Social determinants of mental health

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The social determinants of mental health (SDOMH) are societal problems that disrupt mental health, increase risk of mental illness among certain groups, and worsen outcomes for individuals with mental illnesses. [1] Much like the social determinants of health (SDOH), SDOMH include the non-medical factors that play a role in the likelihood and severity of health outcomes, such as income levels, education attainment, access to housing, and social inclusion. [2] Disparities in mental health outcomes are a result of a multitude of factors and social determinants, including fixed characteristics on an individual level – such as age, gender, race/ethnicity, and sexual orientation – and environmental factors that stem from social and economic inequalities – such as inadequate access to proper food, housing, and transportation, and exposure to pollution. [3]

Contents

Definitions

Mental health describes emotional, psychological, and social well-being. Mental Health Word Cloud.svg
Mental health describes emotional, psychological, and social well-being.

Mental health, as defined by the CDC, encompasses individuals' emotional, psychological, and social well-being, while the most common mental disorders include anxiety-disorders such as generalized anxiety disorder, social anxiety, and panic disorder; depression; and post-traumatic stress disorder (PTSD). [4] [5]

The concept of social determinants stems from the life course approach. It draws from theories that explain the social, economic, environmental, and physical patterns that result in health disparities and vary across different stages of life (e.g. prenatal, early years, working age, and older ages). [6] Identifying the social and structural determinants of mental health, in addition to individual determinants, enables policy makers to promote mental health and reduce risk of illness by designing appropriate interventions and taking action beyond the health sector. [7]

Inequities in mental health

Globally, in 2019, 1 in every 8 individuals (12.5% of the population) lived with a mental disorder; however, in 2020, due to the COVID-19 pandemic, that number grew dramatically by around 27%. [8] While mental illnesses and disorders have become more prevalent, studies have shown that mental health outcomes are worse for some populations and communities than others. One such inequity is that of gender: females are twice as likely to have a mental illness than males. [9] [10] [11]

Fixed characteristics

Fixed characteristics refers to those that are genetic and biological and/or are not subjected to be influenced by the environment or social living conditions of an individual. [12]

Gender

The second leading cause of global disability burden in 2020 was unipolar depression, and research showed that depression was twice as likely to be prevalent in women than in men. [9] [10] [13] Gender-based mental health disparities suggest that gender is a factor that could be leading to unequal health outcomes. [14]

Research studies included in Lancet Psychiatry Women's Mental Health Series focuses on understanding why some of these gendered disparities might exist. [15] Kuehner in her article Why is depression more common among women than among men? mentions several risk factors that contributes to these inequities, including the role of a women's sex hormones and "blunted hypothalamic-pituitary-adrenal axis response to stress". [16] Other factors include a woman's increased likelihood to body shaming and rumination and stressors on an interpersonal level, as well as sexual abuse during childhood. Further, the prevalence of gender inequality and discrimination in society against women may also be a contributing factor. Li et al. finds that the monthly and lifespan fluctuations of sex hormones oestradiol and progesterone in women may also influence the gender gap, especially in the context of trauma-related, stress-related, and anxiety disorders, such as through increasing vulnerability to development of these disorders and permitting the continued persistence of symptoms for these disorders. [17]

Increased likelihood of gender-based violence for women compared to men is also another risk factor that was studied by Oram et al. Researchers found that women have a higher risk of being subjected to domestic and sexual violence, thereby increasing their prevalence to post-traumatic stress, anxiety, and depression. Also notable to consider in the context of gender-based trauma are female genital mutilation, forced and early marriage, human trafficking, and honor crimes.  

While women are reported to experience higher rates of depressive and anxiety related disorders, men are more likely to die by suicide than women: in the United Kingdom, suicide is the biggest cause of death for men 45 and younger, and in the likelihood of dying by suicide, men are four times more likely in Russia and Argentina, three and a half times more likely in the United States, and three times more likely in Australia, than women, to name a few countries. [18] Gender differences in suicide are commonly explained by pressure for gender roles and higher risk-taking behavior among men. [19]

Sexual orientation

In studies comparing mental health outcomes between members of the lesbian, gay, bisexual, transgender, queer (questioning), intersex, asexual, aromantic and agender (LGBTQIA+) community with heterosexuals, the former showed increased risks of poor mental health. [20] [21] In fact, LGBTQIA+ individuals are twice as likely to have a mental disorder compared to their heterosexual counterparts, and two and a half times more likely to experience anxiety, depression, and substance misuse. [22] [23]

Based on the minority stress model, these mental health disparities among LGBTQIA+ people are due to discrimination and stigma. In fact, LGBTQIA+ individuals have expressed difficulty in accessing healthcare due to experienced discrimination and stigma, which as a result, causes them to not seek healthcare at all or rather delay it. [24] Further societal isolation and feelings of rejection may also contribute to the prevalence of mental disorders among this community. [25] In addition to the perceived and experienced stigma, LGBTQIA+ have an increased likelihood of being victims of violence. [26] These factors, alongside others, contribute significantly to differences in mental health experiences for members of the LGBTQIA+ community in comparison to their heterosexual counterparts, thereby result in mental health inequities by sexual orientation. [27]

Race/ethnicity

Studies in the conducted in the United States have indicated that minorities have similar or smaller rates of prevalence for mental health disorders as their majority counterparts. [28] Blacks (24.6%) and Hispanics (19.6%) have lower depression rates than their White counterparts (34.7%) in the United States. [29] While racial/ethnic minority groups may have similar prevalence rates, the consequences because of mental illness are more prolonged – which may be partly explained due to the smaller access rates for mental health treatments.  In 2018, while 56.7% of the general US population who had a mental illness didn't seek treatment, 69.4% and 67.1% Black and Hispanics didn't access care. [30] Further, in the instances of some mental illnesses, such as schizophrenia, Blacks in the United States have been reported to have higher rates compared to their White counterparts, however, research suggests that this could be due to an overdiagnosis among clinicians and underdiagnosis for other illnesses, such as mood disorders, for which Blacks had lower reported prevalence rates for major depression. [31] [32] [33] These instances of misdiagnosis may be due to "lack of cultural understanding by health care providers,...language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms. Minority groups commonly report experiences with racism and discrimination, and they consider these experiences to be stressful. In a national probability sample of minority groups and whites. African Americans and Hispanic American reported experiencing higher overall levels of global stress than did whites. [34]

Environment

According to Paul and Moser’s meta-analysis, countries with high income inequality and poor unemployment protections have worse mental health outcomes among the unemployed. [35]

Environmental factors

In addition to fixed characteristics, environmental factors, such as adequate access to food, housing, and health and exposure to pollution,

Social determinants of mental health include social, economic, and environmental factors SDOH model.gif
Social determinants of mental health include social, economic, and environmental factors

impacts an individual’s likelihood and severity of mental health outcomes. Although these factors can not directly change an individual's fixed characteristics of the social determinants of mental health, they can affect the degree to which an individual is influenced.

Inadequate access to proper food

Mental illnesses are common among those that are food insecure due to associated factors of stress and weaker community belonging. [36] Food security refers to the state of having access to sufficient and nutritious foods in order to maintain a healthy and active life, and deviations from this can lead to food insecurity. [37] While seen as an economic indicator, food insecurity can increase the risk to mental illnesses through stress, making individuals more vulnerable to worse mental health outcomes.

Another contributing factor that can explain this association between food insecurity and mental illnesses is social isolation. Research, for instance, shows that the majority of food insecure individuals in Canada do not have access to community food programs or food banks, suggesting that there is little to no access to social resources for these people. [38] [39] This factor can impact an individual's ability to feel supported or a sense of belonging within their community, thereby increasing their vulnerability to mental illnesses. The impact of food-insecurity on mental health may be worse in countries where food insecurity is less common, because it suggests a reduced standard of living and lower social standing within that country. [40]

Housing

Studies have found a co-occurrence between homelessness and mental illnesses. The “housing first” intervention in Canada – the At Home/Chez Soi study – which aimed to provide permanent housing to individuals reported that for the study cohort, suicidal ideation diminished over time. [41] Another study, one of the largest of its kind aimed to characterize the health of Canada's homeless youth, reported that 85% of its participants had high levels of psychological distress and 42% attempted suicide at least once. [42]

In addition to suffering from mental illnesses, homeless individuals also have trouble accessing care: for example, 50% of homeless men in a New York City shelter reported being overtly mental ill, and nearly 20–35% of mentally ill homeless individuals were in need of psychiatric services. [43] [44] While homeless shelters were once viewed as transient facilities, they have been burdened to take up the role of providing care for the large number of mentally ill homeless people that occupy these shelters. [45] However, a United Kingdom survey found that only 27.1% of homeless shelters believed that their mental health services were adequate to meet the needs of the homeless youth population surveyed in the study. [46]

Pollution

Despite the vast literature on the effect of air pollution on physical health outcomes, research on the mental health effects of air pollution are limited. [47] Data from the China Family Panel Studies found a positive relationship between air pollution and mental illnesses, where an 18.04 μg/m3 increase in average PM2.5 has a 6.67% increase in the probability of having a score corresponding with a severe mental illness, approximating a cost of US$22.88 billion in health expenditures associated with mental illness and treatment.

New evidence, although still non-conclusive, suggests the association between various mental health disorders and major environmental pollutants, including air pollutants, heavy metals, and environmental catastrophes, and have found that these pathogens have a direct and indirect role on the brain and in the generation of stress levels. [48] For instance, noise pollution could affect wellbeing and quality of life as a result of disturbances in circadian rhythms, noise annoyance, and noise sensitivity. [49]

Climate

In addition to the role of pathogen and pollutant exposure on mental health, adverse environmental and climate changes can lead to climate-related migration and displacement that burdens and causes a mental health toll on impacted individuals. From the disruption of social ties and support systems in their native communities to the financial and emotional stress (often due to the stigma that make it hard for climate migrants to integrate) that arises due to relocating, climate migrants experience negative mental health outcomes. [50] Forced migrants, compared to host populations, experience more common mental health disorders, including post-traumatic stress disorder, anxiety, major depression, psychosis, and suicidality due to the stressors that they experience. [51]

Changes in climate can also impact food security in regions, food prices, and household livelihoods, thereby impacting the mental health of residents. [52] [53] [54] [55] In an Australian sample, drought was reported to affect food availability, resulting in individuals skipping meals; individuals consuming below-average food levels expressed higher levels of distress compared to those eating at above-average levels. [37]

Social factors

The social factors of the determinants of mental health looks at the role of social influences, such as discrimination and stigma, that increase the likelihood of mental health disorders among certain minority communities.

Discrimination

Extensive literature has pointed to the strong association of discrimination on mental health and worse psychological wellbeing of individuals – with some studies even suggesting that the role of discrimination on mental health is greater than on physical health outcomes. [56] [57] [58] In the scope of ‘physical health’, studies have found that discrimination in health care delivery affects standard of care for ethnic minority communities: for example, African Americans and Latinos are less likely than their white counterparts to receive sufficient pain medication for long bone fracture or kidney stones. [59]

Focusing on mental health specifically though, community and laboratory studies have found that discrimination, such as racial/ethnic discrimination, is associated with worse mental health outcomes through increased depression, anxiety, and psychological distress. [56] [60] Occupational discrimination – discrimination in work organizations – also points to this same trend, in which regardless of race, those who acknowledge being discriminated against had worse poorer mental health outcomes. [61] The literature suggests that discrimination, despite the type, is harmful for mental health.

Researchers have also studied the role of multiple types of discrimination on mental health risk and have pointed to two risk models– first, the risk model in which groups that experience discrimination have an increased risk for worse mental health and second, the resilience model, in which these groups become more resilient to various other forms of discrimination. [62] An extensive literature review on existing studies found that generally the findings aligned with the risk model, as opposed to the resilience model. Specifically, there were a higher risk for symptoms of depression among groups that experienced various forms of discrimination – including racism, heterosexism. The role of multiple forms of discrimination on other mental health problems, such as anxiety, posttraumatic stress disorder, substance use, are less, and the results are mixed.

Discrimination also exists in mental health care delivery among marginalized communities. Provider discrimination can affect mental health treatment among racial minorities, for example: in the United States, minority groups have similar or lower prevalence rates of mental disorders when compared to their white counterparts, however Blacks were only half as likely as whites to receive treatment for diseases of similar severity. [63] [64] [65]

Stigma

Studies have found that the stigma associated with mental health problems can impact care seeking and participation. Reasons that decrease the likelihood of care seeking include prejudice against people with mental health illnesses as well as just the expectation of prejudice and discrimination for those who seek treatment. [66] Further, lack of knowledge of mental illnesses and how to access treatment can also impact care seeking behaviors; the associated stigma surrounding mental health issues can contribute to this knowledge gap. Corrigan et al. 2014 outlines three levels of stigma – public stigma that results from label avoidance, self-stigma that results from self-shame, and structural stigma. [67] Given these varying structures of stigma and a person's varying interactions with them, the avoidance for care seeking and participation behaviors may vary vastly. A global review on the stigma of mental illnesses and discrimination found that “there is no known country, society, or culture where people with mental illness (diagnosed or recognized as such by the community) are considered to have the same value or be as acceptable as persons who do not have mental illness”. [66]

Economic factors

Economic factors can influence the frequency and severity of mental health outcomes in people of all ages. [68] Economic factors include proximal factors such as assets, debt, financial strain, food security, income, relative deprivation and unemployment, as well as distal factors such as economic inequality, economic recessions, macroeconomic policy and subjective financial strain. According to research, there is a complicated and bi-directional relationship between economic factors such as unemployment, food insecurity, poverty and increased prevalence of adult common mental disorders in low-income, middle-income, and high-income countries. [68] [69] [70] The relationship between economic factors and mental health is relevant throughout the lifecourse. [71]

Other factors

Biological factors

Biological factors can also affect the likelihood of certain mental illnesses among individuals. When considering major depression, for example, the HTR1A −1019C>G genotype was found to be significantly associated among patients in Utah, United States. [72] Further, the functional BDNF Val66Met polymorphism has also been found to be a potential genetic risk factor for depression because it impacts the volume of the hippocampus, and stress-induced hippocampal atrophy has been associated with the origination and development of affective disorders. [73] Extensive research and literature in the fields of neuroscience and psychology – and their intersection – aim to identify these genetic and anatomical risk factors.

Interventions

Research has been conducted into examining mental health treatments and interventions that consider these social determinants of mental health and the roles they play in mental health outcomes. For example, nutritional psychiatry is an emerging area of study which aims to improve mental health of individuals through diet and food: Adan et al. 2019 highlights that intervention studies have found that diet and lifestyle could potentially influence mental health treatment and prevention. [74]

Related Research Articles

A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.

<span class="mw-page-title-main">Causes of mental disorders</span> Etiology of psychopathology

A mental disorder is an impairment of the mind disrupting normal thinking, feeling, mood, behavior, or social interactions, and accompanied by significant distress or dysfunction. The causes of mental disorders are very complex and vary depending on the particular disorder and the individual. Although the causes of most mental disorders are not fully understood, researchers have identified a variety of biological, psychological, and environmental factors that can contribute to the development or progression of mental disorders. Most mental disorders result in a combination of several different factors rather than just a single factor.

<span class="mw-page-title-main">Postpartum depression</span> Mood disorder experienced after childbirth

Postpartum depression (PPD), also called postnatal depression, is a mood disorder experienced after childbirth, which can affect men and women. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns. PPD can also negatively affect the newborn child.

<span class="mw-page-title-main">Mental health</span> Level of human psychological well-being

Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. According to the World Health Organization (WHO), it is a "state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community". It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health includes subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one's intellectual and emotional potential, among others.

<span class="mw-page-title-main">Social determinants of health</span> Economic and social conditions that influence differences in health status

The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions, rather than individual risk factors that influence the risk or vulnerability for a disease or injury. The distribution of social determinants is often shaped by public policies that reflect prevailing political ideologies of the area.

Mental health in China is a growing issue. Experts have estimated that about 130 million adults living in China are suffering from a mental disorder. The desire to seek treatment is largely hindered by China's strict social norms, as well as religious and cultural beliefs regarding personal reputation and social harmony.

Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. For example, women are more likely to be diagnosed with major depression, while men are more likely to be diagnosed with substance abuse and antisocial personality disorder. There are no marked gender differences in the diagnosis rates of disorders like schizophrenia and bipolar disorder. Men are at risk to suffer from post-traumatic stress disorder (PTSD) due to past violent experiences such as accidents, wars and witnessing death, and women are diagnosed with PTSD at higher rates due to experiences with sexual assault, rape and child sexual abuse. Nonbinary or genderqueer identification describes people who do not identify as either male or female. People who identify as nonbinary or gender queer show increased risk for depression, anxiety and post-traumatic stress disorder. People who identify as transgender demonstrate increased risk for depression, anxiety, and post-traumatic stress disorder.

<span class="mw-page-title-main">Mental distress</span> Symptoms and experiences that are troubling, confusing, or unusual

Mental distress or psychological distress encompasses the symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing or out of the ordinary. Mental distress can potentially lead to a change of behavior, affect a person's emotions in a negative way, and affect their relationships with the people around them.

<span class="mw-page-title-main">Mental health literacy</span>

Mental health literacy has been defined as "knowledge and beliefs about mental disorders which aid their recognition, management and prevention. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking". The concept of mental health literacy was derived from health literacy, which aims to increase patient knowledge about physical health, illnesses, and treatments.

Youth suicide is when a young person, generally categorized as someone below the legal age of majority, deliberately ends their own life. Rates of youth suicide and attempted youth suicide in Western societies and other countries are high. Amoung youth, attempting suicide is more common among girls; however, boys are more likely to actually perform suicide. Among youth, the rate of suicide nearly tripled between the 1960s and 1980s. For example, in Australia suicide is second only to motor vehicle accidents as its leading cause of death for people aged 15 to 25.

Minority stress describes high levels of stress faced by members of stigmatized minority groups. It may be caused by a number of factors, including poor social support and low socioeconomic status; well understood causes of minority stress are interpersonal prejudice and discrimination. Indeed, numerous scientific studies have shown that when minority individuals experience a high degree of prejudice, this can cause stress responses that accrue over time, eventually leading to poor mental and physical health. Minority stress theory summarizes these scientific studies to explain how difficult social situations lead to chronic stress and poor health among minority individuals.

The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. The majority of people around the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.

<span class="mw-page-title-main">Homelessness and mental health</span>

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. A 2009 US study, estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts.

Mental health inequality refers to the differences in the quality, access, and health care different communities and populations receive for mental health services. Globally, the World Health Organization estimates that 350 million people are affected with depressive disorders. Mental health can be defined as an individual's well-being and/or the absence of clinically defined mental illness. Inequalities that can occur in mental healthcare may include mental health status, access to and quality of care, and mental health outcomes, which may differ across populations of different race, ethnicity, sexual orientation, sex, gender, socioeconomic statuses, education level, and geographic location. Social determinants of health, more specifically the social determinants of mental health, that can influence an individual's susceptibility to developing mental disorders and illnesses include, but are not limited to, economic status, education level, demographics, geographic location and genetics.

Arline Geronimus wrote about the weathering hypothesis the early 1990s to account for health disparities of newborn babies and birth mothers due to decades and generations of racism and social, economic, and political oppression. It is well documented that people of color and other marginalized communities have worse health outcomes than white people. This is due to multiple stressors including prejudice, social alienation, institutional bias, political oppression, economic exclusion, and racial discrimination. The weathering hypothesis proposes that the cumulative burden of these stressors as individuals age is "weathering", and the increased weathering experienced by minority groups compared to others can account for differences in health outcomes. In recent years, social scientists investigated the biological plausibility of the weathering hypothesis in studies evaluating the physiological effects of social, environmental and political stressors among marginalized communities. The weathering hypothesis is more widely accepted as a framework for explaining health disparities on the basis of differential exposure to racially based stressors. Researchers have also identified patterns connecting weathering to biological phenomena associated with stress and aging, such as allostatic load, epigenetics, telomere shortening, and accelerated brain aging.

Serious mental illness (SMI) is characterized as any mental health condition that impairs seriously or severely from one to several significant life activities, including day to day functioning. Four common examples of SMI include bipolar disorders, borderline personality disorder, psychotic disorders, post-traumatic stress disorders, and major depressive disorders. People having SMI experience symptoms that prevent them from having experiences that contribute to a good quality of life, due to social, physical, and psychological limitations of their illnesses. In 2021, there was a 5.5% prevalence rate of U.S. adults diagnosed with SMI, with the highest percentage being in the 18 to 25 year-old group (11.4%). Also in the study, 65.4% of the 5.5% diagnosed adults with SMI received mental health care services.

<span class="mw-page-title-main">Impact of the COVID-19 pandemic on suicide rates</span>

Suicide cases have remained constant or decreased since the outbreak of the COVID-19 pandemic. According to a study done on twenty-one high and upper-middle-income countries in April–July 2020, the number of suicides has remained static. These results were attributed to a variety of factors, including the composition of mental health support, financial assistance, having families and communities work diligently to care for at-risk individuals, discovering new ways to connect through the use of technology, and having more time spent with family members which aided in the strengthening of their bonds. Despite this, there has been an increase in isolation, fear, stigma, abuse, and economic fallout as a result of COVID-19. Self-reported levels of depression, anxiety, and suicidal thoughts were elevated during the initial stay-at-home periods, according to empirical evidence from several countries, but this does not appear to have translated into an increase in suicides.

Hispanic immigrants living in the United States have been found to have higher levels of exposure to trauma and lower mental health service utilization than the general population. Those who met the criteria for asylum and experience trauma before migrating are vulnerable to post-traumatic stress disorder (PTSD) symptoms. Higher levels of trauma-related symptoms are associated with increased post-migration living difficulties. Despite the need for mental health services for Hispanic immigrants living in the United States, cultural and structural barriers make accessing treatment challenging.

The psychological impact of discrimination on health refers to the cognitive pathways through which discrimination impacts mental and physical health in members of marginalized, subordinate, and low-status groups. Research on the relation between discrimination and health became a topic of interest in the 1990s, when researchers proposed that persisting racial/ethnic disparities in health outcomes could potentially be explained by racial/ethnic differences in experiences with discrimination. Although the bulk of the research tend to focus on the interactions between interpersonal discrimination and health, researchers studying discrimination and health in the United States have proposed that institutional discrimination and cultural racism also give rise to conditions that contribute to persisting racial and economic health disparities.

People who are LGBT are significantly more likely than those who are not to experience depression, PTSD, and generalized anxiety disorder.

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