Using newly available U.S. Department of Housing and Urban Development (HUD) administrative data linked with National Health Interview Survey (NHIS) data, this study estimates the prevalence of serious psychological distress (SPD) among non-elderly HUD-assisted adults and examines differences in health, health behaviors, and health care utilization for this population. The linked data estimate that 13% of HUD-assisted adults experience SPD. Controlling for individual characteristics and HUD program type, assisted housing residents who had SPD experienced higher rates of self-reported fair or poor health, chronic disease, and cigarette smoking than HUD-assisted adults without SPD. Adults with SPD had more frequent use of emergency rooms and were more likely than residents without SPD to have more frequent contact with specialists, general doctors, and mental health providers, although they also reported increased levels of unmet health care needs due to affordability. Policy implications are discussed.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
National Institute of Mental Health (NIMH). Mental illness. Bethesda, MD: NIMH. Available online at: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed January 4, 2018.
Kessler RC, Parker PR, Colpe LJ et al. Screening for serious mental illness in the general population. Archives of General Psychiatry. 2003; 60(2): 184–189.
Pratt LA, Dey AN, Cohen AJ. Characteristics of adults with serious psychological distress as measured by the K6 scale: United States, 2001–04. Advance data from vital and health statistics; no 382. Hyattsville, MD: National Center for Health Statistics, 2007.
Cohen RA & Zammitti EP. Access to health care among adults aged 18-64 with serious psychological distress: Early release of estimates from the National Health Interview Survey, 2012 – September 2015. Washington, DC: National Center for Health Statistics, 2016. Available online at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/er_spd_access_2015_f_auer.pdf.
Butterworth P, Rodgers B, Windsor TD. Financial hardship, socio-economic position and depression: Results from the PATH through life survey. Social Science and Medicine. 2009, 69: 229–237.
Jenkins RD, Bhugra P, Bebbington T et al. Debt, income and mental disorder in the general population. Psychological Medicine, 2008; 38(10):1485–93.
Weich S & Lewis G. Poverty, unemployment, and common mental disorders: Population based cohort study. British Medical Journal. 1998; 317:115–19.
Weissman J, Pratt LA, Miller EA, et al. Serious psychological distress among adults: United States, 2009–2013. NCHS data brief, no 203. Hyattsville, MD: National Center for Health Statistics. 2015.
Hammel J, Smith J, Scovill S et al. Rental housing discrimination on the basis of mental disabilities: Results of pilot testing. Washington, DC: U.S. Department of Housing and Urban Development, 2017. Accessed January 4, 2018: https://www.huduser.gov/portal/publications/MentalDisabilities-FinalPaper.html.
Tsemberis, S, Gulcur, L, Nakae, M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 2004; 94(4), pp.651–656.
Padgett, DK, Stanhope, V, Henwood, BF, Stefancic, A. Substance use outcomes among homeless clients with serious mental illness: comparing housing first with treatment first programs. Community Mental Health Journal, 2011; 47(2), pp.227–232.
Tsemberis, S, Eisenberg, R.F. Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 2000; 51(4), pp.487–493.
Wong YLI & Stanhope V. Social Science & Medicine. 2009; 68:1376–1387. https://doi.org/10.1016/j.socscimed.2009.01.046
Wong, YLI, Solomon, PL. Community integration of persons with psychiatric disabilities in supportive independent housing: A conceptual model and methodological considerations. Mental Health Services Research, 2002; 4(1), pp.13–28.
Abernathy K, Zhang J, Mauldin P, et al. Acute care utilization in patients with concurrent mental health and complext medical conditions. Journal of Primary Care & Community Health, 2016; 7(4): 226–233.
U.S. Department of Housing and Urban Development. U.S. Department of Housing and Urban Development strategic plan 2014-2018. Washington DC: HUD, 2014. Available online at: http://portal.hud.gov/hudportal/documents/huddoc?id=hudstrategicplan2014-2018.pdf.
Pearson CL, Locke G, Montgomery AE et al. The applicability of housing first models to homeless persons with serious mental illness. Cambridge, MA: Abt Associates, 2007. Available online at: https://www.huduser.gov/portal/publications/hsgfirst.pdf.
Lloyd PC & Helms VE NCHS-HUD linked data: Analytic considerations and guidelines. Hyattsville, Maryland: NCHS, 2016.
U.S. Department of Housing and Urban Development (HUD), Office of Policy Development & Research (PD&R). (2015) Picture of subsidized housing: 2015. Washington, DC: HUD, 2016. Available online at: http://www.huduser.org/portal/datasets/picture/yearlydata.html.
Dawkins CJ & Miller M. A picture of disability and designated housing. College Park, MD: University of Maryland, 2015. Available online at: https://www.huduser.gov/portal/sites/default/files/pdf/mdrt_disability_designated_housing.pdf .
Brucker DL, Helms V & Souza T. Health and health services access among adults with disabilities who receive federal housing assistance. Housing Policy Debate. 2017; 28(2): 248–266. DOI: https://doi.org/10.1080/10511482.2017.1357048.
Fenelon A, Mayne P, Simon AE et al. Housing assistance programs and adult health in the United States. American Journal of Public Health. 2017; 107(4): 571–57. DOI: https://doi.org/10.2105/AJPH.2016.303649.
Bostic RW, Thornton RLJ, Rudd EC et al. Health in all policies: The role of the US Department of Housing and Urban Development and present and future challenges. Health Affairs. 2012; 31(9): 2130–2137. DOI: https://doi.org/10.1377/hlthaff.2011.1014
U.S. Department of Housing and Urban Development. Section 811 project rental assistance – Bringing permanent supportive housing to scale: Status report to Congress. Washington, DC: HUD, 2014. Available online at: http://portal.hud.gov/hudportal/documents/huddoc?id=Sec811_Congressional_Rpt.pdf .
Technical Assistance Collaborative (TAC) and Consortium for Citizens with SPD. Priced out in 2014. Boston, MA: TAC, 2015.
National Alliance of Mental Illness. Securing stable housing. NAMI, 2017. Available online at: https://www.nami.org/Find-Support/Living-with-a-Mental-Health-Condition/Securing-Stable-Housing. Accessed January 3, 2018.
Newman, S, Goldman, H. Putting housing first, making housing last: Housing policy for persons with severe mental illness. American Journal of Psychiatry, 2008; 165(10), pp.1242–1248.
Helms VE, Sperling J, & Steffen B. A health picture of HUD-assisted adults, 2006–2012. Washington, DC: HUD, 2016.
U.S. Department of Housing and Urban Development. Evaluation of the Section 811 rental housing assistance program. Washington, DC: U.S. Department of Housing and Urban Development, 2018. https://www.huduser.gov/portal/section-811-process-evaluation.html .
Fauth RC, Leventhal T, Brooks-Gunn J. Short-term effects of moving from public housing in poor to middle-class neighborhoods on low-income, minority adults’ outcomes. Social Science and Medicine. 2004; 59(11): 2271–2284.
Simon AE, Fenelon A, Helms V et al. HUD housing assistance associated with lower un-insurance rates and unmet medical need. Health Affairs. 2017; 36(6): 1016–1023. DOI: https://doi.org/10.1377/hlthaff.2016.1152.
Leventhal T, Brooks-Gunn J. Moving to opportunity: an experimental study of neighborhood effects on mental health. American Journal of Public Health. 2003; 93(9): 1576–1582.
Ludwig J, Sanbonmatsu L, Gennetian L, et al. Neighborhoods, obesity and diabetes – a randomized social experiment. New England Journal of Medicine. 2011; 365:1509–19.
Orr L, Feins JD, Jacob R et al. Moving to Opportunity for Fair Housing Demonstration program: Interim impacts evaluation. Washington, DC: Department of Housing and Urban Development, 2003. Available online at: http://www.huduser.org/Publications/pdf/MTOFullReport.pdf
Rosenbaum E, & Harris LE. Residential mobility and opportunities: early impacts of the Moving to Opportunities Demonstration Program in Chicago. Housing Policy Debate. 2001; 12(2): 321–346.
U.S. Department of Housing and Urban Development. FY 2017 Congressional justifications: Housing for persons with SPD (Section 811). Washington DC: HUD, 2016. Available online at: http://portal.hud.gov/hudportal/documents/huddoc?id=27-HSNGforPersons.w.Disab.pdf
Digenis-Bury EC, Brooks DR, Chen L et al. Use of a population-based survey to describe the health of Boston public housing residents. American Journal of Public Health. 2008; 98(1): 85–91.
Heinrich KM, Lee RE, Regan GR et al. How does the built environment relate to body mass index and obesity prevalence among public housing residents? American Journal of Health Promotion. 2008; 22:187–94.
Altman BM, Bernstein A. Disability and health in the United States, 2001–2005. Hyattsville, MD: US DHHS, 2008.
Albrecht GL, Devlieger PJ. The disability paradox: High quality of life against all odds. Social Science and Medicine. 1999; 48(8): 977–88.
Armour BS, Campbell VA, Crews, JE et al. State-level prevalence of cigarette smoking and treatment advice, by disability status, United States, 2004. Preventing Chronic Disease. 2007; 4(4): 1–11.
Carroll DD, Courtney-Long, EA, Stevens, AC et al. Vital signs: Disability and physical activity – United States, 2009-2012. Morbidity and Mortality Weekly Report. 2014; 63, 18, 407–413.
Courtney-Long EA, Stevens, AC, Caraballo R et al. Disparities in current cigarette smoking prevalence by type of disability, 2009-2011. Public Health Reports. 2014; 129: 252–260.
Froehlich-Grobe K, Lee, J, Washburn, RA. Disparities in obesity and related conditions among Americans with SPD. American Journal of Preventive Medicine. 2013; 45(1): 83–90.
Krahn GL, Walker, D.K., Correa-De-Araujo R. Persons with SPD as an unrecognized health disparity population. American Journal of Public Health. 2015; 105 Supplement 2: S19–206.
Miller, NA, Kirk, A, Kaiser, MJ et al. The relation between health insurance and health care disparities among adults with SPD. American Journal of Public Health. 2014; 104(3): e85-e93. DOI: https://doi.org/10.2105/AJPH.2013.301478.
Rasch EK, Gully SP, & Chan L. Use of emergency department among working age adults with SPD: A problem of access and service needs. Health Services Research. 2013; 48(4): 1334–1358. DOI: https://doi.org/10.1111/1475-6773.12025.
Reichard A, Stolzle H. Diabetes among adults with cognitive limitations compared to individuals with no cognitive SPD. Intellectual and Developmental SPD. 2011; 49(3): 141–154.
Steinmetz E. Americans with SPD, 2002. Washington, DC: U.S. Department of Commerce, 2006.
Smith AE, Molton IR, Jensen MP. Self-reported incidence and age of onset of chronic comorbid medical conditions in adults aging with long-term physical disability. Disability & Health Journal. 2016; 9: 533–538.
Alegria M, Jackson JS, Kessler RC et al. Collaborative psychiatric epidemiology surveys (CPES), 2001-2003. ICPSR20240-v8. Ann Arbor, MI: Inter-university Consortium for Political and Social Research, 2015. DOI: https://doi.org/10.3886/ICPSR20240.v8.
Walker ER, Druss BG. Cumulative burden of comorbid mental disorders, substance use disorders, chronic medical conditions and poverty on health among adults in the U.S.A. Psychology, Health & Medicine. 2017; 22(6): 727–736.
Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry, 2015; 72: 334–341.
Bartels SJ, Pratt SI, Aschbrenner KA, et al. Clinically significant improved fitness and weight loss among overweight persons with serious mental illness. Psychiatric Services, 2013; 64:729–736.
Kilbourne AM, Morden NE, Austin K, et al. Excess heart-disease related mortality in a national study of patients with mental disorders: Identifying modifiable risk factors. Gen Hosp Psychiatry 2009; 31:555–563.
WHO & Wonca Working Parity on Mental Health. What is primary care mental health? Mental Health and Family Medicine. 2008; 5: 9–13.
Cook, JA, Razzano L, Jonikas J et al. Correlates of co-occurring diabetes and obesity among community mental health program members with serious mental illness. Psychiatric Services. 2016; 67(11): 1269–1271.
Daumit GL, Dickerson FB, Wang NY, et al. A behavioral weight-loss intervention in persons with serious mental illness. New England Journal of Medicine. 2013; 368:1594–1602.
Green CA, Yarborough BJ, Leo MC, et al. The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. American Journal of Psychiatry. 2015; 172:71–81.
Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database Syst Rev. 2013; 2:CD007253
National Center for Health Statistics. NHIS-HUD linked file sample sizes and percentage linked among sample adults and sample children, by survey and age at interview. Hyattsville, MD: NCHS, 2016. Available online at: http://www.cdc.gov/nchs/data/datalinkage/hud_table_2.pdf
Gordon EL, Chipungu S, Bagley LM et al. Improving housing subsidy surveys: Data collection techniques for identifying the housing subsidy status of survey respondents. Washington, DC: HUD, 2005.
Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences andtrends in non-specific psychological distress. Psychological Medicine. 2002; 32(6):959–976.
U.S. Center for Disease Control and Prevention (CDC). Leisure-time physical activity recodes. Atlanta, GA: CDC, 2017. Available online at: https://www.cdc.gov/nchs/nhis/physical_activity/pa_recodes.htm
U.S. Center for Disease Control and Prevention (CDC), National Health Interview Survey general concepts. Atlanta, GA: CDC 2017. Available online at: https://www.cdc.gov/nchs/nhis/tobacco/tobacco_glossary.htm
National Center for Health Statistics (NCHS). NCHS urban-rural classification scheme for counties. Hyattsville, MD: NCHS, 2016 Available from: www.cdc.gov/nchs/data_access/urban_rural.htm .
Lucas S. Connecting Fragmented Systems: Understanding Large PHAs' Partnerships with the Health Sector and Identifying Opportunities for Cross-Sector Collaboration. Cityscape. Forthcoming July 2018.
Ward MC, White DT, Druss BG. A meta-review of lifestyle interventions for cardiovascular risk factors in the general medical population: lessons for individuals with serious mental illness. Journal of Clinical Psychiatry, 2015; 76:e477–e486.
U.S. Department of Housing and Urban Development. Smoke-free multifamily housing toolkits. Washington, DC: HUD, 2016. Available online at: http://portal.hud.gov/hudportal/HUD?src=/smokefreetoolkits1.
A portion of the work on this project was funded by the U.S. Department of Health and Human Services (DHHS), National Institute for Disability, Independent Living and Rehabilitation Research, under cooperative agreements H133B130015 and 90RTGE00010100. The findings and conclusions are those of the authors and do not represent the opinion or the policies of either DHHS or the U.S. Department of Housing and Urban Development. The authors retain sole responsibility for any errors or omissions.
Conflict of Interest
The authors declare that they have no conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Brucker, D.L., Helms, V. Health, Health Behaviors, and Health Care Utilization Among Adults with Serious Psychological Distress Who Receive Federal Housing Assistance. J Behav Health Serv Res 46, 586–606 (2019). https://doi.org/10.1007/s11414-018-09647-z