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

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 less than $15,000.

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 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 greater than or equal to 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 greater than or equal to 18 years using SUDAAN{Registered} (Software for the Statistical Analysis of Correlated Data).

Persons who reported greater than or equal to 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 less than or equal to 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% (Table_1). 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 less than $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 greater than or equal to $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 greater than or equal to 65 years (2.6%) (Table_2). * 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 greater than or equal to 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 greater than or equal to 65 years (5.4%) (Table_2). Similarly, the overall FMD prevalence among women was highest among persons aged 18-24 years (12.3%) and lowest among persons aged greater than or equal to 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 greater than or equal to 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.

Editorial Note

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 expected (6) 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 (greater than 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).

References

  1. National Institute of Mental Health. Mental illness in America: the National Institute of Mental Health agenda. World-Wide Web site http://www.nimh.nih.gov/research/amer.htm. Accessed April 13, 1998.

  2. Substance Abuse and Mental Health Services Administration. Mental health, United States, 1996. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1997.

  3. Mrazek PJ, Haggerty RJ, eds. Reducing risks for mental disorders: frontiers for preventive intervention research. Washington, DC: National Academy Press, 1994.

  4. CDC. Health-related quality of life and activity limitation -- eight states, 1995. MMWR 1998;47:134-40.

  5. Milazzo-Sayre LJ, Henderson MJ, Manderscheid RW. Serious and severe mental illness and work: what do we know? In: Bonnie RJ, Monahan J, eds. Mental disorder, work disability, and the law. Chicago, Illinois: University of Chicago Press, 1997.

  6. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

  7. Newschaffer CJ. Validation of BRFSS HRQOL measures in a statewide sample. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1998.

  8. Albert SM. Validation of BRFSS QOL items: Harlem Prostate Screening Project (final report, project U48/CU209663). New York: Columbia University College of Physicians and Surgeons, 1997.

  9. Substance Abuse and Mental Health Services Administration. Estimation methodology for adults with serious mental illness (SMI). Federal Register 1997:62;14928.

  10. Durch J, Bailey LA, Stoto MA, eds. Improving health in the community: a role for performance monitoring. Washington, DC: National Academy Press, 1997.

* 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.



Table_1
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TABLE 1. Number of respondents to a question about mental health and
percentage who self-reported frequent mental distress (FMD),*  by
demographic characteristics -- United States, Behavioral Risk Factor
Surveillance System, 1993-1996
=======================================================================
Characteristic                     No. respondents       %   (SE+)
-----------------------------------------------------------------------
Sex
 Women                                     254,250    10.2   (0.1)
 Men                                       181,857     6.9   (0.1)
Age group (yrs)
 18-24                                      41,197    10.0   (0.3)
 25-34                                      90,678     8.7   (0.1)
 35-44                                      99,864     9.4   (0.1)
 45-54                                      69,982     9.1   (0.2)
 55-64                                      48,709     7.8   (0.2)
 65-74                                      51,473     6.1   (0.2)
  >=75                                      34,204     6.5   (0.2)
Race/Ethnicity
 White,non-Hispanic                        358,755     8.3   (0.1)
 Black,non-Hispanic                         37,245     9.7   (0.2)
 Hispanic                                   23,127    10.3   (0.3)
 Asian/Pacific Islander                      9,228     6.1   (0.5)
 American Indian/ Alaskan Native             4,667    12.9   (0.8)
 Other                                       2,292    10.7   (1.0)
Marital status
 Married                                   240,530     7.3   (0.1)
 Divorced                                   53,653    13.4   (0.4)
 Widowed                                    47,055    15.9   (1.2)
 Separated                                  11,266    18.5   (0.7)
 Never married                              74,291     9.3   (0.3)
 Unmarried couple                            8,574    12.0   (1.1)
Education level
 Less than high school graduate             60,801    12.9   (0.3)
 High school graduate                      143,542     9.0   (0.1)
 Some college or technical                 118,529     8.6   (0.1)
school
 College graduate                          112,381     5.9   (0.1)
Employment status
 Employed for wages                        231,815     6.7   (0.1)
 Self-employed                              37,698     7.0   (0.3)
 Unemployed <=1 year                         9,593    14.7   (0.6)
 Unemployed >1 year                          6,985    17.8   (0.9)
 Homemaker                                  35,648     9.4   (0.3)
 Student                                    15,145     9.6   (0.8)
 Retired                                    82,786    11.9   (2.1)
 Unable to work                             12,903    33.2   (0.9)
Annual household income
        <$15,000                            76,807    15.5   (0.2)
 $15,000-$24,999                            82,792    10.0   (0.2)
 $25,000-$49,999                           136,984     7.2   (0.1)
       >=$50,000                            84,546     5.7   (0.2)
Health insurance
 Yes                                       382,600     8.0   (0.1)
 No                                         52,457    12.5   (0.3)

Total                                      436,107     8.6   (0.1)
-----------------------------------------------------------------------
* FMD applies to persons reporting 314 days of the preceding 30 days
  when their mental health was not good. Numbers in groups may not add
  to the overall sample size because persons for which values were
  missing were excluded from this analysis. Percentages in all groups
  except the age groups were age-adjusted to the 1990 U.S. population
  aged 318 years.
+ Standard error.
=======================================================================

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Table_2
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TABLE 2. Frequent mental distress (FMD) among adults,* by state, age group, and sex -- United States, Behavioral Risk Factor Surveillance System, 1993-1996
=================================================================================================================================================================================

                                   18-24 yrs                              25-44 yrs                            45-64 yrs                               >=65 yrs
                           ------------------------------      --------------------------------     --------------------------------       --------------------------------------
                              Men              Women               Men               Women              Men               Women                Men                 Women
                           -------------    -------------      ---------------   --------------     ---------------    -------------       ------------------    ----------------
State                      %       (SE+)     %      (SE)        %        (SE)      %      (SE)       %        (SE)      %      (SE)         %           (SE)     %      (SE)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                    8.8     (1.7)     8.2    (1.4)       6.1     (0.7)     9.8    (0.7)       7.2     (1.0)      9.6   (0.9)        6.3         (1.1)     7.1   (0.8)
Alaska                     5.1     (2.0)     8.7    (2.3)       7.4     (0.9)    10.7    (1.0)       5.4     (1.0)      6.9   (1.2)        7.7         (2.8)     7.2   (2.4)
Arizona                    5.9     (1.5)     9.9    (1.9)       8.0     (1.3)     9.8    (0.9)       6.5     (1.1)     10.9   (1.2)        4.9         (1.1)     6.4   (0.9)
Arkansas                   4.7     (1.2)     9.3    (1.5)       6.1     (0.8)    10.9    (0.9)       6.5     (0.9)     10.3   (0.9)        6.3         (1.2)     8.3   (1.0)
California                 9.1     (1.5)    13.6    (1.4)       7.6     (0.5)    12.3    (0.6)       8.7     (0.9)     10.4   (0.7)        5.1         (0.8)     6.6   (0.7)
Colorado                  13.1     (2.2)    17.3    (2.3)       7.9     (0.7)    11.8    (0.8)       6.0     (0.9)      9.6   (0.9)        4.3         (1.1)     8.1   (1.1)
Connecticut                5.8     (1.6)     9.9    (1.7)       5.7     (0.7)     7.8    (0.6)       5.3     (0.8)      9.1   (1.0)        2.9         (0.8)     4.4   (0.8)
Delaware                   5.8     (1.5)    13.5    (1.8)       7.5     (0.8)    11.9    (0.8)       6.9     (0.9)     12.3   (1.0)        4.3         (0.8)     6.8   (0.8)
District of Columbia       4.9     (1.8)     7.0    (2.0)       3.6     (0.8)     6.7    (0.9)       2.5     (0.8)      7.0   (1.3)        6.4         (1.9)     6.4   (1.5)
Florida                   12.6     (1.7)    13.7    (1.5)       8.2     (0.6)    13.8    (0.7)       8.8     (0.8)     10.8   (0.7)        5.3         (0.6)     7.5   (0.6)
Georgia                    6.8     (1.5)     8.0    (1.4)       6.4     (0.6)     8.6    (0.6)       6.2     (0.8)      8.0   (0.8)        7.0         (1.1)     6.7   (0.8)
Hawaii                     7.7     (1.6)     8.4    (1.4)       6.3     (0.7)     8.8    (0.7)       5.0     (0.9)      8.0   (0.9)        3.4         (0.9)     4.7   (0.8)
Idaho                      7.0     (1.4)    14.1    (1.9)       7.9     (0.9)    12.0    (0.8)       5.9     (0.9)     11.9   (1.1)        4.7         (0.9)     6.0   (0.8)
Illinois                   6.5     (1.4)    10.3    (1.5)       4.3     (0.5)     8.5    (0.6)       5.7     (0.7)      8.5   (0.8)        5.3         (1.0)     5.3   (0.7)
Indiana                   10.1     (1.7)    13.9    (1.8)       7.4     (0.7)    13.8    (0.8)       7.3     (0.9)     12.4   (1.0)        5.3         (1.0)     7.8   (0.8)
Iowa                       5.7     (1.0)    10.7    (1.4)       5.2     (0.5)     9.3    (0.6)       6.5     (0.8)     10.5   (0.8)        6.9         (0.9)     7.3   (0.7)
Kansas                     6.1     (1.7)    10.9    (1.8)       5.9     (0.7)     8.8    (0.7)       5.8     (0.9)      8.4   (0.9)        4.4         (0.9)     4.7   (0.7)
Kentucky                   7.9     (1.4)    14.9    (1.6)       9.4     (0.8)    16.5    (0.8)      11.8     (1.0)     18.0   (1.0)        8.0         (1.0)    11.4   (0.9)
Louisiana                  6.2     (1.5)    11.8    (1.9)       7.5     (0.9)    12.3    (0.9)       6.8     (1.1)     11.5   (1.1)        5.0         (1.2)     5.9   (0.9)
Maine                      4.2     (1.5)     9.1    (2.2)       6.3     (0.9)     8.3    (0.8)       7.1     (1.1)      8.2   (1.0)        5.5         (1.2)     4.9   (0.8)
Maryland                   6.9     (1.1)     9.9    (1.1)       5.7     (0.4)     8.0    (0.4)       5.1     (0.5)      8.5   (0.6)        4.9         (0.7)     6.3   (0.7)
Massachusetts              8.8     (1.9)    14.7    (2.2)       9.4     (0.9)    13.0    (0.9)       7.6     (1.0)     11.4   (1.1)        4.0         (0.9)     8.2   (1.1)
Michigan                   9.5     (1.7)    14.5    (1.7)       7.6     (0.7)    13.2    (0.8)       6.8     (0.8)     10.0   (0.8)        5.6         (1.1)    10.0   (1.0)
Minnesota                  8.6     (1.2)    12.0    (1.3)       7.5     (0.5)    10.9    (0.5)       6.2     (0.6)      8.3   (0.6)        8.0         (0.9)     7.8   (0.7)
Mississippi                4.7     (1.3)    11.8    (2.0)       6.2     (0.8)     9.5    (0.8)       6.9     (1.0)     12.5   (1.1)        5.9         (1.3)     7.9   (1.0)
Missouri                   6.0     (1.7)    11.1    (1.9)       8.2     (0.9)    12.3    (0.9)       6.1     (1.0)     12.2   (1.1)        8.0         (1.5)     6.8   (0.9)
Montana                    3.5     (1.7)     9.6    (1.9)       6.6     (0.8)     9.6    (0.9)       6.7     (1.1)      9.4   (1.0)        3.5         (0.9)     4.5   (0.8)
Nebraska                   6.7     (4.1)     8.9    (2.7)       6.6     (0.8)     9.7    (0.7)       5.5     (0.9)      8.9   (0.9)        5.6         (1.0)     5.5   (0.7)
Nevada                    10.7     (1.9)    18.4    (2.1)      11.2     (1.0)    12.7    (0.9)       7.4     (1.1)     12.9   (1.2)        4.8         (1.2)    10.7   (1.6)
New Hampshire              8.8     (2.4)    11.2    (2.1)       7.2     (0.8)    10.6    (0.8)       5.1     (0.8)      9.2   (1.0)        4.4         (1.1)     6.9   (1.1)
New Jersey                 5.1     (1.4)     8.4    (1.5)       5.3     (0.7)     9.4    (0.8)       6.3     (1.0)      7.3   (0.8)        6.4         (1.4)     6.9   (1.0)
New Mexico                 7.1     (1.9)     8.8    (2.0)       6.0     (0.9)    11.4    (1.1)       5.6     (1.0)      9.4   (1.1)        4.1         (1.0)     6.3   (1.1)
New York                   9.5     (1.5)    19.1    (2.6)       7.8     (0.6)    11.3    (0.6)       6.2     (0.7)     11.3   (0.9)        5.9         (1.0)     6.5   (0.8)
North Carolina             3.5     (0.9)     5.9    (1.1)       5.8     (0.6)     8.2    (0.6)       4.2     (0.6)      9.2   (0.8)        4.3         (0.8)     6.8   (0.8)
North Dakota               3.7     (0.9)    13.7    (1.8)       6.1     (0.7)    12.0    (0.9)       8.3     (1.1)      9.9   (1.0)        4.6         (0.8)     7.4   (0.8)
Ohio                       4.4     (1.7)     8.7    (1.7)       6.9     (1.0)     8.9    (0.8)       5.7     (1.0)      9.3   (1.0)        3.7         (1.0)     5.1   (0.8)
Oklahoma                   9.0     (2.0)     7.3    (1.9)       7.1     (1.0)     8.6    (0.8)       3.9     (0.8)      9.7   (1.0)        2.9         (0.7)     3.3   (0.5)
Oregon                     8.9     (1.4)    14.7    (1.6)       8.0     (0.6)    12.0    (0.7)       6.4     (0.7)     11.1   (0.8)        4.0         (0.7)     6.1   (0.7)
Pennsylvania               8.4     (1.4)     8.6    (1.3)       6.5     (0.5)    13.1    (0.9)       6.8     (0.7)      9.7   (0.7)        5.5         (0.8)     6.7   (0.7)
Rhode Island               9.4     (2.3)    11.7    (2.0)       8.8     (0.9)    13.8    (1.0)       7.8     (1.1)     11.5   (1.2)        5.0         (1.1)     4.6   (0.9)
South Carolina             6.6     (1.4)     9.0    (1.4)       5.9     (0.7)    11.4    (0.8)       8.2     (1.1)     10.5   (0.9)        5.3         (1.2)     7.6   (1.0)
South Dakota               2.9     (0.8)     7.9    (1.4)       4.3     (0.6)     6.6    (0.7)       4.3     (0.7)      5.8   (0.8)        2.6         (0.6)     4.3   (0.7)
Tennessee                  4.2     (1.0)    10.1    (1.5)       5.0     (0.5)     9.6    (0.6)       6.8     (0.8)      9.7   (0.7)        7.9         (1.2)     7.5   (0.8)
Texas                      8.4     (1.9)    16.0    (2.2)       8.4     (0.9)    11.0    (0.8)       8.7     (1.1)      9.6   (1.0)        6.7         (1.6)     6.7   (1.1)
Utah                       7.9     (1.3)    11.3    (1.4)       7.0     (0.7)    12.3    (0.9)       6.1     (0.9)     10.1   (1.0)        4.9         (1.0)     6.2   (0.9)
Vermont                    6.5     (1.6)     8.6    (1.5)       7.5     (0.7)    12.0    (0.7)       6.5     (0.8)     10.5   (0.8)        3.8         (0.8)     5.5   (0.7)
Virginia                   7.0     (1.4)    15.2    (2.1)       6.3     (0.7)    10.0    (0.7)       6.5     (1.0)      8.0   (0.9)        3.7         (1.1)     7.2   (1.1)
Washington                 9.0     (1.3)    15.0    (1.5)       7.2     (0.5)    12.2    (0.6)       6.5     (0.6)      9.7   (0.7)        3.9         (0.8)     5.7   (0.8)
West Virginia              5.9     (1.4)     7.6    (1.4)       6.6     (0.7)    11.5    (0.7)      10.0     (1.0)     11.0   (0.8)        5.4         (0.9)     7.6   (0.7)
Wisconsin                  4.8     (1.4)     9.8    (1.9)       6.5     (0.7)     9.7    (0.8)       6.2     (1.0)      8.4   (1.0)        4.3         (1.1)     7.0   (1.1)
Wyoming                    8.7     (1.9)     7.5    (2.4)       7.4     (1.0)    10.9    (0.9)       6.6     (1.1)      9.1   (1.0)        4.0         (1.0)     5.8   (1.1)

Total                      7.8     (0.3)    12.3    (0.4)       7.1     (0.1)    11.1    (0.1)       6.9     (0.2)     10.0   (0.2)        5.4         (0.2)     6.8   (0.2)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* FMD applies to persons reporting 3 14 days of the preceding 30 days when their mental health was not good. Total sample size= 436, 107.
+ Standard error.
=================================================================================================================================================================================

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