Abstract
Mental health is an important part of overall health and well-being. The interdependency of mental and physical health is especially significant in older population. Chronic physical disorders and physical disabilities tend to increase with age. 1 As physical well-being declines with age, mental health becomes important in maintaining the overall well-being of older adults. Despite the significant public health efforts over the last five decades that has led to successfully eradication of many infectious diseases and the establishment of preventive programs for chronic conditions, the prevalence of mental illness continues to rise in the United States.2-5
In the clinical literature, there is no clear distinction between mental disorder and mental illness. As opposed to mental disorders that are distinct syndromes objectively diagnosable by trained clinical professionals, mental distress refers to poor mental health, subjectively reported by the person experiencing it; mental distress is not a clinical diagnosis. 6
Frequent mental distress (FMD) is a measure of poor mental health, and it is more prevalent than diagnosable mental illness. FMD is an important concept because it can identify the subsyndromal depressive symptoms not identifiable by clinical screening instruments. It is preventable and can be decreased or eliminated by public health prevention programs and self-help strategies. 7 However, without proper detection, FMD may develop into a more serious mental disorder that will require more specialized and costly clinical services.
The purpose of this study was to investigate if activity limitations and healthcare access are associated with FMD in the US population aged 65 years and older.
Methods
We utilized data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) survey in this study. A detail description of the survey is provided elsewhere. 8 Briefly, BRFSS is a continuous state-based cross-sectional telephone survey. It includes standardized questionnaires developed by the Center for Disease Control’s (CDC’s) Behavioral Surveillance Branch (BSB) and the state health departments. The questionnaire has the following three components: core, optional modules, and state added questions. In BRFSS, the measured variables are organized into several constructs. FMD is within the healthy days construct, which is also called health related quality of life measure (HRQoL) 9 . A total of 414 509 individuals participated in the 2008 BRFSS. Of these, 123 427 were 65 years or older. 8
Dependent Variable
The dependent variable in this study was FMD. In BRFSS, FMD is a part of the HRQoL. Participants were asked, “Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Respondents who reported having 14 or more mentally unhealthy days during the past 30 days were classified as FMD = 1, 0 otherwise. 10 Of the 123 427 study participants aged 65 years or older, 120 445 participants responded to the BRFSS number of mentally unhealthy days in the last 30 days (FMD) question and were included in the final analysis.
Independent Variables
The main independent variables in this study were activity limitations due to health problems, and healthcare factors such as personal health care provider and health care cost barrier. Activity limitation due to physical, mental, or emotional problems was defined based on responses to the question, “Are you limited in any way in any activities due to physical, mental, or emotional problems?” The variable, personal health care provider, was categorized based on responses to the question, “Do you have one person you think of as your personal doctor or health care provider?” into: yes, have only one personal health care provider; yes, have more than one personal health care provider; and do not have personal health care provider (reference group). Lastly, cost barrier was assessed based on responses to questions whether participants experienced a time in the past 12 months when they could not see a doctor because of cost.
Covariates
The covariates included in the analysis were age (measured at four levels: 65-69, 70-74, 75-79, and 80 years of age and older), race/ethnicity (white, non-Hispanic; black, non- Hispanic; Hispanic; and other race/ethnicity which includes Asian, American Indian, Alaska Native, and multiracial origins), gender, marital status (grouped as never married, married/unmarried couple, divorced/widowed/separated), and employment status (retired, employed for wages or self-employed, out of work for more than one year/out of work for less than one year, homemaker/student, and unable to work). In addition, emotional support and life satisfaction were also included as covariates in the analysis. Emotional support was categorized based on the question, “How often do you need the emotional support you need?” into: 0 (always or usually) and 1 (sometimes, rarely, or never). Life satisfaction was determined by the question, “In general, how satisfied are you with your life?” and was categorized as very satisfied or satisfied (coded as 0) and dissatisfied or very dissatisfied (coded as 1).
Statistical Analysis
The study sample was described using weighted frequency distribution. Weighted prevalence estimates of FMD were obtained for the total sample. To explore the relationships between the variables, logistic regression models were developed. First, separate logistic regression models were developed to explore the association between the dependent variable (FMD) and each of the independent variables and covariates. Then, a full multiple logistic regression model, including all the main independent variables and covariates, was developed to estimate adjusted odds ratios for the studied factors. All analyses were done using Stata statistical software package, version 11.0 (Stata Inc, College Station, TX), taking into account the survey features of the BRFSS dataset.
Results
Females comprised approximately 58% of the elderly study population. One-quarter of the study population were age 80 years and older. The majority were white, non-Hispanic (78.9%), married or unmarried couples (58.3%), and retired (72.4%). Approximately 32% reported activity limitations due to physical, mental, or emotional problems, and 4.7% did not visit their physician in the last 12 month because of cost. Approximately 6% of the study population did not have a personal health care provider (Table 1). Only 11% of those who responded that cost was a barrier to visit their physician did not have any personal care provider. The largest group without a personal health care provider was aged 65-69 years old (35%) (data not shown).
Descriptive Characteristics of the Study Population—Behavioral Risk Factors Surveillance System, 2008
Variables may not sum 100% due to missing values.
Unweighted n and weighted % reported
Other race/ethnicity are non-Hispanic as well and includes Asian, American Indian, Alaska Native, and multiracial origins.
The prevalence of FMD in the study population was 6.5% (95% CI = 6.3-6.8) with estimates significantly greater among women (7.2%, 95% CI = 6.9-7.6) as compared to men (5.5%, 95% CI = 5.1-6.0) (Table 2). Approximately 11% of Hispanics reported FMD. The prevalence of FMD was lowest among married/unmarried couples (5.4%). Those who were out of work or were unable to work had the highest prevalence of FMD. Similarly, the prevalence of FMD was significantly greater among those who reported absence of emotional support and dissatisfaction with life. Those who reported having more than one health care provider, cost barrier, and activity limitations also had a higher prevalence of FMD (Table 2).
Prevalence of Frequent Mental Distress Among the US Older Population (Age 65+ )—Behavioral Risk Factors Surveillance System, 2008
Other race/ethnicity are non-Hispanic as well and includes Asian, American Indian, Alaska Native, and multiracial origins.
Table 3 presents results from the unadjusted and adjusted logistic regression analysis. The odds of FMD were more than 2-fold elevated for those who reported activity limitations due to physical, mental, or emotional problems (adjusted OR = 2.59, 95% CI = 2.33-2.87) and among those who reported health care cost as a barrier to see a doctor (adjusted OR = 2.14, 95% CI = 1.75-2.61). Study participants who reported having more than one personal care provider were 28% more likely to report FMD. However, the results became statistically nonsignificant when adjusted for other covariates in the multivariable analysis. Elderly women were 23% more likely to experience FMD as compared to men (adjusted OR = 1.23, 95% CI = 1.10-1.37). Consistent with the results from the bivariate analysis, the odds of FMD declined as the study population ages. Hispanic ethnicity, divorced/separated or widowed status, inability to work, absence of emotional support, and general dissatisfaction with life were significantly associated with elevated odds of FMD (Table 3).
Unadjusted and Adjusted Odds Ratio of Association between Activity Limitations, Healthcare Access, and Frequent Mental Distress among the US Older population (Aged 65+ years)—Behavioral Risk Factors Surveillance System, 2008
Odds ratios are adjusted simultaneously for all variables in the model.
Other race/ethnicity are non-Hispanic as well and includes Asian, American Indian, Alaska Native, and multiracial origins.
Discussion
Mental distress is a subjectively reported measure of poor mental health. It is not a diagnosable mental disorder, but it is much more prevalent in the population than mental disorder. Although, FMD is a subjective measure, it is a valid measure. The validity of self-reports as measures of poor mental health has been consistently shown in earlier studies.11-14
This study found that activity limitation due to physical, mental, or emotional distress is a significant risk factor for FMD in older adults (adjusted OR = 2.59, 95% CI = 2.33-2.87). Strine et al 15 examined FMD in adults aged 45 years or older with arthritis and found that persons with arthritis and FMD were more likely to report activity limitations than those with arthritis and without FMD (adjusted OR = 2.2, 95% CI = 1.9-2.4). In another study, Strine et al 16 investigated FMD in adults aged 45 years or older with heart disease and found that FMD was associated with disability (adjusted OR = 2.0, 95% CI = 1.3-3.0). As the US population ages, there will be a greater need for providing mental health services to older adults with disabilities that would help them cope with their limitations. Also, mental health goals should be incorporated into treatment plans of health care providers to prevent mental distress in older adults with disabilities.
Cost of medical care was found to be a significant risk factor for FMD in this study. Older adults who could not see a doctor because of cost were more likely to report FMD than those without health care cost barrier (adjusted OR = 2.14, 95% CI = 1.75-2.61). Fitzpatrick et al 17 studied barriers to health care access among elderly and found that medical bills were one of the most common health care barriers among older adults; 22% of participants could not see a physician because of cost. The finding that seniors perceive cost as a barrier in accessing health care is surprising, because the majority of US citizens 65 years and older receive government sponsored health care under Medicare plans. Yet, seniors are distressed by not being able to see a doctor due to the cost. The prevalence of FMD associated with cost barrier was consistently higher across all the age groups (data not shown). This finding can in part be explained by the rising cost of health care in the United States and support the assertion that shifting funds from the Medicare system would increase the cost barrier in accessing medical services for seniors, increase their emotional distress, and decrease their physical health and overall quality of life.
Availability of a personal health care provider was not significantly associated with FMD in this study. Approximately 6% of the study population did not have a personal care provider. However, there were no significant differences in prevalence of FMD between those who have a personal care provider or did not have one. Consistent with our earlier study, 18 we found that the odds of FMD increases in a dose-dependent manner (although nonsignificant) for those who reported having more than one health care provider, implying that older adults who make more medical visits are more likely to suffer from poor mental health. It appears from our findings that cost may be a bigger barrier than availability of a health care provider in determining access to care for FMD among older adults.
The present study has several limitations. First, the results of this study are only generalizable to the target population of adults 65 years and older and no inferences can be made to other age groups of the population. Second, because of the cross-section in nature, causal relationships cannot be inferred from the results of this study. A major limitation of this study is the exclusion of persons who are institutionalized or those who are unable to complete a telephone survey. Adults with the most severe mental health problems likely did not have an equal chance to participate in this study, because they may be placed in institutions or may not be able to participate in a telephone survey. Therefore, mental distress may be underreported in the current study. Another limitation of this study is that the survey questions may be perceived differently in different ethnic groups. The results of the current study showed that Hispanic elderly are more likely to report FMD than other ethnic groups. This result may be biased due to the different perception of mental distress or the BRFSS mentally healthy days question in the Hispanic ethnic group. Cultural biases have not been examined in the BRFSS survey design. Lastly, there was no question asked specifically about presence of Medicaid, a state controlled medical coverage offered to low income individuals. Some of the older adults may have both Medicare and Medicaid. However, we were not able to evaluate differences in access to care that may be attributed to additional coverage provided by Medicaid.
The findings of this study showed that mental health is an important part of overall well-being and health in older adults. Seniors who are limited in their daily activities due to physical, mental, and emotional problems are especially vulnerable to mental distress, as suggested by the strong association between activity limitation and mental distress. This study also found that elderly who reported that they could not see a doctor because of cost were more likely to report FMD. These results suggest that mental distress in older adults may be prevented or reduced by providing preventive mental health interventions for older adults with disabilities and by eliminating cost barriers in seniors’ access to health care. In addition, other steps such as provision of expanded transportation to and from doctors offices and improved access to mobility assistive devices would considerably improve the quality of life of older adults and contribute to improvement of community health.
Footnotes
The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
Financial Disclosure/Funding The authors received no financial support for the research and/or authorship of this article.