Housing Instability and Mental Distress among US Veterans

Abstract

Evidence has suggested increased risk for homelessness and suicide among US veterans, but little is known about the associations between housing instability and psychological distress (including suicidal ideation). We examined frequent mental distress (FMD) and suicidal ideation among a probability-based sample of 1767 Nebraska veterans who participated in the 2010 Behavioral Risk Factor Surveillance Survey who had and had not experienced housing instability in the past 12 months. Veterans experiencing housing instability had increased odds of FMD and suicidal ideation.

Veterans are disproportionally overrepresented in the homeless population, accounting for 14% of all adults experiencing homelessness.¹ On any given night, more than 67 000 US veterans are homeless.¹ Housing is considered a basic human need, and housing-related stress can have stark ramifications for physical and mental health, including mental distress and suicidal ideation. Previous studies have reported associations between suicidal ideation and homelessness^2,3 and housing instability and depression.⁴ Schinka et al.⁵ recently noted that prevalence of suicidal ideation and attempt were significantly elevated among older veterans enrolled in an intervention program for homelessness. Veterans are a priority population in addressing the public health problem of suicide risk,⁶ and the US Department of Veterans Affairs has devoted considerable resources to screening and ameliorating homelessness and housing instability among veterans.⁷ However, little is known about associations between housing-related financial distress (i.e., housing instability⁸) and mental distress and suicidal ideation among veterans. Our purpose in this article is to increase knowledge of risk for poor mental health associated with risk for homelessness by investigating the characteristics of housing instability, mental distress, and suicidal ideation among a probability-based sample of veterans.

METHODS

We obtained data from 1767 Nebraska veterans who participated in the 2010 Behavioral Risk Factor Surveillance Survey, a survey administered annually to a representative sample of noninstitutionalized adults aged 18 years and older.⁹ The overall response rate for the 2010 Nebraska Behavioral Risk Factor Surveillance Survey was 56.3%.¹⁰ One item assessed housing instability (i.e., “How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?”). We dichotomized responses into “always/usually” and “sometimes/rarely/never.” Outcomes were suicidal ideation (i.e., “Has there been a time in the past 12 months when you thought of taking your own life?”) and frequent mental distress, measured as 6 or more days of poor mental health in the past 30 days.¹¹ We used the χ² test of independence and the Fisher exact test to examine differences in variables for veterans who had or had not experienced housing instability in the past 12 months. Two logistic regression models were used to test the association of housing instability with suicidal ideation and with frequent mental distress while adjusting for gender, age, race/ethnicity, marital status, and self-report lifetime diagnosis of depression, anxiety, or posttraumatic stress disorder. We conducted all analyses using SAS version 9.2 (SAS Institute, Cary, NC). Because analyses were drawn from a single state, the subsample of people with housing instability was small (n = 66), and veteran populations differed on key demographics (e.g., age, gender, race/ethnicity) used in derivation of Behavioral Risk Factor Surveillance Survey weights, the analyses are unweighted.^12,13

RESULTS

A total of 2.2% of veterans reported suicidal ideation in the past 12 months, 11.3% reported frequent mental distress, and 3.7% indicated housing instability. Veterans reporting housing instability were significantly more likely to be female, younger, and unmarried; have a history of depression, anxiety, or posttraumatic stress disorder; and report suicidal ideation or frequent mental distress (Table 1). In adjusted multiple logistic regression models, veterans with past-year housing instability had 5 times the odds of frequent mental distress and more than 6 times the odds of suicidal ideation than veterans not experiencing housing instability.

TABLE 1—

Demographics by Housing Instability and Odds of Mental Health-Related Outcomes among Veterans: 2010 Behavioral Risk Factor Surveillance Survey, Nebraska

	Bivariate Analyses		Multivariate Analyses
Demographics	Housing Instability (n = 66), No. (%)	No Housing Instability (n = 1701), No. (%)	Suicidal Ideation, AOR (95% CI)	Frequent Mental Distress AOR (95% CI)
Gender
Men	57 (86.4)	1610 (94.7)	2.40 (0.65, 8.87)	0.38** (0.22, 0.67)
Women	9* (13.6)	91 (5.3)	1.00 (Ref)	1.00 (Ref)
Age group, y
18–39	6* (9.1)	66 (3.9)	1.00 (Ref)	1.00 (Ref)
40–64	35 (53.0)	639 (37.6)	1.69 (0.38, 7.53)	0.91 (0.43, 1.94)
> 64	25 (37.9)	992 (58.3)	0.74 (0.16, 3.45)	0.80 (0.37, 1.71)
Racea
Non-White	4 (6.1)	74 (4.4)	1.00 (Ref)	1.00 (Ref)
White	62 (93.9)	1627 (95.6)	0.65 (0.23, 1.86)	0.62 (0.32, 1.20)
Partnership status
Married or cohabitating	38 (57.6)	1217 (71.5)	0.89 (0.42, 1.90)	0.45** (0.32, 0.63)
Single, divorced, separated, widowed	28* (42.4)	484 (28.5)	1.00 (Ref)	1.00 (Ref)
Explanatory Factors
Lifetime psychiatric diagnosis
Yes	22 (33.3)*	174 (10.2)	12.47** (5.94, 26.17)	8.97** (6.17, 13.04)
No	44 (66.7)	1527 (89.8)	1.00 (Ref)	1.00 (Ref)
Housing instability in past 12 mo
Always or usually	66 (100.0)	…	6.46** (2.60, 16.07)	5.21** (2.90, 9.33)
Sometimes, rarely, or never	…	1701 (100.00)	1.00 (Ref)	1.00 (Ref)
Outcomes
Frequent psychological distress
1–5 d to 30 d	36 (54.5)	1532 (90.1)	…	…
6–30 d to 30 d	30** (45.5)	169 (9.9)	…	…
Suicidal ideation in past 12 mo
Yes	11** (16.7)	28 (1.6)	…	…
No	55 (83.3)	1673 (98.4)	…	…

Note. AOR = adjusted odds ratio; CI = confidence interval. The sample size for veterans was n = 1767. Three respondents in the No Housing Instability group were missing data for age.

^aWhite vs non-White (i.e., Black/African American, Asian, Native Hawaiian/other Pacific Islander, American Indian or Alaska Native, other race).

^*P < .05 in bivariate analyses; **P < .05 in multivariate analysis.

DISCUSSION

To our knowledge, this study is the first to examine financial strain related to housing instability among a sample of veterans. The results among this sample corroborate previous findings of associations of mental distress and suicidal ideation with housing instability.^2,4 More importantly, these results suggest that in addition to realized or chronic homelessness, even financial strain related to housing instability is associated with mental distress and suicidal ideation. That is to say, psychological distress associated with homelessness may be elevated distally at the period preceding actual homelessness. Moreover, the association of housing instability remained robustly associated with mental distress and suicidal ideation even after controlling for self-reported psychiatric diagnoses. Increased awareness of housing status and proactive referral to housing services may provide an opportunity to decrease risk of psychological distress and suicidal ideation associated with loss or threat of loss of housing.

We must note several limitations. First, data used in these analyses are from 1 state and the analyses are unweighted, which preclude generalizability. These precursory findings require further research. Second, small sample size resulted in wide confidence intervals, and point estimates should be interpreted with caution. Nonetheless, despite small sample size and rare event outcomes, the associations for housing instability remained significant even after adjusting for psychiatric diagnoses. Third, the definition of housing instability was limited to financial strain and may have missed other indications of housing instability (e.g., moving frequently).⁸ Fourth, data are cross-sectional and reference periods differed across key variables (e.g., past 30 days, lifetime, past 12 months), precluding examination of causality or temporal relationships among the variables. Fifth, other variables associated with housing instability (e.g., substance abuse) were not included in the final model. Finally, we could not verify the self-reported measure of veteran status against official records to ascertain history of US military service, thus inviting potential misclassification bias.

The Department of Veterans Affairs has initiated bold campaigns to address suicide¹⁴ and homelessness⁷ among veterans. Beginning in fiscal year 2013, the Department of Veterans Affairs implemented a public health prevention model that screened all veterans eligible for Department of Veterans Affairs health care for eminent risk of homelessness and proactively connected them to support services. Future research in this area can provide crucial information about how independent efforts devoted to suicide prevention and homelessness may find innovative mergers that enhance safety and improve the quality of life of veterans in need.