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Presumptive depression and post-traumatic stress disorder (PTSD) were highly prevalent among residents of Flint, Michigan, 5 years after they were exposed to contamination in their tap water, which was not declared safe until nearly 3 years later, a cross-sectional survey study showed.

Of the 1,970 residents who responded to the survey, 22.1% met the DSM-5 criteria for presumptive past-year depression, 24.4% met criteria for presumptive past-year PTSD, and 14% met criteria for both, reported Aaron Reuben, PhD, MEM, of Medical University of South Carolina in Charleston, and colleagues.

After adjusting for sociodemographic covariates and multiple comparisons, residents who felt that the water crisis had affected their health or their family's health were significantly more likely than those who did not to meet the criteria for depression (risk ratio [RR] 2.23, 95% CI 1.80-2.76), PTSD (RR 1.66, 95% CI 1.36-2.03), or both (RR 2.06, 95% CI 1.56-2.71), they noted in .

Furthermore, respondents who said they had low confidence in the accuracy of information about the crisis provided by public officials were significantly more likely than those who did not express this to meet the criteria for depression (RR 1.47, 95% CI 1.17-1.83), PTSD (RR 1.44, 95% CI 1.16-1.78), and comorbid disorder (RR 1.50, 95% CI 1.12-2.02).

"Despite clear indication that the crisis was psychologically traumatic, the vast majority of our respondents were never offered mental health services," said Reuben in a press release.

Of the 1,970 survey respondents, only 34.8% had been offered mental health support to assist with water crisis-related psychiatric symptoms. Of these, 79.3% accepted the help.

After adjusting for race, income, and sex, those who were offered and took the help were 36% less likely to have presumptive depression (adjusted RR 0.64, 95% CI 0.50-0.83) and 10% less likely to have presumptive PTSD (aRR 0.90, 95% CI 0.72-1.13), "although the latter result was not statistically significant," Reuben and team noted.

According to survey responses, some groups were offered mental health services more often than others. "Somewhat unexpectedly, Black residents were more likely to be offered these services than white residents," the researchers pointed out (RR 1.21, 95% CI 1.04-1.40). In addition, residents who were making less than $25,000 a year were offered services more often than affluent residents (RR 1.19, 95% CI 1.01-1.40).

When applying weighted sample prevalence estimates to the population, the researchers estimated that approximately 22,600 Flint residents may have had depression, 25,000 may have had PTSD, and 14,300 may have had comorbid depression and PTSD in 2019 to 2020.

"These presumptive prevalence estimates exceed regional, national, and global benchmarks," Reuben and colleagues wrote, noting that the prevalence of presumptive past-year depression in Flint was two-fold greater than estimated rates for the state of Michigan overall (9.4%), the U.S. (7.8%), and globally (7.2%), while the prevalence of presumptive past-year PTSD was two- to five-fold greater than rates for veterans after deployment (12.1%), the general U.S. population (4.7%), and estimated global averages (2.8%).

In the first year of the community's water crisis, other studies found evidence of high rates of mental health issues in Flint. A showed that increasing physical symptoms were linked with psychological trauma (OR 2.1, P<0.01) and depression/anxiety (OR 1.9, P<0.01).

that reported on federal and state data collected from 2016 to 2018 while the crisis was still in bloom showed that "residents continued to experience crisis-related stress, including fear that the crisis would never be fixed," authors noted.

For this study, Reuben and colleagues used DSM-5 criteria to evaluate presumptive depression and PTSD in Flint residents 5 years after the water crisis. Data were collected from August 2019 to April 2020, just as the COVID-19 pandemic was beginning. Most surveys were collected before March 10, 2020, when Michigan had its first COVID-19 cases and the WHO declared a pandemic.

Of the 10,000 Flint residents who received survey recruitment letters in the mail, 2,195 accessed the survey. Of these, 1,970 completed the survey (54.5% women, 53.5% Black, and 42.5% white). They were given $35 for their time to complete the survey.

Of the 86.8% of respondents who lived in homes directly affected by tap water quality problems during the crisis, nearly all (97.7%) said they changed their daily behavior to reduce exposure, noting that they avoided drinking tap water (78%), cooking with it (91.9%), and cleaning with it (47.0%).

Despite making changes to limit contaminated water exposure, 75.3% said they thought their own health was affected and 73.8% said their family's health had been affected due to contaminated water exposure.

Most said they were concerned about the long-term health affects (80.1%).

When asked how they felt about the crisis now that 5 years had passed, 41.0% reported they still had mental or emotional problems related to water contamination concerns.

Of note, those with prior physical or sexual assault were more than three times more likely to have depression and more than six times more likely to have PTSD than those without this history. "This highlights the importance of considering the cumulative effects of prior exposure to traumatic events when evaluating the effects of environmental disasters on mental health," said co-author Dean Kilpatrick, PhD, of the University of South Carolina, in the press release.

In addition to behavioral changes, the crisis came with a financial cost to residents. More than three-quarters said they paid out of pocket to reduce their risk of lead and toxic chemical exposure. In 31.2% of cases, costs exceeded $1,000, and in 3.7% of cases, costs exceeded $10,000.

Importantly, more than half (56.8%) of survey respondents reported an annual income of less than $25,000.

Reuben and team noted that presumptive cases of depression and PTSD were not confirmed by clinicians. Furthermore, estimates of prevalence of depression and PTSD may have been low if respondents were less impaired than those who did not respond. Finally, they said that future research should include biomarkers of exposure.

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