Self-Reported Frequent Mental Distress Among Adults --- United States, 1993--2001

Poor mental health is a major source of distress, disability, and social burden (1); in any given year, as many as one in five adults in the United States has a mental disorder (2). To identify differences among populations and factors contributing to poor mental health, CDC examined the prevalence of frequent mental distress (FMD) among U.S. adults by race/ethnicity, socioeconomic status (SES), and sex, by using aggregate data from Behavioral Risk Factor Surveillance System (BRFSS) surveys for 1993--2001. This report describes the results of that analysis, which indicated that the prevalence of FMD varied among racial/ethnic populations and increased substantially among whites and blacks. In addition, FMD was reported more frequently by women and by persons with low SES within each racial/ethnic population. Targeting adverse socioeconomic risk factors and improving access to mental health services might decrease FMD among adults and reduce racial/ethnic disparities in mental health (2).

BRFSS is an ongoing, state-based, random-digit--dialed telephone survey of the noninstitutionalized, civilian, U.S. population aged >18 years (3). The study described in this report included 1,283,258 respondents from all 50 states and the District of Columbia. The median state response rate* ranged from 71.4% in 1993 to 51.1% in 2001 (3). In response to the 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?," a person who reported >14 days was identified as having FMD. This 14-day minimum period was selected because physicians and researchers often use a similar period as a marker for clinical depression and anxiety disorders (4). Racial/ethnic populations were mutually exclusive. To study associations of FMD with SES, respondents were identified as having 1) low SES: those without a high school diploma or with <$15,000 annual household income; 2) high SES: those with a college education and >$50,000 annual household income; or 3) middle SES: all other respondents.

Data were weighted to estimate population parameters. To examine how certain variables accounted for differences in FMD, unadjusted, age- and sex-adjusted, and multivariable-adjusted estimates (i.e., adjusted for age, sex, marital status, education, annual household income, employment status, and health insurance status) were calculated. Unadjusted and adjusted prevalences and their standard errors were calculated by using cross-tabulation and logistic regression analyses to account for the complex BRFSS survey design. Multicollinearity testing indicated no collinearity among independent variables in the models (5).

Overall, the prevalence of FMD among U.S. adults increased significantly, from 8.4% in 1993 to 10.1% in 2001 (p<0.05). Moreover, FMD prevalence increased for non-Hispanic whites, from 8.1% to 9.7%, and for non-Hispanic blacks, from 9.5% to 11.3% (Figure 1). FMD was most common among American Indians/Alaska Natives (AI/ANs) (14.4% unadjusted and 11.4% multivariable-adjusted) and non-Hispanics of other race^† (12.9% unadjusted and 12.3% multivariable-adjusted) and least common among Asians/Pacific Islanders (A/PIs) (6.2% unadjusted and 7.5% multivariable-adjusted). Among non-Hispanic whites, the prevalence of FMD was 8.6% unadjusted and 9.4% multivariable-adjusted; among Hispanics, 10.5% unadjusted and 8.4% multivariable-adjusted; and among blacks, 10.3% unadjusted and 8.0% multivariable-adjusted (Table).

Across all racial/ethnic populations, respondents with high SES were least likely to have FMD; however, racial/ethnic differences remained consistent within socioeconomic categories. For high-SES respondents, the prevalence of FMD was highest among non-Hispanics of other race (7.9%) and AI/ANs (7.7%) and lowest among A/PIs (3.8%). Non-Hispanic whites, non-Hispanic blacks, and Hispanics had intermediate FMD prevalences (4.7%, 6.1%, and 5.9%, respectively) (Figure 2). In all racial/ethnic populations, persons with low SES were at least twice as likely to have FMD as those with high SES.

FMD was more prevalent among women than men in all racial/ethnic populations except A/PIs and AI/ANs (both unadjusted and multivariable-adjusted prevalences) (Table). After multivariable adjustment, prevalence of FMD was highest among women who identified themselves as non-Hispanic of other race (14.3%) and AI/AN (12.5%), followed by women who identified themselves as non-Hispanic white (11.1%), Hispanic (9.5%), non-Hispanic black (9.2%), and A/PI (7.7%). Respondents in all racial/ethnic populations who were younger, female, separated, divorced, widowed, unemployed, or unable to work or who had <$15,000 annual household income, less than a high school education, or no health insurance reported significantly more FMD.

Reported by: HS Zahran, MD, R Kobau, MPH, DG Moriarty, MM Zack, MD, WH Giles, MD, Div of Adult and Community Health; J Lando, MD, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Previous analyses have indicated that poor mental health is more prevalent among certain racial/ethnic minority populations. These differences might be associated with multiple factors (2,6). In this analysis, SES was strongly associated with FMD among all racial/ethnic populations, a finding consistent with previous studies relating SES to poor mental health (4,6--8). SES shapes a person's exposure to psychosocial, environmental, behavioral, and biomedical risk factors that directly and indirectly affect mental health (9).

The findings in this report also indicate that racial/ethnic differences in FMD prevalence persisted during 1993--2001. AI/ANs reported the highest prevalence of FMD, whereas A/PIs reported the lowest. The pattern for these two populations persisted after adjustments for age, sex, and the other variables in the model. Non-Hispanic blacks and Hispanics had higher unadjusted FMD percentages than whites; however, whites had higher FMD percentages after multivariable adjustment, suggesting that socioeconomic and other factors accounted for the unadjusted differences.

Among AI/ANs, unhealthy behaviors and comorbidity (e.g., alcoholism and other substance abuse), physical and social environment (e.g., social disadvantage, inadequate schools, and violence), psychosocial and historical factors (e.g., racism, discrimination, and disenfranchisement), and other unmeasured sociodemographic factors might contribute to the disproportionate burden of FMD (2). Among A/PIs, protective factors attenuating FMD and cultural norms and perceptions of stigma inhibiting disclosure of FMD might partly explain lower unadjusted and multivariable-adjusted FMD prevalence (2). Among all populations, cultural and social contexts can influence mental health and alter the types of mental health services persons seek and receive (2,6).

Although physiologic and social factors unique to women (e.g., pregnancy, care giving, and social roles) might affect FMD in women, men's reluctance to disclose psychological distress also might account for the difference in FMD by sex (2). Moreover, unique social and cultural influences relevant to A/PIs and AI/ANs or low statistical power because of small numbers of respondents might explain the similar FMD prevalence among men and women in these two populations.

The findings in this report are subject to at least five limitations. First, because BRFSS surveys include only noninstitutionalized adults with telephones, persons in institutions and in households without telephones (i.e., populations that might have worse mental health than others) are excluded (6). Because certain racial/ethnic minorities are disproportionately represented in these vulnerable populations, their overall FMD prevalence likely is underestimated. Second, because states commonly use only English- or Spanish-language surveys, persons who speak another primary language are excluded. Third, because BRFSS is a cross-sectional survey, whether the characteristics studied (e.g., SES and marital status) affect FMD or whether FMD affects these characteristics is uncertain. Fourth, although the characteristics studied explained some of the variability in FMD among racial/ethnic populations, risk behaviors, physical and social environment, psychosocial factors, health conditions, stressful life events, unmeasured socioeconomic factors, and cultural factors might account for additional FMD differences among racial/ethnic populations. Finally, the BRFSS mental health measure was not validated for detection of mental illness with clinical psychiatric examinations.

Unfavorable socioeconomic factors were associated with increased self-reported FMD in all racial/ethnic populations. However, the proportion of persons with low SES differed among racial/ethnic populations. Targeting adverse socioeconomic risk factors, improving access to culturally competent mental health services and social services (e.g., job training programs and educational programs that address stigma), and promoting supportive relationships and social cohesion could decrease FMD among all adults and reduce racial/ethnic disparities in FMD prevalence.

Acknowledgments

This report is based on data contributed by state BRFSS coordinators. The project was supported under a cooperative agreement from CDC through the Assoc of Teachers of Preventive Medicine, Atlanta, Georgia.

References

1. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020; summary. Boston, MA: Harvard School of Public Health; 1996.
2. US Department of Health and Human Services. Mental health: culture, race, and ethnicity. A supplement to Mental Health: A Report to the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2001.
3. CDC. Behavioral Risk Factor Surveillance System. Available at http://www.cdc.gov/brfss Atlanta, GA: US Department of Health and Human Services, CDC; 2004.
4. CDC. Self-reported frequent mental distress among adults---United States, 1993--1996. MMWR 1998;47:326--31.
5. Davis CE, Hyde JE, Bangdiwala SI, et al. An example of dependencies among variables in a conditional logistic regression. In: Moolgavkar SH, Prentice RL, eds. Modern statistical methods in chronic disease epidemiology. New York, NY: John Wiley & Sons; 1986:140--7.
6. Chung H, Teresi J, Guarnaccia P, et al. Depressive symptoms and psychiatric distress in low-income Asian and Latino primary-care patients: prevalence and recognition. Community Ment Health J 2003;39:33--46.
7. Strine TW, Balluz L, Chapman DP, et al. Risk behaviors and healthcare coverage among adults by frequent mental distress status, 2001. Am J Prev Med 2004;26:213--6.
8. Dunlop DD, Song J, Lyons JS, Manheim LM, Chang RW. Racial/ethnic differences in rates of depression among preretirement adults. Am J Public Health 2003;93:1945--52.
9. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Inequality in education, income, and occupation exacerbates the gaps between the health "haves" and "have-nots." Health Aff 2002;21:60--76.

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