Houstonians, that is residents of Houston, Texas, USA, have experienced multiple disasters since 2017. First, Houston residents experienced Hurricane Harvey, which made landfall in Texas in late August 2017 as a category 4 hurricane and was one of the wettest and costliest hurricanes in US history. Hurricane Harvey resulted in approximately $125 billion in damages and displaced 40,000 flood victims who took refuge in shelters (Blake and Zelinsky, 2017; FEMA, 2018). Overall, the hurricane directly resulted in 68 deaths, with about half of these deaths occurring in the Houston metropolitan area (Blake and Zelinsky, 2017; FEMA, 2018). Second, Houstonians have experienced the COVID-19 pandemic, which was declared a global pandemic on March 11, 2020. As of February 23, 2023, the city of Houston has cumulatively experienced 540,914 confirmed COVID-19 cases and 4806 COVID-19 related deaths (“Case Data | Harris County COVID-19 Data Hub prod2,” n.d.).

Depression and Posttraumatic Stress Disorder (PTSD) are 2 of the most common mental health conditions that follow disasters (Goldmann and Galea, 2014), and have been observed following both Hurricane Harvey (Bevilacqua et al., 2020; Fitzpatrick, 2021; Schwartz et al., 2018) and the emergence of COVID-19 (Abdalla et al., 2021; Ettman et al., 2020). These conditions are associated with a substantial burden of disease and disability (GBD 2019 Mental Disorders Collaborators, 2022), including years lived with disability, years of life lost, and unemployment. Population mental health, including depression and PTSD, are also sensitive to economic conditions and resources. In addition to increasing in the context of disasters, these mental health ailments also have been shown to emerge in the context of economic recessions and downturns such as that following the COVID-19 pandemic (Margerison-Zilko et al., 2016; Modrek et al., 2015).

Common measures of economic conditions and resources include unemployment and income, each of which has been linked to a wide range of health indicators, including mental health. Unemployment has been linked to depression across a variety of contexts (Amiri, 2022), and to persistence of PTSD following disasters (Nandi et al., 2004). Low income has also been linked to depression across a range of contexts (Costello et al., 2003; Ettman et al., 2020; Zimmerman and Katon, 2005), and financial strain has been linked to PTSD in the context of disaster exposure, including COVID-19 (Abdalla et al., 2021; Neria et al., 2008). Beyond individual-level factors, neighborhood context is an important predictor of mental health, as shown by prior research (Lowe et al., 2015). For example, income inequality – a neighborhood-level construct, has been found to be associated with both depression (Ahern and Galea, 2006; Patel et al., 2018) and PTSD (Pabayo et al., 2017).

While the connections between individual-level economic conditions and PTSD and depression are well understood generally, less is known about how these factors are associated with PTSD and depression at the neighborhood-level. Findings on the relationship between neighborhood-level socioeconomic conditions and depression have been mixed (Richardson et al., 2015), and there are few studies on neighborhood socioeconomic conditions and PTSD. In particular, there are no studies of neighborhood socioeconomic conditions and mental health among survivors of Hurricane Harvey in Houston. Moreover, it is not well understood how these economic factors affect depression and PTSD symptoms among people who have experienced multiple disasters. It is unclear, for example, whether these underlying neighborhood-level advantages may be associated with protection against the consequences of multiple mass traumatic events. Moreover, it is unclear whether identified associations between neighborhood factors and symptoms of depression and PTSD will remain after adjustment for individual-level stressful and traumatic events from each of these disasters. Houstonians who have experienced not only Hurricane Harvey, but also now COVID-19, represent a unique population with which to address these questions. Therefore, in this study, we examine associations between neighborhood-level unemployment, median income, and income inequality and individual-level symptoms of depression and PTSD.