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Edwin van Wijngaarden, Ph.D., Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 644, Rochester, NY 14642, USA, edwin_van_wijngaarden/at/urmc.rochester.edu
Susan G. Fisher, M.S., Ph.D., Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 644, Rochester, NY 14642, USA, susan_fisher/at/urmc.rochester.edu
Thomas M. Richardson, Ph.D., Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 300 Crittenden Boulevard, Rochester, NY 14642, USA, trichardson222/at/gmail.com
Yeates Conwell, M.D., Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 300 Crittenden Boulevard, Rochester, NY 14642, USA, yeates_conwell/at/urmc.rochester.edu
Anxiety and depression in socioeconomically disadvantaged older adults frequently go unrecognized and untreated. This study aims to characterize mental illness and its treatment in older adult public housing residents who have many risk factors for anxiety and depression.
Public housing high-rises in Rochester, NY.
190 residents aged 60 years and older.
Anxiety and depression were assessed using the Structured Clinical Interview for the DSM-IV, GAD-7, and PHQ-9. We obtained information on mental health care from medication review and self-report.
Participants had a median age of 66 years, 58% were female, 80% were black, and 92% lived alone. Many participants (31%) were in need of mental health care: 21% had syndromal and 11% had subsyndromal anxiety or depression. Mental health care need was associated with younger age, intact cognitive functioning, impairments in instrumental activities of daily living (IADL), more medical illness, decreased mobility, smaller social network size, more severe life events, and increased utilization of medical, human, and informal services. Of those with mental health care need, most were not receiving it. Compared to residents receiving mental health care, residents with untreated need were more likely to be male and have less IADL impairment, medical illness, severe life events, onsite social worker use, and human services utilization.
Mental illness was common and largely untreated in public housing residents. Increasing collaboration between medical, mental, and human services is needed to improve identification, treatment, and ultimately prevention of late-life mental illness in this community setting.
The United States’ mental health care system inadequately serves the rapidly expanding minority older adult population.1 Significant disparities are present with minorities having less access to mental health care and receiving lower quality care relative to other groups.2,3 Public housing is a promising setting for helping to understand and possibly overcome some of these mental health care inequalities. A national study of public housing adult residents indicates a high need for mental health care.4 Public housing exists in all 50 states and is home to approximately 900,000 older adults, most of whom are of minority status.5 U.S. citizens or people with eligible immigration status who have low incomes are eligible for public housing, with income requirements varying by locale.6
Older adults living in public housing have characteristics that may put them at risk for mental illness. Especially relevant to the development of late-life anxiety and depression is that residents often live alone and have limited educational attainment, low incomes, and high levels of medical comorbidity and functional impairment.7,8 In Baltimore the prevalence of psychiatric disease in older residents was 1.5 times higher than in a community-based sample. Among these residents, 8% and 2% had a one-month prevalence of a mood and anxiety disorder, respectively.9 Another study estimated that 26% and 12% of older residents had a 12-month prevalence of major depression and generalized anxiety disorder, respectively.8 Examination of a disparate group of psychopathologies (e.g., anxiety, mood, substance use, psychotic, and cognitive disorders) suggests that more than one-third of older adult residents needed mental health care, and in most the need was unmet.7 At six years of follow-up, 70 to 80% of community-dwelling older adults with anxiety or depression continued to suffer from these illnesses.10,11 Left untreated, late-life anxiety and depression are chronic conditions that can have serious consequences, such as increased disability,12,13 disease-specific mortality,13 family disruption,13 lower sense of well-being,12,13 and suicide.13
Our understanding of late-life anxiety and depression in public housing residents is incomplete and at times conflicting. Anxiety and depression prevalence is uncertain as estimates vary widely with depression being uniformly elevated in this setting, but with mixed findings on anxiety disorders.8,9 Furthermore, we have limited knowledge of subsyndromal anxiety and depression in public housing residents. Yet subsyndromal illnesses can cause suffering and lead to poor health outcomes and excess cost.14,16
This study seeks to expand on prior public housing research by characterizing older adult public housing residents with regard to: 1) the prevalence of syndromal and subsyndromal anxiety and depression and 2) the prevalence and correlates of their mental health care need and service utilization. We consider previously identified late-life anxiety and depression correlates17,18 that span multiple domains: 1) sociodemographics, 2) associated mental health, 3) physical health and disability, 4) coping mechanisms, social support, and life events, and 5) various forms of service utilization. Our longer-term objective is to inform the design of community-based interventions that seek to overcome mental health care disparities.
We conducted a two-stage cross-sectional study within four public housing high-rises reserved for older adults in Rochester, NY, from May 2009 through June 2010. The high-rises housed 553 public housing residents who had a median age of 64 years, and 53% were female, 75% were non-Hispanic, and 61% were black. The University of Rochester Research Subjects Review Board approved this study.
During Stage 1, we sent a series of mailings (in English and Spanish) to all residents and organized a series of onsite educational and recruitment activities. The purpose of Stage 1 was to engage residents in the study, provide data across demographic groups, and facilitate recruitment into Stage 2’s psychiatric research interview. The first two mailings contained educational material on late-life health issues. Onsite educational booths were staffed to coincide with these mailings. The 3rd and 4th mailings had a questionnaire assessing demographics and general health; the 4th mailing was sent to non-responders. After completing the health questionnaire, residents returned it to an onsite recruitment booth where they were immediately reimbursed $5. On the questionnaire, residents indicated their willingness to participate in the Stage 2 interview.
Stage 2 comprised a 1.5 hour psychiatric research interview conducted in English either in the participant’s apartment or a different private onsite location. To participate in the interviews, residents had to be English-speaking, be aged 60 years and older, and have capacity to provide informed consent. The interview assessed sociodemographic characteristics; mental health; physical health and disability; coping mechanisms, social support, and life events; and service utilization domains. Interview participants received $25.
Stage 1 had 358 participants (65% response rate) with responders were more likely to be non-Hispanic (χ2 = 14.849, degrees of freedom = 1, p < 0.001) and black (Fisher’s Exact Test: p < 0.001) than non-responders. Of Stage 1 responders, 210 (59%) met eligibility criteria for Stage 2; the most common reasons for Stage 1 responders being ineligible for Stage 2 were age younger than 60 years (n = 101; 28%) and inability to speak English (n = 35; 10%). The Stage 2 interview had 190 participants, which constituted the sample for analyses presented here. This sample included 180 (62%) of an estimated 292 non-Hispanic residents aged 60 years and older who were English-speaking and cognitively able to provide informed consent. The high-rises were also home to 89 Hispanic residents aged 60 years and older. Forty-three of these Hispanic residents completed the Stage 1 questionnaire. Only 13 of these 43 responders could speak English, of whom we interviewed 10.
Among non-Hispanic Stage 2 eligible residents, Stage 2 responders were younger than the 112 non-responders (66.3 vs. 71.5 years, respectively; Mann-Whitney Test: z = 3.749, p < 0.001), but did not differ by gender or race. These analyses of non-response characteristics of eligible Stage 2 residents did not include Hispanic residents because we did not know which of the 46 Stage 1 non-responding Hispanic residents had the English-speaking ability necessary for participation.
The Structured Clinical Interview for the DSM-IV (SCID) is based on DSM-IV-TR criteria.19 In our study, the SCID evaluated the presence of panic disorder with and without agoraphobia, agoraphobia without history of panic disorder, social phobia, specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, major depressive episode, and dysthymic disorder.19 All interviews were conducted by the first author (A.S.) and diagnoses were assigned based on review of all available data by a geriatric psychiatrist (Y.C.).
The GAD-7 is a seven-item anxiety scale scored from 0 to 21. A score of 10 or greater has a sensitivity of 68% and specificity of 88% for detecting generalized anxiety, posttraumatic stress, panic, and social anxiety disorders.20 The suggested severity threshold values for the GAD-7 are 0 to 4 (minimal), 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe).20 We defined subsyndromal anxiety as a GAD-7 score of at least 10 in the absence of a current (syndromal) anxiety disorder as diagnosed by the SCID.
The PHQ-9 is a nine-item depression scale scored from 0 to 27. A score of 10 or greater has a sensitivity and specificity both equal to 88% for detecting major depression.21 The suggested PHQ-9 severity threshold values are 0 to 4 (minimal), 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe).21 We defined subsyndromal depression as a PHQ-9 score of at least 10 in the absence of a current (syndromal) major depressive episode or dysthymic disorder as diagnosed by the SCID.
Participants reported if and when they had seen a mental health professional for either inpatient or outpatient care. They also reported whether they were currently prescribed medication for any mental health problem such as depression, anxiety, or stress. Furthermore, we reviewed medications and medication lists to document anxiolytic and antidepressant use; we did not examine use of antipsychotics, anticonvulsants, or lithium. We also asked interviewees whether in the past six months they felt they might need to see a professional because of problems with emotions or nerves. Lastly, participants rated their current mental health as very bad, poor, fair, good, or excellent.
We defined residents with psychiatric need as those having at least one of four criteria present: 1) syndromal anxiety and/or depression as diagnosed by the SCID, 2) subsyndromal anxiety and/or depression, 3) self-rated mental health that was reported as poor or very bad, or 4) self-reported need to see a professional in the past six months because of problems with emotions or nerves. Subsyndromal anxiety and depression were included with syndromal disorders when examined as indicators of mental health care need. Doing so provides a sample size better suited to analysis of the relationship of interest to us. Additionally, subsyndromal anxiety and depressive disorders as defined here represent clinically significant conditions with at least a moderate degree of symptom severity based on their GAD-7 and PHQ-9 cut-off scores.
We considered mental health treatment received if residents satisfied at least one of three criteria: 1) saw a mental health professional within the past six months, 2) were currently prescribed a medication for mental health problems based on self-report, or 3) had an anxiolytic or antidepressant based on medication review.
To provide a context for characterizing mental health treatment need, we examined late- life anxiety and depression correlates that spanned five domains.
Self-report provided information on age, education, gender, race, and living status.
We evaluated cognitive impairment with the Mini-Cog. The Mini-Cog has comparable sensitivity (99%) and specificity (93%) to the Mini-Mental Status Exam for detecting dementia.22
In this domain we included activities of daily living (ADLs),23 instrumental activities of daily living (IADLs),24 and a list of medical conditions (adapted from the Minimum Data Set25). Additionally, the Life-Space Assessment rated mobility within an individual’s home, immediate surroundings, neighborhoods, towns, and beyond; the total score ranged from 0 to 120.26
The Brief COPE evaluates coping using 14 two-item subscales.27 Based on adaptive and maladaptive coping research,27–29 we dichotomized the 14 subscales into adaptive coping (active coping, planning, using instrumental support, positive reframing, acceptance, religion, using emotional support, humor) and maladaptive coping (venting, behavioral disengagement, denial, self-distraction, self-blame, substance use). The adaptive and maladaptive coping summary scores ranged from 0 to 48 and 0 to 36, respectively. The six-item Lubben Social Network Scale assessed family and friend support as a measure of isolation in community-dwelling older adults.30 The combined family and friend score ranged from 0 to 30. The Multidimensional Scale of Perceived Social Support characterized perceived social support with 12 questions. Its total score ranged from 12 to 84.31 We modified the Louisville Older Persons Events Scale32 to measure negative life events within the three months preceding the interview. The worst reported event’s subjective impact was assessed with three questions concerning 1) the amount of change attributed to the event, 2) how bad the event was, and 3) how much it has been on the participant’s mind. The summary score ranged from 0 to 9, with a higher score representing greater impact of the event.
To characterize healthcare and human services utilization in the past three months we combined items from the Cornell Services Index, which evaluates health services use,33 with items from a list of human and healthcare services.34 Our modified Cornell Services Index had summary scores representing the number of health (0 to 12) and human services (0 to 13) used. Six questions assessed informal service utilization, some of which were derived from a previous study.35 These questions asked if the resident had received assistance from family members, friends, or clergy in the past three months for medical, non-medical, emotional, nerves, alcohol or drugs, or mental health reasons. Total informal support scores ranged from 0 to 6. History of ever receiving assistance from the onsite social worker (yes/no) was determined by examining social worker records.
Basic descriptive statistics (e.g., medians, interquartile ranges) described the participant characteristics, prevalence of anxiety and depression, and utilization of mental health services. Bivariate analyses characterized differences between two types of resident groupings: 1) residents with and without mental health care need and 2) residents with mental health care need that had and had not received mental health treatment. Pearson Chi-Square and Fisher’s Exact tests examined differences in categorical variables. The non-parametric Mann-Whitney Test for non-normal data contrasted differences in continuous variables. Based on the bivariate analyses of residents with and without mental health care need, we included variables with a p-value of 0.10 or less in a multivariate logistic regression model to estimate the risk of having mental health care need. This model used a stepwise selection method with an entry and stay p-value of 0.10. Because of the limited sample size of residents needing mental health care, we did not use multivariate logistic regression to estimate the risk of not receiving mental health care in this group. We conducted our analyses with SAS statistical software version 9.2 (SAS Institute, Inc., Cary, NC).
The study’s 190 participants had a median age of 66 years (interquartile range: 63 to 73), and 95% were non-Hispanic, 80% were black, 58% were women, 47% had not completed 12th grade, and 92% lived alone.
Thirty-nine (21%) residents had syndromal or subsyndromal anxiety, and 28 (15%) residents had syndromal or subsyndromal depression. In total, 48 (25%) residents were experiencing a syndromal and/or subsyndromal condition (Table 1). Analyses of mental illness by race or ethnicity yielded no significant differences across demographic groupings (data not shown).
Mental health care need was present if residents fulfilled at least one of four criteria: 1) 39 (21%) residents had syndromal anxiety and/or depression, 2) 21 (11%) had subsyndromal anxiety and/or depression, 3) 7 (4%) had poor self-reported mental health, and 4) 23 (12%) reported a need to see a mental health professional in the six months prior to the interview. Combining these indicators of mental distress, 59 (31%) public housing residents had a need for mental health care (Table 2).
Among all interviewees, 18 (10%) reported seeing a mental health professional in the prior six months and, based on medication review, 44 (23%) were prescribed an antidepressant and 7 (4%) an anxiolytic. Twenty-eight (21%) residents without a mental health care need were receiving mental health care treatment. Of those with a mental health care need, only 27 (46%) had received treatment.
Those with mental health care need were younger (64 vs. 68 years) and had less cognitive impairment, more IADL impairments, more medical conditions, less mobility, smaller social networks, more severe life events, and more utilization of medical (e.g., outpatient doctor visits), human (e.g., transportation assistance), and informal (e.g., family assistance) services than those without need for mental health care (Table 3). In a multivariate logistic regression analysis, younger age, smaller social network size, more severe recent life events, and more medical services utilization were independently associated with mental health care need (Table 4).
Among residents with need for mental health services, residents receiving mental health care had more IADL impairments, medical conditions, severe life events, and human services utilization and were more likely to be female (78% vs. 50%) and use the onsite social worker (100% vs. 78%) than those not receiving mental health care (Table 5).
Syndromal and subsyndromal anxiety and depression afflicted 1 in 4 older adult public housing residents participating in our study. Our one-month syndromal anxiety prevalence (17%) is more consistent with the Connecticut public housing study (12-month generalized anxiety disorder: 12%) than the Baltimore study (one-month anxiety disorder: 2%), while our syndromal depression level (6%) is in agreement with the Baltimore study (one-month major depression: 6%), but not the Connecticut study (12-month major depression: 26%).8,9
In addition to the disadvantaged socioeconomic situation experienced by many residents, residents had high levels of medical comorbidity and functional impairment, characteristics that can increase the residents’ risk for late-life anxiety and depression.17 Congruent with prior work,17 and highlighting the complex interplay of factors that contribute to mental health care need, characteristics spanning sociodemographic; associated mental health; physical health and disability; coping mechanisms, social support, and life events; and service utilization domains were associated with mental health care need. Functionally impaired and medically ill residents with limited mobility and social support networks were especially at risk.
Our treatment need findings closely paralleled a previous study that estimated 37% of residents needed mental health care, of whom the mental health care need was unmet in 58% (our respective estimates were 31% and 54%).7 Interestingly, among our participants with mental health care need, the most vulnerable residents (e.g., medically ill, functionally impaired) were more likely to have received mental health care.
Current evidence indicates that the mental health system does not benefit many of these older adult residents. To improve the mental health system, investigators have devised outreach programs that can increase identification and subsequent treatment of late-life mental illness.36 Many of the outreach programs, however, require a mental health specialist team. This highly credentialed team can be cost-prohibitive to sustain or translate to locations where funding is limited. Alternative, more sustainable and context-dependent approaches are needed. Approaches that empower extant community agencies to serve as a safety net for mentally ill older adults may be especially pragmatic – especially in settings that have health and social work professionals directly available to those with mental health care need. Such an approach has been applied to home healthcare services.37 The public housing setting is also uniquely well-suited for community-based interventions because there is demonstrated need for mental health services and social work professionals interact closely with many of the residents.
To some extent, public housing high-rises may loosely represent a form of assisted living for community dwelling older adults: rent and utilities are highly subsidized, services can be readily accessible (e.g., transportation assistance), and maintenance workers are freely available for home repairs. Additionally, in our region as elsewhere,38 many public housing high-rises have onsite social workers that interact daily with the residents. A major function of these social workers is to connect residents to outside resources and help residents age-in-place. Onsite social workers had – at one time or another – provided assistance to 84% of our participants, and they may be ideal candidates for connecting residents to indicated mental health care. One possibility would be for the onsite social workers to use anxiety and depression screening tools and refer positive screens for further evaluation and care. Utilizing onsite social workers to systematically screen, refer, and possibly treat (e.g., problem-solving therapy for subsyndromal depression) the residents could require fewer resources and be more easily adopted than outreach models that rely on using (and funding) mental health specialists.
Our findings have some limitations. First, this study occurred in a single locale, interviewed English-speakers only, and had higher response among non-Hispanics and younger residents, which may limit its generalizability (e.g., it is not generalizable to non-English-speaking Hispanic residents). Second, we lacked detailed information on study non-responders, limiting our ability to characterize them. Nonetheless, our study had a good response among the non-Hispanic and black residents who constitute about 4 in 5 and 1 in 2 national public housing residents, respectively.5 Third, the interviews may not have been conducted in a participant’s native or preferred language. Since many of the 10 Hispanic interviewees were likely native Spanish speakers, we excluded them in sensitivity analyses which yielded findings that had negligible differences with the analyses including these Hispanic residents. Fourth, we did not have access to patient records and have incomplete information on prescription medications, including the doses and indications for which they were prescribed, and the participant’s treatment adherence. This precluded our ability to examine treatment adequacy and appropriateness, and prevents us from knowing whether the mental health care received by the 21% of residents not meeting our need criteria represents successful treatment. Lastly, we did not adjust for multiple comparisons (increases the possibility of Type I Error) in an effort to minimize Type II Error,39 which we regard at this stage of research to be a greater threat. Therefore, we have attempted to interpret the findings conservatively and in light of the overall pattern of findings.
This study illustrates the relatively high prevalence of syndromal anxiety and depression among these older adult residents, reinforces the evidence that there is considerable unmet mental health care need in this setting, and was the first to examine subsyndromal late-life anxiety and depression. Future research in public housing should include other regions of the United States as most studies have been located in the Northeast. Nonetheless, these findings indicate potential opportunities to improve mental health care in this setting (e.g., prevention studies targeting subsyndromal conditions). Sustainable community-based interventions should be designed and tested as a means to reduce the mental health disparities evident in these vulnerable older adults.
The authors thank the staff of the Rochester Housing Authority and Eldersource for making this work possible. Adam Simning is a trainee in University of Rochester’s Medical Scientist Training Program funded by National Institutes of Health (NIH) T32 GM07356, and this research was supported in part by grants from the Agency for Healthcare Research and Quality (AHRQ) (R36 HS018246), National Institute for Mental Health (NIMH) (R24 MH071604), and the National Center for Research Resources (NCRR) (TL1 RR024135), a component of the NIH and NIH Roadmap for Medical Research. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the AHRQ, NIMH, NCRR, or NIH.
Conflict of Interest: No disclosures to report.
Previous Presentation: We will present some of this article’s findings at the Annual Meeting of the American Association for Geriatric Psychiatry in San Antonio, TX, from March 17-21, 2011.