Psychological Distress in California : Identifying Those at Greatest Risk

In order to address the unmet need for prevention and treatment of psychological distress and mental disorders, program planners and treatment providers need to identify individuals at high risk. The results of the California Health Interview Survey from 2009 (n = 47,614) indicate that there are high relative risks by demographics and smoking status for reports of psychological distress and intermediate measures: feeling nervous, hopeless, worthless, depressed, restless, and that everything is an effort. Specific demographic factors and smoking status can predict a greater need for prevention and treatment of psychological distress and lack of insurance coverage for treatment. Profiles associated with high risk can help in referral for diagnosis or to plan prevention programs.


Introduction
According to the 1999 Surgeon General's report, "Mental health is fundamental to health" and therefore mental health promotion is fundamental to health promotion.Mental disorders are often chronic and disabling.There is a great unmet need for prevention and treatment of mental disorders.Identifying groups at higher risk of mental disorders can both give evidence for the need and give direction to prevention and treatment efforts.

Psychological Distress
Serious psychological distress is a precursor to serious mental illness like depression and anxiety disorders and is a risk factor for suicide.Distress is also a risk factor for cardiovascular diseases and injuries.Distress can lengthen recovery from a variety of illnesses and injuries.Serious psychological distress is prevalent and de-structive.

Demographic Factors and Psychological Distress
It has been established in the professional literature that psychiatric disorders and their precursors do not occur evenly among the population.Disparities in mental health mirror some of the established risk factors for poor physical health in the US.Physical health diminishes with age and members of minority communities are at greater risk of disability and early death.Risk factors for depression, serious psychiatric distress and chronic mental disorders also include older age [1] [2] and minority status [3].Additional risk factors are less education, being unmarried, unemployment, low income [4], lack of health insurance [1] and gender [5].
Extensive research regarding gender differences and health disparities by gender clearly indicates that men and women have different mental and physical health problems.It is also believed that gender differences in mental health contribute to gender differences in physical health.Needham asserts that women have more internalizing mental disorders as well as excess arthritis, headaches and gallbladder removal, while men have more externalizing mental disorders as well as excess heart disease and high blood pressure [5].
Examining physical and mental health disparities is truly artificial since mental health disorders often occur simultaneously with diabetes, cardiac disease and arthritis in older adults [2].In addition to highly prevalent physical disorders in older adults, "One in four adults lives with depression, anxiety disorders or other significant psychiatric disorder" [2].As the population ages there is an increased need for mental health services and the difficulties of aging are exacerbated by limited access to mental health services [2].
The unmet need for mental health services is compounded by the lack of preventive mental health interventions.In an editorial published in December 2010, Perry, Presley-Cantrell and Dhingra [6] recommend an integrated approach to achieving total health for a population in which physical and mental health are comprehensive including primary care, mental health and public health.It is one thing to declare that something should be done and another to provide evidence regarding how it should be done.To this end, Salum [7] convinces that there is an urgent need for investigations on preventive interventions in individuals at risk for mental disorders.

Smoking and Psychological Distress
In addition to the need for interventions to prevent mental disorders, it is equally important to enhance the health of those with mental disorders.Smoking cessation is a significant need.Tobacco-related cancer, heart disease and lung disease are the leading causes of death for individuals with serious mental illness [8].The prevalence of smoking among people with mental disorders was higher in the 2007 National Health Interview Survey than the prevalence among people without mental disorders [9] and has been reported as 2 to 4 times greater among individuals with serious mental illness [10].While the rate of smoking among Californians is lower than the rest of the nation, the smoking rate among those with mental disorders or psychological distress is unknown.
In addition to the well-established risks of smoking, people with mental illness also risk diminished effects of their psychotherapeutic drugs.Tobacco smoking induces the metabolism of a number of psychiatric medications, resulting in reduced therapeutic blood levels [11].Tobacco smoking may also contribute to psychological distress in the now minority population that smokes.
Many mental health practitioners are skeptical about the need for smoking cessation and share low expectations of successful smoking cessation with their patients.A 2006 survey found that psychiatrists of all medical specialties, are the least likely to treat tobacco dependence [12].It may be true that patients with mental illness present additional challenges to those providing smoking cessation.Pregnant women with a history of a mental disorder and high stress scores have higher odds of continuing smoking [13].However, many people with serious mental disorders are motivated to attend smoking cessation and are successful [14].

Research Questions
The following research questions were determined for this secondary analysis:

California Health Interview Survey
The public use data base analyzed in this study was collected by the UCLA Center for Health Policy Research in collaboration with the California Department of Public Health and the Department of Health Care Services as the California Health Interview Survey (CHIS).The 2009 data were released on February 16, 2011.CHIS is the nation's largest state health survey.It is a random-dial telephone survey conducted every two years on a wide range of health topics that gives a detailed picture of the health and health care needs of California's large and diverse population.CHIS is conducted in six languages: English, Spanish, Mandarin, Cantonese, Korean and Vietnamese.

Variables Selected
Eighteen of the 576 variables that relate to psychological distress were selected for this analysis.They include experience of psychological distress in the past year; psychological distress in the past month and intermediate indicators of feeling nervous, hopeless, worthless, depressed, and restless and that everything is an effort in the past month.The independent variables were selected as possible variables of association based on literature review.They include: age, gender, marital status, educational attainment, working status, race and ethnicity, born in US, insurance coverage, and smoking.General Health Condition was selected as a comparison variable.
Psychological distress measures • Psychological distress in past month • Psychological distress in past year • Feel worthless in past month • Feel that everything is an effort • Feel depressed in past month • Feel nervous in past month • Feel hopeless in past month • Feel restless in past month

Data Analysis
Univariate analyses that report frequencies and percentages were extracted directly from the CHIS data dictionary.They are reported with only minor alterations to table format.
Bivariate analyses were conducted using SPSS version 17.The differences in distribution of each dependent variable (psychological distress and intermediate symptoms) were calculated using chi-square for the nominal and ordinal, discreet variables and Pearson correlation for age.Relative risks were calculated by dividing the percentages in each category who answered "all of the time" by the percentage in the largest category who also answered "all of the time" for each of the study variables.
Multivariate analyses were also calculated using SPSS version 17.The profiles of those at highest risk for each psychological distress variable were determined using stepwise linear regression.All selected variables were included in each analysis.

Note
This research is exempt from institutional review board approval since it is a secondary analysis of data previously collected.The CHIS survey was approved by the UCLA institutional review board.1-10)

Univariate Analysis
Of the 47,614 survey respondents, 28,186 are females (40.8%) and 19,428 are males (59.2%) (Table 3), 65% are non-Hispanic whites (Table 3), 52% married (Table 5), 76% were born in the US (Table 6), 42% were em-  ployed full-time (Table 7), 23% had a bachelor's degree (Table 8), 89% had health insurance (Table 9), and 11% smoked cigarettes (Table 10).When asked if their insurance covers treatment for mental illnesses, 71% of those who recalled having the need for treatment reported that their insurance included coverage (Table 1).Table 1 lists the frequencies and percentages for each of the selected dependent variables.The respondents reported these psychological distress measures at least a little of the time:  • 13% depressed • 13% worthless Almost 3% experienced psychological distress in the month prior to the survey.Almost 6% experienced serious psychological distress in the year prior to the survey.Also, 5% of the respondents self-reported "poor" health.

Bivariate Analysis
Age is positively correlated with feeling nervous, hopeless, and restless and that everything is an effort, but negatively correlated with serious distress in past month or year and feelings of depression and worthlessness.The correlations are very weak and do not account for much of the variation in psychological symptoms (Table 2).All selected dependent measures (psychological distress markers, general health conditions and insurance that covers mental health) varied significantly by all selected demographic variables and by smoking status.Chisquare statistics were calculated and all except one p-value was <0.001 * .The exception was the relationship between poor general health and gender which has a p-value of 0.035.
The relative risks were calculated comparing the prevalence of the psychological symptom or measure in those of the largest category in each variable with those in the other categories (Tables 1-10).
Women are more likely to report psychological distress (1.45 more likely in the past month or year), feeling depressed (1.2 times more likely), hopeless (1.2 times more likely), poorer general health (1.1 times more often) and having insurance that covers treatment of mental health (1.54 times more often).Men are more likely to report feeling worthless (1.1 times more often) and restless (1.1 times more often) (Table 3).
As indicated in Table 4, Hispanics, African-Americans, American Indians and those of two or more races more frequently report all of the measures of psychological distress than whites.Hispanics, African-Americans and American Indians are also less likely to have insurance that covers treatment of mental disorders.Asians, Pacific Islanders and others report some symptoms more often and some less often than whites.
Marriage predicts lower levels of all psychological distress measures.Those who are widowed, separated or divorced express the most feelings of worthlessness and depression (Table 5).
Table 6 indicates much higher risk of psychological distress measures and less insurance coverage among those with less than college education.The group who has attended some graduate school shows lower risk than those with a BS or BA degree.The relationship between psychological distress measures and education is not linear.The protective effect diminishes from master's degree to doctorate degrees.Those with PhD are more likely to report feeling depressed than those with bachelor's degrees.
The unemployed report more psychological distress with those looking for work at the highest risk.The exception is that those not looking for working are more likely to report poor general health (Table 7).Those born outside of the US report more symptoms with the exception of restlessness.They are also less likely to have health insurance that covers treatment of mental disorders (Table 8).Those at the greatest risk are the least likely to have insurance that covers treatment of mental disorders (Table 9).Smokers are 4.5 times more likely to report feeling depressed in the past month (Table 10).

Multivariate-Stepwise Linear Regression Analysis
The following profiles emerged for each of the psychological distress symptoms and measures: Serious psychological distress in past year • Unemployed • Smoker • Less than BS education  These symptoms are precursors to serious mental disorders, suicide and physical disorders.Coupled with unemployment is lack of health insurance coverage.In addition, those with health insurance may not have coverage for treatment of mental illnesses.People at the greatest risk of psychological distress are also less likely to have insurance that covers their symptoms.
In addition to the demographic correlates with psychological distress, one behavioral variable was examined.Smoking is correlated with psychological distress measures especially feeling depressed.Smoking is the leading cause of preventable death in the United States and the mentally ill are at even higher risk.Smokers are also more likely to experience psychological distress.Smokers with the dual risks of mental and physical illnesses are especially in need of effective cessation programs that deal with nicotine addiction and address negative feelings among smokers.

Limitations
The survey response rate for 2009 is not yet published.However, the statewide response rate for the landline/list sample in the 2007 adult interview was 52.8 percent, a decrease of 1.2 percentage points from CHIS 2005.Larger counties had lower response rates than smaller counties.To address the possible bias of landline surveys, a sample of cellular phone surveys were conducted in 2009.
Since the CHIS is specific to California, the results cannot be generalized to the entire nation.However, one-fifth of the nation's population does live in California.Cross-sectional measurements of this type cannot be used for identifying temporal sequence and causation.

Further Studies
In addition to the closed-ended questions in the survey, additional qualitative research may increase the depth of understanding of the associations among psychological distress symptoms and measures and demographic variables.A mixed methods approach could assist in understanding the causative aspects of the associations and may shed light on possible avenue for treatment.
Prospective or case-control studies could investigate the temporal and possible causative link between smoking and psychological distress.Smoking may contribute to the pathway to psychological distress by changing neurotransmission in the brains of smokers.Psychological distress may contribute to smoking initiation and difficulty with cessation.Alternatively both smoking and psychological distress may have other similar causative factors.

Conclusions
Primary care physicians and nurse practitioners may be able to identify patients at higher risk of psychological distress.Smokers and others who are identified by profile risk characteristics can be given additional screening for psychological distress and mental disorders.This can lead to more appropriate referrals for diagnosis and treatment.
Public health program planners can identify groups of people at higher risk for primary prevention interventions.Additional attention can be devoted to the mental health needs of smokers who are targeted for cessation activities.The unemployed who are looking for work may benefit from support groups and attention to their mental health.Public health educators can plan mass media campaigns tailored to the mental health needs of the newly divorced or widowed.Community health workers who have been shown to be effective in programs to control chronic diseases can be trained to combat psychological distress as well.Public mental health programs can enhance the lives of countless people in our communities.

•
How prevalent are the psychological distress measures among the respondents in the California Health Interview Survey in 2009?• What are the factors associated with the psychological distress measures in the California Health Interview Survey in 2009?• Which combination of factors is most predictive of psychological distress?

Table 1 .
Selected variables for analysis: frequencies and percentages.
*Asked of those who had experienced mental health problems.

Table 2 .
Correlation of psychological distress by age.

Table 3 .
Relative risks of psychological symptoms by gender.
*Females compared to males for those who answered "all the time".

Table 4 .
Relative risks of psychological symptoms by ethnicity.
*Relative risk compared to white, those who answered "all of the time".

Table 5 .
Relative risks of psychological symptoms by marital status.
*Relative risk compared to married, those who answered "all of the time".

Table 6 .
Relative risks of psychological symptoms by US born.
*Born outside US compared to born inside US for those who said "all of the time".

Table 7 .
Relative risks of psychological symptoms by working status.
*Relative risk compared to full time, those who answered "all of the time".

Table 8 .
Relative risks of psychological symptoms by educational attainment.

Table 9 .
Relative risks of psychological symptoms by currently insured.
*Uninsured compared to insured.

Table 10 .
Relative risks of psychological symptoms for smokers.
*Compared to non-smokers for those who answered "all of the time".