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.

Pandemic stressors and mental health indicators in eight countries.

PURPOSE: The Covid-19 pandemic has exacted a significant physical, financial, social, and emotional toll on populations throughout the world. This study aimed to document the association between pandemic stressors and mental health during the pandemic across countries that differ in cultural, geographic, economic, and demographic factors. METHODS: We administered an online survey randomly in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States from September 2020 to November 2020. This survey included questions on Covid-19-related stressors as well as the Patient Health Questionnaire-2 and the Primary Care PTSD Checklist to screen for depression and post-traumatic stress disorder (PTSD) symptoms, respectively. We performed bivariable and multivariable regression analyses to assess the prevalence and odds ratios of overall depression symptoms and probable PTSD and in relation to stressors across countries. RESULTS: Among 8754 respondents, 28.9% (95% CI 27.5-30.0%) experienced depression symptoms, and 5.1% (95% CI 4.5-6.0%) experienced probable PTSD. The highest prevalence of depression symptoms was in Egypt (41.3%, 95% CI 37.6-45.0%) and lowest in the United States (24.9%, 95% CI 22.3-27.7%). The highest prevalence of probable PTSD was in Brazil (7.3%, 95% CI 5.6-9.4%) and the lowest in China (1.2%, 95% CI 0.7-2.0%). Overall, experiencing six or more Covid-19-related stressors was associated with both depression symptoms (OR 1.90, 95% CI 1.46-2.48) and probable PTSD (OR 13.8, 95% CI 9.66-19.6). CONCLUSION: The association between pandemic related stressors and the burden of adverse mental health indicators early in the Covid-19 pandemic transcended geographic, economic, cultural, and demographic differences between countries. The short-term and long-term impacts of the pandemic on mental health should be incorporated in efforts to tackle the consequences of Covid-19.

Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults.

BACKGROUND: COVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic. METHODS: Between 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups. RESULTS: We found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression. CONCLUSION: Populations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Do assets explain the relation between race/ethnicity and probable depression in U.S. adults?

Depression is a leading cause of disability in the U.S. across all race/ethnicity groups. While non-Hispanic Black and Hispanic persons have worse physical health on most indicators than non-Hispanic White persons, the literature on the association between race/ethnicity and rates of depression is mixed. Given unequal distribution of assets across racial/ethnic groups, it is possible that social and economic differences may explain differential rates of depression across race/ethnicity groups. Using National Health and Nutrition Examination Survey (NHANES) data from 2007-2016, we constructed a nationally representative sample of 26,382 adults over 18 years old (11,072 non-Hispanic White, 5,610 non-Hispanic Black, 6,981 Hispanic, and 2,719 Other race). We measured symptoms of depression using the Patient Health Questionnaire-9 (PHQ-9), with a score of 10 or more indicating probable depression. We identified three kinds of assets: financial assets (income), physical assets (home ownership), and social assets (marital status and education). We estimated the weighted prevalence of probable depression across race/ethnicity groups, odds ratios controlling for assets, and predicted probabilities of probable depression across race/ethnicity and asset groups. Three results contribute to our understanding of the differences in probable depression rates between race/ethnicity groups: 1) Non-Hispanic Black and Hispanic persons had a higher weighted prevalence of probable depression in the U.S. than non-Hispanic White persons. In models unadjusted for assets, non-Hispanic Black and Hispanic persons had 1.3 greater odds of probable depression than non-Hispanic White persons (p<0.01). 2) We found an inverse relation between assets and probable depression across all race-ethnicity groups. Also, non-Hispanic Black and Hispanic persons had fewer assets than non-Hispanic Whites. 3) When we controlled for assets, non-Hispanic Black and Hispanic persons had 0.8 times lower odds of probable depression than non-Hispanic White persons (p<0.05). Thus, when holding assets constant, minorities had better mental health than non-Hispanic White persons in the U.S. These three findings help to reconcile findings in the literature on race/ethnicity and depression. Given vastly unequal distribution of wealth in the U.S., it is not surprising that racial minorities, who hold fewer assets, would have an overall larger prevalence of mental illness, as seen in unadjusted estimates. Once assets are taken into account, Black and Hispanic persons appear to have better mental health than non-Hispanic White persons. Assets may explain much of the relation between race/ethnicity group and depression in the U.S. Future research should consider the role of assets in protecting against mental illness.

Is wealth associated with depressive symptoms in the United States?

PURPOSE: The aim of the study was to assess the relation between family wealth and depression in U.S. adults. METHODS: Participants were 5134 members of the 2015-2016 National Health and Nutrition Examination Survey who were aged 18 years or older and completed the depression screener. Using the Patient Health Questionnaire and household demographics interview data, we calculate the adjusted odds of depressive symptoms for persons with low relative to high family savings, using multivariable logistic regression. We estimate predicted probabilities of having depressive symptoms for low and high family savings groups at low, middle, and high family income categories. RESULTS: Overall, 57.4% of the total weighted population had low family savings (below $20,000), and 23.7% of the weighted population had depressive symptoms. Persons with low family savings had 1.49 times higher odds (95% confidence interval, 1.01-2.21) of having depressive symptoms than persons with high family savings, controlling for gender, age, race, education, marital status, family size, and family income. Predicted probabilities of depressive symptoms were higher for low family savings groups than high family savings groups at every income level. CONCLUSIONS: Family wealth is associated with lower prevalence of current depressive symptoms in U.S. adults. Wealth may be an important determinant of population mental health, separate and independent from income.

Potential Impact of 2020 US Decennial Census Data Collection on Disaster Preparedness and Population Mental Health.

Increasing in frequency and impact in the United States and worldwide, disasters can lead to serious mental health consequences. Although US census data are essential for disaster preparedness and the identification of community-level risk factors for adverse postdisaster mental health outcomes, the US Census Bureau faces many challenges as we approach 2020 Decennial Census data collection. Despite the utility of the information provided by the Census and American Community Survey (ACS), the 2020 US Census and subsequent ACS data face threats to validity. As a result, public health funding could be misallocated, and disaster preparedness and response efforts misinformed; this can also contribute to the worsening of mental health inequities, particularly in the context of disaster. Undercutting the Census and the ACS, rich data sources that allow representation of all people in the United States, is a step backward in our effort to mitigate the population mental health consequences of disasters.

Improved social services and the burden of post-traumatic stress disorder among economically vulnerable people after a natural disaster: a modelling study.

BACKGROUND: Hurricanes and other natural disasters produce public health and economic consequences that last well beyond their immediate aftermath. Resource loss is a core driver of post-traumatic stress disorder (PTSD) after large-scale traumatic events. We examined the effect of restoration of residential and housing-related financial resources on recovery from PTSD in post-disaster contexts. METHODS: We built an agent-based model, empiricised with observational and experimental data, to test the effects of differing health service approaches on PTSD recovery, measured by prevalence and persistence. We tested a social services case management (SSCM) approach similar to Psychological First Aid, featuring shelter-based social service provision and linkage to mental health treatment for people who were displaced and had income loss, by comparing the treatment effectiveness of usual care alone, usual care with SSCM, stepped care alone, and stepped care with SSCM. FINDINGS: An SSCM approach to restore housing and provide linkage to mental health services among people who were displaced and had income loss after a large-scale natural disaster resulted in between 1·56 (95% CI 1·55-1·57) and 5·73 (5·04-6·91) times as many remitted PTSD cases as non-SSCM conditions at the end of the first year, and between 1·16 (1·16-1·17) and 2·28 (2·25-2·32) times as many remitted cases at the end of the second year. INTERPRETATION: Restoring economic and housing resources to populations affected by a natural disaster would significantly reduce the mental health burden in populations, particularly those with resource loss, after a disaster. FUNDING: US Department of Health and Human Services.

Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster.

Importance: Psychiatric interventions offered after natural disasters commonly address subsyndromal symptom presentations, but often remain insufficient to reduce the burden of chronic posttraumatic stress disorder (PTSD). Objective: To simulate a comparison of a stepped care case-finding intervention (stepped care [SC]) vs a moderate-strength single-level intervention (usual care [UC]) on treatment effectiveness and incremental cost-effectiveness in the 2 years after a natural disaster. Design, Setting, and Participants: This study, which simulated treatment scenarios that start 4 weeks after landfall of Hurricane Sandy on October 29, 2012, and ending 2 years later, created a model of 2 642 713 simulated agents living in the areas of New York City affected by Hurricane Sandy. Interventions: Under SC, cases were referred to cognitive behavioral therapy, an evidence-based therapy that aims to improve symptoms through problem solving and by changing thoughts and behaviors; noncases were referred to Skills for Psychological Recovery, an evidence-informed therapy that aims to reduce distress and improve coping and functioning. Under UC, all patients were referred only to Skills for Psychological Recovery. Main Outcomes and Measures: The reach of SC compared with UC for 2 years, the 2-year reduction in prevalence of PTSD among the full population, the 2-year reduction in the proportion of PTSD cases among initial cases, and 10-year incremental cost-effectiveness. Results: This population of 2 642 713 simulated agents was initialized with a PTSD prevalence of 4.38% (115 751 cases) and distributions of sex (52.6% female and 47.4% male) and age (33.9% aged 18-34 years, 49.0% aged 35-64 years, and 17.1% aged ≥65 years) that were comparable with population estimates in the areas of New York City affected by Hurricane Sandy. Stepped care was associated with greater reach and was superior to UC in reducing the prevalence of PTSD in the full population: absolute benefit was clear at 6 months (risk difference [RD], -0.004; 95% CI, -0.004 to -0.004), improving through 1.25 years (RD, -0.015; 95% CI, -0.015 to -0.014). Relative benefits of SC were clear at 6 months (risk ratio, 0.905; 95% CI, 0.898-0.913), with continued gains through 1.75 years (risk ratio, 0.615; 95% CI, 0.609-0.662). The absolute benefit of SC among cases was much stronger, emerging at 3 months (RD, -0.006; 95% CI, -0.007 to -0.005) and increasing through 1.5 years (RD, -0.338; 95% CI, -0.342 to -0.335). Relative benefits of SC among cases were equivalent to those observed in the full population. The incremental cost-effectiveness of SC compared with UC was $3428.71 to $6857.68 per disability-adjusted life year avoided, and $0.80 to $1.61 per PTSD-free day. Conclusions and Relevance: The results of this simulation study suggest that SC for individuals with PTSD in the aftermath of a natural disaster is associated with greater reach than UC, more effectiveness than UC, and is well within the range of acceptability for cost-effectiveness. Results should be considered in light of limitations inherent to agent-based models.

Population health in an era of rising income inequality: USA, 1980-2015.

Income inequality in the USA has increased over the past four decades. Socioeconomic gaps in survival have also increased. Life expectancy has risen among middle-income and high-income Americans whereas it has stagnated among poor Americans and even declined in some demographic groups. Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution-ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans. Having missed out on decades of income growth and longevity gains, low-income Americans are increasingly left behind. Without interventions to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century health-poverty trap and the further widening and hardening of socioeconomic inequalities in health.

Perceived Service Need After Hurricane Sandy in a Representative Sample of Survivors: The Roles of Community-Level Damage and Individual-Level Stressors.

OBJECTIVE: We aimed to explore how individually experienced disaster-related stressors and collectively experienced community-level damage influenced perceived need for mental health services in the aftermath of Hurricane Sandy. METHODS: In a cross-sectional study we analyzed 418 adults who lived in the most affected areas of New York City at the time of the storm. Participants indicated whether they perceived a need for mental health services since the storm and reported on their exposure to disaster-related stressors (eg, displacement, property damage). We located participants in communities (n=293 census tracts) and gathered community-level demographic data through the US Census and data on the number of damaged buildings in each community from the Federal Emergency Management Agency Modeling Task Force. RESULTS: A total of 7.9% of participants reported mental health service need since the hurricane. Through multilevel binomial logistic regression analysis, we found a cross-level interaction (P=0.04) between individual-level exposure to disaster-related stressors and community-level building damage. Individual-level stressors were significantly predictive of individual service needs in communities with building damage (adjusted odds ratio: 2.56; 95% confidence interval: 1.58-4.16) and not in communities without damage. CONCLUSION: Individuals who experienced individual stressors and who lived in more damaged communities were more likely to report need for services than were other persons after Hurricane Sandy. (Disaster Med Public Health Preparedness. 2016;10:428-435).