Mental Health

Self-rated health and mental health before and during the early phase of the COVID-19 pandemic in Germany: the population-based German National Cohort (NAKO) study.

TL;DR

During the early COVID-19 pandemic, many participants experienced improvements in self-rated health but suffered deterioration in mental health and physical activity engagement, with female participants, those who were physically inactive, and those with pre-existing mental disorders more likely to report poorer health.

Key Findings

A substantial proportion of participants reported improved self-rated health from baseline to the early COVID-19 pandemic phase.

  • Among participants with good health at baseline, 39.3% reported better health during the early pandemic phase.
  • Among participants with less good health at baseline, 69.7% reported better health during the early pandemic phase.
  • The sample size was N = 91,809 participants from the German National Cohort (NAKO).
  • The median time from baseline to early pandemic phase was 3.1 years (IQR: 2.1–4.1 years).

The percentage of participants with high depression, anxiety, and stress scores increased from baseline to the early pandemic phase.

  • High depression scores (≥10) increased from 6.2% at baseline to 8.6% during the early pandemic.
  • High anxiety scores (≥10) increased from 4.1% at baseline to 5.6% during the early pandemic.
  • High stress scores (≥10) increased from 4.3% at baseline to 10.1% during the early pandemic.
  • The stress score showed the largest absolute increase among the three mental health measures.

Being younger, male, highly educated, employed, having higher life satisfaction, and being more physically active were associated with improved self-rated health.

  • These associations were identified using multinomial logistic regression models.
  • Heavy drinking was also associated with improved self-rated health in the multivariable models.
  • Experiencing improved anxiety symptoms was additionally associated with improved self-rated health.
  • These findings were derived from multivariable models adjusting for multiple covariates.

Smoking and having mental health disorders were associated with worse self-rated health during the early pandemic.

  • Both smoking status and pre-existing mental health disorders were identified as factors associated with worse self-rated health in multivariable models.
  • Mental health disorders at baseline were associated with poorer health outcomes during the pandemic.
  • These associations were found using multinomial logistic regression.

Being younger, female, smoking, drinking heavily, and drinking more since baseline were associated with higher depression scores during the early pandemic.

  • These factors were identified using quantile regression models for mental health outcomes.
  • Female sex was specifically associated with higher depression scores, in contrast to its association with self-rated health.
  • Increased alcohol consumption since baseline (drinking more) was an additional risk factor for higher depression scores.
  • Younger age was associated with worse depression scores, which contrasted with younger age being associated with improved self-rated health.

Having had a coronavirus test was associated with worse self-rated health and more severe anxiety and stress.

  • Coronavirus testing was associated with worse self-rated health in multivariable models.
  • Coronavirus testing was also associated with more severe anxiety and stress scores.
  • This association was identified in the multivariable regression models for both self-rated health and mental health outcomes.

Physical activity engagement declined during the early COVID-19 pandemic.

  • Many participants experienced deterioration in physical activity engagement during the early pandemic phase.
  • Physical inactivity was associated with poorer health outcomes during the pandemic.
  • Those who were physically inactive were more likely to report poorer health.

Female participants, physically inactive individuals, and those with pre-existing mental disorders were more likely to report poorer health during the early pandemic.

  • These three groups were identified as particularly vulnerable subgroups.
  • Pre-existing mental health disorders were associated with both worse self-rated health and worse mental health outcomes.
  • Female sex was specifically identified as a risk factor for poorer mental health outcomes.
  • These findings were based on a large population-based cohort of N = 91,809 participants across Germany.

What This Means

This large German study followed nearly 92,000 adults from before the COVID-19 pandemic through its early phase, comparing their physical and mental health at two time points separated by a median of about three years. Surprisingly, many people actually reported better overall physical health during the early pandemic — including 39% of those who had good health before and nearly 70% of those who had poorer health before. However, mental health told a different story: rates of high depression, anxiety, and stress all increased, with stress showing the largest jump (from 4.3% to 10.1% of participants reporting high stress levels). The research suggests that different groups of people were affected very differently by the pandemic. Men, younger adults, those with higher education, and those who were employed tended to fare better in terms of overall self-rated health. Women were more likely to experience higher depression scores. People who smoked, had pre-existing mental health conditions, had been tested for COVID-19, or were physically inactive were more vulnerable to worse health outcomes. Increased or heavy alcohol consumption was associated with both better self-rated physical health but worse mental health (specifically depression), highlighting the complexity of health behaviors during this period. This research suggests that while some people may have experienced certain lifestyle benefits during the early pandemic (such as reduced commuting or slower pace of life that improved perceived physical health), the psychological toll — particularly stress and depression — was real and measurable across a large population. The findings highlight that vulnerable groups, especially women, physically inactive individuals, and those with existing mental health conditions, may need targeted support during public health crises and accompanying social distancing measures.

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Citation

Xi Y, Keil T, Krist L, Pischon T, Velásquez I, Schulze M, et al.. (2026). Self-rated health and mental health before and during the early phase of the COVID-19 pandemic in Germany: the population-based German National Cohort (NAKO) study.. BMC public health. https://doi.org/10.1186/s12889-026-27633-5