This cross-sectional study examines self-reported mental health outcomes among a nationally representative sample of US adults who experienced disaster-induced displacement in the past 12 months.
Key Points
Question
How is displacement from home by natural disasters and the duration of the displacement associated with depression and anxiety symptoms among the US adult population?
Findings
In a cross-sectional study of a weighted sample of 183 730 553 adults, natural disaster–induced displacement was associated with increased odds of reporting depression and anxiety symptoms. Individuals who did not return home in the past 12 months had the highest odds of mental health symptoms compared with those with shorter duration of displacement.
Meaning
As natural disasters increase in scale and frequency, there is an urgent need to address mental health care among adults displaced by natural disasters.
Abstract
Importance
Mental health symptoms associated with disaster-induced displacement on a national scale are unknown. Knowledge of mental health outcomes can inform disaster management and recovery.
Objective
To investigate the association of depression and anxiety symptoms with disaster-induced displacement and the duration of displacement.
Design, Setting, and Participants
This cross-sectional study analyzed data from the US Census Bureau Household Pulse Survey, which was administered nationwide online between December 9, 2022, and October 30, 2023. One adult per selected US household with an email and/or mobile telephone number was eligible to participate.
Exposures
Natural disaster–induced displacement from home in the past 12 months and the duration of displacement.
Main Outcomes and Measures
Depression and anxiety symptoms were assessed using shortened (2-item) versions of the Patient Health Questionnaire and the Generalized Anxiety Disorder questionnaire. The composite questionnaire scores were used to determine the participants’ symptoms.
Results
The weighted sample included 183 730 553 US adults (mean [SD] age, 49.22 [16.65] years; 94 445 996 females at birth [51.4%]). In multivariable analyses, individuals who were displaced for more than a week had higher odds of depression (odds ratio [OR], 1.77; 95% CI, 1.40-2.25) and anxiety (OR, 1.54; 95% CI, 1.22-1.94) symptoms compared with those who were not displaced. The longer the duration of displacement, the higher the odds of reporting depression and anxiety symptoms; individuals who never returned home reported higher odds of depression (OR, 2.43; 95% CI, 1.70-3.49) and anxiety (OR, 3.04; 95% CI, 2.10-4.39) symptoms. Socially vulnerable populations, such as younger adults, sexual and gender minority groups, and people with lower educational level, lower annual income, and disabilities, had a higher prevalence of depression and anxiety symptoms.
Conclusion and Relevance
This study found that, in US adults, disaster-induced displacement from home was associated with increased odds of depression and anxiety symptoms, with the highest odds among those who never returned home. There is an urgent need to address mental health care for populations displaced by natural disasters, particularly socially vulnerable populations.
Introduction
Disaster-induced displacement, when individuals are forced to leave their homes due to natural or person-made disasters, has substantial implications for mental health.1,2,3 The psychological impact of such displacement is profound and multifaceted, often associated with increased rates of anxiety, depression, and posttraumatic stress disorder among affected populations.4,5,6 Individuals who experience displacement encounter a variety of stressors, including housing instability or losing their family home, unemployment or decreased financial stability, and lack of community resources, which can intensify feelings of isolation and hopelessness.7
Much of the literature on disaster-induced displacement and mental health outcomes is dominated by studies outside of the US,2,8 limiting the application of the findings to the US population. The few US-based studies that exist are limited by relatively small sample sizes, with many of them involving from 100 to a few hundred participants.3,9,10,11 Compounding this challenge is the lack of a standardized questionnaire that defines mental health symptoms, which limits the generalizability of the evidence.6 Another key knowledge gap is that studies of displaced residents have rarely included those who never returned home, as most studies survey only those who return to disaster sites.12 Additionally, previous studies have focused on a type of disaster, such as hurricanes,9,13 or individual disasters,9,13 thus limiting comparisons of mental health outcomes of different disasters and types of disasters across larger geographic regions of the US.
We used data from a previous US Census Bureau Household Pulse Survey (HPS), which was administered to adults nationwide and included questions on displacement by natural disasters, the duration of displacement, and mental health outcomes. This study’s objective was to investigate the association of depression and anxiety symptoms with disaster-induced displacement and the duration of displacement. As climate change is expected to increase the frequency and intensity of natural disasters,14 knowledge of the extent of outcomes associated with characteristics of displacement can inform mental health service models for disaster-displaced populations in the US.
Methods
The study used data from the cross-sectional online HPS conducted between December 9, 2022, and October 30, 2023 (survey weeks 52-63). The sample was drawn from approximately 130 million housing units derived from the Census Bureau’s Master Address File. More than 85% of addresses in the Master Address File matched with a contact frame consisting of telephone numbers and/or email addresses and were eligible for the sample. One adult respondent from each of the selected households was invited via text and email to complete the survey online. In accordance with the Common Rule, this cross-sectional study was exempt from ethics review and informed consent requirement because deidentified data were used. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.15
The HPS provides person weights that, when applied, are nationally representative of the US adult population. The Census Bureau applies an adjustment to the person weights, which considers nonresponse bias, the occupied housing unit ratio based on the 2021 American Community Survey, and the number of adults living in the sample household. Additionally, it uses an iterative raking procedure to adjust person weights to population controls from Census estimates (ie, the 2021 American Community Survey and the 2022 and 2023 Population Estimates Program) based on demographic characteristics, including age, sex, race, ethnicity, and educational level, within each state.16
Outcomes
Depression and anxiety outcomes were assessed with a modified version of the 2-item Patient Health Questionnaire (PHQ-2) and the 2-item Generalized Anxiety Disorder (GAD-2), respectively.17 Both questionnaires asked about symptoms occurring in the past 2 weeks. For example, the PHQ-2 asked, “Over the last two weeks, how often have you been bothered by … (1) having little interest or pleasure in doing things and (2) feeling down, depressed, or hopeless?” The GAD-2 asked, “How often have you been bothered by … (1) feeling nervous, anxious, or on edge and (2) not being able to stop or control worrying?” Responses and scores included the following: 0 for not at all, 1 for several days, 2 for more than half the days, and 3 for nearly every day. The 2 responses for each scale were summed together, and a score equal to 3 or greater on PHQ-2 and GAD-2 was screened for a diagnosis of major depressive disorder and generalized anxiety disorder, respectively.18,19
Exposures
The exposures of interest were natural disaster–displacement from home and the duration of the displacement. Beginning in December 2022, HPS respondents were asked, “In the past year, were you displaced from your home because of a natural disaster?” Those who responded yes were asked, “How long were you displaced from your home?” Responses included less than a week, more than a week but less than a month, 1 to 6 months, more than 6 months, and never returned to home. Those who responded no to the displacement question were not asked any questions about natural disasters, including disaster types. The no displacement group served as the reference group and may include populations who experienced natural disasters but were not displaced. Respondents with missing data on displacement were excluded from the analysis, as displacement is the primary exposure of interest. The eMethods in Supplement 1 provides details on sample selection.
Covariates
We obtained self-reported sociodemographic characteristics, such as sex at birth, educational level, annual income, and marital status, from the HPS database. Continuous variables, such as age group, household size, and number of children in the home, were grouped into categorical data. For sexual orientation, the responses gay or lesbian, bisexual, something else, and I do not know were grouped into 1 category due to small sample sizes.
We assessed race and ethnicity in the study because an earlier analyses on correlates of disaster-induced displacement indicated that certain population groups, such as non-Hispanic Black and non-Hispanic other, were more likely to be displaced compared with non-Hispanic White.20 Race and ethnicity were self-reported and obtained from 2 separate questions. The HPS database listed 4 categories for race: Asian, Black, White, and other race or combination of races. The other category included American Indian or Alaska Native, Chamorro, Native Hawaiian, Other Pacific Islander, Samoan, or multiracial. Data on Hispanic ethnicity were reported in 2 categories: no—not of Hispanic, Latino, or Spanish origin; yes—of Hispanic, Latino, or Spanish origin. We combined the race and ethnicity variables following a Census practice21 and created 5 categories: Hispanic of any race, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and non-Hispanic other (hereafter as Hispanic, Asian, Black, White, and other, respectively).
Functional disability was derived from a set of 6 questions on difficulty with the following: seeing, hearing, remembering or concentrating, walking or climbing stairs, self-care, and communicating. The responses included no—no difficulty, yes—some difficulty, yes—a lot of difficulty, and cannot do at all. We categorized the last 2 responses (yes—a lot of difficulty and cannot do at all) as having a disability.
Statistical Analysis
Data were pooled across 12 independent survey weeks with a mean (SD) response rate of 6.6% (0.005%) and a mean (SD) number of respondents of 68 912 (5440) per survey week. The final study size was obtained after missing data, ranging from 0% (no missing data) to 7.7% for each variable (eTable in Supplement 1), were dropped from the study sample using listwise deletion. We used person weights provided by the Census Bureau to create nationally representative estimates for all of the analyses.
We generated descriptive statistics using weighted frequency and proportion. We assessed the bivariate association between outcomes (depression and anxiety symptoms) with each independent variable individually using the Rao–Scott χ2 statistics. We ran 2 multivariable logistic regression models to evaluate the association between depression and anxiety symptoms and disaster-induced displacement. The models were adjusted for sociodemographic characteristics to reduce confounding bias; covariates were all categorical data and included age group, sex at birth, sexual orientation, race and ethnicity, educational level, annual income, marital status, household size, number of children in the home, housing type, homeownership, functional disability, and Census region. We reported the odds ratio (OR) and 95% CIs for each independent variable.
Two-sided P < .05 was used to indicate statistical significance. We used R, version 4.4.1 (R Project for Statistical Computing), for all analyses and the survey package svyglm function (Thomas Lumley)22 for the weighted logistic regression. Data analyses were conducted from October 2024 to January 2025.
Results
Of the 183 730 553 US adults in the sample, 2 429 909 (1.3%) reported natural disaster–induced displacement in the past year. The study population had a mean (SD) age of 49.22 (16.65) years, with 48 629 213 people (26.5%) in the 35 to 49 years age category, included 94 445 996 females at birth (51.4%) and 89 284 557 males at birth (48.6%); and 5.1% who self-identified as Asian, 10.0% as Black, 15.7% as Hispanic, 65.0% as White, and 4.2% as other race and ethnicity (Table 1). The majority had no children in the home (64.0%) and lived in a detached single-family home (68.2%).
Table 1. Study Population Characteristics.
| Characteristic | Full weighted sample, No. (%) (N = 183 730 553) |
|---|---|
| Displacement | |
| No displacement | 181 300 644 (98.7) |
| <1 wk | 1 055 617 (0.6) |
| >1 wk but <1 mo | 603 114 (0.3) |
| 1-6 mo | 257 628 (0.1) |
| >6 mo | 176 121 (0.1) |
| Never returned home | 337 428 (0.2) |
| Age group, y | |
| 18-25 | 12 910 601 (7.0) |
| 26-34 | 32 114 374 (17.5) |
| 35-49 | 48 629 213 (26.5) |
| 50-64 | 47 798 068 (26.0) |
| 65-74 | 31 203 102 (17.0) |
| ≥75 | 11 075 195 (6.0) |
| Sex at birth | |
| Female | 94 445 996 (51.4) |
| Male | 89 284 557 (48.6) |
| Sexual orientation | |
| Straight | 161 714 215 (88.0) |
| Gay, lesbian, or bisexual | 22 016 338 (12.0) |
| Race and ethnicitya | |
| Hispanic | 28 764 392 (15.7) |
| Non-Hispanic Asian | 9 328 700 (5.1) |
| Non-Hispanic Black | 18 451 519 (10.0) |
| Non-Hispanic White | 119 508 811 (65.0) |
| Non-Hispanic otherb | 7 677 130 (4.2) |
| Educational level | |
| ≤High school diploma | 62 510 226 (34.0) |
| Some college or associate’s degree | 54 383 077 (29.6) |
| ≥Bachelor’s or graduate degree | 66 837 250 (36.4) |
| Annual income, $ | |
| <35 000 | 41 566 748 (22.6) |
| 35 000-74 999 | 54 036 791 (29.4) |
| 75 000-149 999 | 55 178 714 (30.0) |
| ≥150 000 | 32 948 300 (17.9) |
| Marital status | |
| Now married | 105 558 249 (57.5) |
| Widowed, divorced, or separated | 33 998 377 (18.5) |
| Never married | 44 173 927 (24.0) |
| Household size, persons | |
| 1-2 | 80 149 144 (43.6) |
| 3-4 | 69 667 758 (37.9) |
| ≥5 | 33 913 651 (18.5) |
| No. of children in the home | |
| No children | 117 614 597 (64.0) |
| 1-2 | 52 263 036 (28.4) |
| ≥3 | 13 852 921 (7.5) |
| Housing type | |
| Detached single-family | 125 242 797 (68.2) |
| Attached single-family | 13 447 003 (7.3) |
| Apartment | 34 605 078 (18.8) |
| Otherc | 10 435 675 (5.7) |
| Homeownership | |
| Owner | 129 341 389 (70.4) |
| Renter | 54 389 164 (29.6) |
| Functional disability, severe | |
| No disability | 154 515 378 (84.1) |
| 1 | 21 855 330 (11.9) |
| ≥2 | 7 359 845 (4.0) |
| Census region | |
| Northeast | 31 034 205 (16.9) |
| South | 69 897 331 (38.0) |
| Midwest | 38 621 295 (21.0) |
| West | 44 177 721 (24.0) |
Self-reported by participants.
Includes American Indian or Alaska Native, Chamorro, Native Hawaiian, Other Pacific Islander, Samoan, and multiracial.
Includes mobile home, boat, RV (recreational vehicle), and van.
In the bivariate analyses, displacement was associated with a higher prevalence of depression and anxiety symptoms compared with nondisplacement. For example, depression symptoms were reported in 44.2% of participants who were displaced for more than 6 months compared with 21.6% in the nondisplaced population (Table 2). The prevalence of depression and anxiety symptoms was also highest among those in the youngest (18-25 years) compared with older age groups; who identified as gay, lesbian, or bisexual compared with straight; or with other race and ethnicity compared with Asian, Black, Hispanic, and White groups.
Table 2. Bivariate Correlates of Depression and Anxiety Symptoms.
| Characteristic | Patients, No. (%) | |
|---|---|---|
| Depression symptoms (n = 40 056 618) | Anxiety symptoms (n = 51 473 559) | |
| Displacement | ||
| No displacement | 39 171 782 (21.6) | 50 435 300 (27.8) |
| <1 wk | 279 972 (26.5) | 349 172 (33.1) |
| >1 wk but <1 mo | 238 783 (39.6) | 261 879 (43.4) |
| 1-6 mo | 91 258 (35.4) | 113 335 (44.0) |
| >6 mo | 77 796 (44.2) | 78 971 (44.8) |
| Never returned home | 197 028 (58.4) | 234 902 (69.6) |
| Age group, y | ||
| 18-25 | 4 691 372 (36.3) | 5 580 393 (43.2) |
| 26-34 | 9 582 503 (29.8) | 12 191 218 (38.0) |
| 35-49 | 11 048 577 (22.7) | 14 934 048 (30.7) |
| 50-64 | 9 305 518 (19.5) | 11 995 656 (25.1) |
| 65-74 | 4 193 385 (13.4) | 5 241 105 (16.8) |
| ≥75 | 1 235 264 (11.2) | 1 531 140 (13.8) |
| Sex at birth | ||
| Female | 21 459 503 (22.7) | 29 861 075 (31.6) |
| Male | 18 597 115 (20.8) | 21 612 484 (24.2) |
| Sexual orientation | ||
| Straight | 31 538 242 (19.5) | 40 917 609 (25.3) |
| Gay, lesbian, or bisexual | 8 518 376 (38.7) | 10 555 951 (47.9) |
| Race and ethnicitya | ||
| Hispanic | 7 290 879 (25.3) | 8 874 890 (30.9) |
| Non-Hispanic Asian | 1 519 674 (16.3) | 1 785 565 (19.1) |
| Non-Hispanic Black | 4 212 471 (22.8) | 5 033 484 (27.3) |
| Non-Hispanic White | 24 835 421 (20.8) | 32 990 016 (27.6) |
| Non-Hispanic otherb | 2 198 174 (28.6) | 2 789 604 (36.3) |
| Educational level | ||
| ≤High school diploma | 16 549 799 (26.5) | 19 250 297 (30.8) |
| Some college or associate’s degree | 14 007 250 (25.8) | 17 743 068 (32.6) |
| ≥Bachelor’s or graduate degree | 9 499 570 (14.2) | 14 480 195 (21.7) |
| Annual income, $ | ||
| <35 000 | 13 986 608 (33.6) | 16 394 020 (39.4) |
| 35 000-74 999 | 13 302 286 (24.6) | 16 658 593 (30.8) |
| 75 000-149 999 | 9 546 993 (17.3) | 13 180 151 (23.9) |
| ≥150 000 | 3 220 731 (9.8) | 5 240 796 (15.9) |
| Marital status | ||
| Now married | 17 325 415 (16.4) | 24 097 971 (22.8) |
| Widowed, divorced, or separated | 8 571 864 (25.2) | 10 456 935 (30.8) |
| Never married | 14 159 339 (32.1) | 16 918 653 (38.3) |
| Household size, persons | ||
| 1-2 | 16 038 845 (20.0) | 20 351 425 (25.4) |
| 3-4 | 15 459 740 (22.2) | 20 260 560 (29.1) |
| ≥5 | 8 558 033 (25.2) | 10 861 574 (32.0) |
| No. of children in the home | ||
| No children | 25 379 614 (21.6) | 31 713 763 (27.0) |
| 1-2 | 11 378 087 (21.8) | 15 267 045 (29.2) |
| ≥3 | 3 298 918 (23.8) | 4 492 752 (32.4) |
| Housing type | ||
| Detached single-family | 24 013 440 (19.2) | 31 563 808 (25.2) |
| Attached single-family | 2 920 085 (21.7) | 3 785 360 (28.2) |
| Apartment | 9 900 172 (28.6) | 12 342 764 (35.7) |
| Otherc | 3 222 921 (30.9) | 3 781 628 (36.2) |
| Homeownership | ||
| Owner | 23 066 122 (17.8) | 30 593 908 (23.7) |
| Renter | 16 990 497 (31.2) | 20 879 651 (38.4) |
| Functional disability, severe | ||
| No disability | 25 904 871 (16.8) | 35 505 449 (23.0) |
| 1 | 9 396 896 (43.0) | 10 913 881 (49.9) |
| ≥2 | 4 754 852 (64.6) | 5 054 229 (68.7) |
| Census region | ||
| Northeast | 6 183 140 (19.9) | 8 209 048 (26.5) |
| South | 16 202 779 (23.2) | 20 409 330 (29.2) |
| Midwest | 8 021 125 (20.8) | 10 437 796 (27.0) |
| West | 9 649 574 (21.8) | 12 417 385 (28.1) |
Self-reported by participants.
Includes American Indian or Alaska Native, Chamorro, Native Hawaiian, Other Pacific Islander, Samoan, and multiracial.
Includes mobile home, boat, RV (recreational vehicle), and van.
In our multivariable regression analyses, displacement was associated with depression and anxiety symptoms, particularly for participants who reported displacement of 1 week or longer (Table 3). For example, those who were displaced for more than 1 week but less than 1 month had higher odds of experiencing depression symptoms (OR, 1.77; 95% CI, 1.40-2.25) and anxiety symptoms (OR, 1.54; 95% CI, 1.22-1.94) compared with those who did not experience any displacement. In general, the longer the duration of displacement, the higher the odds of experiencing depression and anxiety symptoms. People who never returned home reported higher odds of depression (OR, 2.43; 95% CI, 1.70-3.49) and anxiety (OR, 3.04; 95% CI, 2.10-4.39) symptoms.
Table 3. Multivariable Analyses of Depression and Anxiety Symptoms Associated With Displacement.
| Characteristica | Odds ratio (95% CI) | |
|---|---|---|
| Depression symptoms (n = 40 056 618) | Anxiety symptoms (n = 51 473 559) | |
| Displacement | ||
| No displacement | 1 [Reference] | 1 [Reference] |
| <1 wk | 1.08 (0.91-1.29) | 1.13 (0.92-1.38) |
| >1 wk but <1 mo | 1.77 (1.40-2.25) | 1.54 (1.22-1.94) |
| 1-6 mo | 1.33 (0.95-1.87) | 1.59 (1.15-2.20) |
| >6 mo | 1.75 (1.04-2.96) | 1.39 (0.82-2.33) |
| Never returned home | 2.43 (1.70-3.49) | 3.04 (2.10-4.39) |
| Age group, y | ||
| 18-25 | 1 [Reference] | 1 [Reference] |
| 26-34 | 1.08 (1.01-1.16) | 1.04 (0.98-1.12) |
| 35-49 | 0.87 (0.81-0.94) | 0.88 (0.82-0.94) |
| 50-64 | 0.59 (0.54-0.63) | 0.57 (0.53-0.61) |
| 65-74 | 0.33 (0.31-.036) | 0.30 (0.28-0.32) |
| ≥75 | 0.23 (0.21-0.25) | 0.21 (0.19-0.23) |
| Sex at birth | ||
| Female | 0.96 (0.93-0.99) | 1.31 (1.28-1.35) |
| Male | 1 [Reference] | 1 [Reference] |
| Sexual orientation | ||
| Straight | 1 [Reference] | 1 [Reference] |
| Gay, lesbian, or bisexual | 1.64 (1.58-1.71) | 1.74 (1.67-1.81) |
| Race and ethnicityb | ||
| Hispanic | 0.85 (0.81-0.89) | 0.78 (0.75-0.82) |
| Non-Hispanic Asian | 0.81 (0.75-0.87) | 0.61 (0.57-0.66) |
| Non-Hispanic Black | 0.84 (0.80-0.88) | 0.72 (0.69-0.75) |
| Non-Hispanic White | 1 [Reference] | 1 [Reference] |
| Non-Hispanic otherc | 1.07 (1.00-1.13) | 1.04 (0.98-1.09) |
| Educational level | ||
| ≤High school diploma | 1 [Reference] | 1 [Reference] |
| Some college or associate’s degree | 1.02 (0.98-1.05) | 1.13 (1.09-1.16) |
| ≥Bachelor’s or graduate degree | 0.71 (0.68-0.73) | 0.89 (0.86-0.92) |
| Annual income, $ | ||
| <35 000 | 1 [Reference] | 1 [Reference] |
| 35 000-74 999 | 0.82 (0.79-0.85) | 0.83 (0.80-0.86) |
| 75 000-149 999 | 0.62 (0.60-0.65) | 0.65 (0.62-0.67) |
| ≥150 000 | 0.38 (0.36-0.40) | 0.43 (0.41-0.45) |
| Marital status | ||
| Now married | 1 [Reference] | 1 [Reference] |
| Widowed, divorced, or separated | 1.34 (1.29-1.39) | 1.20 (1.16-1.24) |
| Never married | 1.22 (1.17-1.27) | 1.07 (1.03-1.11) |
| Household size, persons | ||
| 1-2 | 1 [Reference] | 1 [Reference] |
| 3-4 | 1.15 (1.11-1.19) | 1.15 (1.11-1.19) |
| ≥5 | 1.35 (1.27-1.44) | 1.27 (1.20-1.35) |
| No. of children in the home | ||
| No children | 1 [Reference] | 1 [Reference] |
| 1-2 | 0.82 (0.79-0.86) | 0.88 (0.85-0.92) |
| ≥3 | 0.70 (0.65-0.76) | 0.83 (0.77-0.89) |
| Homeownership | ||
| Owner | 1 [Reference] | 1 [Reference] |
| Renter | 1.19 (1.16-1.24) | 1.23 (1.19-1.27) |
| Functional disability, severe | ||
| No disability | 1 [Reference] | 1 [Reference] |
| 1 | 3.40 (3.28-3.53) | 3.14 (3.03-3.25) |
| ≥2 | 8.10 (7.62-8.60) | 6.92 (6.51-7.37) |
| Census region | ||
| Northeast | 1 [Reference] | 1 [Reference] |
| South | 1.08 (1.03-1.13) | 1.04 (1.00-1.08) |
| Midwest | 0.95 (0.91-1.00) | 0.93 (0.90-0.97) |
| West | 1.01 (0.96-1.06) | 1.00 (0.96-1.04) |
All variables listed are included in the multivariable analyses.
Self-reported by participants.
Includes American Indian or Alaska Native, Chamorro, Native Hawaiian, Other Pacific Islander, Samoan, and multiracial.
Females at birth had lower odds for depression symptoms (OR, 0.96; 95% CI, 0.93-0.99) but had higher odds for anxiety symptoms (OR, 1.31; 95% CI, 1.28-1.35) compared with males at birth. Other sociodemographic characteristics associated with higher odds of mental health symptoms were gay, lesbian, or bisexual sexual orientation; nonmarried status (widowed, divorced, separated, or never married); larger households; being a home renter, having functional disabilities; and living in the South (Table 3). For example, having 1 severe disability was associated with higher odds of having depression (OR, 3.40; 95% CI, 3.28-3.53) and anxiety (OR, 3.14; 95% CI, 3.03-3.25) symptoms, compared with those without any disability. Having children in the house (eg, ≥3) was associated with lower odds of depression (OR, 0.70; 95% CI, 0.65-0.76) and anxiety (OR, 0.83; 95% CI, 0.77-0.89) symptoms, compared with no children in the house. Racial and ethnic minority groups (eg, Asian) also had lower odds of depression (OR, 0.81; 95% CI, 0.75-0.87) and anxiety (OR, 0.61; 95% CI, 0.57-0.66) symptoms, compared with the White population. Similarly, those with higher income (eg, $75 000 to $149 999) had lower odds of depression (OR, 0.62; 95% CI, 0.60-0.65) and anxiety (OR, 0.65; 95% CI, 0.62-0.67) symptoms than those with income lower than $35 000.
Discussion
In this cross-sectional study, natural disaster–induced displacement was associated with depression and anxiety symptoms. The longer the duration of displacement, the higher the odds of mental health symptoms in a pattern indicating a dose-response association. Our findings, based on nationally representative data, are generalizable to the US adult population. We examined various types of natural disasters that extended beyond those in previous studies, which had more modest sample sizes and focused on individual disaster events in the US.
Our finding that an association exists between displacement duration and mental health outcomes is important. Only a limited number of studies have examined longer duration of displacements or individuals who never returned home after displacement. This literature includes a study of New Orleans residents after Hurricane Katrina, which found a higher prevalence of mild to severe mental illnesses among those who remained displaced from the city after 1 year compared with those who returned (51% vs 31%).10
Furthermore, another study examined 4 dimensions of displacement: distance from the predisaster community, type of postdisaster housing, number of postdisaster moves, and time spent in temporary housing.3 That study, which focused on New Orleans residents displaced by Hurricane Katrina, found that unstable postdisaster housing experiences and relocation (not returning home) were associated with more adverse mental health outcomes.3 The current study illustrated that the duration of displacement may be an additional key aspect of the displacement profile that should be considered when studying the association between displacement and mental health outcomes.
In a previous study,20 experiencing fires and multiple disasters in the past year was associated with a longer duration of displacement (ie, displaced for more than 6 months or never returned home). This finding suggests that, for populations displaced by fires or multiple disasters in a year, mental health services will be more crucial. Furthermore, whereas setting up mental health services in a disaster area can target people who return, mental health practitioners will need to develop care models to reach permanently displaced individuals.
We cannot be certain whether experiencing displacement was the sole factor in depression and anxiety symptoms or whether experiencing other outcomes associated with disasters, such as fear for one’s life during the disaster and property damage, also played a role in mental health condition. A 1-year follow-up study of New Orleans residents who were displaced and who did not return home after Hurricane Katrina found that severe damage and destruction of their homes was a major factor in mental illness.10
Our finding that racial and ethnic minority groups (Asian, Black, and Hispanic) had lower odds of experiencing depression and anxiety symptoms compared with White individuals is interesting. Although studies found that racial and ethnic minority people were more likely to experience mental health symptoms compared with their White counterparts after natural disasters,23,24 a systematic review found that, after adjusting for socioeconomic status and other social support, race was no longer a factor in some studies.6
We found the highest odds of mental health symptoms among participants who reported functional disabilities than any other characteristics examined. Studies on the mental health of people with disabilities after natural disasters are still limited. A study of Hurricane Harvey in Texas found that health care access was limited for those with disabilities23 and may have a causal association with higher rates of anxiety and depression among this population. We recommend that future studies focus on people with disabilities and on mental health services in the context of natural disasters for this socially vulnerable population. The availability of mental health resources in both the short and long term will be critical. The mental health outcomes of displacement can continue well after the disaster occurs, as individuals struggle with the ambiguity about not only their future but also the process of creating what that future entails. This emotional distress can be especially difficult for underresourced or underrepresented groups, including children (aged <18 years) and older adults (aged ≥65 years), but also for individuals with existing stressors, such as chronic physical and mental health issues.25,26,27 During a disaster and the weeks and months afterward, the inability to access mental health professionals and resources can intensify adverse health outcomes.28,29 This would require that health care practitioners are appropriately trained to recognize and provide tailored care to patients with a history of disaster-induced displacement. Training and educational programs for health care practitioners can benefit from the inclusion of various stakeholders, including communities at risk of natural disasters, mental health care practitioners, and people who have experienced displacement.
Limitations
We note several limitations of this study. First, the HPS is associated with low response rates; the survey used in this study had a mean response rate of 6.6%. The issue of low response rates of the HPS has been described elsewhere,20 and the Census Bureau applies nonresponse weighting adjustments to minimize nonresponse bias.30 Second, the HPS relied on self-reported measures, including exposure (displacement and duration of displacement) and outcomes (depression and anxiety symptoms). The HPS mental health questions relied on validated PHQ-2 and GAD-2 measures. Finally, the cross-sectional nature of the data precludes any conclusion about causality as we could not be sure if people who reported depression and anxiety symptoms before displacement were more likely to experience the symptoms after displacement. It is possible that people with preexisting mental health symptoms prior to the disaster choose not to return to their predisaster residences or not to return after a longer delay. This kind of methodological limitation is common in the current literature on displacement and mental health, prompting the need for prospective and longitudinal studies that consider baseline predisaster mental health characteristics.6,31
Conclusions
In this cross-sectional study, disaster-induced displacement was associated with depression and anxiety symptoms with higher risks among individuals who were displaced over a longer duration or who never returned home. As climate change increases the severity and frequency of many of the natural disasters we examined, mental health services for a growing number of displaced populations will become more critical.
eMethods
eTable. Unweighted Missing Data Among Those Who Responded to Displacement Question
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods
eTable. Unweighted Missing Data Among Those Who Responded to Displacement Question
Data Sharing Statement