Many community-dwelling African Americans interviewed in the NSAL endorsed high levels of neighborhood crime and drug problems – 1 in 5 and 2 in 5, respectively. Although the directionality is uncertain, there is a positive association between reported neighborhood stressors and psychiatric disorder prevalence, which is consistent with previous work suggesting that perceived neighborhood problems correspond with increased mental distress [12
]. Furthermore, while the status of previous neighborhood environments in which the participants resided is unknown, the association we found between a 12-month history of mental illness with the current neighborhood environment is suggestive that a link between mental health and living environment may exist. Overall community-dwelling African Americans are less likely to have psychiatric disorders than whites [21
], however, this study’s sample of African Americans that reported problems with neighborhood stressors had more substance use and similar levels of anxiety and mood disorders compared to a national (largely white) population [23
]. The association between perceived neighborhood problems and mental illness is concerning because a large proportion of African Americans reported these problems and African Americans also suffer from mental healthcare inequities. Relative to whites, African Americans are more likely to lack health insurance and have Medicaid (a health insurance program for the poor) [24
], experience a more severe, chronic course of depression [25
], not access and receive adequate mental health services [26
], prematurely terminate treatment [28
], and be less accurately diagnosed with mental illness in primary care clinics [29
]. Neighborhood stressors endured by many African Americans may have an underappreciated contribution to the presence of mental healthcare disparities and merit further consideration as potential healthcare barriers. For example, very frequent neighborhood crime may interfere with a person’s ability to comfortably and safely attend primary care visits or psychotherapy sessions.
The association between these neighborhood stressors and mental illness may result in part because African Americans perceiving higher levels of neighborhood problems were more socioeconomically disadvantaged than other African Americans. Those reporting high levels of neighborhood problems were more likely to be unemployed, be unmarried, have less education, and have lower income – all of which may either impact mental health or result from mental illness [21
]. After accounting for these characteristics in logistic regression modeling, however, the association between neighborhood problems and psychiatric disorders persisted. Interestingly, the association between neighborhood characteristics and mental illness was strongest for the substance use disorders and weaker for mood disorders. The reasons for these differential findings are unclear. One proposed hypothesis is that African Americans living in stressful environments may engage in unhealthy behaviors (e.g., drug use) as a coping mechanism, which may be associated with lower levels of depression in African Americans [4
Defining cause and effect relationships between psychiatric illness and neighborhood variables is difficult, because individual factors can affect neighborhood factors and vice versa [7
]. For example, psychiatric disorders can result in substantially decreased earnings [33
]. Decreased earnings can limit a person’s housing options, leading to relatively more mentally ill people residing in distressed communities (i.e., “downward drift”), as well as a person’s ability to positively invest in the community. Distressed communities may in turn have fewer formal (e.g., primary care offices) and informal (e.g., social support networks) resources to help alleviate residents’ mental illness. In such a situation, both the individual- (mental illness resulting in less income) and neighborhood-level (community’s socioeconomic distress leading to fewer formal and informal resources) variables could negatively impact each other.
Our finding that African Americans living in communities with higher levels of perceived crime and drugs are more likely to suffer from mental illness is concerning because mentally ill people are also more likely to be victimized by crime [34
]. This may result in a circular situation in which those suffering from mental illness are more likely to be exposed to crime, which perpetuates their illness, and so on. In such situations, traditional therapeutic approaches (e.g., prescription medications, primary care, and outpatient mental health) may successfully treat the disease symptoms while neglecting important social factors (e.g., neighborhood vandalism, crime, and drugs). Different approaches may be warranted, especially since community-dwelling populations may suffer from anxiety and depression for many years [35
] and psychiatric disorders can have serious consequences.
More comprehensively understanding neighborhood context may inform treatment and research approaches that better account for the social and psychological factors of disease. Investigating neighborhood context thereby has great potential to further our understanding of disease development and to inform neighborhood-level policy to counter disease development [7
]. Mental health experts can apply their expertise to inform the development of neighborhood interventions, and many have already done so (e.g., enhancing support networks, strengthening community block organizations) [2
]. Improving neighborhood characteristics such as collective efficacy (e.g., social cohesion and willingness to work towards the common good) may result in less neighborhood violence [37
]. Neighborhoods also have the potential to help mentally ill people recover [38
] as well as protect against mental illness [39
]. It follows that future interventions may be more effective if they consider both a person’s mental illness symptoms and neighborhood factors that could contribute to such symptoms.
This study has some limitations. First, we do not have objective information (e.g., crime reports) on the levels of crime and drug use in respondents’ neighborhoods. While self-reported neighborhood problems correlate with objective measures of crime, individual characteristics may also differentially influence experience in and perception of the neighborhood [40
]. For instance, anxious respondents may (or may not) systematically over-report neighborhood problems. Future studies should thereby include objective neighborhood reports to confirm the association we found between mental illness and self-reported neighborhood crime and drug use. Second, the self-reported neighborhood problems only approximate neighborhood-level variables as they are individual-level assessments of the neighborhood. The publically available dataset did not have census tract information available, which precludes us from grouping residents by their neighborhoods. Lacking this information also prevents us from incorporating objective assessments of the neighborhoods such as poverty and educational status. Third, the analyses examine cross-sectional data, and we can only speculate on the direction of the relationship between our exposure and outcome variables. Fourth, the research interviews were not conducted by mental health professionals, and reliance on non-mental health professionals for data collection may lead to inaccuracies in psychiatric disorder prevalence estimates. When compared to the gold standard clinician-administered Structured Clinical Interview for the DSM-IV, however, the Composite International Diagnostic Interview demonstrated a moderate to good concordance (area under the ROC curves were between 0.6 and 0.9) for lifetime history of anxiety, mood, and substance use disorders as well as 12-month anxiety and mood disorders [41
]. Fifth, the length of time participants had lived in their neighborhood is unknown. We are subsequently unable to examine how the duration of neighborhood residency associates with mental illness. Sixth, African Americans are overrepresented in disadvantaged groups not examined by the NSAL (e.g., homeless population), exclusion of which may result in underestimation of the actual mental illness burden and obscure the relationship between neighborhood problems and mental illness.
Nevertheless, to our knowledge these analyses are the first to use a nationally representative sample of African Americans to characterize the association between perceived neighborhood problems with crime and drugs with anxiety, mood, and substance use disorders in this population. This study provides evidence of a positive association between these neighborhood stressors and psychiatric disorders. After accounting for sociodemographics and chronic illness, the association between perceived neighborhood problems and mental illness remained. Our findings raise further support for investigating neighborhood factors and designing interventions that target both individuals as well as the disadvantaged communities in which many of them reside. In particular, the association between recent mental illness and current neighborhood living environment is of concern. Longitudinal studies are needed to determine the directionality of this association. To confirm our findings, the association between mental illness and objective measures of neighborhood stress such as poverty levels, educational attainment, and crime reports should be further examined.