Psychology, Health & Medicine

ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20

Cumulative burden of comorbid mental disorders,

substance use disorders, chronic medical
conditions, and poverty on health among adults in
the U.S.A.

Elizabeth Reisinger Walker & Benjamin G. Druss

To cite this article: Elizabeth Reisinger Walker & Benjamin G. Druss (2016): Cumulative
burden of comorbid mental disorders, substance use disorders, chronic medical conditions,
and poverty on health among adults in the U.S.A., Psychology, Health & Medicine, DOI:
10.1080/13548506.2016.1227855

To link to this article: http://dx.doi.org/10.1080/13548506.2016.1227855

Published online: 03 Sep 2016.

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Psychology, Health & Medicine, 2016
http://dx.doi.org/10.1080/13548506.2016.1227855

Cumulative burden of comorbid mental disorders, substance

use disorders, chronic medical conditions, and poverty on
health among adults in the U.S.A.
Elizabeth Reisinger Walkera and Benjamin G. Drussb
a
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University,
Atlanta, GA, USA; bDepartment of Health Policy & Management, Rollins School of Public Health, Emory
University, Atlanta, GA, USA

ABSTRACT ARTICLE HISTORY

The health of individuals in the U.S.A. is increasingly being defined Received 23 November 2015
by complexity and multimorbidity. We examined the patterns of Accepted 18 August 2016
co-occurrence of mental illness, substance abuse/dependence, and KEYWORDS
chronic medical conditions and the cumulative burden of these Chronic disease; comorbidity;
conditions and living in poverty on self-rated health. We conducted mental disorders;
a secondary data analysis using publically-available data from the socioeconomic status;
National Survey on Drug Use and Health (NSDUH), which is an annual substance use
nationally-representative survey. Pooled data from the 2010–2012
NSDUH surveys included 115,921 adults 18 years of age or older.
The majority of adults (52.2%) had at least one type of condition
(mental illness, substance abuse/dependence, or chronic medical
conditions), with substantial overlap across the conditions. 1.2%, or
2.2 million people, reported all three conditions. Generally, as the
number of conditions increased, the odds of reporting worse health
also increased. The likelihood of reporting fair/poor health was
greatest for people who reported AMI, chronic medical conditions,
and poverty (AOR = 9.41; 95% CI: 7.53–11.76), followed by all three
conditions and poverty (AOR = 9.32; 95% CI: 6.67–13.02). For each
combination of conditions, the addition of poverty increased the
likelihood of reporting fair/poor health. Traditional conceptualizations
of multimorbidity should be expanded to take into account the
complexities of co-occurrence between mental illnesses, chronic
medical conditions, and socioeconomic factors.

Introduction
The health of individuals in the U.S.A. is increasingly being defined by complexity and
multimorbidity, the co-occurrence of two or more chronic medical conditions (Nardi et al.,
2007). The high prevalence of comorbid conditions has been well documented among people
with mental disorders (Barnett et al., 2012; Lin, Zhang, Leung, & Clark, 2011); however there
is little research on multimorbidity in this population. Furthermore, people with mental

CONTACT Elizabeth Reisinger Walker [email protected]

© 2016 Informa UK Limited, trading as Taylor & Francis Group
2 E. R. Walker and B. G. Druss

illness experience greater socioeconomic disadvantage (Barnett et al., 2012) and individuals
with mental disorders or medical conditions report worse self-rated health compared to
healthy individuals (Fok et al., 2014; Perruccio, Katz, & Losina, 2012).
Given the medical and socioeconomic complexities faced by people with mental illness
and the paucity of research on multimorbidity with mental disorders, we examined patterns
of multimorbidity in the United States. We answered the following research questions: What
proportion of adults experience each combination of mental illness, substance abuse or
dependence, and chronic medical conditions? What are the associations of these combi-
nations, as well as poverty, with self-rated health?

Methods
We used publically-available data from three waves (2010–2012) of the National Survey on
Drug Use and Health (NSDUH), which included 115,921 adults ages 18 and older (United
States Department of Health and Human Services, 2010, 2011, 2012). The NSDUH is an
annual survey conducted by the Substance Abuse and Mental Health Services Administration
(SAMHSA) that provides nationally representative estimates of drug use and mental illness
for the civilian, noninstitutionalized United States population. In-person interviews are
conducted at the participant’s residence, utilizing a computer-assisted self-administered
process. The weighted response rates for each year ranged from 86.1–88.8% for household
screening and 73.0–74.7% for interviews (Substance Abuse and Mental Health Services
Administration, 2011, 2012, 2013a, 2013b).

Measures
Any mental illness (AMI) in the past year is based on participants’ responses to the
Kessler-6 scale, measuring psychological distress (Kessler et al., 2002), and the World Health
Organization Disability Assessment Schedule, assessing functional impairment (Novak,
Colpe, Barker, & Gfroerer, 2010). SAMHSA developed prediction models to determine
the presence of AMI, rather than specific diagnoses. These models are valid in predicting
presence of AMI among subsamples of participants who completed a Structured Clinical
Interview for DSM-IV Axis I Disorders (Aldworth et al., 2010; Liao et al., 2012).
The NSDUH includes structured questions based on the criteria in the DSM-IV
(American Psychiatry Association, 2002) to assess abuse or dependence on illicit drugs
and alcohol in the past 12 months. Illicit drugs assessed included marijuana, hallucinogens,
inhalants, tranquilizers, cocaine, heroin, pain relievers, stimulants, and sedatives. We used
a combined variable of abuse or dependence on illicit drugs and/or alcohol.
Respondents indicated whether a physician had ever told them (yes or no) they had the
following ten chronic medical conditions: asthma, cirrhosis, diabetes, heart disease, hep-
atitis, high blood pressure, HIV/AIDS, lung cancer, pancreatitis, and stroke. Respondents
were grouped in two categories (zero conditions or one or more chronic conditions).
The NSDUH uses family income relative to the national poverty thresholds published by
the U.S. Census Bureau to determine poverty status (United States Department of Health
and Human Services, 2012). Respondents were classified as living in poverty (family income
less than 100% of the poverty threshold) or not living in poverty.
 Psychology, Health & Medicine  3

Self-rated health was assessed by the question, ‘Would you say your health in general
is excellent, very good, good, fair, or poor?’ Responses were grouped into excellent/very
good/good health and fair/poor health.
Demographic and socioeconomic status correlates included age (18–25, 26–34, 35–49,
50–64, 65 or older), gender, racial or ethnic group (Non-Hispanic white, Non-Hispanic
black, Hispanic, other), marital status (married, previously married, never married), county
metro status (nonmetro, small metro, large metro), education level (less than high school,
high school graduate, college and above), employment status (not working, working), health
insurance status (uninsured, insured), and government assistance (receiving, not receiving).

Statistical analyses
We conducted descriptive statistics and chi-square tests to describe demographic charac-
teristics by condition. We ran logistic regression models for each pair of conditions and
poverty to assess the likelihood of the conditions co-occurring. We then ran logistic models
assessing the associations between all combinations of the conditions and poverty with self-
rated health. Logistic regression models were run unadjusted and then adjusted for age,
gender, race/ethnicity, marital status, education, employment, health insurance, government
assistance, and county metro status. Data analyses were conducted in IBM SPSS Statistics
21, using the complex samples module to account for the NSDUH’s complex sampling
design and weights (for more detail, see: SAMHSA, 2013a). To reduce the chance of type I
error due to running multiple statistical tests, we assessed statistical significance at p < .01.

Results
Overall, 18.4% of adults had a past-year mental illness, 8.6% reported past-year substance
abuse/dependence, 37.8% had one or more chronic medical conditions in their lifetime,
and 14.7% were living in poverty. Compared to individuals without any condition, adults
with one condition (AMI, substance abuse/dependence, or chronic conditions) reported
higher percentages of living in poverty, receiving government assistance, having less than
a high school education, being unemployed, and having no health insurance (see Table 1).
Looking at co-occurrence of these conditions, 6.4% of individuals reported AMI and
chronic conditions, 2.2% reported AMI and substance abuse/dependence, 1.5% reported
substance abuse/dependence and chronic medical conditions, and 1.2%, equivalent to
2.2 million people, reported all three conditions. The logistic regression models assessing
associations between each pair of conditions, as well as poverty, are shown in Table 2.
People with AMI were over three times more likely to report substance abuse/dependence
(AOR = 3.30; 95% CI: 3.10–3.50), almost 1.5 times more likely to have a chronic medical
condition (AOR = 1.46; 95% CI: 1.38–1.56), and 1.2 times more likely to live in poverty
(95% CI: 1.12–1.31) compared to people without AMI.
We then examined the odds of reporting fair/poor health for every combination of
conditions, with and without poverty (see Table 3). Generally, as the number of conditions
increased, the odds of reporting fair/poor health also increased (see Figure 1). The likelihood
of reporting fair/poor health was greatest for people who reported AMI, chronic medical
conditions, and poverty (AOR = 9.41; 95% CI: 7.53–11.76), followed by all three conditions
4 E. R. Walker and B. G. Druss

Table 1. Characteristics of adults in the 2010–2012 NSDUH, by past-year mental illness, past-year sub-
stance abuse and/or dependence, and lifetime chronic medical conditions.a
One or more
Substance abuse chronic medi-
None of the condi- Any mental illness and/or dependence cal conditions
Characteristic tions (n = 46,017) (n = 23,094) (n = 15,743) (n = 13,490)
n (weighted %) n (weighted %) n (weighted %) n (weighted %)
Age group
18–25 21,622 (14.6) 11,076 (15.2)** 10,840 (33.0)** 11,110 (7.8)**
26–34 7747 (18.7) 3917 (18.9) 2187 (24.1) 3657 (9.2)
35–49 10,701 (31.4) 5040 (29.6) 1977 (24.9) 6965 (21.3)
50–64 4222 (24.5) 2156 (26.4) 610 (14.0) 5430 (32.3)
65 or older 1725 (10.8) 905 (11.7) 129 (4.1) 4328 (29.4)
Gender
Female 23,512 (50.6) 14,694 (61.0)** 6203 (34.8)** 17,014 (52.1)
Male 22,505 (49.4) 8400 (39.0) 9540 (65.2) 14,476 (47.9)
Race or ethnic group
Non-Hispanic white 30,208 (68.3) 15,399 (70.8)** 10,224 (68.4)** 20,488 (69.8)**
Non-Hispanic black 4597 (8.9) 2527 (10.9) 1727 (11.2) 4658 (13.4)
Hispanic 7282 (15.0) 3028 (11.8) 2390 (15.5) 3840 (10.8)
Other 3930 (7.8) 2140 (6.5) 1402 (4.9) 2504 (6.0)
Marital status
Married 19,204 (58.9) 6804 (42.9)** 2488 (30.4)** 12,863 (55.6)**
Previously married 4144 (15.3) 3722 (26.1) 1372 (16.8) 5568 (26.1)
Never married 22,669 (25.8) 12,568 (31.0) 11,883 (52.8) 13,059 (18.3)
County metro status
Nonmetro 9101 (14.2) 4908 (16.5)** 3112 (13.8)** 701 (17.8)**
Small metro 15,977 (29.9) 8609 (32.5) 5740 (31.5) 11,248 (30.8)
Large metro 20,939 (55.9) 9577 (51.0) 6891 (54.7) 13,228 (51.4)
Poverty
Living in poverty – 5686 (20.3)** 3831 (20.3)** 6103 (13.0)**
Not living in poverty – 17,020 (79.7) 11,439 (79.7) 24,946 (87.0)
Received Government
assistance
No 39,577 (89.1) 15,841 (71.4)** 11,589 (75.1)** 23,339 (80.5)*
Yes 6440 (10.9) 7253 (28.6) 4154 (24.9) 8151 (19.5)
Education
Less than high school 5613 (10.3) 3808 (16.1)** 2821 (16.9)** 4979 (14.9)**
High school 14,230 (27.7) 7306 (29.9) 5116 (29.8) 10,475 (32.0)
College and above 26,174 (62.0) 11,980 (54.0) 7806 (53.3) 16,036 (53.0)
Employment Status
Working full or part 35,128 (75.9) 13,935 (56.8)** 10,551 (67.7)** 19,094 (55.2)**
time
Unemployed or not in 10,889 (24.1) 9159 (43.3) 5192 (32.3) 12,396 (44.8)
labor force
Health Insurance
Uninsured 8712 (15.0) 5043 (19.1)** 4037 (25.4)** 5140 (11.7)**
Insured 37,305 (85.0) 18,051 (80.9) 11,706 (74.6) 26,350 (88.3)
Any mental illness
No – – 9912 (60.9)** 23,933 (79.8)**
Yes – – 5831 (39.1) 7557 (20.2)
Substance abuse and/
or dependence
No – 17,263 (81.6)** – 27,691 (92.9)**
Yes – 5831 (18.4) – 3799 (7.1)
Chronic medical
conditions
0 – 14,860 (57.9)** 11,592 (69.3)**
1 or more – 7557 (42.1) 3799 (30.7)
Self-rated health
Fair/Poor 1806 (4.7) 4285 (25.5)** 1720 (14.9) 5382 (20.6)**
Excellent/Very good/ 44,205 (95.3) 18,807 (74.5) 14,020 (85.1) 26,100 (79.4)
Good
a
Mental illness, substance abuse and/or dependence, chronic medical conditions, and poverty groups are not mutually
exclusive. Chi square tests for each group compared having the condition to not having the condition.
*p < .01; **p < .001.
 Psychology, Health & Medicine  5

Table 2. Odds ratios for co-occurrence of mental illness, substance abuse and/or dependence, chronic
medical conditions, and poverty.
Adults with this condition:
AMI SAoD CMC
Who also have one of these conditions: OR (95% CI) OR (95% CI) OR (95% CI)
SAoD Unadjusted 3.27 (3.08–3.48)** – –
Adjusteda 3.37 (3.17–3.58)** – –
CMC Unadjusted 1.24 (1.78–1.31)** .71 (.66–.75)** –
Adjusteda 1.46 (1.38–1.56)** 1.12 (1.04–1.20)* –
Poverty Unadjusted 1.72 (1.60–1.84)** 1.60 (1.49–1.73)** .86
(.81–.92)**
Adjusteda 1.20 (1.12–1.31)** 1.08 (.99–1.17) .99 (.92–1.07)
Notes. AMI = any mental illness; CI = confidence intervals; CMC = chronic medical conditions; OR = odds ratio; SAoD = sub-
stance abuse and/or dependence.
Reference categories were not having the condition.
a
Adjusted for age, gender, race/ethnicity, marital status, county metro status, education, employment, government assis-
tance, and health insurance.
*p < .01; **p < .001.

Table 3. Odds ratios for poor or fair self-reported health among adults with use mental illness, substance
abuse and/or dependence, chronic medical conditions, and/or living in poverty.
Unadjusted Adjusteda
N (Weighted %) OR (95% CI) AOR (95% CI)
No conditions (reference)b 46017 (41.3) – –
1 condition
AMI only 8176 (6.8) 2.96 (2.56–3.42)** 3.08 (2.63–3.60)**
SAoD only 5574 (3.1) 1.23 (.98–1.55) 1.54 (1.19–2.00)*
CMC only 17890 (25.8) 3.68 (3.35–4.05)** 2.72 (2.44–3.02)**
Poverty only 11770 (6.4) 2.81 (2.57–3.21)** 1.43 (1.23–1.66)**
2 conditions
AMI and SAoD 2893 (1.7) 2.74 (2.14–3.50)** 3.48 (2.69–4.50)**
AMI and CMC 4309 (5.1) 8.71 (7.81–9.72)** 6.72 (5.92–7.63)**
AMI and poverty 2466 (1.5) 8.22 (6.89–9.81)** 4.24 (3.45–5.23)**
SAoD and CMC 1556 (1.2) 4.38 (3.26–5.89)** 4.00 (2.97–5.39)**
SAoD and poverty 1716 (.7) 3.05 (2.08–4.46)** 2.04 (1.37–3.03)*
CMC and poverty 3654 (3.0) 10.07 (8.61–11.78)** 3.56 (2.95–4.30)**
3 conditions
AMI, SAoD, and CMC 1191 (.9) 6.49 (5.18–8.13)** 6.07 (4.54–8.12)**
AMI, SAoD, and poverty 1033 (.5) 8.14 (6.27–10.57)** 4.72 (3.44–6.46)**
AMI, CMC, and poverty 1489 (1.3) 24.54 (20.42–29.51)** 9.41 (7.53–11.76)**
SAoD, CMC, and poverty 488 (.2) 8.35 (5.73–12.18)** 4.53 (2.87–7.13)**
4 conditions
AMI, SAoD, CMC, and poverty 472 (.3) 17.04 (12.27–23.67)* 9.32 (6.67–13.02)**
Notes. AMI = any mental illness; AOR = adjusted odds ratio; CI = confidence intervals; CMC = chronic medical conditions;
OR = odds ratio SAoD = substance abuse and/or dependence.
Odds of reporting poor/fair self-rated health compared to good/very good/excellent health.
a
Adjusted for age, gender, race/ethnicity, marital status, county metro status, education, employment, government assis-
tance, and health insurance.
b
All groups are mutually exclusive.
*p < .01; **p < .001.

and poverty (AOR = 9.32; 95% CI: 6.67–13.02). For each combination of conditions, the
addition of poverty increased the likelihood of reporting fair/poor health.
6 E. R. Walker and B. G. Druss

1 condition
2 conditions
3 conditions
4 conditions

Figure 1. Adjusted odds ratios of reporting poor or fair health among all combinations of adults with
mental illness, substance abuse and/or dependence, chronic medical conditions, and/or living in poverty.
AMI = any mental illness; CMC = chronic medical conditions; SAoD = substance abuse and/or dependence.
a
Odds of reporting fair/poor self-rated health compared to good/very good/excellent health. Reference category is no mental
illness, substance abuse and/or dependence, chronic medical condition, or poverty. All groups are mutually exclusive. Adjusted
for age, gender, race/ethnicity, marital status, county metro status, education, employment, government assistance, and
health insurance.

Discussion
Traditionally, multimorbidity has been conceptualized as the co-occurrence of two or more
chronic conditions, generally medical conditions, at the same time (Nardi et al., 2007;
Valderas, Starfield, & Sibbald, 2009). This view often fails to capture mental illnesses and
substance use disorders, as well as the impact of socioeconomic factors on health and
quality of life. We found that 1.2% of individuals in the U.S.A. Report co-occurring AMI,
substance abuse/dependence, and chronic medical conditions, which is equivalent to about
2.2 million people. Generally, increasing numbers of conditions were associated with poorer
self-health, with poverty further elevating the association with poor health.
Recently, work has been done to examine measurement of multimorbidities (Diederichs,
Berger, & Bartels, 2011) and generate guidelines and recommendations for improving the
health of people with multiple medical conditions (Uhlig et al., 2014). While these guidelines
often include depression due to its high prevalence, our findings indicate that any mental
illness and substance abuse/dependence are also important considerations. Improving the
health of people with multimorbidities will involve increased access to and coordination
between a variety of services. Collaborative care models are effective in treating mental
illnesses in primary care (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006) and providing
primary care in specialty mental health settings (Druss & von Esenwein, 2006). These mod-
els are less commonly applied to substance use disorders, which can result in fragmentation
in care for people with these conditions (Gurewich, Prottas, & Sirkin, 2014).
Our findings also suggest the need to broaden our view of illness complexity beyond
the health care system to address disadvantage and other social determinants of heath
(Shim et al., 2014). Strategies to address social determinants include wellness and recovery-­
oriented initiatives (Cook et al., 2009), supported employment (Kinoshita et al., 2013), and
supported housing (Patterson, Currie, Rezansoff, & Somers, 2015).
 Psychology, Health & Medicine  7

Limitations
The results should be considered in light of several limitations. First, this is a cross-sectional
study, which prevents causal claims regarding the association between multimorbidity and
self-rated health. Second, although estimates of AMI were based on validated prediction
models, the measure of AMI involved self-reported responses to scales rather than struc-
tured diagnostic interviews. The NSDUH measures the presence of AMI, but not specific
diagnoses or the number of co-occurring mental disorders. Third, the NSDUH includes a
select number of medical conditions, thus we were unable to assess other relevant medical
conditions or conditions for which participants were not treated. Finally, the conditions were
measured on different timescales, thus we were unable to verify that all of them occurred
together.

Conclusions
Mental illness, substance abuse/dependence, chronic medical conditions, and poverty com-
monly overlap and this multimorbidity contributes to poor health. Conceptualizations of
multimorbidity must be expanded to include the complexities of co-occurrence of mental
illnesses, chronic medical conditions, and socioeconomic factors.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the National Institutes of Health/National Institute of General Medical
Sciences [grant number K12 GM00680-05]; the National Institute of Mental Health [grant number
5K01MH09582302].

ORCID
Elizabeth Reisinger Walker http://orcid.org/0000-0001-7221-3089

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