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Research Article | DOI: https://doi.org/10.31579/2637-8892/271
Pharmacotherapy Department, College of Pharmacy, University of North Texas Health Science Center, Fort Worth, Texas, United States of America
*Corresponding Author: Bo Zhou, PhD, Pharmacotherapy Department, College of Pharmacy, University of North Texas Health Science Center, Fort Worth, Texas, United States of America.
Citation: Bo Zhou, Jadea Jackson, Jahnavi Pinnamraju, Mona Pathak, Usha Sambamoorthi, (2024), Association of Inflation-related Stress with Depression and Anxiety among Older Adults, Psychology and Mental Health Care, 8(6): DOI:10.31579/2637-8892/271
Copyright: © 2024, Bo Zhou. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 17 April 2024 | Accepted: 04 June 2024 | Published: 17 July 2024
Keywords: mental health; socioeconomic status; observational studies; perceived inflation
Objectives:
To analyze the association of stress due to price increases with anxiety and depression among older adults in the US using near real-time survey data.
Method:
Cross-sectional study using Census Household Pulse Survey data collected between Jan 4-Jan 16, 2023. The study sample included older adults (age ≥ 65 years) without missing data on anxiety, depression, perception of inflation, the stress of price increases in the past two months, and health insurance (unweighted N=16,079 representing 47 million older adults). Depression and anxiety were measured using Patient Health Questionnaire-2 and two-item Generalized Anxiety Disorder-2 instruments, respectively. The associations were examined with Rao-Scott Chi-square tests and multivariable logistic regressions adjusted for demographics, social determinants of health, long-COVID, and COVID-19 vaccination.
Results:
The majority of our study population were female (53.0%), aged between 65-74 years (72.9%), and non-Hispanic white (77.1%). Overall, 93.3% reported experiencing price increases, 31.4% and 28.9% reported price increases to be very and moderately stressful respectively. Among those who were very stressed, a higher percentage of adults reported anxiety (32.8% vs 2.4%) and depression (25.2% vs 1.8%) compared to those without any stress. In adjusted logistic regressions, those who were very stressed due to inflation had higher odds of anxiety (AOR=6.27, 95% CI=3.46, 11.34) and depression (AOR=5.47, 95% CI=2.91,10.29).
Discussion:
Those with high stress of price increases had higher odds of depression and anxiety. Policies have to address the rise in demand for mental health care in the near future.
Financial affordability of goods and services can be influenced by unexpected personal and external events such as the COVID-19 pandemic, economic crisis, and inflation. In the United States (US), which has already impacted by the COVID-19 pandemic, inflation has surged since early 2021, reaching a peak of 9.1% in June 2022, and remaining around 6.0% in February 2023 (Figure 1). Since World War II, there have been six periods (1946–48, 1950–51, 1969–71, 1973–82, 1989-1991 and 2008) in which inflation—as measured by CPI—was 5% or higher (Rouse et al., 2021).
Data Source: https://www.bls.gov/charts/consumer-price-index/consumer-price-index-by-category-line-chart.htm
Figure 1: 12-month Percentage Change in Consumer Price Index (CPI), All Items, Mar 2020-Feb 2023
Many studies have reported that financial stress can lead to poor mental health such as depression and anxiety(Guan et al., 2022; Ridley et al., 2020). Inflation erodes purchasing power of income and raise uncertainty about future prices and adversely impact the physical and mental health of the economically disadvantaged population. Recent studies documented that inflation has psychological impacts such as depression, tension and anxiety among in developing countries (Naz et al., 2012). However, no study on the association between inflation and mental health in the US using real-world data exists in the past 30 years, as there was no persistent inflation between 1992 and 2020 in the country. Dating back to 1976, a seminal survey of almost 2000 families found more than one-fourth families reported that financial pressures due to inflation had damaged their mental health (Caplovitz, 1981)(1981). The author measured inflation in two ways: objective inflation, which measures the extent income falls behind prices; and subjective inflation, which measures the degree to which it is hurting because of inflation. The study found 59 percent of families reported income fallen behind prices, while 52 percent of families experienced subjective inflation crunch.
Older adults are vulnerable to negative financial shocks due to their unique circumstances, such as income drops upon retirement and high healthcare expenditures that is paid out-of-pocket. A prospective cohort study found negative wealth shock is associated with all-cause-mortality among adults aged 51 and older(Pool et al., 2018). During the Great Recession of 2008, unemployment and decrease in income were associated with an increase in depressive symptoms among older adults(Hawkley et al., 2020; Wilkinson, 2016). Inflation shock may negatively affect older adults because they may delay or forego essential medical and basic care to cope with the price increases. Despite the well-established association between financial stress and decreased mental health, the impact of inflation on the mental well-being of older adults has been rarely studied due to the lack of observational data. Understanding the relationship between inflation related stress and mental health among older adults is particularly important during the COVID-19 pandemic, as older adults already have higher risks of severe complications from virus infections and have experienced increased loneliness during the pandemic (Emerson, 2020).
In this study, we used data from near real-time nationwide survey to examine the association of stress due to price increases with anxiety and depression among older adults (age ≥ 65 years) in the US during January 4th and January 16, 2023. We selected the time period based on consistent decline in inflation rates for 6 months and recency of data. We used subjective inflation measure from the survey as previous study documented difference in subjective and objective inflation measures among the retired population (Caplovitz, 1981).
Study Design and Data Source
We adopted a cross-sectional analysis of data from the online Household Pulse Survey (HPS) collected between Jan 4-Jan 16, 2023 (week 53). The U.S. Census Bureau, in partnership with 16 additional federal agencies, carries out the HPS to examine the impact of COVID-19 and other emergent concerns on the lives of American families. The HPS is structured for rapid and effective deployment, gathering information to assess household experiences throughout the COVID-19 pandemic and recovery phase. The collected data is shared promptly to support federal and state response and recovery strategies. The survey has been conducted regularly, on a weekly basis from April 23, 2020, until September 2021 and then biweekly starting from October 2021. Since October 2022, HPS has also collected data on perception of price change and stress of price increase.
Analytical Sample
The study was restricted to older adults (ages 65 or older) with health insurance. Respondents with missing data in anxiety or depression, perception of inflation and stress of price increase were excluded. The study sample included 16,079 individuals representing 46,954,005 older adults in the US population.
Dependent Variables
Anxiety and depression are the dependent variables. Anxiety was measured using the following questions: “Over the last 2 weeks, how often have you been bothered by 1. Feeling nervous, anxious, or on edge? 2. Not being able to stop or control worrying?” The responses include not at all (score 0), several days (1), more than half the days (2) and nearly every day (3). The two-item Generalized Anxiety Disorder (GAD-2) scale the score was calculated by adding score for each question. A score of >=3 points was considered as anxiety (Donker et al., 2011). Depression was measured by the Patient Health Questionnaire-2 (PHQ-2) score using the following questions: “Over the last 2 weeks, how often have you been bothered by 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless?” The responses include not at all (score 0), several days (1), more than half the days (2) and nearly every day (3). A total score of 3 or greater was considered as depression (Kroenke et al., 2003).
Key Explanatory Variable: Stress Due to Inflation
The key explanatory variable was stress due to inflation. The HPS queried respondents “in the area where you live and shop, do you think the prices for goods and services have changed in the last two months?”. People who perceived a price increase were queried “How stressful, if at all, has the increase in prices in the last two months been for you?” The choices were: 1) Very stressful; 2) Moderately stressful; 3) A little stressful; and 4) Not at all stressful. We combined the two questions and created a 5-category variable consisting of the level of stress and a category for those who perceived prices “declined, no change, and do not know”.
Other Explanatory Variables
Demographic variables were defined as age groups (65 – 74 years, 75 years or older), gender (female, male, transgender), race and ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic/Latino, Non-Hispanic Asian, and other), marital status (married, widowed, separated/divorced, and never married). Other socioeconomic variables included education (less than high school, high school, some college, associate degree and college), income (including 8 categories ranging from less than $25,000 to greater than $200,000), food insufficiency (low/very low , no food insufficiency), difficulty in paying for household expenses in the last 7 days (very difficult, somewhat difficult, little difficult, not difficult), region(North East, South, Midwest, West), and private health insurance coverage (yes/no). In addition, we included COVID-19 vaccination (yes/no) and long COVID (long COVID, no long COVID, no COVID).
We examined the associations between categorical variables and Anxiety and Depression using Rao-Scott chi-square tests. Three nested multivariable logistic regression models were designed to analyze the association between stress due to inflation with anxiety and depression after adjusting for other variables. Each model adjusted for different factors: Model 1 adjusted for difficulties in paying for household expenses in the last 7 days. Model 2 adjusted for age, gender, race and ethnicity, education, income, food insufficiency, and difficulties in paying for household expenses in the last 7 days, insurance type, marital status, region, long COVID, and COVID-19 vaccination. Model 3 included all factors from Model 2 and additionally adjusted for comorbid anxiety and depression. All analyses utilized SAS survey procedures, incorporating the jackknife method and replicate survey weights (SAS, 2017).
We described the characteristics of our study sample of 16,079 older adults in Table 1. A majority of the individuals were female (53.0%), aged between 65-74 years (72.9%), and non-Hispanic white (NHW, 77.1%). Most individuals were married (63.3%) and nearly one-third had a college education (33.1%). The income distribution was dispersed, with 13.1% of individuals earning less than $25,000, and 4.7
In this first nation-wide study of stress due to inflation during the third year of a pandemic and health outcomes, we observed that an overwhelming majority of older adults (93.3%) reported price increases in the last two months in the areas they live. Approximately, one in three older were very stressed about the price increases. As suggested by social stress theory older adults may feel stressed because of their vulnerability to stress and fewer coping resources (Mossakowski, 2014). Such stress can be due to limited financial resources to cushion against inflation. For example, 9 out of 10 Americans over the age of 65 were using social security benefits and more than 50 percent receive their income from social security and were receiving less than $2000 per month (Social Security Administration, 2023). Furthermore, the average annual medical expense for retirees over 65 is $4,274 out of pocket (McInerney et al., 2017). Thus, inflation may affect affordability and may make it difficult to pay for usual household expenses. Indeed, in our study, 30.7% of older adults reported that it had been very difficult or somewhat difficult to pay for usual household expenses with the past 7 days.
A main finding from our research is that older adults who were very stressed about price increases, had higher odds of anxiety and depression compared to those who had no stress about price increases. This finding suggest that inflation may be related to declining health outcomes through stress. As there are no nationwide studies on how the current inflation affects mental health, we have relied on studies on financial stress and outcomes to draw parallels of our study. Financial strain, whether due to inflation or recession have been reported to affect mental health of older adults (Ryu & Fan, 2023). Our findings are consistent with a NBER study on prescription drug price increase and health outcomes. In the simulation study, a $10 increase in prescription drug prices was associated with 33% increase in mortality because individuals may cut back on essential medications (Chandra et al., 2021).
The inflation in the US has come during the COVID-19 pandemic, which has already highlighted the shortages of mental health professionals and unmet mental health treatment needs among older individuals (Coley & Baum, 2022). The Department of Health and Human Service projected a shortage of 10,000 social workers by 2025 (U.S. Department of Health and Human Services, 2016). Despite the implementation of policies and strategies such as telehealth assisted by Medicare, challenges remain as the COVID-19 pandemic worsened the national shortage of mental health care professionals. According to House Pulse Survey, 12.8% of older adults report an unmet need for mental health treatment (Nagata et al., 2022). A recent survey of patients in an age-friendly health system found 15.2% of vulnerable older adults had unmet need for mental health services, and those who had depression or anxiety also had a higher unmet need for medications and food insecurity (Tai‐Seale et al., 2023).
Our findings highlighted the importance of public policy to reduce the stress due to inflation. The Inflation Reduction Act of 2022, which will invest approximately $433 billion in energy, climate and health to reduce deficit, is a step in the right direction (117th Congress, 2022). In particular, this bill will allow Medicare to negotiate for prescription drug prices, and cap the annual out-of-pocket prescription drug costs at $2000. Such policy responses are especially important to older adults with high out-out-pocket expenses for health care (McInerney et al., 2017).
While this is a first nationwide study of associated stress due to inflation during the third year COVID-19 pandemic, the study presents with limitations. This was a cross sectional study and self-reported data is subject to recall bias. In addition, because the HPS survey is an online survey there is a potential for selection bias as it is only accessible to households who have at least one email address or cell phone number. Furthermore, the data lacked information on chronic conditions and physical health status, which may influence depression and anxiety.
COVID-19 pandemic shed light on the shortcomings of mental health access and exacerbated an already short supply of therapist, psychologists, psychiatrists, and social workers leading to access barriers. This study not only highlights the association of depression and anxiety in individuals who perceive price increase but also calls to attention the consequences, such as individuals delaying medical care due to inflation (Weinick et al., 2005). Furthermore, as the mental health impact of external shocks outlasts the physical impact, our study findings suggest the demand for mental health care may increase in the coming months, and policies and programs must address both the demand and supply for appropriate health care professionals. Finally, public health and policy interventions should be developed and implemented to identify the patients with high risk of stress due to inflation and address mental health-related unmet social needs.
The authors received no financial support for the research, authorship, and/or publication of this article. The authors declare that they have no conflict of interest. Study data can be downloaded at the United States Census Bureau website: (https://www.census.gov/programs-surveys/household-pulse-survey/datasets.html).
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