong, V.I.O. Coronavirus Disease 2019 Pandemic: Health System and Community Response to a Text Message (Text4Hope) Program Supporting Mental Health in Alberta. Disaster Med. Public Health Prep. 2020, 22, 1–5. [CrossRef] [PubMed] 50. Agyapong, V.I.; Mrklas, K.; Juhas, M.; Omeje, J.; Ohinmaa, A.; Dursun, S.M.; Greenshaw, A.J. Cross-sectional survey evaluating Text4Mood: Mobile health program to reduce psychological treatment gap in mental healthcare in Alberta through daily supportive text messages. BMC Psychiatry 2016, 16, 378. [CrossRef] [PubMed] 51. Urichuk, L.; Hrabok, M.; Hay, K.; Spurvey, P.; Sosdjan, D.; Knox, M.; Fu, A.; Surood, S.; Brown, R.; Coulombe, J.; et al. Enhancing peer support experience for patients discharged from acute psychiatric care: Protocol for a randomised controlled pilot trial. BMJ Open 2018, 8, e022433. [CrossRef] [PubMed] 52. Agyapong, V.I.O.; Juhás, M.; Ohinmaa, A.; Omeje, J.; Mrklas, K.; Suen, V.Y.M.; Dursun, S.M.; Greenshaw, A.J. Randomized controlled pilot trial of supportive text messages for patients with depression. BMC Psychiatry 2017, 17, 286. [CrossRef] [PubMed] 53. Agyapong, V.I.; Ahern, S.; McLoughlin, D.M.; Farren, C.K. Supportive text messaging for depression and comorbid alcohol use disorder: Single-blind randomised trial. J. Affect Disord. 2012, 141, 168–176. [CrossRef] [PubMed] 54. Agyapong, V.I.O.; Juhas, M.; Mrklas, K.; Hrabok, M.; Omeje, J.; Gladue, I.; Kozak, J.; Leslie, M.; Chue, P.; Greenshaw, A.J. Randomized controlled pilot trial of supportive text messaging for alcohol use disorder patients. J. Subst. Abus. Treat. 2018, 94, 74–80. [CrossRef] 55. Hartnett, D.; Murphy, E.; Kehoe, E.; Agyapong, V.; McLoughlin, D.M.; Farren, C. Supportive text messages for patients with alcohol use disorder and a comorbid depression: A protocol for a single-blind randomised controlled aftercare trial. BMJ Open 2017, 7, e013587. [CrossRef] 56. Cohen, S.; Kamarck, T.; Mermelstein, R. A Global Measure of Perceived Stress. J. Health Soc. Behav. 1983, 24, 385–396. [CrossRef] 57. Spitzer, R.L.; Kroenke, K.; Williams, J.B.; Löwe, B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch. Intern. Med. 2006, 166, 1092–1097. [CrossRef] 58. Kroenke, K.; Spitzer, R.L.; Williams, J.B. The PHQ-9: Validity of a brief depression severity measure. J. Gen. Intern. Med. 2001, 16, 606–613. [CrossRef] 59. Agyapong, V.I.O.; Hrabok, M.; Vuong, W.; Gusnowski, A.; Shalaby, R.; Mrklas, K.; Li, D.; Urichuk, L.; Snaterse, M.; Surood, S.; et al. Closing the Psychological Treatment Gap During the COVID-19 Pandemic With a Supportive Text Messaging Program: Protocol for Implementation and Evaluation. JMIR Res. Protoc. 2020, 9, e19292. [CrossRef] 60. Mrklas, K.; Shalaby, R.; Hrabok, M.; Gusnowski, A.; Vuong, W.; Surood, S.; Urichuk, L.; Li, D.; Li, X.-M.; Greenshaw, A.J.; et al. COVID-19 pandemic: Prevalence of Perceived Stress, Anxiety, Depression, and Obsessive-Compulsive Symptoms vary among Healthcare and non-Healthcare Workers in Alberta. JMIR Ment. Health 2020. [CrossRef] [PubMed] Behav. Sci. 2021, 11, 115 13 of 13 61. Abba-Aji, A.; Li, D.; Hrabok, M.; Shalaby, R.; Gusnowski, A.; Vuong, W.; Surood, S.; Nkire, N.; Li, X.M.; Greenshaw, A.J.; et al. COVID-19 Pandemic and Mental Health: Prevalence and Correlates of New-Onset Obsessive-Compulsive Symptoms in a Canadian Province. Int. J. Environ. Res. Public Health 2020, 17, 6986. [CrossRef] [PubMed] 62. Nwachukwu, I.; Nkire, N.; Shalaby, R.; Hrabok, M.; Vuong, W.; Gusnowski, A.; Surood, S.; Urichuk, L.; Greenshaw, A.J.; Agyapong, V.I.O. COVID-19 Pandemic: Age-Related Differences in Measures of Stress, Anxiety and Depression in Canada. Int. J. Environ. Res. Public Health 2020, 17, 6366. [CrossRef] [PubMed] 63. Statista Canadian Aboriginal’s Life Stress Perception 2007–2014, by Indigenous Identity. Available online: https://www.statista. com/statistics/817337/perceived-life-stress-among-aboriginals-canada-by-aboriginal-identity/ (accessed on 1 July 2020). 64. Statista Share of Canadian Aboriginals with a Mood Disorder 2007–2014, by Indigenous Identity. Available online: https: //www.statista.com/statistics/817334/mood-disorders-among-aboriginals-canada-by-aboriginal-identity/ (accessed on 4 July 2020). 65. Cardinal, J.; Schopflocher, D.; Svenson, L.; Morrison, K.; Laing, L. First Nations in Alberta: A Focus on Health Service Use. Edmonton: Alberta Health and Wellness. 2004. Available online: https://open.alberta.ca/dataset/212381eb-ba02-49c8-82d0-279 50a9a16df/resource/43a8b731-3937-41f1-b52e-06bba2e0b613/download/First-Nation-Service-Use-2004.pdf (accessed on 1 July 2020). 66. Statistics Canada Table 17-10-0005-01 Population Estimates on 1 July by Age and Sex. Available online: https://www150.statcan. gc.ca/t1/tbl1/en/tv.action?pid=1710000501 (accessed on 2 July 2020). 67. Agyapong, V.I.O.; Milnes, J.; McLoughlin, D.M.; Farren, C.K. Perception of patients with alcohol use disorder and comorbid depression about the usefulness of supportive text messages. Technol. Health Care 2013, 21, 31–39. [CrossRef] [PubMed] 68. Agyapong, V. Mobile Phone Text Message Interventions in Psychiatry—What are the Possibilities? Curr. Psychiatry Rev. 2011, 7, 50–56. [CrossRef] 69. Agyapong, V.I.O.; McLoughlin, D.M.; Farren, C.K. Six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder. J. Affect. Disord. 2013, 151, 100–104. [CrossRef] [PubMed] 70. Agyapong, V.I.O.; Mrklas, K.; Suen, V.Y.M.; Rose, M.S.; Jahn, M.; Gladue, I.; Kozak, J.; Leslie, M.; Dursun, S.; Ohinmaa, A.; et al. Supportive Text Messages to Reduce Mood Symptoms and Problem Drinking in Patients With Primary Depression or Alcohol Use Disorder: Protocol for an Implementation Research Study. JMIR Res. Protoc. 2015, 4, e55. [CrossRef]

Journal

Behavioral SciencesMultidisciplinary Digital Publishing Institute

Published: Aug 24, 2021

Keywords: COVID-19; mobile phones; text; anxiety; depression; stress; psychological distress; pandemic; ethnic groups; Indigenous people

There are no references for this article.