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.