According to the WHO, Mental health is defined as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to the community.[1] Mental illness is defined as all diagnosable mental disorders or health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired function.[2] Examples of mental disorders include mood disorders such as depression; psychotic disorders such as schizophrenia; dementia due to Alzheimer’s disease or other disease, event, or injury to the brain; intellectual disabilities; and developmental disorders (e.g. autism).[3] Substance dependence can also be considered a mental health disorder and is covered in more detail in the Substance Abuse section of this assessment.
Depression is the most common type of mental illness in the US.[4] There are several forms of depression including persistent depressive disorder (lasting for at least two years), perinatal depression (women experiencing depression following childbirth), Psychotic depression (depression with psychosis), and seasonal affective disorder (depression in winter).[5] Depression often begins in adulthood but can occur in children and adolescents.
Determinants of Mental Health and the Life Course
Mental Health is influenced by complex interactions between social, cultural, economic, political, and environmental factors as well as individual attributes (e.g., psychology, personality, and biology) that occur at every stage of life.[3,6,7] Key development stages for mental health include reproductive decisions, prenatal/postnatal period, the transition to school, adolescence, transition to independence, and adult life including family, work, and retirement.[8] Figure 1 shows some of the main risk factors for poor mental health over the life course.
Preconception to childhood
Events and circumstances occurring early in life, even before birth, affect later mental health. Parents who are prepared emotionally, socially, and economically for having children are most likely to raise healthy, well-adjusted children. Risk factors for later mental health problems occurring preconception or in early childhood include pregnancy during adolescence, low birthweight, perinatal complications, maternal substance use, parental mental illness, family conflict, and child neglect or abuse. [7] Inadequate prenatal care can lead to low birthweight babies and subsequent behavioral, emotional and learning problems. Substance use during pregnancy increases the likelihood of premature deliveries, low birthweight, and long-term neurological, cognitive, and emotional development problems. Adolescents who become pregnant are less likely to develop employment and survival skills and more likely to experience parental stress; consequently their children are at higher risk of developmental delays and substance-related problems, and are more likely to live under deprived conditions. Prenatal depression, low self-esteem, child care stress, and prenatal anxiety can lead to postpartum depression, which affects bonding and the quality of care given to the infant.[8]
Childhood
Childhood is a vital time for development of social, cognitive, and emotional skills important in later mental health.[7,8] Protective factors during this period include supportive parenting, feelings of security, positive learning environments, and exercise. Mental health risk factors include violence or conflict, negative life events, lack of connection to school, poor bonding with parents, having a parent with a mental illness, and trauma due to bullying, abuse, or parental loss. Socioeconomic status also impacts opportunities for learning and positive social interaction as well as exposes children to disease and injury.
Adolescence
Many mental disorders manifest their first signs and symptoms on onset during adolescence and early adulthood.[4] In addition to the risks that affect development of younger children, adolescents are vulnerable to tobacco, alcohol, and drug use. Adolescents with family unrest or behavioral problems during childhood are more likely to use drugs and alcohol. Furthermore, academic failure, peer pressure, and media influence are associated with greater substance use which itself is linked to lower educational outcomes, increased violence, and risky sexual behavior.[7,8] Protective factors for mental health among adolescents include problem solving skills, conflict management skills, and safe and supportive communities.
Adulthood
Being able to successfully manage the choices and challenges of adulthood, is dependent on events and circumstances in childhood and adolescence. For example, adolescent pregnancy and a failure to develop skills and good work habits can leave adults inadequately prepared economically. Work-life balance, community involvement, and general health status are also key determinants of mental health in adulthood. Excessive time spent working and caring for others, as well as operating in a difficult or insecure work environment often lead to stress and anxiety.[8] Unemployment and persistent socio-economic pressures, in particular, are associated with poor mental health, higher health care usage, and increased mortality.[6,8]
Inability to participate in the community due to lack of access, neighborhood violence or crime, or having burdensome child- or elder-care responsibilities can lead to social exclusion and loneliness in the individual and an absence of social capital in the community.[7] Furthermore, poor physical health co-occurs with poor mental health, especially depression. Mental Health is negatively affected by both the presence of or treatment for serious medical illnesses—including diabetes, cancer, cardiovascular disease, asthma, and Parkinson’s disease—and many risk behaviors for chronic disease—including low physical activity, tobacco use, alcohol consumption, and a lack of sleep.[5,9] Additional risk factors for poor mental health include personal or family history, excessive substance use, rapid social change, experiencing discrimination, and major life changes, trauma, or stress.[5,6] Protective factors include the ability to cope with stress, the ability to deal with adversity, problem-solving skills, literacy, social support from family and friends, and social and conflict management skills.
Old Age
Older adults are at particularly high risk for mental health issues resulting from social isolation and chronic disease.[8] Social isolation is common as older adults withdraw from the labor market, and lose partners and friends to illness and death. Social isolation and chronic disease are significant predictors of depression in older adults.
Vulnerable Populations
Persons with a large number of protective factors and few risk factors over a lifetime are at increased likelihood for good mental health while those adversely affected by social determinants of health are at increased risk of poor mental health. Social determinants of health affect mental health both directly—through unmitigated (chronic) stress and epigenetic mechanisms—and indirectly—by influencing healthy behaviors, and access to safe housing and healthcare.[10] People with lower education, income, and/or social status, and those who experience discrimination on the basis of race, gender, social class, or other characteristics are at a particularly high risk of mental illness. Figure 2 shows the co-dependency of mental health risk factors and economic vulnerabilities on mental health status.
Mental health among prisoners and inmates
More than half of all male and almost three quarters of female prisoners and inmates suffer from mental illness.[13] Inmates and prisoners with a mental illness are twice as likely to have been homeless in the year prior to incarceration or to have lived in a foster home, agency, or institution while growing up. Availability of appropriate mental health care can reduce the risk of incarceration among persons with mental illness.[14]
Mental health and children and adolescents in the Child Welfare System
Children and adolescents in the Child Welfare system are 4 times more likely to have a mental disorders compared to children in the general population.[11] These children are particularly vulnerable to mental illness due to histories of child abuse and neglect, separation from their biological parents, placement instability, and inability to access appropriate and continuous mental health care.
Mental health among the homeless
The prevalence of mental illness among homeless persons is estimated to be between 40 and 70 percent.[12] The relationship between homelessness and deteriorating mental health is complicated with each further contributing to the other. While lack of affordable housing is the main driver for homelessness, presence of a mental disorder can make it difficult for someone to care for themselves, alienate them from their friends and family, and cause them to be unable to maintain a job and subsequently their home. Likewise, homelessness is traumatizing and can lead to depression, substance abuse, and declining mental and physical health.
Mental illnesses are the leading causes of years lived with disability worldwide.[15] Mental health and well-being are crucial to supporting, maintaining, and optimizing quality of life.[6] The presence of mental illness can adversely impact the ability to function at work, at home, and in social settings and impacts individuals as well as their respective families and communities.[3,4] In fact, poor mental health is a predictor of unemployment, and subsequent debt and impoverishment.[6,8] In the absence of support, intervention, or treatment, mental health disorders can readily worsen over time, leading to impaired quality of life, disability, hospitalization, institutionalization, incarceration, suicide and self-injury, and/or death.[3] As mental disorders progress over time, access to care and treatment influence the progression and course of the illness.[6]
Substance use is common among persons with mental illness. Approximately 30% of all mentally ill persons and 50% of persons with a severe mental disorder also abuse drugs and/or alcohol. Conversely, nearly 40% of persons who abuse alcohol and more than 50% of those who use drugs have at least one serious mental illness.[16] Drugs and alcohol, while often used to mitigate the symptoms of depression or anxiety, can both increase the underlying risk for mental disorders as well as make symptoms worse. Persons with co-occurring mental illness and substance abuse disorders have high rates of incarceration.[17]
There is high comorbidity within and across mental illnesses, and between mental and physical health.[18] For example, better mental health correlates with physical health indicators like lower incidence of disease, more frequent treatment success, and slower progression of chronic diseases such as cancer, heart disease, diabetes, asthma, and obesity. Poor mental health status, however, is associated with greater participation in risky health behaviors (e.g. smoking, low physical activity, insufficient sleep, excessive drinking, drug use) that can in turn promote chronic disease.[4,12]
Depression is the most common mental illness. It is estimated that more than a quarter of the U.S. adult population is affected by depression and that by 2020 depression will be the second leading cause of disability in the world.[4] Depressed youth are more likely to engage in risk-taking behaviors including drug use, unsafe sex, attempting suicide, and running away from home, and are less likely to succeed in school and possibly later in life.[19]
Poor mental health and psychiatric disorders are strong and consistent risk factors for suicide and suicidal behavior.[20] In 2015, suicide was the 10th-leading cause of death in the United States. Among younger people, suicide was even more common—it was the second-leading cause of death among youth and young adults ages 15-34 years, and it was the third-leading cause of death among youth age 10-14 years.[21] Major depression and other mood disorders, substance abuse disorders, schizophrenia, and personality disorders are the most common disorders among those who die by suicide.[22]
Adult self-reporting of psychological distress, and seeking and receiving treatment
In 2016, a greater percentage of adults, age 18 or older, who participated in the CHIS survey, reported needing help for mental health or substance use issues in San Francisco (22.5 percent) than in California overall (16.4 percent) (Figure 1A). Asians were less likely to report needing help than other ethnicities (Figure 1B). Caution should be exercised in interpreting estimates by ethnicity as cultural attitudes towards mental health and survey response rates may affect results. A greater percentage of adults with household incomes below 200 percent of the Federal Poverty Line (FPL) reported needing help with mental health compared to those with household incomes above 200 percent of the FPL (Figure 1D).
In 2014-2016, 7 percent of adults experienced serious psychological distress in San Francisco (Figure 2A). In 2011-2016, those living below 200 percent of the FPL (15.2 percent) were more likely to experience distress than those living above 200 percent of the FPL (5.3 percent) (Figure 2B).
Prenatal depressive symptoms
In 2013-2015, citywide, 14.4 percent of pregnant women, who responded to the MIHA survey, reported prenatal depressive symptoms. Prenatal depression varied significantly by level of education, income, and type of insurance.
Women with less than high school education were more than 3 times more likely to report prenatal depressive symptoms than women with a college degree (37.6 vs 9.0 percent). Women with Medi-Cal insurance were more likely than women with private insurance to report prenatal depressive symptoms (24.1 vs 8.9 percent). Hispanic and Black/African American women were more likely to report prenatal depressive symptoms than White or Asian women (26.7 and 21.4 percent vs 9.5 and 11.8 percent).
Feelings of sadness and suicidal ideation among youth
Prolonged sad or hopeless feelings and suicidal ideation—consideration of suicide attempts—are predictors of suicide. In 2017, 26.1 percent of San Francisco high school students reported prolonged sad or hopeless feelings in the past year (Figure 3A). Females (31.7 percent) as well as Black/African Americans (30.7 percent) and Filipinos (38.6 percent) reported higher rates than did males and other ethnicities (Figure 3B). The percentage was also significantly higher among bisexual (61.9 percent) and gay or lesbian (42.5 percent) high school students (Figure 3C).
Almost 13 percent of high school students and 19.4 percent of middle school students in San Francisco had considered attempting suicide in 2017. Similarly, female, Filipino, Latino, Black/African American, bisexual, and gay or lesbian students were more likely than other groups to have considered suicide (Figure 4A, 4B, 4C).
Major depression and self-inflicted injury hospitalizations
In 2012-2016, the rate of hospitalization due to major depression remained fairly stable, while the rate of emergency room (ER) visits due to major depression increased from 16.768 to 20.427 per 10,000 residents. On the other hand, both corresponding rates due to self injury decreased significantly by more than 50 percent between 2012 and 2016 (Figure 5A). Rates were the highest among Black/African American for all hospitalizations and emergency room visits in 2016 (Figure 5B). During the same time period, residents 45-54 years old and 18-24 years old were more likely to visit the emergency room due to depression or self injury (Figure 5C). Rates were also highest in the Tenderloin and South of Market neighborhoods (Map 5).
In 2013-2016, suicide rates increased by 87 percent to 11.8 per 100,000 population in San Francisco (Figure 6A). The rate was the highest among Whites and the lowest among Asians in 2013-2017 (Figure 6B). Although the data by neighborhood was not complete due to small numbers, the map indicates that Castro had the highest suicide rate 21.87 per 100,000 population which was three times higher than the lowest suicide rate (Map 6).
CDPH Death Statistical Master Files, California Department of Public Health (CDPH).
CHIS California Health Interview Survey (CHIS), UCLA Center for Health Policy.
MIHA Maternal Infant Health Assessment Survey, California Department of Public Health.
OSHPD California Office of Statewide Health Planning and Development (OSHPD).
YRBSS Youth Risk Behavior Surveillance System (YRBSS), Centers for Disease Control and Prevention.
Hospitalizations and Emergency Room Visits: Hospitalization and ER rates measure the number of admissions or visits, not the number of residents who are hospitalized. Admissions records may include multiple admissions by the same person.
Self-inflicted injury: Agency for Healthcare Research and Quality’s Clinical Classification Software versions 2015 (ICD-9) and 2017 (ICD-10) were used to identify visits with a primary diagnosis of self inflicted injury.
Major Depression: The following ICD-9 and ICD-10 codes were used to identify visits primarily due to Major Depression:
Population estimates for rates:
Standard Population for age adjustment:
Statistical instability: Statistically unstable estimates are not shown in this document. Statistical instability may arise from:
Statistical instability indicates a lack of confidence in an estimates ability to accurately and reliably represent the population. Due to statistical instability, estimates are not available for all age, gender, ethnicity, or other groups.
[1] World Health Organization. Mental health: a state of wellbeing. http://www.who.int/features/factfiles/mental_health/en/, 2014. Accessed 10.23.17.
[2] US Surgeon General. Mental health: A report of the surgeon general. Rockville, MD: Us department of health and human services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
[3] World Health Organization. Mental disorders: fact sheet. Media Centre: Mental disorders – Fact sheet No. 396 (October 2014), 2017. Accessed 10.23.17.
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[5] National Institute of Medicine. Depression. https://www.nimh.nih.gov/health/topics/depression/index.shtml, 2016. Accessed 10/24/17.
[6] World Health Organization. Mental health: Strengthening our response. http://www.who.int/mediacentre/factsheets/fs220/en/, 2016. Accessed 10.23.17.
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[11] Guillaume Bronsard, Marine Alessandrini, Guillaume Fond, Anderson Loundou, Pascal Auquier, Sylvie Tordjman, and Laurent Boyer. The prevalence of mental disorders among children and adolescents in the child welfare system: A systematic review and meta-analysis. Medicine, 95:e2622, February 2016.
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[13] Doris J James and Lauren E Glaze. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report, 2006.
[14] Richard A Van Dorn, Sarah L Desmarais, John Petrila, Diane Haynes, and Jay P Singh. Effects of outpatient treatment on risk of arrest of adults with serious mental illness and associated costs. Psychiatric services (Washington, D.C.), 64:856–862, September 2013.
[15] Harvey A Whiteford, Louisa Degenhardt, Jürgen Rehm, Amanda J Baxter, Alize J Ferrari, Holly E Erskine, Fiona J Charlson, Rosana E Norman, Abraham D Flaxman, Nicole Johns, Roy Burstein, Christopher J L Murray, and Theo Vos. Global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. Lancet (London, England), 382:1575–1586, November 2013.
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[17] Alison Luciano, Johannes Belstock, Per Malmberg, Gregory J McHugo, Robert E Drake, Haiyi Xie, Susan M Essock, and Nancy H Covell. Predictors of incarceration among urban adults with co-occurring severe mental illness and a substance use disorder. Psychiatric Services, 65(11):1325–1331, 2014.
[18] Shekhar Saxena, Eva Jané-Llopis, and Clemens Hosman. Prevention of mental and behavioural disorders: implications for policy and practice. World psychiatry : official journal of the World Psychiatric Association (WPA), 5:5–14, February 2006.
[19] American College of Obstetricians and Gynecologists. Mental health disorders in adolescents. ACOG Committee Opinion, 705. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co705.pdf, July 2017.
[20] Matthew K Nock, Guilherme Borges, Evelyn J Bromet, Christine B Cha, Ronald C Kessler, and Sing Lee. Suicide and suicidal behavior. Epidemiologic reviews, 30(1):133–154, 2008.
[21] Centers for Disease Control and Prevention-WISQARS. Leading causes of death reports, 1981-2015. https://webappa.cdc.gov/sasweb/ncipc/leadcause.html, 2017.
[22] José Manoel Bertolote and Alexandra Fleischmann. Suicide and psychiatric diagnosis: a worldwide perspective. World psychiatry : official journal of the World Psychiatric Association (WPA), 1:181–185, October 2002.
