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Differential Mortality for Persons With Psychological Distress and Low Socioeconomic Status: What Does It Mean and What Can Be Done?Comment on “The Combined Association of Psychological Distress and Socioeconomic Status With All-Cause Mortality”

Differential Mortality for Persons With Psychological Distress and Low Socioeconomic Status: What... We have long known that people who live in poverty have shorter life expectancies than those who are better off.1 Similarly, psychological distress is a risk factor for early mortality.2 Lazzarino and colleagues3 provide evidence that the effect of psychological distress on mortality is greater among adults of lower socioeconomic status (SES). The finding is based on 66 518 adults completing the Health Survey for England in 1 of 10 years (1994-2004), with survey data linked to mortality data to 2008 (mean follow-up of 8 years). Their analysis relied on a brief measure of psychological distress (symptoms of anxiety and depression, low confidence, and social dysfunction), an occupation measure (categories from managerial/professional to unskilled), and adjustment for age, sex, body mass index, smoking, and diabetes mellitus and for hypertension and physical activity in sensitivity analyses. They found that occupational status and psychological distress had significant main effects on mortality and an interaction reflecting a stronger effect of distress on mortality among persons of lower social class. The authors featured all-cause mortality but found similar conclusions for mortality due to stroke and coronary heart disease and for men and women, older and younger adults, and early and late survey cohorts. A higher relative risk for mortality with mental disorders such as depression (relative risk, 1.7), schizophrenia and bipolar disorder (2.6), alcohol abuse (1.8), and substance abuse (2.0)4 has been well documented, and the risk is largely owing to medical causes rather than accidents and suicides. A recent nationally representative study in the United States found that socioeconomic factors largely accounted for approximately one-quarter of mortality in persons with mental illnesses, a figure similar to estimates of the role played by SES in the health of the general population.5 If this finding is true, the excess mortality associated with lower SES among persons with psychological distress may be accounted for by those who are distressed and poor but do not have mental disorders. On the other hand, depression and anxiety can interfere with adherence to treatments for physical conditions, can affect coping responses in the face of stressors, and have been associated with changes in biological response, such as changes in the inflammatory and cortisol responses. The identification by Lazzarino and colleagues of an interactive effect between psychological distress and SES on mortality makes clear the need to understand the mechanisms underlying this compound burden on health and to develop interventions specifically to improve distress and physical health in lower-SES populations. What are the implications of these findings for lower-SES communities? Culture may be a powerful mediator of health in poor communities. Evidence suggests that immigrant Mexican Americans enjoy better mental and physical health than their US-born Mexican American counterparts.6 Similarly, despite higher rates of poverty, ethnic minority populations enjoy lower or similar rates of mental disorders than their wealthier white counterparts.6 Efforts to strengthen the social capital of poor communities might well reverse the dual challenges to health of poorer resources and marginalization or demoralization. What are the clinical implications of this potential interaction, and what might clinicians or health care systems do about it? The response most likely depends on the mechanism. For example, if distress represents a marker of worse prognosis of physical illness because of delayed identification in lower-SES groups, then the most effective response may be more aggressive outreach or management of physical illnesses. If the mechanism is distress interfering more with treatment adherence in persons of lower social class, then efforts to couple disease self-management with management of psychological distress may be in order. If the mechanism is greater physiological activation, then options may include behavioral management of stress or addressing mediating mechanisms, such as inflammatory response. If the mechanism is primarily due to weak buffering of stress with fewer social supports or limited coping resources, then social services from staff trained to work effectively with persons of lower SES and with psychological distress or resiliency approaches, such as meditation, may be appropriate. Physical health is a social determinant of mental health, and collaborative care programs that jointly address depression and physical conditions, such as heart disease and diabetes, can improve mental and physical health outcomes.7 To address the increased risk for mortality associated with psychological distress in persons of lower SES, health care providers and partnering public health and community agencies likely will require an integrated strategy to address poverty-related hardship, psychological distress, physical disorders, and social determinants of health in combination. Thomas et al8 have outlined an approach to develop and evaluate such comprehensive interventions to reduce multiple sources of disparities while attending to implications of race and equity within the research leadership, an approach called Health Equity Action and Research Trajectory (HEART). Community-based participatory research is recommended for addressing health disparities and is noted in the HEART model as an approach to implement research and action jointly and equitably. Early examples of this approach in mental health include the Community Partners in Care Study9 to address depression in underresourced communities and studies of shifting some behavioral health tasks to health care workers. The engagement of communities affected by multiple disparities to improve health care and address social determinants of health may be one promising approach to improve quality of life and reduce mortality for persons of lower SES with psychological distress. Although such approaches will require policy support and funding for implementation, clinicians can be mindful that conventional treatments of common mental disorders are effective in vulnerable groups. At the same time, clinicians can attend to concurrent physical health conditions and seek to enhance coping and social support through social services or collaborating community partners, similar to the concept of a community health home. Managers of such systems can consider implementing quality-improvement programs for depression and anxiety that are based on the collaborative care model. Relative to usual care, the collaborative model can improve health outcomes and reduce depression outcome disparities for underserved minorities compared with whites for multiple years.10,11 At a minimum, such interventions will improve quality of life. Which of these approaches may best address differential mortality is a question for future research because mechanisms underlying the interaction are clarified to inform interventions. Given the large sample sizes required to examine mortality as an outcome, intervention studies should track mortality consistently to facilitate future meta-analyses. Back to top Article Information Correspondence: Dr Wells, Center for Health Services and Society, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd, Ste 300, Los Angeles, CA 90024 (kwells@mednet.ucla.edu). Published Online: December 3, 2012. doi:10.1001/jamainternmed.2013.1542 Conflict of Interest Disclosures: None reported. Funding/Support: The authors are supported by grant P30MH068639 from the National Institute of Mental Health. Disclaimer: The content is the responsibility of the authors and does not necessarily represent the views of the sponsor. References 1. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-110415781105PubMedGoogle Scholar 2. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007;370(9592):1089-110017822755PubMedGoogle ScholarCrossref 3. Lazzarino AI, Hamer M, Stamatakis E, Steptoe A. The combined association of psychological distress and socioeconomic status with all-cause mortality: a national cohort study [published online December 3, 2012]. JAMA Intern Med. 2013;173(1):22-27Google Scholar 4. Eaton WW, Martins SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P. The burden of mental disorders. Epidemiol Rev. 2008;30:1-1418806255PubMedGoogle ScholarCrossref 5. Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6):599-60421577183PubMedGoogle ScholarCrossref 6. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry. 1998;55(9):771-7789736002PubMedGoogle ScholarCrossref 7. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-262021190455PubMedGoogle ScholarCrossref 8. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health. 2011;32:399-41621219164PubMedGoogle ScholarCrossref 9. Chung B, Jones L, Dixon EL, Miranda J, Wells K.Community Partners in Care Steering Council. Using a community partnered participatory research approach to implement a randomized controlled trial: planning community partners in care. J Health Care Poor Underserved. 2010;21(3):780-79520693725PubMedGoogle ScholarCrossref 10. Wells K, Miranda J, Bruce ML, Alegria M, Wallerstein N. Bridging community intervention and mental health services research. Am J Psychiatry. 2004;161(6):955-96315169681PubMedGoogle ScholarCrossref 11. Miranda J, McGuire TG, Williams DR, Wang P. Mental health in the context of health disparities. Am J Psychiatry. 2008;165(9):1102-110818765491PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Differential Mortality for Persons With Psychological Distress and Low Socioeconomic Status: What Does It Mean and What Can Be Done?Comment on “The Combined Association of Psychological Distress and Socioeconomic Status With All-Cause Mortality”

JAMA Internal Medicine , Volume 173 (1) – Jan 14, 2013

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American Medical Association
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Copyright © 2013 American Medical Association. All Rights Reserved.
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2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.1542
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Abstract

We have long known that people who live in poverty have shorter life expectancies than those who are better off.1 Similarly, psychological distress is a risk factor for early mortality.2 Lazzarino and colleagues3 provide evidence that the effect of psychological distress on mortality is greater among adults of lower socioeconomic status (SES). The finding is based on 66 518 adults completing the Health Survey for England in 1 of 10 years (1994-2004), with survey data linked to mortality data to 2008 (mean follow-up of 8 years). Their analysis relied on a brief measure of psychological distress (symptoms of anxiety and depression, low confidence, and social dysfunction), an occupation measure (categories from managerial/professional to unskilled), and adjustment for age, sex, body mass index, smoking, and diabetes mellitus and for hypertension and physical activity in sensitivity analyses. They found that occupational status and psychological distress had significant main effects on mortality and an interaction reflecting a stronger effect of distress on mortality among persons of lower social class. The authors featured all-cause mortality but found similar conclusions for mortality due to stroke and coronary heart disease and for men and women, older and younger adults, and early and late survey cohorts. A higher relative risk for mortality with mental disorders such as depression (relative risk, 1.7), schizophrenia and bipolar disorder (2.6), alcohol abuse (1.8), and substance abuse (2.0)4 has been well documented, and the risk is largely owing to medical causes rather than accidents and suicides. A recent nationally representative study in the United States found that socioeconomic factors largely accounted for approximately one-quarter of mortality in persons with mental illnesses, a figure similar to estimates of the role played by SES in the health of the general population.5 If this finding is true, the excess mortality associated with lower SES among persons with psychological distress may be accounted for by those who are distressed and poor but do not have mental disorders. On the other hand, depression and anxiety can interfere with adherence to treatments for physical conditions, can affect coping responses in the face of stressors, and have been associated with changes in biological response, such as changes in the inflammatory and cortisol responses. The identification by Lazzarino and colleagues of an interactive effect between psychological distress and SES on mortality makes clear the need to understand the mechanisms underlying this compound burden on health and to develop interventions specifically to improve distress and physical health in lower-SES populations. What are the implications of these findings for lower-SES communities? Culture may be a powerful mediator of health in poor communities. Evidence suggests that immigrant Mexican Americans enjoy better mental and physical health than their US-born Mexican American counterparts.6 Similarly, despite higher rates of poverty, ethnic minority populations enjoy lower or similar rates of mental disorders than their wealthier white counterparts.6 Efforts to strengthen the social capital of poor communities might well reverse the dual challenges to health of poorer resources and marginalization or demoralization. What are the clinical implications of this potential interaction, and what might clinicians or health care systems do about it? The response most likely depends on the mechanism. For example, if distress represents a marker of worse prognosis of physical illness because of delayed identification in lower-SES groups, then the most effective response may be more aggressive outreach or management of physical illnesses. If the mechanism is distress interfering more with treatment adherence in persons of lower social class, then efforts to couple disease self-management with management of psychological distress may be in order. If the mechanism is greater physiological activation, then options may include behavioral management of stress or addressing mediating mechanisms, such as inflammatory response. If the mechanism is primarily due to weak buffering of stress with fewer social supports or limited coping resources, then social services from staff trained to work effectively with persons of lower SES and with psychological distress or resiliency approaches, such as meditation, may be appropriate. Physical health is a social determinant of mental health, and collaborative care programs that jointly address depression and physical conditions, such as heart disease and diabetes, can improve mental and physical health outcomes.7 To address the increased risk for mortality associated with psychological distress in persons of lower SES, health care providers and partnering public health and community agencies likely will require an integrated strategy to address poverty-related hardship, psychological distress, physical disorders, and social determinants of health in combination. Thomas et al8 have outlined an approach to develop and evaluate such comprehensive interventions to reduce multiple sources of disparities while attending to implications of race and equity within the research leadership, an approach called Health Equity Action and Research Trajectory (HEART). Community-based participatory research is recommended for addressing health disparities and is noted in the HEART model as an approach to implement research and action jointly and equitably. Early examples of this approach in mental health include the Community Partners in Care Study9 to address depression in underresourced communities and studies of shifting some behavioral health tasks to health care workers. The engagement of communities affected by multiple disparities to improve health care and address social determinants of health may be one promising approach to improve quality of life and reduce mortality for persons of lower SES with psychological distress. Although such approaches will require policy support and funding for implementation, clinicians can be mindful that conventional treatments of common mental disorders are effective in vulnerable groups. At the same time, clinicians can attend to concurrent physical health conditions and seek to enhance coping and social support through social services or collaborating community partners, similar to the concept of a community health home. Managers of such systems can consider implementing quality-improvement programs for depression and anxiety that are based on the collaborative care model. Relative to usual care, the collaborative model can improve health outcomes and reduce depression outcome disparities for underserved minorities compared with whites for multiple years.10,11 At a minimum, such interventions will improve quality of life. Which of these approaches may best address differential mortality is a question for future research because mechanisms underlying the interaction are clarified to inform interventions. Given the large sample sizes required to examine mortality as an outcome, intervention studies should track mortality consistently to facilitate future meta-analyses. Back to top Article Information Correspondence: Dr Wells, Center for Health Services and Society, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd, Ste 300, Los Angeles, CA 90024 (kwells@mednet.ucla.edu). Published Online: December 3, 2012. doi:10.1001/jamainternmed.2013.1542 Conflict of Interest Disclosures: None reported. Funding/Support: The authors are supported by grant P30MH068639 from the National Institute of Mental Health. Disclaimer: The content is the responsibility of the authors and does not necessarily represent the views of the sponsor. References 1. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-110415781105PubMedGoogle Scholar 2. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007;370(9592):1089-110017822755PubMedGoogle ScholarCrossref 3. Lazzarino AI, Hamer M, Stamatakis E, Steptoe A. The combined association of psychological distress and socioeconomic status with all-cause mortality: a national cohort study [published online December 3, 2012]. JAMA Intern Med. 2013;173(1):22-27Google Scholar 4. Eaton WW, Martins SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P. The burden of mental disorders. Epidemiol Rev. 2008;30:1-1418806255PubMedGoogle ScholarCrossref 5. Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6):599-60421577183PubMedGoogle ScholarCrossref 6. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry. 1998;55(9):771-7789736002PubMedGoogle ScholarCrossref 7. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-262021190455PubMedGoogle ScholarCrossref 8. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health. 2011;32:399-41621219164PubMedGoogle ScholarCrossref 9. Chung B, Jones L, Dixon EL, Miranda J, Wells K.Community Partners in Care Steering Council. Using a community partnered participatory research approach to implement a randomized controlled trial: planning community partners in care. J Health Care Poor Underserved. 2010;21(3):780-79520693725PubMedGoogle ScholarCrossref 10. Wells K, Miranda J, Bruce ML, Alegria M, Wallerstein N. Bridging community intervention and mental health services research. Am J Psychiatry. 2004;161(6):955-96315169681PubMedGoogle ScholarCrossref 11. Miranda J, McGuire TG, Williams DR, Wang P. Mental health in the context of health disparities. Am J Psychiatry. 2008;165(9):1102-110818765491PubMedGoogle ScholarCrossref

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Jan 14, 2013

Keywords: socioeconomic factors

References