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From the Centers for Disease Control and Prevention
June 10, 1998

Self-Reported Frequent Mental Distress Among Adults—United States, 1993-1996

JAMA. 1998;279(22):1772-1773. doi:10.1001/jama.279.22.1772

MMWR. 1998;47:325-331

2 tables omitted

IN THE United States, an estimated 10% of persons have some recent disability from a diagnosable mental illness (e.g., schizophrenia, phobias, depression, and anxiety disorders), and up to 24% of adults have experienced a mental disorder during the preceding year.1,2 In 1997, the estimated cost of mental illness exceeded $150 billion for treatment, social services, disability payments, lost productivity, and premature mortality.1 However, information is limited about the overall prevalence of general mental distress, which can be associated with the incidence and prevalence of specific mental illnesses and conditions.3 This report describes differences in the prevalence of self-reported frequent mental distress (FMD) for noninstitutionalized adults in the United States for specific demographic groups and by state and age-sex group using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1993-1996. The findings indicate high prevalences of FMD among persons who are unemployed or unable to work, indicated a "separated" or "widowed" marital status, or had annual household incomes of <$15,000.

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged ≥18 years that tracks the prevalence of key health- and safety-related behaviors and characteristics. Since January 1993, the interviews have included four health-related quality-of-life (HRQOL) questions,4 including the following general mental health question: "Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?" Persons who reported that their mental health was not good for ≥14 of the preceding 30 days were defined as having FMD. This 14-day minimum period was selected because a similar period is often used by clinicians and clinical researchers as a marker for clinical depression and anxiety disorders, and a longer duration of reported symptoms is associated with a higher level of activity limitation.5 To permit comparisons, data were statistically weighted to reflect the age, race/ethnicity, and sex distribution of the state population and, when appropriate, age-standardized to the 1990 U.S. population aged ≥18 years using SUDAAN® (Software for the Statistical Analysis of Correlated Data).

Persons who reported ≥14 days of recent mental health problems had a comparatively high level of disability (i.e., they reported that poor physical or mental health had prevented them from performing their usual activities an average of 7.7 of the previous 30 days). In comparison, respondents with ≤2 recent days of mental distress reported having 0.9 recent days when illness restricted their usual activities.

During 1993-1996, the overall state-weighted prevalence of adults with FMD was 8.6%. Of the demographic groups studied, the FMD prevalence was highest among persons who reported being unable to work (33.2%), indicated a "separated" marital status (18.5%), had annual household incomes of <$15,000 (15.5%), had less than a high school (or equivalent) education (12.9%), were American Indians/Alaskan Natives (12.9%), or were aged 18-24 years (10.0%). Persons with the lowest FMD prevalence were those with annual household incomes of ≥$50,000 (5.7%), college graduates (5.9%), aged 65-74 years (6.1%), Asians/Pacific Islanders (6.1%), employed for wages (6.7%), or married (7.3%). Women were more likely to report FMD (10.2%) than men (6.9%), and persons with no health insurance were more likely to report FMD (12.5%) than persons with insurance (8.0%).

The overall state-level prevalence of FMD among adults ranged from 4.9% in South Dakota to 12.8% in Kentucky. State-level FMD prevalences among men were highest in Colorado (13.1%) for persons aged 18-24 years and lowest in South Dakota for persons aged ≥65 years (2.6%).* State-level FMD prevalences among women were highest in New York (19.1%) for persons aged 18-24 years and lowest in Oklahoma for persons aged ≥65 years (3.3%).

During 1993-1996, overall FMD prevalence among men was highest among persons aged 18-24 years (7.8%) and lowest among persons aged ≥65 years (5.4%). Similarly, the overall FMD prevalence among women was highest among persons aged 18-24 years (12.3%) and lowest among persons aged ≥65 years (6.8%). The difference between FMD among women and among men was highest among persons aged 18-24 years and lowest among persons aged ≥65 years.

Reported by the following BRFSS coordinators:

J Cook, MBA, Alabama; P Owen, Alaska; B Bender, MBA, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; K Powell, MD, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; F Ramsey, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. E Borawski, G Wu, H Jia, Case Western Reserve Univ School of Medicine, Cleveland, Ohio. Survey and Analysis Br, Center for Mental Health Svcs, Substance Abuse and Mental Health Svcs Administration. Health Care and Aging Studies Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

CDC Editorial Note:

Perceived mental distress is a key component of HRQOL and is believed to be an important determinant of health behaviors related to chronic disease and disability prevention.4 Mental illness includes a broad range of emotional and psychological conditions ranging in severity from clinically diagnosed disorders requiring hospitalization and sometimes resulting in suicide to the more common and often undiagnosed affective conditions.2,6 Survey data about the prevalence of mental distress and mental illness have been difficult to obtain because of concerns about potential respondent objections to including mental health questions on a health survey and because earlier batteries of questions to evaluate mental health were too long to be easily added to a general population survey. Administrative data about the prevalence of mental illness are limited because only small proportions of adults with treatable conditions actually seek professional help; for example, only 34.2% of nonrural, noninstitutionalized persons aged 18-54 years with major depressive disorders sought help in 1992, and only 14.3% of adults with personal and emotional problems sought help in 1993.2 The BRFSS data in this report, based on a 99% response rate to the one mental health question in the survey, indicate that respondents' objections to a question about mental health were minimal and identified differences in self-reported FMD between states and between age and sex groups in each state.

The measure of recent mental health described in this report correlates strongly with other BRFSS HRQOL questions used by some states that specifically ask about days of recent depression and anxiety.4 The BRFSS measure also correlates well in a general population comparison with the widely used and clinically validated Medical Outcomes Study Short Form 36 (SF-36).†7 In that comparison, the measure of recent mental health had acceptable validity and correlated most strongly with the related SF-36 scales, including its mental health, role emotional, and mental component summary scales. The BRFSS mental health measure has correlated acceptably (0.59) with the widely-used and clinically validated Center for Epidemiological Studies of Depression scale in a recent study of older, low-income black males.8 The finding of large but expected6 differences in FMD across socioeconomic and demographic groups known to differ in their mental health characteristics further supports the construct validity of the measure in this study. Although these validation findings suggest that persons with FMD may have a high prevalence of diagnosable mental illness, the proportion cannot be estimated accurately without a population study that includes both the BRFSS measure and a clinical psychiatric examination.

This analysis has at least four limitations. First, the BRFSS underrepresents persons with FMD because it excludes homeless persons and persons in institutional settings (including hospitals, prisons, and group homes), who are known to have a very high prevalence of severe mental illness.9 Second, the BRFSS also may underrepresent persons with FMD because households without telephones (which generally have a higher percentage of high-risk persons) are excluded and because adequate respondent physical and mental functional capacity (which can be lacking for distressed persons) are needed to complete the survey. Third, observed state-specific FMD differences may reflect uncontrolled differences in population composition, socioeconomic conditions, climate, natural and human-made disasters, environmental quality, and other unknown factors. Finally, the BRFSS mental health measure was not validated for detection of mental illness with clinical psychiatric examinations.

Additional analyses of these data are planned to examine the relations between reported mental distress, activity limitation, and chronic health conditions, and the effects of mental distress on the adoption and maintenance of preventive health behaviors. The large amount of BRFSS data that state health agencies are collecting about recent mental health and related HRQOL items (>500,000 adults have been surveyed through 1997) gives public health planners a valuable resource of population data.4 This information can help set population health goals and objectives and help monitor the performance of health programs over time.10 The data reported here suggest that public health strategies are needed—particularly for younger adults, women, Hispanics, and American Indians/Alaskan Natives, and for persons who reported the loss of a marital partner, are not working, or have limited socioeconomic resources—to ensure that community health objectives associated with mental health can be met (e.g., increasing adult access to community mental health services and increasing the proportion of persons with clinically significant mental distress who obtain treatment).

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References 10 available.
*The District of Columbia was not included in state comparisons, but during 1993-1996 the prevalence of FMD for men aged 25-44 years and 45-64 years was lower than in any of the states.
†The SF-36 is a set of 36 survey questions and associated subscales designed to measure key aspects of HRQOL in patient and community populations.