Showing papers by "Sandro Galea published in 2013"

A genome-wide association study of post-traumatic stress disorder identifies the retinoid-related orphan receptor alpha (RORA) gene as a significant risk locus

Abstract: We describe the results of the first genome-wide association study (GWAS) of post-traumatic stress disorder (PTSD) performed using trauma-exposed white non-Hispanic participants from a cohort of veterans and their intimate partners (295 cases and 196 controls). Several single-nucleotide polymorphisms (SNPs) yielded evidence of association. One SNP (rs8042149), located in the retinoid-related orphan receptor alpha gene (RORA), reached genome-wide significance. Nominally significant associations were observed for other RORA SNPs in two African-American replication samples—one from the veteran cohort (43 cases and 41 controls) and another independent cohort (100 cases and 421 controls). However, only the associated SNP from the veteran African-American replication sample survived gene-level multiple-testing correction. RORA has been implicated in prior GWAS studies of psychiatric disorders and is known to have an important role in neuroprotection and other behaviorally relevant processes. This study represents an important step toward identifying the genetic underpinnings of PTSD.

An Argument for a Consequentialist Epidemiology

Abstract: Epidemiology is the study of the causes and distributions of diseases in human populations so that we may identify ways to prevent and control disease. Although this definition broadly serves us well, I suggest that in recent decades, our discipline's robust interest in identifying causes has come at the expense of a more rigorous engagement with the second part of our vision for ourselves-the intent for us to intervene-and that this approach threatens to diminish our field's relevance. I argue here for a consequentialist epidemiology, a formalization and recalibration of the philosophical foundations of our discipline. I discuss how epidemiology is, at its core, more comfortably a consequentialist, as opposed to a deontological, discipline. A more consequentialist approach to epidemiology has several implications. It clarifies our research priorities, offers a perspective on the place of novel epidemiologic approaches and a metric to evaluate the utility of new methods, elevates the importance of global health and considerations about equity to the discipline, brings into sharp focus our engagement in implementation and translational science, and has implications for how we teach our students. I intend this article to be a provocation that can help clarify our disciplinary intentions.

Neighborhoods and HIV: a social ecological approach to prevention and care.

Abstract: Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities

Abstract: Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborh...

Psychopathology in the aftermath of the Haiti earthquake: A population-based study of posttraumatic stress disorder and major depression

Abstract: BACKGROUND: In the first population-based study of psychopathology conducted in Haiti, we documented earthquake-related experiences associated with risk for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) 2-4 months following the 2010 Haiti earthquake. METHODS: A population-based survey was conducted of 1,323 survivors randomly selected from the general nondisplaced community, internally displaced persons camps, and a community clinic. Respondents were from the Nazon area of Port-au-Prince, ∼20 miles from the epicenter. RESULTS: Respondents (90.5%) reported at least one relative/close friend injured/killed, 93% saw dead bodies, and 20.9% lost their job post-earthquake. The prevalence of PTSD (24.6%) and MDD (28.3%) was high. History of violent trauma was associated with risk of PTSD and MDD (adjusted odds ratio [AOR] 1.4, 95% confidence interval [CI], 1.0-1.9; AOR, 1.7, 95% CI 1.3, 2.2, respectively). Low social support (AOR, 1.7, 95% CI 1.2, 2.3; AOR 1.4, 95% CI 1.0, 1.9, respectively) increased risk of PTSD and MDD among women. Suffering damage to the home increased risk of MDD in males (AOR 2.8, 95% CI 1.5, 5.5). Associations between being trapped in rubble, major damage to house, job loss, and PTSD; and participation in rescue/recovery, friends/family injured/killed, and MDD varied based on prior history of violent trauma. CONCLUSIONS: Addressing mental health in a post-earthquake setting such as Haiti will require focusing resources on screening and treatment of identified vulnerable groups while targeting improvement of post-earthquake living conditions. Investment in sources of social support for women may make help mitigate the vulnerability of women to PTSD and MDD. Language: en

Adcyap1r1 genotype, posttraumatic stress disorder, and depression among women exposed to childhood maltreatment.

Abstract: BACKGROUND: A growing literature indicates that genetic variation, in combination with adverse early life experiences, shapes risk for later mental illness. Recent work also suggests that molecular variation at the ADCYAP1R1 locus is associated with posttraumatic stress disorder (PTSD) in women. We sought to test whether childhood maltreatment (CM) interacts with ADCYAP1R1 genotype to predict PTSD in women. METHODS: Data were obtained from 495 adult female participants from the Detroit Neighborhood Health Study. Genotyping of rs2267735, an ADCYAP1R1 variant, was conducted via TaqMan assay. PTSD, depression, and CM exposure were assessed via structured interviews. Main and interacting effects of ADCYAP1R1 and CM levels on past month PTSD and posttraumatic stress (PTS) severity were examined using logistic regression and a general linear model, respectively. As a secondary analysis, we also assessed main and interacting effects of ADCYAP1R1 and CM variation on risk of past-month depression diagnosis and symptom severity. RESULTS: No significant main effects were observed for ADCYAP1R1 genotype on either PTSD/PTS severity. In contrast, a significant ADCYAP1R1 × CM interaction was observed for both past month PTSD and PTS severity, with carriers of the "C" allele showing enhanced risk for these outcomes among women exposed to CM. No significant main or interaction effects were observed for past month depression/depression severity. CONCLUSIONS: Genetic variation at the ADCYAP1R1 locus interacts with CM to shape risk of later PTSD, but not depression, among women. The molecular mechanisms contributing to this interaction require further investigation. Language: en

Six Paths for the Future of Social Epidemiology

Abstract: Social epidemiology is now an accepted part of the academic intellectual landscape. However, in many ways, social epidemiology also runs the risk of losing the identity that distinguished it as a field during its emergence. In the present article, we scan the strengths of social epidemiology to imagine paths forward that will make the field distinct and useful to the understanding of population health in future. We suggest 6 paths to such a future, each emerging from promising research trends in the field in which social epidemiologists can, and should, lead in coming years. Each of these paths contributes to the formation of distinct capacities that social epidemiologists can claim and use to elaborate or fill in gaps in the already strong history of social epidemiology. They present an opportunity for the field to build on its strengths and move forward while leading in new and critical areas in population health.

Racial Disparities in Posttraumatic Stress After Diagnosis of Localized Breast Cancer: The BQUAL Study

Abstract: A growing body of evidence suggests that the experience of being diagnosed with breast cancer, a potentially life-threatening event, is associated with substantial psychological distress (1–3). Posttraumatic stress disorder (PTSD) is a psychiatric diagnosis characterized by the development of re-experiencing, avoidance, and increased arousal symptoms after exposure to a traumatic event (4). In 1994, the trauma criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were expanded to include life-threatening illnesses, such as cancer (4). Since that time, PTSD has been investigated in a number of studies of breast cancer survivors; these typically small-scale studies have yielded estimates of prevalence ranging from 0% (5,6) to 32% (7,8). A number of studies have identified risk factors for PTSD after a diagnosis of cancer, including demographic, social, psychosocial, and clinical characteristics, such as socioeconomic status (9–11), less education (10,11), poor social support (12–15), prior individual psychological disturbances (10), younger age at diagnosis (9,11,12,16–19), type of surgery (10,15), lymph node involvement (10,15), stage of disease (12), and less time since treatment (13). Racial disparities have been a concern in breast cancer, generally focused on differences in survival outcomes (20), but some studies have also suggested that the risk of PTSD may also be different across racial/ethnic groups (21,22). For example, Roberts and colleagues (22) found that the risk of PTSD after being exposed to various life traumas among blacks was 1.22 (95% confidence interval [CI] = 1.02 to 1.43), whereas among Asian women the risk was lower (odds ratio [OR] = 0.67, 95% CI = 0.45 to 0.99) in comparison with whites in their sample of more than 34 000 individuals representative of the US noninstitutionalized, civilian population aged 18 years and older. After a cancer diagnosis as the traumatic event, a higher rate of PTSD has been reported for blacks diagnosed with prostate cancer (23) and non-Hodgkins lymphoma (24) than for whites with the same diagnoses, but this issue has received little attention in breast cancer. Rates of PTSD after a diagnosis of breast cancer in Hispanic and Asian Americans have also received little research attention, although there is some evidence of generally lower emotional well-being among women in these minority groups compared with whites (25). In this study, we investigate PTSD in data collected from a large prospective cohort of racially diverse breast cancer patients over a 6-month period after diagnosis based on three time points and explore the impact of demographic and clinical characteristics on PTSD, with a particular emphasis on race.

Longitudinal Associations Between Types of Childhood Trauma and Suicidal Behavior Among Substance Users: A Cohort Study

Abstract: Objectives. We examined the longitudinal associations between different types and severities of childhood trauma and suicide attempts among illicit drug users.Methods. Data came from 2 prospective cohort studies of illicit drug users in Vancouver, Canada, in 2005 to 2010. We used recurrent event proportional means models to estimate adjusted and weighted associations between types and severities of childhood maltreatment and suicide attempts.Results. Of 1634 participants, 411 (25.2%) reported a history of suicidal behavior at baseline. Over 5 years, 80 (4.9%) participants reported 97 suicide attempts, a rate of 2.6 per 100 person-years. Severe to extreme levels of sexual abuse (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI] = 1.4, 4.4), physical abuse (AHR = 2.0; 95% CI = 1.1, 3.8), and emotional abuse (AHR = 3.5; 95% CI = 1.4, 8.7) predicted suicide attempts. Severe forms of physical and emotional neglect were not significantly associated with an increased risk of suicidal behavior.Concl...

Are Network-Based Interventions a Useful Antiobesity Strategy? An Application of Simulation Models for Causal Inference in Epidemiology

Abstract: Recent research suggests that social networks may present an avenue for intervention against obesity By using a simulation model in which artificial individuals were nested in a social network, we assessed whether interventions targeting highly networked individuals could help reduce population obesity We compared the effects of targeting antiobesity interventions at the most connected individuals in a network with those targeting individuals at random We tested 2 interventions, the first “preventing” obesity among 10% of the population at simulation outset and the second “treating” obesity among 10% of the obese population yearly, each in 2 separate simulations One simulation featured a literature-based parameter for the network spread of obesity, and the other featured an artificially high parameter Interventions that targeted highly networked individuals did not outperform at-random interventions in simulations featuring the literature-based parameter However, in simulations featuring the artificially high parameter, the targeted prevention intervention outperformed the at-random intervention, whereas the treatment intervention implemented at random outperformed the targeted treatment intervention Results were qualitatively similar across network topologies and intervention scales Although descriptive studies suggest that social networks influence the spread of obesity, policies targeting well-connected individuals in social networks may not improve obesity reduction We highlight and discuss the potential applications of counterfactual simulations in epidemiology

Interaction between polygenic risk for cigarette use and environmental exposures in the Detroit neighborhood health study

Abstract: Cigarette smoking is influenced both by genetic and environmental factors. Until this year, all large-scale gene identification studies on smoking were conducted in populations of European ancestry. Consequently, the genetic architecture of smoking is not well described in other populations. Further, despite a rich epidemiologic literature focused on the social determinants of smoking, few studies have examined the moderation of genetic influences (for example, gene–environment interactions) on smoking in African Americans. In the Detroit Neighborhood Health Study (DNHS), a sample of randomly selected majority African American residents of Detroit, we constructed a genetic risk score (GRS), in which we combined top (P-value <5 × 10−7) genetic variants from a recent meta-analysis conducted in a large sample of African Americans. Using regression (effective n=399), we first tested for association between the GRS and cigarettes per day, attempting to replicate the findings from the meta-analysis. Second, we examined interactions with three social contexts that may moderate the genetic association with smoking: traumatic events, neighborhood social cohesion and neighborhood physical disorder. Among individuals who had ever smoked cigarettes, the GRS significantly predicted the number of cigarettes smoked per day and accounted for ∼3% of the overall variance in the trait. Significant interactions were observed between the GRS and number of traumatic events experienced, as well as between the GRS and average neighborhood social cohesion; the association between genetic risk and smoking was greater among individuals who had experienced an increased number of traumatic events in their lifetimes, and diminished among individuals who lived in a neighborhood characterized by greater social cohesion. This study provides support for the utility of the GRS as an alternative approach to replication of common polygenic variation, and in gene–environment interaction, for smoking behaviors. In addition, this study indicates that environmental determinants have the potential to both exacerbate (traumatic events) and diminish (neighborhood social cohesion) genetic influences on smoking behaviors.

The Color of Debt: Racial Disparities in Anticipated Medical Student Debt in the United States

Abstract: Context The cost of American medical education has increased substantially over the past decade. Given racial/ethnic inequalities in access to financial resources, it is plausible that increases in student debt burden resulting from these increases in cost may not be borne equally. Objective To evaluate racial/ethnic disparities in medical student debt. Design, Setting, and Participants Authors collected self-reported data from a non-representative sample of 2414 medical students enrolled at 111/159 accredited US medical schools between December 1st 2010 and March 27th 2011. After weighting for representativeness by race and class year and calculating crude anticipated debt by racial/ethnic category, authors fit multivariable regression models of debt by race/ethnicity adjusted for potential confounders. Main Outcome Measures Anticipated educational debt upon graduation greater than $150,000. Results 62.1% of medical students anticipated debt in excess of $150,000 upon graduation. The proportion of Blacks, Whites, Hispanics, and Asians reporting anticipated educational debt in excess of $150,000 was 77.3%, 65.1%, 57.2% and 50.2%, respectively. Both Black and White medical students demonstrated a significantly higher likelihood of anticipated debt in excess of $150,000 when compared to Asians [Blacks (OR = 2.7, 1.3–5.6), Whites (OR = 1.7, 1.3–2.2)] in adjusted models. Conclusion Black medical students had significantly higher anticipated debt than Asian students. This finding has implications for understanding differential enrollment among minority groups in US medical schools.

The course of posttraumatic stress symptoms and functional impairment following a disaster: what is the lasting influence of acute versus ongoing traumatic events and stressors?

Abstract: Purpose Ongoing traumatic events and stressors, rather than acute sources of trauma, may shape long-term post-disaster mental health. The purpose of this study was to compare the influence of acute hurricane-related exposures and ongoing post-hurricane exposures on the short- and long-term course of posttraumatic stress symptoms (PTSS) and functional impairment (FI).

Alcohol Outlets and Binge Drinking in Urban Neighborhoods: The Implications of Nonlinearity for Intervention and Policy

Abstract: Objectives. Alcohol outlet density has long been associated with alcohol-related harms, and policymakers have endorsed alcohol outlet restriction to reduce these harms. However, potential nonlinearity in the relation between outlet density and alcohol consumption has not been rigorously examined.Methods. We used data from the New York Social Environment Study (n = 4000) to examine the shape of the relation between neighborhood alcohol outlet density and binge drinking by using a generalized additive model with locally weighted scatterplot smoothing, and applied an imputation-based marginal modeling approach.Results. We found a nonlinear relation between alcohol outlet density and binge drinking; the association was stronger at densities of more than 80 outlets per square mile. Binge drinking prevalence was estimated to be 13% at 130 outlets, 8% at 80 outlets, and 8% at 20 outlets per square mile.Conclusions. This nonlinearity suggests that reductions in alcohol outlet density where density is highest and ...

Potentially traumatic events and the risk of six physical health conditions in a population-based sample.

Abstract: BACKGROUND: Potentially traumatic events (PTEs) are common in the population, yet, the impact of total burden and specific types of PTEs on physical health has not been systematically investigated. METHODS: Data were drawn from the Detroit Neighborhood Health Study, a community sample of predominately African Americans living in Detroit, Michigan, interviewed in 2008-2009 (N = 1,547) and in 2009-2010 (N = 1,054). Kaplan-Meier and Cox proportional hazards models were used. RESULTS: Respondents with the highest levels of PTE exposure (8+ events) had an average age of adverse physical health condition diagnosis that was 15 years earlier than respondents with no exposure. There was a monotonic relation between number of PTEs and arthritis risk. Compared to those who reported no lifetime events, respondents with 1-2, 3-4, 5-7, and 8+ traumatic events had 1.06, 1.12, 1.73, and 2.44 times the hazard of arthritis. Assaultive violence (HR = 1.7; 95% CI 1.2-2.3) and other threats to physical integrity (HR = 1.5, 95% CI 1.1-2.1) were particularly strong risk factors for arthritis. CONCLUSIONS: These results provide novel evidence linking PTEs, particularly those involving violence and threat to life, to elevated risk for arthritic conditions. Efforts to prevent or mitigate traumatic event exposures may have a broad range of benefits for health. Language: en

Displacement, county social cohesion, and depression after a large-scale traumatic event

Abstract: Background Depression is a common and potentially debilitating consequence of traumatic events. Mass traumatic events cause wide-ranging disruptions to community characteristics, influencing the population risk of depression. In the aftermath of such events, population displacement is common. Stressors associated with displacement may increase risk of depression directly. Indirectly, persons who are displaced may experience erosion in social cohesion, further exacerbating their risk for depression.

Support for association of RORA variant and post traumatic stress symptoms in a population-based study of hurricane exposed adults

Abstract: Post-traumatic stress disorder (PTSD) is moderately heritable, with estimates ranging from 30 to 70%.1 However, most of the genetic variation accounting for this heritability has yet to be identified, and the majority of molecular studies to date on PTSD have been candidate gene designs.2 Only one genome wide association study of PTSD has been published. In a sample of white non-Hispanic trauma-exposed veterans and their spouses/partners with and without PTSD, Logue and colleagues3 found that one single nucleotide polymorphism (SNP; rs8042149) in the retinoid-related orphan receptor alpha gene (RORA) reached genome-wide significance. RORA has been implicated, in part, in protecting brain cells from the damaging effects of injury, stress and disease,3 and it is possible that individuals with the variation in RORA may be at increased risk for developing PTSD due to deficits in initiating neuroprotective processes after trauma. We sought to provide supporting evidence for the genetic association between RORA*rs8042149 and PTSD using data from the 2004 Florida hurricanes study.

Unique and related predictors of major depressive disorder, posttraumatic stress disorder, and their comorbidity after Hurricane Katrina.

Abstract: The current study examined demographic and psychosocial factors that predict major depressive disorder (MDD) and comorbid MDD/posttraumatic stress disorder (MDD/PTSD) diagnostic status after Hurricane Katrina, one of the deadliest and costliest hurricanes in the history of the United States.

Navigating non-positivity in neighbourhood studies: an analysis of collective efficacy and violence

Abstract: Background In multilevel studies, strong correlations of neighbourhood exposures with individual and neighbourhood confounders may generate problems with non-positivity (ie, inferences that are ‘off-support’). The authors used propensity restriction and matching to (1) assess the utility of propensity restriction to ensure analyses are ‘on-support’ and (2) examine the relation between collective efficacy and violence in a previously unstudied city. Methods Associations between neighbourhood collective efficacy and violent victimisation were estimated in data from New York City in 2005 (n=4000) using marginal models and propensity matching. Results In marginal models adjusted for individual confounders and limited to observations ‘on-support’, under conditions of high collective efficacy, the estimated prevalence of violent victimisation was 3.5/100, while under conditions of low collective efficacy, it was 7.5/100, resulting in a difference of 4.0/100 (95% CI 2.6 to 5.8). In propensity-matched analysis, the comparable difference was 4.0/100 (95% CI 2.1 to 5.9). In analyses adjusted for individual and neighbourhood confounders and limited to observations ’on-support’, the difference in violent victimisation associated with collective efficacy was 3.1/100 (95% CI 1.2 to 5.2) in marginal models and 2.4/100 (95% CI 0.2 to 4.5) in propensity-matched analysis. Analyses without support restrictions produced surprisingly similar results. Conclusions Under conditions of high collective efficacy, there was about half the prevalence of violence compared with low collective efficacy. The results contribute to a growing body of evidence that suggests collective efficacy may shape violence, and illustrate how careful techniques can be used to disentangle exposures from highly correlated confounders without relying on model extrapolation.

Epigenetic Signatures May Explain the Relationship between Socioeconomic Position and Risk of Mental Illness: Preliminary Findings from an Urban Community-Based Sample

Abstract: Low socioeconomic position (SEP) has previously been linked to a number of negative health indicators, including poor mental health. The biologic mechanisms linking SEP and mental health remain poorly understood. Recent work suggests that social exposures influence DNA methylation in a manner salient to mental health. We conducted a pilot investigation to assess whether SEP, measured as educational attainment, modifies the association between genomic methylation profiles and traumatic stress in a trauma–exposed sample. Results show that methylation × SEP interactions occur preferentially in genes pertaining to nervous system function, suggesting a plausible biological pathway by which SEP may enhance sensitivity to stress and, in turn, risk of posttraumatic stress disorder.[Supplementary materials are available for this article. Go to the publisher's online edition of Biodemography and Social Biology for the following free supplemental resource: Supplementary tables of full model and functional annotation...

Cumulative and recent psychiatric symptoms as predictors of substance use onset: does timing matter?

Abstract: Aims We examined two questions about the relationship between conduct disorder (CD), depression and anxiety symptoms and substance use onset: (i) what is the relative influence of recent and more chronic psychiatric symptoms on alcohol and marijuana use initiation and (ii) are there sensitive developmental periods when psychiatric symptoms have a stronger influence on substance use initiation? Design Secondary analysis of longitudinal data from the Pittsburgh Youth Study, a cohort study of boys followed annually from 7 to 19 years of age. Setting Recruitment occurred in public schools in Pittsburgh, Pennsylvania, USA. Participants A total of 503 boys. Measurements The primary outcomes were age of alcohol and marijuana use onset. Discrete-time hazard models were used to determine whether (i) recent (prior year); and (ii) cumulative (from age 7 until 2 years prior to substance use onset) psychiatric symptoms were associated with substance use onset. Findings Recent anxiety symptoms [hazard ratio (HR) = 1.10, 95% confidence interval (CI) = 1.03–1.17], recent (HR = 1.59, 95% CI = 1.35–1.87), cumulative (HR = 1.45, 95% CI = 1.03–2.03) CD symptoms, and cumulative depression symptoms (HR = 1.04, 95% CI = 1.01–1.08) were associated with earlier alcohol use onset. Recent (HR = 1.39, 95% CI = 1.22–1.58) and cumulative CD symptoms (HR = 1.38, 95% CI = 1.02–1.85) were associated with marijuana use onset. Recent anxiety symptoms were only associated with alcohol use onset among black participants. Conclusions Timing matters in the relationship between psychiatric symptoms and substance use onset in childhood and adolescence, and the psychiatric predictors of onset are substance-specific. There is no single sensitive developmental period for the influence of psychiatric symptoms on alcohol and marijuana use initiation.

Immediate and Longer-Term Stressors and the Mental Health of Hurricane Ike Survivors

Abstract: Previous research has documented that individuals exposed to more stressors during disasters and their immediate aftermath (immediate stressors) are at risk of experiencing longer-term postdisaster stressors. Longer-term stressors, in turn, have been found to play a key role in shaping postdisaster psychological functioning. Few studies have simultaneously explored the links from immediate to longer-term stressors, and from longer-term stressors to psychological functioning, however. Additionally, studies have inadequately explored whether postdisaster psychological symptoms influence longer-term stressors. In the current study, we aimed to fill these gaps. Participants (N = 448) were from population-based study of Hurricane Ike survivors and completed assessments 2-5 months (Wave 1), 5-9 months (Wave 2) and 14-18 months (Wave 3) postdisaster. Through path analysis, we found that immediate stressors, assessed at Wave 1, were positively associated with Wave 2 and Wave 3 stressors, which in turn were positively associated with Wave 2 and Wave 3 posttraumatic stress and depressive symptoms. Wave 2 posttraumatic stress symptoms were positively associated with Wave 3 stressors, and Wave 1 depressive symptoms were positively associated with Wave 2 stressors. The findings suggest that policies and interventions can reduce the impact of disasters on mental health by preventing and alleviating both immediate and longer-term postdisaster stressors. Language: en