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. Author manuscript; available in PMC: 2026 Feb 3.
Published in final edited form as: Int J Hyg Environ Health. 2025 Dec 19;272:114736. doi: 10.1016/j.ijheh.2025.114736

Psychosocial distress among individuals residing in a rural PFAS-contaminated community

Elizabeth Scharnetzki a,b,†, Lisa B Rokoff a,b,†, Katherine Senechal a, Michelle Bosquet Enlow c, Abby F Fleisch a,b,e,*, Rachel Criswell a,b,d,*
PMCID: PMC12863575  NIHMSID: NIHMS2134063  PMID: 41421190

Abstract

Few studies have evaluated how awareness of PFAS contamination impacts psychosocial distress. We sought to quantify psychosocial distress associated with awareness of drinking water PFAS contamination in the Maine Biosolids Study (n=146), a rural cohort affected by agricultural biosolid spreading. Participants had residential well water PFAS concentrations measured by the Department of Environmental Protection and were notified about concentrations above or below the Maine Interim Drinking Water Standard [∑6 PFAS (PFOA, PFOS, PFNA, PFHxS, PFHpA, PFDA) ≥20ng/L]. We utilized negative binomial mixed effects regression to study associations of awareness of water PFAS above the Standard with PFAS-related psychosocial outcomes and state-dependent anxiety. We explored effect modification by pre-existing mental health diagnoses and resilience coping style. Fifty-eight percent of participants had drinking water PFAS above the Standard, and 35% had pre-existing mental health diagnoses. Affected participants with drinking water PFAS above the Standard had greater PFAS-related anxiety, worry and fears about health risk, and perceived stigma [for example, IRRperceived stigma(95%CI): 1.69(1.32, 2.15)]. Knowledge of elevated water PFAS was associated with greater state-dependent anxiety, although confidence intervals included the null [IRR (95%CI): 1.21 (0.90, 1.61)]. Associations of awareness of water PFAS with worry about PFAS health risk and state-dependent anxiety were stronger among individuals without a prior mental health diagnosis [e.g., IRRworry(95%CI): 2.30(1.49, 3.57) versus 1.27(0.80, 2.02)]. We found no effect modification by resilience coping style. Individuals with knowledge of elevated drinking water PFAS had greater PFAS-related psychosocial distress. Mental health support and community education are public health needs in PFAS-affected communities.

Keywords: PFAS contamination, well water, drinking water, environmental worry, stigma, public risk perceptions

Graphical Abstract

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1. Introduction

Contamination of water and local food systems with per- and polyfluoroalkyl substances (PFAS) is an important and growing environmental issue. In the United States (US), multiple communities with water sources contaminated with PFAS have been in the national news,1 leading to increased awareness and to the Environmental Protection Agency (EPA) releasing its first maximum contaminant levels (MCLs) for PFAS in water in 2024.2 PFAS are ubiquitous and stable (“forever”) chemicals added to consumer products (e.g., fabrics, food packaging, cookware) to resist heat, stains, and grease.3 Research has shown that PFAS exposure is associated with adverse physical health outcomes, including decreased antibody response to vaccines, dyslipidemia, increased risk for kidney cancer, and lower birth weight,4 culminating in several agencies releasing risk reduction and clinical monitoring guidance related to PFAS.4–6

Over 9,500 communities with PFAS contamination have been identified across the US to date.7 Knowledge of environmental contamination may be linked to adverse psychosocial impacts in the setting of uncertainty surrounding health effects, property devaluation, lost income, and loss of community as concerned residents move from the area.8 The psychological distress related to these community and health concerns may be compounded by biological actions of the contaminant. For example, in vitro studies suggest PFAS may impact dopaminergic and serotonergic pathways,9–11 although epidemiologic studies of blood PFAS concentrations, anxiety, and depression have shown mixed results.12–15

A small body of qualitative research has demonstrated that living in a PFAS-contaminated community is associated with greater psychological distress, anxiety, and stress about PFAS-related health issues.16–19 One quantitative study in Australia showed that individuals who live in a PFAS-contaminated community (versus a comparison non-contaminated community) had greater risk of psychological distress, somatization, and anxiety.20 Further characterization of the psychosocial impact of awareness of PFAS contamination is critical to developing contextually relevant, effective mental health support in impacted communities.

In this study, we leveraged data from the Maine Biosolids Study, a rural cohort of adults from four central Maine counties varyingly exposed to PFAS from historical application of PFAS-contaminated biosolids to agricultural land. Participants had drinking well water PFAS concentrations measured by the Maine Department of Environmental Protection (DEP) and were notified of results, including whether concentrations were above or below the Maine State Interim Drinking Water Standard [i.e., ∑6 PFAS (PFOA, PFOS, PFNA, PFHxS, PFHpA, PFDA) ≥20ng/L]. We examined associations of knowledge of well water PFAS above (versus below) the Standard on psychosocial outcomes related to PFAS exposure (anxiety, worry about health risk, frequency of thoughts/fears about health risk, and perceived stigmatization) and state-dependent anxiety. We explored the extent to which pre-existing mental health conditions and resilience coping style modified associations. We also explored the extent to which adjustment for serum PFAS concentrations attenuated associations so as to quantify the impact of contamination awareness independent of any biological actions of PFAS. Our findings lay the groundwork for better understanding the impact of environmental contamination awareness on mental health.

2. Methods

2.1. Study Population and Recruitment

The Maine Biosolids Study is a cohort of adults from central Maine, where biosolids (the solid waste remaining after wastewater treatment) were historically applied to farmland as fertilizer, described in detail elsewhere.21 In brief, in October 2020, after high levels of PFAS were found in milk from a Maine dairy farm that had been spread with biosolids, the Maine Department of Environmental Protection (DEP) was mandated to test PFAS concentrations in the private well water of homes that may have been impacted by biosolids based on hydrological modeling.

We recruited participants from September–December 2023 via mailings to the 1,162 homes in Kennebec, Somerset, Waldo, and Penobscot counties whose residential drinking water wells had been tested for PFAS between September 2020 and November 2023. Participants were eligible if they had lived in the affected home for at least 12 months prior to the PFAS well water measurement. We enrolled 147 adults aged 18 and older from 104 homes through enrollment drives or individual appointments. Of those, one individual did not complete the study questionnaire, resulting in 146 participants in our analytic dataset. All participants provided written informed consent. The study was approved by the MaineHealth Institutional Review Board (IRB). The Redington-Fairview General Hospital (RFGH) IRB ceded review to the MaineHealth IRB.

2.2. PFAS well water concentrations

We obtained participants’ PFAS well water concentrations analyzed between September 2020 through November 2023 from a publicly available database maintained by the Maine DEP. The database documents residential drinking water concentrations of up to 28 individual PFAS analytes analyzed by five different laboratories accredited by the Maine DEP; 93% of samples were analyzed at a single laboratory.21,22 Well water was sampled according to standard operating procedures using field blanks and analyzed according to EPA methods 533, 537, or 537.1.23,24 All residents were notified of results, and if well water PFAS concentrations were equal to or above the state-specific Maine Interim Drinking Water Standard (i.e., 20 ng/L or parts per trillion [ppt] for the ∑6 PFAS (perfluorooctanoic acid [PFOA], perfluorooctane sulfonate [PFOS], perfluorononanoic acid [PFNA], perfluorohexanesulfonic acid [PFHxS], perfluoroheptanoic acid [PFHpA], and perfluorodecanoic acid [PFDA]),22 residents were provided with bottled water to drink, followed by water filter installation and subsequent water testing to ensure integrity of the filtration system. Participants had a water filter placed mean (SD) 1.8 (0.9) years (range 0–3 years) prior to enrollment in the study. Among participants who lived in homes that required filter installation, we reported water PFAS concentrations before the filter was installed with one exception as detailed elsewhere.21

2.3. Psychosocial outcomes

Participants completed a questionnaire at the time of enrollment that assessed psychosocial outcomes anchored on potential exposure to PFAS (anxiety, worry about health risk, frequency of thoughts/fears about health risk, and perceived stigmatization) and state-dependent anxiety.

To assess PFAS-related anxiety, we adapted a six-item subset of the validated Environmental Worry Scale (e.g., I feel frightened when I think of all the PFAS in the world).25 To assess PFAS-related perceptions of health risk, we adapted two items from a previous study on pesticides,26 one focused on worry about health risk (i.e., affective dimensions of risk perception: How often in the past month have you had thoughts or fears about the health effects of PFAS?) and the other focused on frequency of thoughts and fears about health risk (i.e., cognitive dimensions of risk perception: How worried are you that you or your family will experience health problems as a result of PFAS exposure?). To assess PFAS-related perceived stigma, we adapted three probes from a semi-structured interview on dioxin contamination (e.g., Do you feel embarrassed about living in an area with PFAS exposure?).27 We adapted this measure to specifically quantify perceived stigmatization, i.e., the fear or anticipation of others holding negative attitudes towards one on the basis of a social identity, characteristic, or condition.28 We show original and adapted PFAS-related psychosocial items in the Appendix. We assessed state-dependent anxiety (i.e., current feelings of anxiety that may or may not be related to PFAS exposure) via the six-item validated short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI).29

We assessed all psychosocial items using a 4-point Likert scale, and for outcomes consisting of more than one item (i.e., PFAS-related anxiety, perceived stigmatization, and state-dependent anxiety), we summed item scores to create a composite score, with higher scores indicating greater psychosocial distress. For n=2 participants who did not respond to one item on the adapted Environmental Worry Scale, we pro-rated their score and rounded it to the nearest whole number (i.e., multiplying an incomplete composite score by six-fifths). We excluded one participant from the PFAS-related perceived stigmatization analysis because that participant only responded to one of the three items. We multiplied the STAI composite score by 20/6 (i.e., number of items on the full-form of the STAI divided by the number of items on the short-form) for standardization.29

2.4. Descriptive characteristics, covariates, and effect modifiers

Participants reported age, sex assigned at birth, racial identity, ethnicity, education, health insurance status, and household income by questionnaire at the time of enrollment. Participants also reported on their coping style (Brief Resilient Coping Scale [BRCS]30), PFAS-related financial hardship (single 4 Likert item: I have experienced financial hardship as a result of PFAS),31 PFAS-related job insecurity (single 4 Likert item: My job security has been affected by PFAS),31 mental health diagnoses (anxiety, depression, or bipolar disorder) and year first diagnosed, and use of psychiatric medication (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, hydroxyzine, propranolol, buspirone, clonidine, benzodiazepines, atypical antidepressants, tricyclic antidepressants, mirtazapine, mood stabilizers, and risperidone) and year first taken. For coping style, we summed responses to obtain a composite score (range: 4–20) and used established score cut-points30 to classify individuals as low-resilient copers (score: ≤13), medium-resilient copers (score: 14–16), or high-resilient copers (score: ≥17). Individuals classified by the BRCS as high-resilient copers tend to have tenacity, optimism, creativity, aggressive problem solving approaches, and a commitment to extract positive growth from difficult situations, whereas individuals classified as low-resilient copers tend to lack these qualities.30

We classified participants as having a pre-existing mental health condition if they reported a mental health diagnosis and/or use of psychiatric medications prior to the year their well was tested. Because propranolol and clonidine can be prescribed for both psychiatric and non-psychiatric diagnoses, we considered n=3 participants who reported taking clonidine or propranolol but did not report a mental health diagnosis not to have a pre-existing mental health diagnosis. For n=3 participants who did not report the year of their mental health diagnosis and/or initiation of psychiatric medication, we assumed that their mental health diagnosis was pre-existing as most of our participants with complete data regarding their mental health diagnosis (96%) reported that it was pre-existing.

As a part of the Maine Biosolids Study, trained phlebotomists drew blood from 145 of the 147 study participants for analysis of PFAS in serum. Blood was analyzed at the Centers for Disease Control and Prevention (CDC) National Center for Environmental Health Laboratory using online solid phase extraction liquid chromatography-isotope dilution tandem mass spectrometry for the following PFAS: linear PFOA (n-PFOA), branched PFOA isomers (Sb-PFOA), linear PFOS (n-PFOS), perfluoromethylheptane sulfonic acid isomers (Sm-PFOS), PFNA, PFHxS, PFDA, perfluoroundecanoic acid (PFUnDA), and 2-(N-methyl-perfluorooctane sulfonamide) acetic acid (MeFOSAA).21,32,33 The analysis of de-identified serum specimens at the CDC laboratory was determined not to constitute engagement in human subjects’ research. We summed concentrations of these seven individual PFAS to obtain the “sum of seven” PFAS measurement used by the National Academies of Sciences, Engineering, and Medicine (NASEM) to risk-stratify serum PFAS concentrations for clinical care.34

2.5. Statistical analysis

Due to within-household clustering, we used mixed effect models with household as a random effect to examine associations of knowledge of well water PFAS above (versus below) the Maine State Interim Drinking Water Standard with PFAS-related psychosocial outcomes (anxiety, worry about health risk, frequency of thoughts/fears about health risk, and perceived stigma) and state-dependent anxiety. We used a dichotomous primary exposure because having water PFAS concentrations above the Standard was the threshold that resulted in notification by the DEP to stop drinking unfiltered water. Except for PFAS-related anxiety, psychosocial outcome scores had a right-skewed distribution (Supplemental Table 1), even when adding a small positive constant to all outcome values and log-transforming the data. We first tested a linear mixed effects approach, but our models violated assumptions of normality of residuals and of random effects. Thus, we treated our outcome scores as count data and employed the negative binomial modeling approach, which handles overdispersion and naturally models skewness,35 to estimate incidence rate ratios and 95% confidence intervals [IRR (95%CI)].

Based on our a priori review of the literature, we included as covariates/predictors of our studied outcomes: participant age (in years, continuous), sex assigned at birth (male, female), and education level (<college, college or graduate school). When covariate/predictor data was missing (n=2 for age, n=1 for education level), we used single imputation of the median (age) or mode (education level) and included those participants in analyses. We examined but did not include annual household income and type of health insurance in our models, as the inclusion versus exclusion of these covariates did not change the effect estimates or precision of the estimates.

In secondary analyses, we examined the ∑6 PFAS well water concentration as a continuous variable, log2-transformed for ease of interpretability (i.e., IRR per doubling water PFAS concentration). To account for potential recall bias or evolving psychological response in the setting of individuals who had received their well water information up to three years prior to study enrollment, we conducted a sensitivity analysis where we adjusted for year of PFAS testing in our models. We also conducted sensitivity analyses evaluating associations of knowledge of well water PFAS above (versus below) the Drinking Water Standard with psychosocial outcomes among (1) individuals with versus without a pre-existing mental health diagnosis and (2) individuals with low-, medium-, and high-resilient coping styles. To do so, we ran separate models that also included interaction terms between the dichotomized PFAS exposure and (1) pre-existing mental health diagnosis and (2) the three categories from the BRCS. We considered an interaction p-value <0.10 as suggestive of effect modification. We additionally ran models in datasets stratified by these different groups; in a few instances, models would not converge with inclusion of the random effect of household and so we excluded the term in those cases. We were unable to explore effect measure modification by PFAS-related financial or job insecurity because of the small number of participants in some categories. We conducted a sensitivity analysis adjusting our models for participants’ NASEM “sum of seven” serum PFAS concentrations to examine the association of contamination awareness with psychosocial distress independent of potential biological pathways.

We used SPSS version 29 for preliminary dataset cleaning and statistical analyses, and R Version 4.5.0 for the main statistical analyses.

3. Results

3.1. Population Characteristics

Participants had a median age of 63.0 (interquartile range [IQR]: 14.8) years, 58% were female, and 71% lived within a mile of a site of biosolids application. Generally consistent with the demographics of central Maine,36 51% of participants had a household income of less than $70,000; 97% identified as White; and 99% as non-Hispanic. Forty-seven percent of our participants had commercial insurance, and 53% had an education level of college or higher. Fifty eight percent of participants (n=84) lived in a home with a well water concentration above Maine’s Interim Drinking Water Standard. Demographics were similar among participants with water PFAS above versus below the Standard (Table 1). Compared to eligible households who did not enroll in our study, households included in the Maine Biosolids Study on average had higher PFAS water concentrations and were more likely to have well water concentrations above versus below the Interim Drinking Water Standard, but average distance to the nearest biosolids application site was not markedly different.21

Table 1.

Participant characteristics, overall (N=146) and stratified by whether the ∑6 per- and polyfluoroalkyl substances (PFAS) in their residential well drinking water (tested from September 2020-November 2023) was above (versus below) the Maine Interim Drinking Water Standard

Overall
n=146		 ∑6 PFAS below Interim Drinking Water Standarda
n=62		 ∑6 PFAS above Interim Drinking Water Standarda
n=84
Characteristics N (%) or median (interquartile range) p-value b
Age (years) c 63.0 (14.8) 64.7 (13.7) 61.4 (17.5) 0.11
Female sex assigned at birth d 84 (58%) 33 (53%) 51 (61%) 0.40
Racial identity c 0.99
White 139 (97%) 59 (97%) 80 (96%)
Black 1 (1%) 0 (0%) 1 (1%)
More than one racial identity 4 (3%) 2 (3%) 2 (2%)
Hispanic, Latino or Spanish origin c 2 (1%) 1 (2%) 1 (1%) 0.99
Educational attainment c 0.87
Less than college degree 67 (46%) 28 (45%) 39 (47%)
College degree and/or graduate school 78 (54%) 34 (55%) 44 (53%)
Annual household income c 0.99
≤$70,000 69 (51%) 29 (52%) 40 (51%)
>$70,000 65 (49%) 27 (48%) 38 (49%)
Health insurance c 0.34
Medicaid 9 (7%) 6 (10%) 3 (4%)
Medicare 61 (45%) 27 (47%) 34 (44%)
Commercial Insurance 64 (47%) 25 (43%) 39 (51%)
No insurance 1 (1%) 0 (0%) 1 (1%)
Pre-existing mental health diagnosis 51 (35%) 24 (39%) 27 (32%) 0.48
Brief Resilient Coping Style c 0.71
Low-resilient coper 49 (34%) 23 (37%) 26 (31%)
Medium-resilient coper 71 (49%) 28 (45%) 43 (52%)
High-resilient coper 25 (17%) 11 (18%) 14 (17%)
Financial hardship from PFAS c 34 (25%) 6 (10%) 28 (36%) <0.01
Job security affected by PFAS c 16 (12%) 2 (3%) 14 (18%) 0.01
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a

Maine Interim Drinking Water Standard is 20 ng/L for the ∑6 PFAS (perfluorooctane sulfonic acid, perfluorooctanoic acid, perfluorohexane sulfonic acid, perfluorononanoic acid, perfluorodecanoic acid, perfluoroheptanoic acid) in well water.

b

Comparing characteristics among those whose household drinking water PFAS was above (versus below) the Maine Interim Drinking Water Standard using Wilcoxon rank sum tests (for continuous variables) and Fisher’s exact test (for binary and categorical variables).

c

Don’t know/preferred not to answer or missing data: N=2 for age; N=2 for race; N=2 for ethnicity; N=1 for education; N=12 for income; N=11 for health insurance; N=11 for financial hardship; N=9 for job security; N=1 for Brief Resilient Coping Scale.

d

Except for two participants who preferred not to answer, all participants’ gender identity aligned with sex assigned at birth.

Thirty-five percent of participants had a mental health condition prior to the year their well water was tested for PFAS, which is on par with the general US population: the National Institute of Mental Health has estimated that 31.1% of US adults have ever experienced an anxiety disorder37 and 8.3% have had at least one major depressive episode.38 Thirty-four percent of participants were low-resilient copers, 49% medium-resilient copers, and 17% high-resilient copers. Proportions of those with pre-existing mental health diagnoses and the three coping styles were similar among those with drinking water PFAS concentrations above versus below the Interim Drinking Water Standard. Twenty-five percent of participants reported PFAS-related financial hardship, and 12% reported PFAS-related job insecurity. Significantly more participants with water PFAS above the Interim Drinking Water Standard (versus below) reported PFAS-related financial hardship and job insecurity (Table 1).

3.2. Well water PFAS and psychosocial outcomes

In covariate-adjusted models, the PFAS-related anxiety score was 30% higher [IRR (95%CI): 1.30 (1.16, 1.45)], worry about PFAS health risk was 69% higher [IRR (95%CI): 1.69 (1.25, 2.30)], frequency of thoughts/fears about PFAS health risk was 63% higher [IRR (95%CI): 1.63 (1.18, 2.24)], and the perceived PFAS stigma score was 69% higher [IRR (95%CI): 1.69 (1.32, 2.15)] among participants who had drinking water PFAS concentrations above versus below the Interim Drinking Water Standard (Figure 1). The state-dependent anxiety score was 21% higher [IRR (95%CI): 1.21 (0.90, 1.61)] among participants with water PFAS above (versus below) the Interim Drinking Water Standard, but confidence intervals included the null. Results from unadjusted models were not appreciably different from adjusted models (Supplemental Table 2). Results were overall similar with only slight attenuation after adjustment for year of well water testing or serum “sum of seven” legacy PFAS concentration (Supplemental Table 3).

Figure 1.

Figure 1.

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Adjusted incidence rate ratio of psychosocial outcomes among participants with household well water PFAS concentrations above (versus below) the Maine Interim Drinking Water Standard. Notes: As established by the Maine Legislature in June 2021, the Maine Interim Drinking Water Standard is 20 ng/L for the ∑6 PFAS (perfluorooctane sulfonic acid, perfluorooctanoic acid, perfluorohexane sulfonic acid, perfluorononanoic acid, perfluorodecanoic acid, perfluoroheptanoic acid) in well water. All models were adjusted for participant age, sex assigned at birth, and education; N=146 for all outcomes, except N=145 for perceived PFAS stigma score. Abbreviations: CI, confidence interval; PFAS, per- and polyfluoroalkyl substances.

When we examined PFAS well water concentration as a continuous variable in secondary analyses, results were consistent with our primary models. For each doubling in the ∑6 PFAS water concentration, the PFAS-related anxiety score was 3% higher [IRR (95%CI: 1.02, 1.04)], worry about PFAS health risk 6% higher [IRR (95%CI): 1.06 (1.03, 1.10)], frequency of thoughts/fears about PFAS health risk 6% higher [IRR (95%CI): 1.06 (1.02, 1.09)], perceived PFAS stigma score 6% higher [IRR (95%CI): 1.06 (1.03, 1.08)], and state-dependent anxiety score 3% higher [IRR (95%CI): 1.03 (1.00, 1.06)] (Supplemental Table 4).

3.4. Effect modification and stratification

Associations of knowledge of well water PFAS above (versus below) the Interim Drinking Water Standard with worry about PFAS health risk (p-interaction=0.05) and state-dependent anxiety (p-interaction=0.09) were stronger among participants with no pre-existing mental health condition. In stratified analyses, for participants with no pre-existing mental health condition, worry about PFAS health risk was 130% higher [IRR (95%CI): 2.30 (1.49, 3.57)] and state-dependent anxiety score was 60% higher [IRR (95%CI): 1.60 (1.07, 2.40)] among those with water PFAS above versus below the Interim Drinking Water Standard, whereas associations were null among participants with a pre-existing mental health condition (Supplemental Table 5). We did not find evidence of effect modification by coping style (Supplemental Table 6).

4. Discussion

In a community with PFAS contamination from agricultural application of biosolids, individuals who received communication that their water tested above (versus below) the Maine Interim Drinking Water Standard experienced greater PFAS-related anxiety, worry about PFAS health risk, frequent thoughts/fears about PFAS health risk, and perceptions of PFAS-related stigmatization.

Our results are in line with previous qualitative studies indicating that environmental contamination with PFAS17–19,39,40 or other toxicants41–43 is associated with psychosocial distress. A qualitative study consisting of semi-structured interviews with six community members impacted by PFAS contamination across six US states found that affected individuals experienced stress and anxiety due to health concerns and financial burden.17 In a study of 180 individuals from 3 communities in Australia near military bases with PFAS contamination from firefighting foam, researchers noted that across 15 focus groups there were concerns about possible physical health effects from PFAS, specifically greater risk of cancer and mortality, as well as anxiety about the socioeconomic impacts of the PFAS contamination.18 Interviews with 32 individuals who lived in in the Veneto Region of Italy, near a PFAS production plant, expressed shock and devastation upon learning about local PFAS contamination, anxiety surrounding health-related uncertainty, stress surrounding decisions about relocation, and parental guilt.19 These qualitative studies are consistent with our findings, suggesting that awareness of PFAS contamination can lead to considerable anxiety and psychosocial distress, particularly surrounding health-related concerns.

The one prior quantitative study of 881 adults from 3 PFAS-affected communities in Australia and 801 adults from 3 non-contaminated comparison communities found that individuals living in exposed (versus comparison) communities had higher prevalence of psychological distress, somatization, and anxiety (ranging 1.2 to 3.6 times higher prevalence, depending on the comparison). Within the exposed communities, 84% of participants reported health concerns, and 42% reported concerns about stigmatization.20 Our study builds on this prior research by comparing psychosocial outcomes within an exposed community with different levels of exposure rather than comparing exposed and non-exposed populations. This allows us to explore a dynamic in which individuals who received communication of elevated levels of PFAS in their drinking water also experience greater PFAS-related psychosocial impact, even within an impacted community.

Further, our study documents not only higher PFAS-related anxiety but also higher PFAS-related health concerns and perceived stigmatization among individuals who learned that their drinking water PFAS concentrations were elevated. Contamination-related stigmatization may occur due to associations of the contamination with adverse health effects, property devaluation, and lost income27 and is an understudied but important psychosocial sequelae of environmental contamination, as it inhibits access to resources and is a key driver of health.44,45 While we examined only PFAS-related stigmatization in this study, there could be impact of intersecting stigmas among individuals who hold other stigmatized health conditions or socially devalued identities.46 Future research could examine these intersectional stigmas and their association with similar psychosocial and mental health outcomes.

In our study, we examined not only PFAS-related psychosocial outcomes but also state-dependent anxiety (i.e., current feelings of anxiety that may or may not be related to PFAS exposure). We found that individuals who received communication that their drinking water PFAS concentrations were elevated had higher state-dependent anxiety, although as compared to PFAS-related psychosocial outcomes, associations with state-dependent anxiety were weaker and confidence intervals included the null. Our findings suggest that while communication of elevated drinking water PFAS primarily leads to PFAS-related psychosocial concerns, it may also raise overall levels of anxiety. In contrast to a clinical scale such as the Generalized Anxiety Disorder-7 (GAD-7), our use of the STAI to measure current experiences of anxiety was able to capture feelings of stress and anxiety that may fall outside the realm of a clinical diagnosis.

Greater psychosocial distress among individuals who received communication that their home had elevated drinking water PFAS levels may reflect psychosocial responses to contamination notification, financial stress, stigma, or community and health concerns. While some hypothesize that PFAS may affect psychosocial outcomes by directly impacting biological pathways such as dopaminergic and serotonergic pathways,9–11 epidemiologic studies of associations of serum PFAS concentrations with anxiety and depressive symptoms have been inconclusive.12–15 This is consistent with our finding that effect estimates were only minimally attenuated after controlling for serum PFAS concentrations, suggesting that associations between PFAS contamination awareness and psychosocial distress exist independent of any biological links.

We found that individuals with no pre-existing mental health condition had stronger associations between awareness of elevated drinking water PFAS and two psychosocial outcomes—worry about PFAS health risk and state-dependent anxiety. One possible explanation for these findings is that individuals with a pre-existing mental health condition may have already been receiving treatment that tempered their psychosocial distress related to PFAS. Additionally, PFAS-related distress may have particularly impacted those who did not experience psychological distress at baseline, whereas those with pre-existing mental health conditions may already exist in a higher state of distress and therefore felt a more modest psychosocial impact of contamination awareness. We found that the extent to which awareness of elevated water PFAS was associated with psychosocial outcomes did not change regardless of coping style (i.e., low-, medium-, or high-resilient coping), suggesting that even individuals with excellent existing coping skills who have received communication about PFAS contamination would still benefit from mental health interventions.

Our cohort is unique from most other communities that are exposed to PFAS exclusively through a municipal water source, as the source of PFAS exposure in our cohort is land application of contaminated biosolids. Thus, in addition to water contamination, local produce, eggs, meat, wild fish and game, and dairy products may be contaminated with PFAS.47–50 In our largely rural community that depends on local agriculture, hunting, and fishing for food, the perceived ubiquity of PFAS not only in the water but also in the food systems may contribute to stress outcomes. Thus, individuals in our reference group with awareness of lower PFAS concentrations in their drinking water may still experience some degree of PFAS-related stress due to the potential for food contamination. The psychosocial impact that we observed among those learning that their water tested above the Interim Drinking Water Standard may reflect the added psychosocial stress of having confirmed elevated PFAS in one’s own residential drinking water compounded by any additional financial, occupational, or stigmatization concerns.

Prior studies have documented financial uncertainty due to changes in property value or loss of business income in the setting of PFAS or other contamination.16,18,42,43 Indeed, many of the impacted individuals in Maine are reliant for income on local agriculture such as cattle or dairy farming, vegetable and fruit farming, or selling eggs. For example, a previous study from the Maine Biosolids Study indicated that 15% of our participants had ever worked on a farm where biosolids were spread.21 Among participants with high concentrations of PFAS in their well water, 36% indicated financial hardship due to the PFAS contamination, and 18% indicated job insecurity as related to PFAS contamination. These additional potential stresses may have further compounded distress associated with awareness of drinking water contamination.

Notably, a recent study on PFAS well water concentrations in rural areas of the US found that participants appreciated recommendations for taking action to reduce exposure when learning of PFAS contamination in their water. Moreover, the majority of these individuals for whom action was recommended followed the recommendation, suggesting a sense of agency.51 These findings underscore the importance of clear communication in improving psychosocial outcomes among PFAS-affected communities.

A strength of our study is the ability to quantify the impact of learning about PFAS contamination on psychosocial outcomes, including PFAS-related health concerns and perceived stigmatization, supplementing an emerging body of qualitative literature around chronic environmental contamination and psychosocial outcomes. Another strength of our cohort was its rural, socioeconomic, and racial makeup, which is similar to that of other affected PFAS communities52 and representative of the overall population of Maine,36 allowing for external generalizability. Further, in contrast to communities with PFAS contamination through a single municipal water source, our study included participants within a PFAS-affected community with a broad range of PFAS well water concentrations.

This study has some limitations that qualify the interpretation of our results. As expected of a community exposure study recruiting from a population with varying exposure, our study is characterized by selection bias, although it still represents an important and understudied rural population dependent on private wells for drinking water. All outcomes were assessed with self-report survey measures; thus, recall bias and social desirability response bias are possible limitations. Additionally, some of our participants enrolled in the study and completed the study survey up to three years after their well water had been tested for PFAS and had a filtration system installed, and psychological distress may have changed during the interim. However, qualitative studies suggest that psychosocial stress in the setting of PFAS contamination persists up to five years after the initial contamination discovery.40 In addition, when we adjusted our analyses for year of well testing, results were only slightly attenuated and overall similar. Additionally, given the length of time over which wells were tested, some individuals may have learned of the PFAS contamination from local news or from neighbors far in advance of their well water results being communicated to them. This external information may have introduced outcome bias in our study. Finally, defining the true prevalence of mental health disorders is difficult in a survey-based study, given potential stigma around reporting or seeking care for a mental health condition, the lack of qualified mental health providers in rural areas to diagnose these conditions, and the multitude of conditions for which psychiatric medications can be prescribed. While a strength of our study is that we incorporated participant report of both mental health diagnoses and psychiatric medication use in our survey, the additional complexities noted above may result in either under- or overestimation of the true prevalence of mental health disorders. Despite these limitations, our study provides valuable empirical evidence, as it is among the first to quantify the psychosocial experience of individuals exposed to PFAS-contaminated well water.

5. Conclusion

Among participants in the Maine Biosolids Study, we found that communication of PFAS concentrations exceeding the Maine Interim Drinking Water Standard in private residential drinking water wells was associated with greater worry, perceived health risk, and perceived stigmatization. Our findings support calls from other research highlighting the need to integrate mental health research and preventive and supportive mental health care in the setting of environmental contamination,17,39,53 particularly among those with high levels of potential exposure. Our results provide important guidance for clinicians and other social, behavioral, and public health professionals as they seek to include more comprehensive care for people living in communities with PFAS exposure, inclusive of early mental health intervention, targeted social support opportunities, and improved community engagement and outreach to mitigate PFAS-associated social stigma.

Supplementary Material

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2

Highlights:

  • Study participants who knew they had elevated water PFAS had greater worry and fear about health risks.

  • Study participants who had elevated water PFAS had higher PFAS-related anxiety and stigmatization.

  • Lack of a preexisting mental health diagnosis strengthened these associations.

Acknowledgements

The authors would like to thank the Maine DEP, especially Victoria Eleftheriou and Tracy Kelly, for their assistance with accessing and interpreting well water data; and Antonia Calafat and Julianne Cook Botelho at the CDC National Center for Environmental Health Laboratory for analyzing PFAS serum samples. We would additionally like to thank the Education Department at RFGH, especially Bethany Shalit, Brittney Dunphy, and Lori Paradis for their effort in participant recruitment. We would like to thank Deanna Williams for helping with RedCAP survey design. We would also like to acknowledge Hannah Chidekel, Kathleen Grene, and Anne Mullin, who assisted with literature review and data cleaning. Thank you to our Community Advisory Board for their guidance and expertise. Most importantly, we thank our participants for sharing their time and experiences with us.

Funding source

This project was supported by grant R21ES035596 from the National Institute for Environmental Health Sciences (NIEHS). Dr. Fleisch is supported by R01ES030101 from the NIEHS. Dr. Criswell is supported from a grant from the National Institute for Health/National Center for Advancing Translational Sciences (K12TR004384).

Footnotes

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