The cumulative contribution of direct and indirect traumas to the production of PTSD.

OBJECTIVE: Posttraumatic Stress Disorder (PTSD) affects millions of people worldwide. While the relationship between direct exposure to traumatic events and PTSD is well-established, the influence of indirect trauma exposure on PTSD remains unclear. It is similarly unclear what role cumulative exposure to direct and indirect traumas play in the risk of PTSD. METHODS: The study uses data from the Houston Trauma and Recovery Study, conducted on 2020-2021, and involved a random sampling of 1,167 individuals residing in Houston during Hurricane Harvey in 2017. Participants were asked about their experiences related to both Hurricane Harvey and the subsequent COVID-19 pandemic. Exposures were categorized as direct or indirect traumas, in line with the criteria delineated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Cumulative exposures were also calculated. RESULTS: Among participants, 12.6% were experiencing current PTSD. There were significant associations between both direct [OR = 3.18, 95% CI 1.85, 5.46] and indirect [OR = 1.91, 95% CI 1.05, 3.46] traumas related to Harvey, as well as direct [OR = 2.13, 95% CI 1.20, 3.77] and indirect [OR = 1.69, 95% CI 0.93, 3.09] traumas due to COVID and the risk of PTSD in fully adjusted models. Further, significant associations were found between the cumulative exposure to traumas from both Hurricane Harvey and COVID-19 and the risk of PTSD, considering both direct [OR = 2.53, 95% CI 1.36, 4.70] and indirect exposures [OR = 2.79, 95% CI 1.47, 5.28]. CONCLUSIONS: Our study offers support for connections between exposure to both direct and indirect traumas stemming from large-scale disasters and PTSD. Moreover, we show that cumulative exposures to multiple large-scale events increase the risk of PTSD. This highlights the importance of the consideration of a range of exposures as risks for PTSD, particularly in a time of compounding disasters and broad population exposures to these events.

What Can Be Learned From Nonadherent Patients to Promote the Health of Populations?

This JAMA Forum discusses patient- and population-level nonadherence to medical advice and elaborates on 4 main categories of reasons that underpin nonadherence.

Generalized anxiety disorder in low-resourced adults: a nationally representative, longitudinal cohort study across the COVID-19 pandemic.

The burden of generalized anxiety disorder (GAD) accrued disproportionately over the COVID-19 pandemic to low-resource populations. Using a longitudinal, nationally representative study of U.S. adults, we used generalized estimating equations (GEE) to estimate the burden of positive screen for GAD (GAD-7 ≥10) over time. The final sample included 1270 adults ≥18 who completed the CLIMB (COVID-19 and Life Stressors Impact on Mental Health and Well-being) study, collected in Spring 2020, 2021, and 2022. The national prevalence of positive screen for GAD decreased from 24.4% in 2020 to 21.3% in 2022 (p<0.05). Across the COVID-19 pandemic, factors associated with increased odds of positive screen for GAD were: lower income (OR:2.06 [95%CI: 1.17,3.63] for ≤$19,999 relative to ≥$75,000), younger age (OR:2.55 [95% CI:1.67,3.89] for ages 18-39 relative to ≥60 years), and having contracted COVID-19 (OR:1.54 [95%CI:1.12,2.14]). Experiencing stressors was associated with 14% increased odds of positive screen for GAD for each additional stressor. The 2020 stressors most strongly associated with positive screen for GAD in 2022 were job loss and difficulties paying rent. Efforts to address the stressors affecting groups with the highest burden of anxiety post-pandemic may help to mitigate poor mental health exacerbated during the COVID-19 pandemic.

Epigenome-wide association studies identify novel DNA methylation sites associated with PTSD: A meta-analysis of 23 military and civilian cohorts.

Background: The occurrence of post-traumatic stress disorder (PTSD) following a traumatic event is associated with biological differences that can represent the susceptibility to PTSD, the impact of trauma, or the sequelae of PTSD itself. These effects include differences in DNA methylation (DNAm), an important form of epigenetic gene regulation, at multiple CpG loci across the genome. Moreover, these effects can be shared or specific to both central and peripheral tissues. Here, we aim to identify blood DNAm differences associated with PTSD and characterize the underlying biological mechanisms by examining the extent to which they mirror associations across multiple brain regions. Methods: As the Psychiatric Genomics Consortium (PGC) PTSD Epigenetics Workgroup, we conducted the largest cross-sectional meta-analysis of epigenome-wide association studies (EWASs) of PTSD to date, involving 5077 participants (2156 PTSD cases and 2921 trauma-exposed controls) from 23 civilian and military studies. PTSD diagnosis assessments were harmonized following the standardized guidelines established by the PGC-PTSD Workgroup. DNAm was assayed from blood using either Illumina HumanMethylation450 or MethylationEPIC (850K) BeadChips. A common QC pipeline was applied. Within each cohort, DNA methylation was regressed on PTSD, sex (if applicable), age, blood cell proportions, and ancestry. An inverse variance-weighted meta-analysis was performed. We conducted replication analyses in tissue from multiple brain regions, neuronal nuclei, and a cellular model of prolonged stress. Results: We identified 11 CpG sites associated with PTSD in the overall meta-analysis (1.44e-09 < p < 5.30e-08), as well as 14 associated in analyses of specific strata (military vs civilian cohort, sex, and ancestry), including CpGs in AHRR and CDC42BPB. Many of these loci exhibit blood-brain correlation in methylation levels and cross-tissue associations with PTSD in multiple brain regions. Methylation at most CpGs correlated with their annotated gene expression levels. Conclusions: This study identifies 11 PTSD-associated CpGs, also leverages data from postmortem brain samples, GWAS, and genome-wide expression data to interpret the biology underlying these associations and prioritize genes whose regulation differs in those with PTSD.

Posttraumatic Stress Disorder Among Adults in Communities With Mass Violence Incidents.

Importance: Mass violence incidents (MVIs) are prevalent in the US and can have profound and long-lasting psychological consequences on direct survivors, but their outcomes among the broader communities where the MVI occurred are unknown. Objective: To investigate the prevalence of and factors associated with past-year and current posttraumatic stress disorder (PTSD) among adults in communities that experienced an MVI. Design, Setting, and Participants: This cross-sectional survey was completed between February and September 2020 with a household probability sample of adults from 6 communities that had experienced an MVI between 2015 and 2019: Dayton, Ohio; El Paso, Texas; Parkland, Florida; Pittsburgh, Pennsylvania; San Bernadino, California; and Virginia Beach, Virginia. Address-based sampling was used to identify randomly selected households, mail invitations, and select 1 adult per household to complete a self-administered paper or online survey. Data analysis was performed from September to November 2023. Main Outcomes and Measures: The primary outcome was presumptive diagnostic-level past-year PTSD and current (past month) PTSD determined using American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) PTSD criteria. Results: A total of 6867 adults aged 18 years or older accessed the website with a description of the study and consent materials. Of these, 5991 (87.2%) agreed to participate and completed the survey, 343 (6.3%) partially completed the survey, and 443 (6.5%) did not meet eligibility criteria or refused to participate. Most of the 5991 respondents were female (3825 individuals [53.5%]) and had a mean (SD) age of 45.56 (17.58) years. A total of 1261 of 5931 individuals (21.0%) reported high exposure to the MVI (either they or a close friend and/or family member was on site during the shooting). Nearly one-quarter (23.7%; 1417 of 5977 participants reporting PTSD) met presumptive DSM-5 diagnostic criteria for past-year PTSD, with 8.9% (530 participants) meeting the criteria for current PTSD. Regression analyses found that being female (odds ratio, 2.32; 95% CI, 2.01-2.68) and having a history of both physical or sexual assault and other potentially traumatic events (odds ratio, 9.68; 95% CI, 7.48-12.52) were associated with the greatest risk of past-year PTSD. Conclusions and Relevance: In this survey study of 5991 participants, presumptive PTSD was quite prevalent long after the MVI among adults in communities that have experienced an MVI, suggesting that MVIs have persistent and pervasive public health impacts on communities, particularly among those with prior exposure to physical or sexual assault and other potentially traumatic events. Focusing exclusively on direct exposure to MVIs is not sufficient. Incorporating these findings into screening should improve efforts to identify the individuals most in need of prevention or mental health service after MVIs.

Key considerations in the adoption of Artificial Intelligence in public health.

The integration of Artificial Intelligence (AI) into public health has the potential to transform the field, influencing healthcare at the population level. AI can aid in disease surveillance, diagnosis, and treatment decisions, impacting how healthcare professionals deliver care. However, it raises critical questions about inputs, values, and biases that must be addressed to ensure its effectiveness. This article investigates the factors influencing the values guiding AI technology and the potential consequences for public health. It outlines four key considerations that should shape discussions regarding the role of AI in the future of public health. These include the potential omission of vital factors due to incomplete data inputs, the challenge of balancing trade-offs in public health decisions, managing conflicting inputs between public health objectives and community preferences, and the importance of acknowledging the values and biases embedded in AI systems, which could influence public health policy-making.

The Evolving Role of Diversity, Equity, and Inclusion Programs in Academic Health Institutions.

This Viewpoint examines the role of diversity, equity, and inclusion programs in academic health institutions and universities and encourages such institutions to reexamine and reengage with the goals of these programs.

News media as a commercial determinant of health.

Commercial determinants of health frameworks aim to identify the features and actions of corporate entities that can influence health. This Viewpoint conceptualises the work of the news media as a set of commercial forces and provides a framework that can help researchers better understand how features and actions of the news media shape health and health equity. We discuss four key features of news media action that can shape health: agenda setting, framing, priming, and tactics of persuasion. Beyond the direct role of the media in shaping health, we also explore pathways (ie, public relation activities, advertising, and economic pressures) in which the media is used by other commercial actors to affect health. A better understanding of how news media operates can help inform efforts to improve media actions to aid in improving population health outcomes.

Key considerations for the future of mental health epidemiology.

Psychiatric epidemiology has led to substantial progress in our understanding of the causes of mental health disorders. The increasing sophistication of etiologic psychiatric research has been accompanied by a greater focus on the biological and genetic causes of psychiatric disorders, to some extent diverging from field's early focus on the burden of poor mental health due to a breadth of social and economic conditions. We argue that the moment is ripe for advancing a mental health epidemiology that can reconnect the field to these earlier-and still central-concerns, while retaining the strengths of psychiatric epidemiology. Embracing five considerations can help advance the evolving field of mental health epidemiology. First, conceptually, an ambitious vision for the future of the field necessitates investment in refining our definitions and methodologies. Second, there is a need for a renewed focus on the macrosocial determinants of mental health. Third, a deeper engagement with mental health inequities should be central to our scholarship. Fourth, the field would benefit from a more deliberate assessment of the mechanisms leading to adverse mental health outcomes, which can then be used to inform novel interventions. Finally, realizing this future is contingent upon a wholesale commitment to studying population mental health globally.

Depression and assets during the COVID-19 pandemic: A longitudinal study of mental health across income and savings groups.

The prevalence of depression in U.S. adults during the COVID-19 pandemic has been high overall and particularly high among persons with fewer assets. Building on previous work on assets and mental health, we document the burden of depression in groups based on income and savings during the first two years of the COVID-19 pandemic. Using a nationally representative, longitudinal panel study of U.S. adults (N = 1,271) collected in April-May 2020 (T1), April-May 2021 (T2), and April-May 2022 (T3), we estimated the adjusted odds of reporting probable depression at any time during the COVID-19 pandemic with generalized estimating equations (GEE). We explored probable depression-defined as a score of ≥10 on the Patient Health Questionnaire-9 (PHQ-9)-by four asset groups, defined by median income (≥$65,000) and savings (≥$20,000) categories. The prevalence of probable depression was consistently high in Spring 2020, Spring 2021, and Spring 2022 with 27.9% of U.S. adults reporting probable depression in Spring 2022. We found that there were four distinct asset groups that experienced different depression trajectories over the COVID-19 pandemic. Low income-low savings asset groups had the highest level of probable depression across time, reporting 3.7 times the odds (95% CI: 2.6, 5.3) of probable depression at any time relative to high income-high savings asset groups. While probable depression stayed relatively stable across time for most groups, the low income-low savings group reported significantly higher levels of probable depression at T2, compared to T1, and the high income-low savings group reported significantly higher levels of probable depression at T3 than T1. The weighted average of probable depression across time was 42.9% for low income-low savings groups, 24.3% for high income-low savings groups, 19.4% for low income-high savings groups, and 14.0% for high income-high savings groups. Efforts to ameliorate both savings and income may be necessary to mitigate the mental health consequences of pandemics.

Perceptions of the determinants of health across income and urbanicity levels in eight countries.

BACKGROUND: A clear understanding of public perceptions of the social determinants of health remains lacking. This paper aimed to describe the relationship between income and urbanicity levels and public views of the determinants of health in eight middle-and high-income countries that varied across multiple characteristics. METHODS: We conducted a cross-sectional online survey in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States. Respondents were asked to select what they considered to be most important for health out of a list of ten determinants. We stratified the results by income and urbanicity levels and tested significance of differences between groups using two-tailed χ2 tests. Multivariable logistic regression models tested associations between demographic factors and the likelihood of respondents selecting the genetics, healthcare, income and wealth, or social support determinants. RESULTS: Here we show 8753 respondents across eight countries. Rankings of determinants are similar across income groups, except for two determinants. Respondents in the highest income group rank genetics in higher proportions (32.4%, 95%CI: 29.0%,35.8%) compared to other income groups. Conversely, those in lowest income group rank social support more frequently (27.9%, 95%CI: 25.3%,30.7%) than other income groups. Those living in urban settings rank healthcare in higher proportions (61.2%, 95%CI: 59.0%,63.4%) compared to non-urban respondents; meanwhile, higher proportions (26.6%, 95%CI: 24.9%,28.3%) of non-urban respondents rank social support as important for health compared to urban respondents. CONCLUSION: Demographic factors play a role in shaping public views of what affects health. Advancing public understanding about determinants of health requires tailoring public health messaging to account for socioeconomic position within a population.

Various factors determine our health, such as our environment, education, and genetics. Here, we explore how people from different income and urban backgrounds view the factors that affect health. We surveyed participants from Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States. Respondents selected the most important factors for health from a list of ten choices. Overall, people's views on these factors were comparable across income groups, with exceptions. Those with higher incomes tended to emphasize the importance of genetics more, while lower-income individuals valued social support. People in urban areas prioritized healthcare, while those in non-urban areas valued social support. These findings suggest that factors such as income and where people live influence their views about health determinants. These factors should be considered in public health messaging and strategies to promote health amongst different groups.

Unmet need for mental health care is common across insurance market segments in the United States.

A substantial proportion of individuals with depression in the United States do not receive treatment. While access challenges for mental health care have been documented, few recent estimates of unmet mental health needs across insurance market segments exist. Using nationally representative survey data with participant-reported depression symptom severity and mental health care use collected in Spring 2023, we assessed access to mental health care among individuals with similar levels of depression symptom severity with commercial, Medicare, Medicaid, and no insurance. Among individuals who reported symptoms consistent with moderately severe to severe depression, 37.8% did not have a diagnosis for depression (41.0%, 28.1%, 33.6%, and 56.3% with commercial, Medicare, Medicaid, and no insurance), 51.9% did not see a mental health specialist (49.7%, 51.7%, 44.9%, and 91.8%), and 32.4% avoided mental health care due to affordability in the past 12 months (30.2%, 34.0%, 21.1%, and 54.8%). There was substantial unmet need for mental health treatment in all insurance market segments, but especially among individuals without insurance.

Sociopolitical Factors and Mental Health Following the Turkey-Syria Earthquake.

This survey study evaluates the association between sociopolitical factors and mental health following the 2023 Turkey-Syria earthquake.

Experience of Personal Loss Due to Drug Overdose Among US Adults.

Importance: Since 1999, over 1 million people have died of a drug overdose in the US. However, little is known about the bereaved, meaning their family, friends, and acquaintances, and their views on the importance of addiction as a policy priority. Objectives: To quantify the scope of the drug overdose crisis in terms of personal overdose loss (ie, knowing someone who died of a drug overdose) and to assess the policy implications of this loss. Design, Setting, and Participants: This cross-sectional study used data from a nationally representative survey of US adults (age ≥18 years), the fourth wave of the COVID-19 and Life Stressors Impact on Mental Health and Well-Being (CLIMB) study, which was conducted from March to April 2023. Main Outcomes and Measures: Respondents reported whether they knew someone who died of a drug overdose and the nature of their relationship with the decedent(s). They also reported their political party affiliation and rated the importance of addiction as a policy issue. Logistic regression models estimated the associations between sociodemographic characteristics and political party affiliation and the probability of experiencing a personal overdose loss and between the experience of overdose loss and the perceived salience of addiction as a policy issue. Survey weights adjusted for sampling design and nonresponse. Results: Of the 7802 panelists invited to participate, 2479 completed the survey (31.8% response rate); 153 were excluded because they did not know whether they knew someone who died of a drug overdose, resulting in a final analytic sample of 2326 (51.4% female; mean [SD] age, 48.12 [0.48] years). Of these respondents, 32.0% (95% CI, 28.8%-34.3%) reported any personal overdose loss, translating to 82.7 million US adults. A total of 18.9% (95% CI, 17.1%-20.8%) of all respondents, translating to 48.9 million US adults, reported having a family member or close friend die of drug overdose. Personal overdose loss was more prevalent among groups with lower income (<$30 000: 39.9%; ≥$100 000: 26.0%). The experience of overdose loss did not differ across political party groups (Democrat: 29.0%; Republican: 33.0%; independent or none: 34.2%). Experiencing overdose loss was associated with a greater odds of viewing addiction as an extremely or very important policy issue (adjusted odds ratio, 1.37; 95% CI, 1.09-1.72) after adjustment for sociodemographic and geographic characteristics and political party affiliation. Conclusions and Relevance: This cross-sectional study found that 32% of US adults reported knowing someone who died of a drug overdose and that personal overdose loss was associated with greater odds of endorsing addiction as an important policy issue. The findings suggest that mobilization of this group may be an avenue to facilitate greater policy change.

Mental Health and U.S. Attitudes Toward Social Determinants of Health Policies.

INTRODUCTION: Research has suggested that individual health may influence policy attitudes, yet the relationship between mental health and policy support is understudied. Clarifying this relationship may help inform policies that can improve the population mental health. To address this gap, this study measures national support for 5 social determinants of health policy priorities and their relation to mental health and political affiliation. METHODS: This study assessed support for 5 policy priorities related to the social determinants of health using a nationally representative survey of US adults (n=2,430) conducted in March-April 2023. Logistic regression was used to estimate the predicted probability of identifying each priority as important, test differences in support by self-rated mental health, and evaluate whether partisanship modified these relationships. Analyses were conducted in 2023. RESULTS: The majority of US adults, across partisan identities, supported 5 policy priorities related to improving the economy (84%), healthcare affordability (77%), improving K-12 education (76%), housing affordability (68%), and childcare affordability (61%). Worse mental health predicted significantly greater support for addressing housing affordability (73.9% vs 66.2%), and partisanship modified the relationship between mental health and support for improving the economy, improving K-12 education, and housing affordability. CONCLUSIONS: In 2023, there was substantial bipartisan support for federal policy action to address the social determinants of health, and worse mental health was related to greater policy support, particularly among Democrats. Federal policymakers have a broad consensus to take action to address the social determinants of health, which may improve the population mental health.

An Asset Framework to Guide Nonhealth Policy for Population Health.

This JAMA Forum discusses 3 types of assets (financial, physical, and social) that unlock access to resources and shape population health.

Prevalence and Risk Factors of Depression and Posttraumatic Stress Disorder After a Mass Shooting.

This cross-sectional study examines the self-reported mental health outcomes of adults 4 years after witnessing and surviving the shooting at the Route 91 Harvest Music Festival in Las Vegas, Nevada.

Neighborhood-level economic characteristics and depression and PTSD symptoms among Houstonians who have experienced Hurricane Harvey and COVID-19.

Little is known about how neighborhood economic characteristics relate to risk of depression and Posttraumatic Stress Disorder (PTSD) in the context of multiple disasters. We sampled 88 super neighborhoods in Houston, Texas and surveyed 872 residents who were living in Houston during Hurricane Harvey and COVID-19 and lived in the same residence since Hurricane Harvey, about their demographics and symptoms of depression and PTSD. Using data from the American Community Survey, we estimated neighborhood-level unemployment, median income, and income inequality (i.e., Gini coefficient). We investigated whether these underlying neighborhood socioeconomic factors were associated with the mental health consequences of mass traumatic events. We examined associations between neighborhood-level constructs and individual-level depression and PTSD, using multilevel linear models. Partially adjusted multilevel models showed that lower neighborhood median income was associated with higher symptom scores of PTSD, while greater neighborhood income inequality was associated with higher symptom scores of depression and PTSD. However, fully adjusted models showed that these associations are better accounted for by event-specific stressors and traumas. These findings suggest that in the context of multiple large scale traumatic events, neighborhood socioeconomic context may structure individual-level exposure to stressful and traumatic events.