Depression in a Marginalized Community and Household-Level Social Determinants of Health

Background and Purpose: Low-income, underrepresented communities of color are disproportionality affected by depression. According to studies, about 30% of residents in low-income communities tend to suffer from major depression, almost twice the prevalence of major depression among those living outside poverty-affected communities (16%). Overall socio-economic deprivation, community violence, and the substandard quality of built environments have been tied to elevated depression in low-income communities. However, little is known about malleable, household-level determinants of depression, addressable by feasible, stigma-neutral community-based interventions.

The present study for the first time explored relative contributions of various household-level social determinants of health (SDOH) to depression in an urban, low-income underrepresented community, which has long experienced systemic economic and racial injustice. The SDOH in question included respondents’ exposures to household members’ manifestations of anger, alcohol and substance use, as well as residential crowding, household members’ health, communication and cohesiveness. Our analysis built evidence for a novel, theoretically grounded model explaining elevated depression among low-income urban community residents by better understanding their own perspectives on the currently understudied aspects of their domestic lives, and informing potential interventions, which can reduce depressive impacts of household-level SDOH.

Methods:

We analyzed data from a community services survey (N=677) of residents in a low-income urban community of color. Survey respondents’ depression was measured by Center for Epidemiologic Studies Depression Scale. Respondents also rated their exposures to household members’ angry behavior, alcohol and drug use, and other household-level SDOH. The relative contributions of these household-level SDOH to the depression among the survey respondents were derived via dominance indices, the gold-standard approach to relative importance analysis. Each SDOH’s unique contribution to the explained variance of depression was derived, free of collinearity. The SDOH with the largest relative importance/dominance indices made the greatest contribution to depression and provided the most important preventive intervention targets, relative to other SDOH in this model.

Results: The overall model explained a substantial fraction of depression variance among respondents (R² = 0.26). The largest contributors to respondents’ depression were exposures to alcohol use and angry behavior among household members, which accounted for 18.6%, and 18.1%, respectively, of the explained variance of depression. Additionally, concerns about household members’ physical and mental health issues, excessive weight, marijuana and hard drug use accounted for between 6% and 13% of explained variance each.

Conclusions and Implications: A modest group of household-level-only SDOH explained more than a quarter of depression variance. This suggests the utility of community efforts to screen for and address household-level depressogenic SDOH such as alcohol dependence and anger, to prevent/reduce depression in communities overburdened by it. Existing efficient and effective household-based interventions for alcohol and anger-related problems are likely to be less stigmatizing, and thus more acceptable for the residents of low-income communities of color than psychiatric treatment of depression, because members of marginalized communities tend to associate greater stigma with psychiatric problems than with specific risk behaviors.