Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2012 Oct 1.
Published in final edited form as: Soc Psychiatry Psychiatr Epidemiol. 2010 Jul 9;46(10):983–992. doi: 10.1007/s00127-010-0267-2

ANXIETY, MOOD, AND SUBSTANCE USE DISORDERS IN UNITED STATES AFRICAN AMERICAN PUBLIC HOUSING RESIDENTS

Adam Simning 1, Edwin van Wijngaarden 1, Yeates Conwell 2
PMCID: PMC3044217  NIHMSID: NIHMS248665  PMID: 20617430

Abstract

Background

African Americans experience considerable mental healthcare disparities in the United States, but little is known about sensitive subgroups within this population. To better understand healthcare disparities within African Americans communities, we characterized anxiety, mood, and substance use disorder prevalence and associated service utilization among public and non-public housing residents.

Methods

We used data from a nationally-representative sample of African Americans recruited as part of the National Survey of American Life.

Results

In public housing residents, the 12-month prevalence of anxiety disorders was 1.8 times higher than in non-public housing residents (P = 0.002), mood disorders was 1.4 times higher (P = 0.189), and substance use disorders was 2.2 times higher (P = 0.031). Public housing remained associated with mental illness after controlling for sociodemographics and chronic illness. Public and non-public housing residents did not differ significantly in mental healthcare utilization, but utilization was low with 16 to 30% of public housing residents with a 12-month disorder receiving mental health assistance.

Conclusions

A relatively high proportion of African American public housing residents suffered from psychiatric disorders, and few received mental healthcare assistance, indicating that further work is needed to enhance utilization.

Keywords: prevalence, mental illness, disparities, African Americans, community health

Introduction

In the United States, African Americans experience considerable mental healthcare disparities [1]. Compared to whites, African Americans are more likely to lack health insurance [2], 3 times more likely to have Medicaid (a health insurance program for the poor) [2], and less likely to receive equitable and appropriate mental health treatment [3,4]. A larger proportion of mentally ill African Americans also relies on emergency services [5] and prematurely ends treatment than whites [6]. Additionally, African Americans are more likely to fear receiving mental health treatment [7] and to be less accurately diagnosed with mental illness in primary care [8], which limits effective mental health treatment. Many African Americans also experience serious violent crime, which has been associated with mental illness [9], and about 40% of homeless [10] and federal prisoners [11] are African American, groups at high risk for mental illness [1]. These characteristics suggest that, in addition to the lack of health insurance and less effective mental health treatments, African-Americans are at greater risk for mental healthcare disparities because a larger percentage of this population is in marginalized groups. However, there has been relatively little attention regarding the epidemiology of mental healthcare in socioeconomically disadvantaged African Americans.

Public housing residents are one such group that may be especially vulnerable to healthcare inequalities. In the United States, public housing is a federal program that houses 2.4 million people of which 69% are racial and ethnic minorities and 46% are African American [12]. Public housing differs from other federal programs providing disadvantaged individuals with affordable housing in that local housing authorities own and operate public housing units rather than offer rent subsidies for privately owned residences. Limited evidence suggests that public housing residents suffer more from mental illness than non-public housing residents, possibly related to difficulty in accessing care [13] and higher levels of excessive alcohol consumption and violence [14]. In Baltimore, older adult public housing residents had more current mood disorders, schizophrenia, and substance use disorders than did other urban African American older adults [15]. Overall, of the 37% of older adult public housing residents who had a need for mental healthcare, 58% did not receive such services [16].

When compared to other community-dwelling residents, those in public housing may be doubly disadvantaged: public housing residents have limited resources, and many are from racial/ethnic minority groups that already suffer from healthcare inequalities. Our objective is to use a nationally representative sample of African Americans to characterize anxiety, mood, and substance use disorders, as well as mental healthcare utilization, among African American public and non-public housing residents. We hypothesize that African American public housing residents have a higher prevalence of psychiatric disorders and lower reported use of mental healthcare services than do African American non-public housing residents. Knowledge of the need for and utilization of mental health services by public housing residents, in particular African Americans who are socially disadvantaged, will help inform the design of more effective approaches to their care.

Methods

Sample

The National Survey of American Life (NSAL) is a cross-sectional epidemiologic study that characterized mental illness among a nationally representative sample of US African Americans and Afro-Caribbeans [17]. It is 1 of 3 epidemiologic studies included in the National Institute of Mental Health’s Collaborative Psychiatric Epidemiology Surveys [18]; the National Comorbidity Survey Replication and the National Latino and Asian American Study are the others [19]. The NSAL was conducted from 2001 to 2003 and assessed mental illness using the World Mental Health Composite International Diagnostic Interview [20]. A total of 6,199 people, 3,570 of whom were African Americans, were interviewed [17]. The African American sample had a 70.7% response rate [17] and included 472 public housing residents (weighted n = 310) and 3,098 non-public housing residents (weighted n = 2,537); weights account for sampling design and nonresponse. Although Afro-Caribbeans were included in the NSAL, there were not enough Afro-Caribbean public housing residents (weighted n = 14) to conduct meaningful analyses. University of Rochester’s Research Subjects Review Board approved our analyses of the NSAL database.

Public Housing

Public housing is owned and operated by housing authorities receiving federal funding from the US Department of Housing and Urban Development; families, elderly, and disabled persons with low incomes can qualify for public housing [21]. Public housing residents were identified by a single question: “Is this (home/apartment) in a public housing facility, that is, is it owned by a local housing authority or other public agency?” [22] We classified all African Americans who positively endorsed this question (not including non-institutionalized adults who receive rent subsidies) as public housing residents in our analyses; all other African Americans were classified as non-public housing including about 3% of the sample that had ambiguous housing status (most of which are unlikely to be public housing residents).

Psychiatric Disorders

Algorithms based upon the DSM-IV criteria assigned the 12-month and lifetime presence of psychiatric disorders. To account for comorbidity we did not apply a hierarchical classification of mental disorders with the exception of major depressive disorder (e.g., if participants suffered from a major depressive episode their illness was classified as major depressive disorder if mania or hypomania was not present). We grouped psychiatric disorders into the following 3 categories: 1) anxiety disorders (adult separation anxiety disorder, agoraphobia with and without panic disorder, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and social phobia); 2) mood disorders (bipolar I, bipolar II, dysthymia, and major depressive disorder); and 3) substance use disorders (alcohol abuse, alcohol dependence, drug abuse, and drug dependence). Schizophrenia diagnoses are unavailable.

Service Utilization

We examined service utilization in African American public and non-public housing residents with a 12-month history of anxiety, mood, and/or substance use disorders. Service utilization includes seeking assistance for emotions, nerves, mental health, and/or use of alcohol or drugs in the previous 12 months and was divided into 3 categories. Mental health services include hospitalization (for mental health reasons), hotlines, mental health counselors, mental health social workers, psychiatrists, psychologists, and other mental health professionals, whereas general medical services encompass family doctors, general practitioners, other doctors, and non-MD health professionals. Healthcare services represent the use of any mental health or general medical services. Further description on the collection and coding of these variables is available in the online NSAL documentation [22].

Sample Characteristics

We included a number of covariates in our analyses based on known or suspected association with mental health, service utilization, or public housing residence. Covariates included age in years (18–29, 30–44, 45–59, 60+), gender, marital status (married/cohabiting, divorced/separated/widowed, never married), region living (Northeast, Midwest, South, West), employment status (employed, unemployed, not in labor force), education years (0–11, 12, 13–15, 16+), difficulty in paying monthly bills (extremely difficult, very difficult, somewhat difficult, slightly difficult, and not difficult at all), and chronic medical disease (arthritis, ulcers, cancer, high blood pressure, diabetes, liver problem, kidney problem, stroke, asthma, chronic lung disease, blood circulation problem, sickle cell disease, heart trouble, glaucoma, and osteoporosis). We examined self-reported difficulty in meeting monthly payments rather than income because public housing residency eligibility is dependent on income level.

Analyses

Due to the NSAL’s complex survey design, we calculated population-weighted adjusted estimates using SAS survey procedures to account for clustering and stratification sampling methods (SAS Institute, Inc., Cary, NC). Based on recommendations for analyzing complex survey data [23], we used the Rao-Scott modified chi-square test to examine demographic and chronic medical illness, anxiety disorder, mood disorder, and substance use disorder differences between African American public and non-public housing residents; similar analyses characterized 12-month service utilization among African American public and non-public housing residents with a 12-month anxiety, mood, and/or substance use disorder. Multivariable logistical regression analyses controlling for demographic and chronic medical illness characterized the association of public housing residency with 12-month and lifetime presence of an anxiety, mood, and/or substance use disorder. We accounted for the variability of subjects with missing data by using the “not missing completely at random” (i.e., nomcar) option in SAS 9.2 in our analyses. Weighted samples of 307 public and 2,415 to 2,427 non-public housing residents (96% of the eligible African American sample) had psychiatric disorder information.

Results

Sample Characteristics

African American public housing residents differed significantly from non-public housing residents by most demographic measures examined. Compared to non-public housing residents, public housing residents lived in different regions of the United States, had more difficulty paying monthly bills, and were more likely to be female, not or never married, unemployed or not in the labor force, and less educated (Table 1).

TABLE 1.

African American public (weighted n = 310) and non-public housing (weighted n = 2,537) residents’ sample characteristics

Sample Characteristics Public Housing Residents Non-Public Housing Residents Pa
% SE % SE
Age, years 0.073
 18–29 31.6 3.4 23.5 1.1
 30–44 31.6 2.8 35.9 0.9
 45–59 19.9 2.5 24.3 0.9
 60+ 16.9 3.0 16.3 0.9
Gender <0.001
 Female 67.6 2.7 54.6 0.9
 Male 32.4 2.7 45.4 0.9
Marital Statusb <0.001
 Married/Cohabiting 19.8 3.4 44.3 1.1
 Divorced/Separated/Widowed 33.8 3.1 25.9 0.8
 Never Married 46.4 3.4 29.8 1.3
Region 0.017
 Northeast 28.7 6.0 14.1 0.8
 Midwest 16.9 3.7 19.0 2.1
 South 46.5 5.7 57.4 2.4
 West 7.9 1.9 9.4 0.9
Employment Statusc <0.001
 Employed 49.0 2.6 69.0 1.2
 Unemployed 16.2 1.8 9.3 0.8
 Not in Labor Force 34.8 3.2 21.7 1.0
Education, years <0.001
 0–11 37.8 2.8 22.5 1.3
 12 42.9 2.8 37.2 1.2
 13–15 15.4 1.8 24.9 1.0
 16+ 4.0 1.2 15.4 1.3
Paying Monthly Billsd,e <0.001
 Extremely Difficult 7.6 1.3 4.0 0.5
 Very Difficult 9.9 1.8 6.4 0.6
 Somewhat Difficult 23.4 1.6 20.5 0.8
 Slightly Difficult 29.2 3.1 25.9 0.9
 Not Difficult At All 29.9 2.8 43.2 1.5
Chronic Medical Diseasef,g 0.104
 Yes 62.2 2.6 57.2 1.2
 No 37.8 2.6 42.8 1.2
Open in a new tab
a

P determined by the Rao-Scott modified chi-square test

Some characteristics are missing data and the weighted samples analyzed are:

b

310 public housing 2,531 non-public housing;

c

310 public housing, 2,530 non-public housing;

d

309 public housing, 2,493 non-public housing;

f

307 public housing, 2,426 non-public housing

e

“How difficult is it for (you/your family) to meet the monthly payments on your (family’s) bills?”

g

Chronic medical disease includes arthritis, ulcers, cancer, high blood pressure, diabetes, liver problem, kidney problem, stroke, asthma, chronic lung disease, blood circulation problem, sickle cell disease, heart trouble, glaucoma, and osteoporosis

Psychiatric Illness

Table 2 shows the 12-month and lifetime prevalence of anxiety, mood, and substance use disorders among African American public and non-public housing residents. The 12-month and lifetime prevalence of anxiety disorders in public housing residents were 1.8 and 1.5 times greater than the levels in non-public housing residents. Twelve-month and lifetime mood disorder prevalence did not statistically differ between the groups. In regards to alcohol and drug abuse and dependence, the public housing residents’ 12-month and lifetime prevalence of substance use disorders were 2.2 and 1.8 times higher than that of non-public housing residents. Overall, African American public housing residents had a 1.7 and 1.5 times higher 12-month and lifetime prevalence of mental illness (consisting of anxiety, mood, and substance use disorders) than African American non-public housing residents.

TABLE 2.

Psychiatric disorder prevalence in African American public and non-public housing residents

DSM-IV Mental Illness 12-Month
 Pa Lifetime
 Pa
Public Housing Residents Non-Public Housing Residents Public Housing Residents Non-Public Housing Residents
% SE % SE % SE % SE
Anxiety Disorders
 Agoraphobia w/ Panic Disorderb 2.8 0.7 0.9 0.2 4.7 1.1 1.7 0.3
 Agoraphobia w/o Panic Disorderb 4.1 0.8 1.4 0.2 5.5 1.1 2.2 0.4
 Adult Separation Anxiety Disorderc 4.2 1.3 2.0 0.3 11.0 1.5 5.7 0.5
 Generalized Anxiety Disorderb 3.4 1.1 2.4 0.4 6.4 1.7 4.2 0.5
 Panic Disorderb 3.6 0.9 2.1 0.3 6.2 1.2 3.1 0.3
 Posttraumatic Stress Disorderd 8.7 1.8 3.2 0.4 15.9 2.3 8.2 0.6
 Social Phobiab 8.0 1.1 4.1 0.4 10.9 1.6 7.2 0.5
 Any Anxiety Disordere 19.8 2.1 11.0 0.8 0.002 31.8 2.0 20.7 1.0 <0.001
Mood Disorders
 Major Depressive Disorderf 8.1 1.7 4.9 0.4 13.0 2.3 10.0 0.6
 Dysthymiag 3.2 0.7 2.5 0.4 5.1 1.1 3.3 0.4
 Bipolar If 0.2 0.2 0.9 0.2 0.9 0.4 1.3 0.2
 Bipolar IIf 0.5 0.3 0.4 0.2 0.7 0.3 0.5 0.2
 Any Mood Disorderh 9.2 1.7 6.6 0.6 0.189 15.4 2.2 12.1 0.7 0.173
Substance Use Disorders
 Alcohol Abusei 4.9 1.4 1.9 0.3 17.2 1.8 8.8 0.7
 Alcohol Dependencei 3.6 1.1 1.0 0.3 8.3 1.6 3.2 0.4
 Drug Abusec 2.0 0.9 1.2 0.2 11.0 1.8 5.7 0.5
 Drug Dependencec 1.1 0.5 0.7 0.2 3.7 1.1 2.4 0.4
 Any Substance Use Disorderc 6.0 1.6 2.7 0.4 0.031 19.4 1.9 10.5 0.7 <0.001
Any Mental Disorderj 26.3 2.4 15.4 1.0 <0.001 47.0 2.8 31.0 1.3 <0.001
Open in a new tab

Major depression is with hierarchy and any mental disorder includes anxiety, mood, and substance use disorders

a

P determined by the Rao-Scott modified chi-square test

Some analyses are missing data (all public housing estimates had a weighted sample of 307) with the weighted samples of non-public housing estimates being:

b

2,424;

c

2,421;

d

2,415;

e

2,418;

f

2,426;

g

2,427;

h

2,425;

i

2,422;

j

2,418 for 12-month and 2,419 for lifetime mental disorder

After accounting for age, gender, marital status, country region, employment, education, difficulty paying monthly bills, and chronic medical illness, public housing residency among African Americans was associated with an increased risk of lifetime anxiety, 12-month substance use, lifetime substance use, and any lifetime psychiatric disorder (Table 3).

TABLE 3.

Logistic regression analyses of 12-month and lifetime presence of anxiety, mood, and substance use disorders

Sample Characteristics Anxiety Disorders Mood Disorders Substance Use Disorders Any Disorder
12-Month OR (95% CI) Life-Time OR (95% CI) 12-Month OR (95% CI) Life-Time OR (95% CI) 12-Month OR (95% CI) Life-Time OR (95% CI) 12-Month OR (95% CI) Life-Time OR (95% CI)
Public Housing Residency
 Yes 1.39 (0.97, 1.99) 1.37* (1.05, 1.77) 0.92 (0.53, 1.61) 0.98 (0.64, 1.49) 2.04* (1.03, 4.02) 2.02** (1.43, 2.84) 1.40 (1.00, 1.96) 1.62** (1.17, 2.23)
Age, years
 18–29 5.09** (2.58, 10.03) 4.43** (2.62, 7.50) 12.34** (4.64, 32.81) 5.75** (3.37, 9.79) 14.73** (3.14, 69.00) 1.47 (0.82, 2.65) 7.03** (3.71, 13.35) 3.33** (2.18, 5.10)
 30–44 3.32** (1.71, 6.44) 3.20** (2.00, 5.12) 6.80** (3.01, 15.36) 4.16** (2.41, 7.19) 12.99** (3.06, 55.17) 2.11** (1.21, 3.67) 4.45** (2.47, 8.02) 3.13** (2.15, 4.56)
 45–59 3.15** (1.73, 5.76) 2.99** (2.03, 4.41) 6.15** (2.65, 14.31) 3.50** (2.26, 5.42) 8.97** (2.41, 33.29) 2.21** (1.28, 3.84) 4.09** (2.36, 7.11) 2.73** (1.88, 3.96)
Gender
 Female 1.63** (1.23, 2.16) 1.72** (1.36, 2.19) 1.36 (0.95, 1.93) 1.33 (0.99, 1.79) 0.37** (0.21, 0.63) 0.22** (0.17, 0.28) 1.27 (1.00, 1.62) 0.95 (0.79, 1.13)
Marital Status
 Divorced/Separated/Widowed 1.43* (1.04, 1.95) 1.42** (1.13, 1.77) 2.08** (1.21, 3.60) 1.79** (1.20, 2.66) 2.00* (1.14, 3.50) 1.61** (1.24, 2.09) 1.83** (1.35, 2.49) 1.70** (1.36, 2.13)
 Never Married 1.10 (0.81, 1.50) 1.06 (0.82, 1.38) 1.46 (0.92, 2.31) 1.22 (0.89, 1.68) 1.08 (0.51, 2.28) 1.16 (0.79, 1.72) 1.19 (0.90, 1.57) 1.09 (0.85, 1.39)
Region
 Northeast 1.80 (0.99, 3.29) 1.58* (1.00, 2.48) 1.09 (0.61, 1.96) 1.95** (1.23, 3.09) 0.99 (0.24, 4.01) 1.23 (0.54, 2.79) 1.36 (0.93, 1.99) 1.59* (1.05, 2.39)
 Midwest 1.80 (0.91, 3.57) 1.60* (1.02, 2.51) 1.37 (0.76, 2.45) 2.06** (1.26, 3.37) 1.15 (0.30, 4.39) 0.98 (0.40, 2.40) 1.41 (0.91, 2.19) 1.49* (1.01, 2.19)
 South 1.26 (0.71, 2.22) 1.05 (0.70, 1.57) 0.71 (0.40, 1.25) 1.03 (0.63, 1.67) 0.75 (0.22, 2.59) 0.68 (0.30, 1.54) 1.00 (0.75, 1.33) 0.92 (0.63, 1.34)
Employment Status
 Unemployed 1.28 (0.88, 1.88) 1.16 (0.79, 1.72) 1.23 (0.75, 2.00) 1.17 (0.80, 1.73) 2.14** (1.24, 3.68) 1.14 (0.77, 1.70) 1.50* (1.08, 2.10) 1.25 (0.95, 1.64)
 Not in Labor Force 1.44* (1.03, 2.01) 1.18 (0.86, 1.61) 1.33 (0.89, 1.99) 1.13 (0.81, 1.59) 0.76 (0.41, 1.40) 0.85 (0.61, 1.19) 1.30* (1.01, 1.69) 1.07 (0.81, 1.40)
Education, years
 0–11 1.11 (0.69, 1.80) 1.09 (0.77, 1.55) 0.87 (0.48, 1.57) 0.69 (0.42, 1.16) 4.41* (1.33, 14.64) 4.12** (1.92, 8.85) 1.20 (0.75, 1.90) 1.19 (0.87, 1.65)
 12 0.90 (0.55, 1.49) 0.80 (0.54, 1.17) 0.67 (0.34, 1.32) 0.63 (0.40, 1.00) 1.38 (0.48, 4.01) 1.91 (0.89, 4.07) 0.82 (0.51, 1.31) 0.78 (0.56, 1.09)
 13–15 0.83 (0.47, 1.45) 0.90 (0.61, 1.32) 0.71 (0.36, 1.38) 0.77 (0.46, 1.27) 1.15 (0.36, 3.72) 2.67* (1.18, 6.06) 0.78 (0.49, 1.25) 1.00 (0.70, 1.44)
Paying Monthly Bills
 Extremely Difficult 4.61** (2.70, 7.88) 3.44** (2.15, 5.52) 7.45** (4.46, 12.46) 4.60** (2.79, 7.59) 2.22 (0.98, 5.05) 2.79** (1.48, 5.27) 4.72** (2.78, 8.02) 3.39** (2.15, 5.34)
 Very Difficult 2.75** (1.95, 3.88) 1.84** (1.31, 2.60) 3.48** (1.88, 6.45) 2.49** (1.63, 3.80) 1.96 (0.86, 4.47) 2.30** (1.45, 3.66) 3.15** (2.35, 4.23) 2.39** (1.82, 3.13)
 Somewhat Difficult 2.19** (1.64, 2.93) 1.82** (1.32, 2.52) 2.99** (1.73, 5.17) 1.94** (1.31, 2.87) 1.21 (0.66, 2.20) 1.52 (0.96, 2.43) 2.30** (1.71, 3.08) 1.80** (1.38, 2.36)
 Slightly Difficult 1.11 (0.79, 1.56) 1.23 (0.96, 1.59) 1.46 (0.92, 2.30) 1.20 (0.85, 1.70) 0.90 (0.52, 1.55) 1.30 (0.92, 1.83) 1.22 (0.95, 1.57) 1.33** (1.08, 1.64)
Chronic Medical Diseasea
 Yes 1.91** (1.49, 2.45) 1.76** (1.42, 2.18) 1.94** (1.27, 2.94) 1.85** (1.42, 2.39) 1.12 (0.73, 1.72) 1.75** (1.30, 2.34) 1.79** (1.36, 2.37) 1.66** (1.36, 2.04)
Open in a new tab

OR = odds ratio. CI = confidence interval. All logistic model analyses contained a weighted sample of 2698 and all variables were included simultaneously. In logistic regression modeling, the reference groups are non-public housing residency, 60+ years of age, male gender, married/cohabiting marital status, living in the West, employed, 16+ education years, not difficult at all in paying bills, and no chronic medical disease

a

Chronic medical disease includes arthritis, ulcers, cancer, high blood pressure, diabetes, liver problem, kidney problem, stroke, asthma, chronic lung disease, blood circulation problem, sickle cell disease, heart trouble, glaucoma, and osteoporosis

*

P < 0.05;

**

P < 0.01

Service Utilization

Past 12-month service utilization for mental health assistance by African American public and non-public housing residents is presented in Table 4. While there were no statistically significant differences between utilization of services, point estimates were different. Among African Americans with a 12-month anxiety disorder, more public housing residents received healthcare services for mental health assistance than did non-public housing residents (30% vs. 24%; P = 0.221). Fewer African American public housing residents with a 12-month mood disorder (27% vs. 39%; P = 0.195) and substance use disorder (16% vs. 27%; P = 0.358) used healthcare services for mental illness than did non-public housing residents. There was no difference in mental healthcare assistance between African American public and non-public housing residents with a 12-month anxiety, mood, and/or substance use disorder (26% vs. 26%; P = 0.884).

TABLE 4.

African American public and non-public housing residents’ 12-month utilization of healthcare services in the presence of a 12-month psychiatric disorder

Mental Healtha General Medicalb Any Healthcarec
% SE Pd % SE Pd % SE Pd
Anxiety Disordere 0.406 0.935 0.221
 Public Housing Resident 21.3 5.8 15.1 5.0 30.2 4.9
 Non-Public Housing Resident 16.2 1.9 15.5 2.0 23.7 2.0
Mood Disorderf 0.071 0.484 0.195
 Public Housing Resident 14.1 5.3 17.8 7.2 26.7 7.5
 Non-Public Housing Resident 27.0 3.1 23.6 3.6 39.1 3.5
Substance Use Disorderg 0.440 0.934 0.358
 Public Housing Resident 16.4 8.4 6.4 4.6 16.4 8.4
 Non-Public Housing Resident 25.5 6.6 6.9 3.0 26.8 6.3
Any Disorderh 0.987 0.420 0.884
 Public Housing Resident 17.6 4.9 12.7 3.9 25.7 4.4
 Non-Public Housing Resident 17.5 1.6 16.1 1.8 26.3 1.7
Open in a new tab

Service utilization includes those who sought assistance for emotions, nerves, mental health, and/or use of alcohol or drugs in the previous 12 months

a

Consists of hospitalization (for mental health reasons), hotlines, mental health counselors, mental health social workers, psychiatrists, psychologists, and other mental health professionals

b

Consists of family doctors, general practitioners, other doctors, and non-MD health professionals

c

Accounts for both mental health and general medical categories

d

P determined by Rao-Scott modified chi-square test Analyses have weighted samples of:

e

61 public housing, 263 non-public housing;

f

28 publichousing, 159 non-public housing;

g

19 public housing, 64 non-public housing;

h

81 public housing, 368 non-public housing

Discussion

A larger proportion of African American public housing residents suffered from anxiety and substance use disorders than African American non-public housing residents, which is consistent with previous studies reporting that public housing residents are less healthy than non-public housing residents [15, 24, 25]. Sociodemographic differences were present that may contribute to the observed mental illness disparity. Compared to non-public housing residents, public housing residents had higher unemployment levels, larger proportions of females and unmarried residents, and less educational achievement, all of which may either impact mental health or treatment of mental illness [26–30]. Low income, a qualification for public housing, is another possible risk factor for anxiety and depression [31], and serious mental illness is associated with decreased annual earnings of approximately $16,000 [32]. This reduction in income may enable more mentally ill African Americans to qualify for public housing than non-mentally ill individuals, which would subsequently increase mental illness levels among public housing residents. After controlling for sociodemographics and chronic medical illness, however, the association of public housing residency with increased likelihood of having a 12-month or lifetime psychiatric (i.e., anxiety, mood, and/or substance use) disorder persisted. Although non-Hispanic blacks may have less risk for anxiety, mood, and substance use disorders than whites [30], this trend was not present in African American public housing residents who had similar levels of anxiety and mood disorders, as well as more substance use disorders than a national largely white adult population [33]. For comparison, among US English-speaking adult household residents the estimated 12-month prevalence of anxiety, mood, and substance use disorder levels were 18.1%, 9.5%, and 3.8% [33] (African American public housing residents had levels of 19.8%, 9.2% and 6.0%).

We did not find statistically significant differences in utilization of mental health assistance from medical providers with 30.2%, 26.7%, and 16.4% of public and 23.7%, 39.1%, and 26.8% of non-public housing residents with a 12-month history of an anxiety, mood, or substance use disorder receiving care. These findings are indicative of mental healthcare disparities because among a national primarily white population of community-dwelling adults, 36.9%, 50.9%, and 34.5% of those with a 12-month history of an anxiety, mood, or substance use disorder utilized health services for mental healthcare [34], which are higher than our utilization estimates. Such racial and ethnic disparities may result because depressed Latinos, Asians, and African Americans are less likely to access mental health services than non-Latino whites [35], and depressed African Americans may have a more severe and chronic course and receive less treatment than non-Hispanic whites [36].

African American public (and non-public) housing residents may have great need for mental health treatment as only 26% of residents with a 12-month history of an anxiety, mood, and/or substance use disorder received mental health services from general or mental health providers. These illnesses can have serious consequences [33] and anxiety and depression often have chronic courses [37, 38]. Many residents may never recover from their mental illness without appropriate medical care and psychosocial interventions. The public housing setting may offer opportunities to improve services for detection and treatment of mental illnesses such as substance use disorders due to the relatively high prevalence of mental illness and low levels of service utilization. One such public housing intervention has had some success [39]. Many public housing residents may also benefit from multi-disciplinary services, and service providers such as social service agencies may be well positioned to educate residents about mental illness, help with screening, and be involved with treatment management. Specifically, some public housing apartment complexes have social workers or other potential gatekeepers that could help with mental illness education, screening, referral to appropriate care, and follow-up. Nevertheless, our data suggest that African American public housing residents do not receive or benefit from these potential opportunities to deliver improved care.

A limitation of these analyses is that the public housing residents were a small subsample of the NSAL’s nationally representative African American population. The NSAL African American public housing subgroup was estimated to represent 2.5 million adults, whereas the US Department of Housing and Urban Development estimated that 1.1 million African Americans lived in public housing in 2000 [12]; thus, the NSAL sample of public housing residents is likely not entirely representative of public housing residents nationally. Also, mental health professionals did not conduct the research interviews, and reliance on non-mental health professionals for data collection may lead to inaccuracies in psychiatric illness prevalence estimates. Another limitation is that the classification of public housing status relied on a single self-report question that may be inaccurately reported. Many African Americans are also overrepresented in disadvantaged groups not examined by the NSAL (e.g., prison [11] and homeless [10] populations), exclusion of which may lead to underestimation of the true burden of mental illness among African Americans.

Conclusions

To our knowledge, using a nationally representative sample of African Americans, these analyses are the first to estimate psychiatric disorder prevalence among public housing residents nationally and to explore service utilization patterns of residents with a recent or current psychiatric disorder. This study indicates that: 1) African American public housing residents had higher levels of anxiety and substance use disorders than African American non-public housing residents, 2) in this population, public housing was associated with elevated levels of mental illness even after accounting for sociodemographic variables and chronic medical disease; and 3) public and non-public housing residents did not differ significantly in utilization of mental healthcare, but utilization was low with only 16 to 30% of public housing residents with a 12-month disorder receiving mental health assistance from the healthcare sector. The relatively high level of psychiatric disorders in the public housing sample in combination with low utilization rates demonstrates a need to better understand mental healthcare barriers public housing residents encounter. In the US, African American public housing residents appear to be a high risk group that could benefit from mental illness screening and early identification programs with appropriate referral to coordinated medical and psychiatric treatment.

Acknowledgments

These analyses and subsequent research report were supported by the National Center for Research Resources (NCRR) (TL1RR024135 to A. Simning; principal investigator Thomas Pearson), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or NIH. Information on the NCRR is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.

Footnotes

Disclosures The authors declare they have no conflicts of interest to report.

References

  • 1.US Department of Health and Human Services. A supplement to mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001. Mental health: culture, race, and ethnicity. [PubMed] [Google Scholar]
  • 2.Brown RE, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. Los Angeles, CA: UCLA Center for Health Policy and Research and The Henry J Kaiser Family Foundation; 2000. [Google Scholar]
  • 3.Swartz MS, Wagner HR, Swanson JW, Burns BJ, George LK, Padgett DK. Comparing use of public and private mental health services: the enduring barriers of race and age. Community Ment Health J. 1998;34:133–144. doi: 10.1023/a:1018736917761. [DOI] [PubMed] [Google Scholar]
  • 4.Wang PS, Demler O, Kessler RC. Adequacy of treatment for serious mental illness in the United States. Am J Public Health. 2002;92:92–98. doi: 10.2105/ajph.92.1.92. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Hu TW, Snowden LR, Jerrell JM, Nguyen TD. Ethnic populations in public mental health: services choice and level of use. Am J Public Health. 1991;81:1429–1434. doi: 10.2105/ajph.81.11.1429. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Sue S, Fujino DC, Hu LT, Takeuchi DT, Zane NW. Community mental health services for ethnic minority groups: a test of the cultural responsiveness hypothesis. J Consult Clin Psychol. 1991;59:533–540. doi: 10.1037//0022-006x.59.4.533. [DOI] [PubMed] [Google Scholar]
  • 7.Sussman LK, Robins LN, Earls F. Treatment-seeking for depression by black and white Americans. Soc Sci Med. 1987;24:187–196. doi: 10.1016/0277-9536(87)90046-3. [DOI] [PubMed] [Google Scholar]
  • 8.Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells KB. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000;15:381–388. doi: 10.1046/j.1525-1497.2000.12088.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626–632. doi: 10.1001/archpsyc.55.7.626. [DOI] [PubMed] [Google Scholar]
  • 10.Barrett DF, Anolik I, Abramson FH. The 1990 census shelter and street night enumeration. Washington, DC: US Bureau of the Census; 1992. [Google Scholar]
  • 11.Pastore AL, Maguire K. [Accessed 14 December 2009];Sourcebook of criminal justice statistics 2003. 2005 http://www.albany.edu/sourcebook/pdf/t653.pdf.
  • 12.US Department of Housing and Urban Development Office of Policy Development and Research. [Accessed 14 December 2009];A picture of subsidized households - 2000. 2009 http://www.huduser.org/picture2000/index.html.
  • 13.Malmgren JA, Martin ML, Nicola RM. Health care access of poverty-level older adults in subsidized public housing. Public Health Rep. 1996;111:260–263. [PMC free article] [PubMed] [Google Scholar]
  • 14.Wiggers J, Radvan D, Clover K, Hazell T, Alexander J, Considine R. Public housing, public health: health needs of public housing tenants. Aust N Z J Public Health. 2001;25:111–114. doi: 10.1111/j.1753-6405.2001.tb01830.x. [DOI] [PubMed] [Google Scholar]
  • 15.Rabins PV, Black B, German P, Roca R, McGuire M, Brant L, Cook J. The prevalence of psychiatric disorders in elderly residents of public housing. J Gerontol A Biol Sci Med Sci. 1996;51:M319–M324. doi: 10.1093/gerona/51a.6.m319. [DOI] [PubMed] [Google Scholar]
  • 16.Black BS, Rabins PV, German P, McGuire M, Roca R. Need and unmet need for mental health care among elderly public housing residents. Gerontologist. 1997;37:717–728. doi: 10.1093/geront/37.6.717. [DOI] [PubMed] [Google Scholar]
  • 17.Jackson JS, Torres M, Caldwell CH, Neighbors HW, Nesse RM, Taylor RJ, Trierweiler SJ, Williams DR. The national survey of American life: a study of racial, ethnic and cultural influences on mental disorders and mental health. Int J Methods Psychiatr Res. 2004;13:196–207. doi: 10.1002/mpr.177. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Heeringa SG, Wagner J, Torres M, Duan N, Adams T, Berglund P. Sample designs and sampling methods for the collaborative psychiatric epidemiology studies (CPES) Int J Methods Psychiatr Res. 2004;13:221–240. doi: 10.1002/mpr.179. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Pennell BE, Bowers A, Carr D, Chardoul S, Cheung GQ, Dinkelmann K, Gebler N, Hansen SE, Pennell S, Torres M. The development and implementation of the national comorbidity survey replication, the national survey of American life, and the national Latino and Asian American survey. Int J Methods Psychiatr Res. 2004;13:241–269. doi: 10.1002/mpr.180. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Kessler RC, Ustun TB. The world mental health (WMH) survey initiative version of the World Health Organization (WHO) composite international diagnostic interview (CIDI) Int J Methods Psychiatr Res. 2004;13:93–121. doi: 10.1002/mpr.168. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.US Department of Housing and Urban Development. [Accessed 14 December 2009];HUD's public housing program. 2009 http://www.hud.gov/renting/phprog.cfm.
  • 22.Alegria M, Jackson JS, Kessler RC, Takeuchi D. Collaborative psychiatric epidemiology surveys (CPES), 2001–2003. Ann Arbor, MI: Institute for Social Research, Survey Research Center and Inter-university Consortium for Political and Social Research; 2009. [Accessed 14 December 2009]. http://www.icpsr.umich.edu/CPES/ [Google Scholar]
  • 23.Centers for Disease Control and Prevention. [Accessed 14 December 2009];Continuous NHANES web tutorial. 2009 http://www.cdc.gov/nchs/tutorials/nhanes/index_current.htm.
  • 24.Digenis-Bury EC, Brooks DR, Chen L, Ostrem M, Horsburgh CR. Use of a population-based survey to describe the health of Boston public housing residents. Am J Public Health. 2008;98:85–91. doi: 10.2105/AJPH.2006.094912. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Fertig AR, Reingold DA. Public housing, health and health behaviors: is there a connection? J Policy Anal Manage. 2007;26:831–859. doi: 10.1002/pam.20288. [DOI] [PubMed] [Google Scholar]
  • 26.Beekman AT, Bremmer MA, Deeg DJ, van Balkom AJ, Smit JH, de Beurs E, van Dyck R, van Tilburg W. Anxiety disorders in later life: a report from the longitudinal aging study Amsterdam. Int J Geriatr Psychiatry. 1998;13:717–726. doi: 10.1002/(sici)1099-1166(1998100)13:10<717::aid-gps857>3.0.co;2-m. [DOI] [PubMed] [Google Scholar]
  • 27.Smit F, Comijs H, Schoevers R, Cuijpers P, Deeg D, Beekman A. Target groups for the prevention of late-life anxiety. Br J Psychiatry. 2007;190:428–434. doi: 10.1192/bjp.bp.106.023127. [DOI] [PubMed] [Google Scholar]
  • 28.Bebbington PE, Brugha TS, Meltzer H, Jenkins R, Ceresa C, Farrell M, Lewis G. Neurotic disorders and the receipt of psychiatric treatment. Psychol Med. 2000;30:1369–1376. doi: 10.1017/s0033291799002974. [DOI] [PubMed] [Google Scholar]
  • 29.Prince MJ, Harwood RH, Thomas A, Mann AH. A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The gospel oak project VII. Psychol Med. 1998;28:337–350. doi: 10.1017/s0033291797006478. [DOI] [PubMed] [Google Scholar]
  • 30.Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:593–602. doi: 10.1001/archpsyc.62.6.593. [DOI] [PubMed] [Google Scholar]
  • 31.Vink D, Aartsen MJ, Schoevers RA. Risk factors for anxiety and depression in the elderly: a review. J Affect Disord. 2008;106:29–44. doi: 10.1016/j.jad.2007.06.005. [DOI] [PubMed] [Google Scholar]
  • 32.Kessler RC, Heeringa S, Lakoma MD, Petukhova M, Rupp AE, Schoenbaum M, Wang PS, Zaslavsky AM. Individual and societal effects of mental disorders on earnings in the United States: results from the national comorbidity survey replication. Am J Psychiatry. 2008;165:703–711. doi: 10.1176/appi.ajp.2008.08010126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:617–627. doi: 10.1001/archpsyc.62.6.617. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:629–640. doi: 10.1001/archpsyc.62.6.629. [DOI] [PubMed] [Google Scholar]
  • 35.Alegria M, Chatterji P, Wells K, Cao Z, Chen CN, Takeuchi D, Jackson J, Meng XL. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. 2008;59:1264–1272. doi: 10.1176/appi.ps.59.11.1264. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Williams DR, Gonzalez HM, Neighbors H, Nesse R, Abelson JM, Sweetman J, Jackson JS. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the national survey of American life. Arch Gen Psychiatry. 2007;64:305–315. doi: 10.1001/archpsyc.64.3.305. [DOI] [PubMed] [Google Scholar]
  • 37.Beekman AT, Geerlings SW, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, Braam AW, Penninx BW, van Tilburg W. The natural history of late-life depression: a 6-year prospective study in the community. Arch Gen Psychiatry. 2002;59:605–611. doi: 10.1001/archpsyc.59.7.605. [DOI] [PubMed] [Google Scholar]
  • 38.Schuurmans J, Comijs HC, Beekman AT, de Beurs E, Deeg DJ, Emmelkamp PM, van Dyck R. The outcome of anxiety disorders in older people at 6-year follow-up: results from the longitudinal aging study Amsterdam. Acta Psychiatr Scand. 2005;111:420–428. doi: 10.1111/j.1600-0447.2005.00531.x. [DOI] [PubMed] [Google Scholar]
  • 39.Rabins PV, Black BS, Roca R, German P, McGuire M, Robbins B, Rye R, Brant L. Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA. 2000;283:2802–2809. doi: 10.1001/jama.283.21.2802. [DOI] [PubMed] [Google Scholar]

RESOURCES