Author ORCID Identifier

https://orcid.org/0000-0002-6733-4764

Date Available

7-20-2027

Year of Publication

2025

Document Type

Doctoral Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

Public Health

Department/School/Program

Public Health

Faculty

Min-Woong Sohn, PhD

Abstract

Social determinants of health (SDOH) are conditions that influence physical, mental, emotional, and social health outcomes. Depressive disorders are a category of neuropsychiatric illness with substantial impact on morbidity and mortality. Depression is associated with SDOH factors such as socioeconomic status, social support, education, food insecurity, built environment, and adverse life events. In the United States, individuals from racial and ethnic minority groups are disproportionately affected by both adverse social determinants and poor mental health outcomes, although the relationship between SDOH and depression among racial and ethnic minorities has not been fully characterized.

Study One examined racial and ethnic group differences in the relationship between SDOH burden and depression using data from the Social Determinants and Health Equity module of the Behavioral Risk Factor Surveillance (BRFSS) survey. Responses from 442,787 individuals from BRFSS 2022 and BRFSS 2023 were included, representing 41 US states and territories. Hispanic, Non-Hispanic (NH) Black, and Other race or ethnicity groups had higher mean SDOH burden compared to NH Asian and NH White groups. An increase in SDOH burden by one adverse factor was associated with increased odds of depression by 50% (95% CI: 48–52%). Group differences in depression probability were magnified with the presence of adverse social determinants.

Sleep dysfunction is one pathway by which SDOH may influence depression, given the important role of sleep in brain development and neurological health maintenance. Snoring occurs due to intermittent narrowing of the airway and is commonly used as a surrogate marker for more severe pathology that has been shown to have negative health outcomes. Study Two investigated whether self-reported snoring was associated with depression in US adults, including whether that relationship differed by race and ethnicity. Data from 48,586 individuals surveyed in BRFSS 2017 were utilized to estimate marginal potential outcome means and an average treatment effect for the effects of snoring on depression using inverse probability of treatment weighting (IPTW). Under the counterfactual condition of no snoring in the population, the estimated prevalence of depression was 13.9% (95% CI: 13.1-14.7). The average treatment effect of snoring was 2.73% (95% CI: 1.49-3.97). Snoring had a significant effect on depression for the NH White group but not for other groups.

Study Three elaborated on these findings by investigating the association between snoring frequency and depression, hypothesizing that a stronger association would be observed with higher snoring frequency. Data from 4,106 individuals participating in the National Longitudinal Study of Adolescent to Adult Health (Add Health), Wave V, were included. IPTW was utilized to estimate average treatment effects for the relationship between depression and a multicategory treatment measure of self-reported snoring frequency (1-2, 3-5, and 6-7 nights per week) compared to the absence of snoring. The marginal prevalence of depression for nonsnorers was 11.6% (95% CI: 8.4–14.8). Snoring 6-7 nights per week accounted for an absolute increase in depression by 7.3% (95% CI: 1.2–13.4) and similar increases in depression diagnosis and depression symptoms. Less frequent snoring was not associated with any depression outcome measure.

These findings demonstrate compelling evidence for the relationships between social determinants, sleep-disordered breathing, and depression. Future research could further evaluate the utility of self-reported snoring measures for evaluating mental health outcomes from survey data. Our findings may also assist clinicians and patients in understanding the importance of mental illness comorbid with sleep-disordered breathing, including how they interact to affect patient and population health. Ultimately, the improvement of SDOH-related conditions might mitigate these risks, particularly for underrepresented or at-risk groups.

Digital Object Identifier (DOI)

https://doi.org/10.13023/etd.2025.302

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Available for download on Tuesday, July 20, 2027

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