The nation's home foreclosure epidemic may be taking its toll on Americans' health as well as their wallets. Nearly half of people studied while undergoing foreclosure reported depressive symptoms, and 37 percent met screening criteria for major depression, according to new University of Pennsylvania School of Medicine research published online this week in the American Journal of Public Health. Many also reported an inability to afford prescription drugs, and skipping meals. The authors say their findings should serve as a call for policy makers to tie health interventions into their response to the nation's ongoing housing crisis.

"The foreclosure crisis is also a health crisis," says lead author Craig E. Pollack, MD, MHS, who conducted the research while working as an internist and Robert Wood Johnson Foundation Clinical Scholar at Penn. "We need to do more to ensure that if people lose their homes, they don't also lose their health."

In addition to the high number of participants reporting depression symptoms, the study of 250 Philadelphia homeowners undergoing foreclosure also shed light on other health care problems that may be spurred by difficulties keeping up with housing costs. The study participants were recruited with the Consumer Credit Counseling Service of Delaware Valley, a non-profit, U.S. Housing and Urban Development-approved mortgage counselor. The authors found that compared to a sample of residents in the general public, those in foreclosure were more likely to be uninsured (22 percent compared to 8 percent), though similar health problems were seen among both the insured and uninsured. Nearly 60 percent reported that they had skipped or delayed meals because they couldn't afford food, and people undergoing foreclosure were also more likely to have forgone filling a prescription because of the expense during the preceding year (48 percent vs. 15 percent). The study also revealed that for 9 percent of respondents, a medical condition in their family was the primary reason for the home foreclosure, and more than a quarter of those surveyed said they had significant unpaid medical bills.

Because the financial hardships of foreclosure may lead homeowners to cut back on health care spending that they consider "discretionary" – preventive care visits, healthy foods or drugs for chronic conditions like hypertension – Pollack theorizes that the prolonged period of time that most homeowners spend in foreclosure could have a serious effect on health outcomes. In addition, the stress of undergoing foreclosure may exacerbate health-undermining behaviors. Among the participants who smoke, for instance, 65 percent said they had been smoking more since they received notice of foreclosure.

The "exceptionally high" rate of depressive symptoms found in the study is especially concerning, Pollack says, compared to previous research showing that only about 12.8 percent of people living in poverty meet criteria for major depressive disorder.

"When people purchase homes, they are buying a piece of the American Dream," says co-author Julia Lynch, PhD, the Janice and Julian Bers Assistant Professor in the Social Sciences in Penn's department of political science. "Losing a home can be especially devastating because it means the loss of this dream. When this happens, there is reason to worry not only about the health of the home owner but also that of family members and the broader community they live in."

The authors say that the data collected in Philadelphia may be only the tip of the iceberg when compared to other cities that have experienced a sharp spike in housing foreclosures. Although foreclosure filings nearly doubled between 2007 and 2008 in Philadelphia, other large cities have higher unemployment and foreclosure rates.

To combat the health problems revealed in the study, Pollack and Lynch suggest that health care workers and mortgage counseling agencies coordinate their efforts to help people at risk of foreclosure access both medical and housing help. Doctors, they suggest, should ask their patients about their housing situation and steer them towards mortgage relief resources. Mortgage counselors, meanwhile, can provide information about how to access safety net health care, enroll in public insurance programs like SCHIP or Medicaid, or apply for nutritional assistance programs for pregnant and nursing mothers and their children. The implications for policy, too, are vast.

"This study raises the stakes of the housing crisis," Pollack says. "The policy push to get people into mortgage counseling should be combined with health outreach in order to fully help people during this tremendously difficult period in their lives."