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Context: In the United States, more than 50 million people experience mental illness and disabilities. However, despite research suggesting improved mental health is associated with disability prevention, there has been limited study of mental health indicators and standardized disability identifiers included in national surveys for public health surveillance efforts. Moreover, studies are complicated by the fact that functional limitations are common to both mental disorders and disabilities and it is unclear how well mental health symptoms, function, and disability are differentiable in populationbased studies. Specific Aims: The goals of this dissertation were to (1) examine the association between non-specific psychological distress (NSPD), duration of activity limitations due to mental health conditions (ALMH), and the function and activity difficulties used to identify people with disabilities in U.S. national surveys (Study 1); (2) determine the risk of experiencing disabilities among people reporting combinations of NSPD or ALMH to test if mental health symptoms and conditions could be distinguished (Study 2); and (3) measure the association between mental health, social determinants of health (SDH), and cognitive disability and identify groups with distinct conceptual and empirical differences across measures (Study 3). Methods: 2008-2015 National Health Interview Survey data was used to (1) estimate the risk of disabilities among people reporting NSPD or ALMH (Study 1), (2) estimate risk of disabilities across combined NSPD-ALMH subgroups and demographic factors (Study 2); and (3) estimate the prevalence of SDH and risk of cognitive disability among people with poor mental health (Study 3). Results: The first study found that people reporting NSPD and ALMH were at significantly increased risk of reporting a disability, including hearing and vision disabilities. For example, after adjusting for gender and race/ethnicity, people ages 35-54 years reporting severe NSPD were at 8.5 times greater risk of reporting a cognitive disability, compared to people ages 35-64 reporting no NSPD. The second study found synergy between NSPD and ALMH when estimating disability risk. For example, people reporting NSPD and ALMH were at 7.1 (95% CI = 6.6, 7.6) times the risk of reporting cognitive disabilities, compared to people reporting NSPD and no ALMH. The third study found the prevalence of cognitive disability and adverse SDH increased in a robust, stepwise fashion across gradients of poor mental health (defined by NSPD and/or ALMH). Within NSPD-ALMH groups, cognitive disability risk was increased among people with adverse SDH, compared to people without adverse SDH. Conclusion: The findings of this dissertation provide evidence that people with any psychological distress and/or any duration of mental health conditions are at significantly increased risk of experiencing all disability types. This should be more heavily recognized in the mental health and disability literature and provides evidence that people with disabilities, especially cognitive disabilities, identified by federally recognized disability questions, represent a population experiencing psychological distress and serious mental illness. Theoretically, the results of this dissertation were consistent with the conceptual framework supported by the International Classification of Functioning, Disability, and Health (ICF). I was able to show that the risk of disabilities increases on a continuum of impairment described by the ICF, with severity of psychological distress and duration of mental health condition. Further, I was also able to validate both the psychiatric literature and ICF and show that the distinction between mental health symptoms and conditions matters in a very concrete, quantitative, inferential manner in a population study. Although federally recognized disability questions are designed to capture conceptually distinct populations, disability as a field should recognize the pervasiveness of poor mental health among people with disabilities. In national surveillance, identifying people based on mental health symptoms and/or conditions identifies subpopulations with differential distributions of social determinants of health and disability risk targetable for public health interventions. Disability and mental health policy can now use this information to improve and provide more specific supports, services, and programs for both groups. The over 65 federally recognized definitions of disability should recognize that mental health plays a substantial role in the disability experience. |
