State-Specific Prevalence and Characteristics of Frequent Mental Distress and History of Depression Diagnosis Among Adults with Arthritis — United States, 2017

Janae D. Price, MPH1,2; Kamil E. Barbour, PhD1; Yong Liu, MD1; Hua Lu, MS1; Nancy L. Amerson2; Louise B. Murphy, PhD1; Charles G. Helmick, MD1; Renee M. Calanan, PhD1,3; Michelle Sandoval-Rosario, DrPH1,4; Claudine M. Samanic, PhD1,5; Kurt J. Greenlund, PhD1; Craig W. Thomas, PhD1 (View author affiliations)

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Summary

What is already known about this topic?

Persons with arthritis have unique challenges because the interplay between anxiety, depression, and chronic pain is cyclical, with each having the potential to exacerbate the others.

What is added by this report?

In 2017, frequent mental distress and history of depression were commonly reported by adults with arthritis in all states, with clustering of high prevalence of frequent mental distress in Appalachian and southern states.

What are the implications for public health practice?

All adults with arthritis might benefit from systematic mental health screening by their health care team (if needed, referral to mental health services) and participation in evidence-based interventions such as physical activity and self-management education programs whose proven benefits include reduced pain and improved mental health.

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An estimated 54.4 million (22.7%) U.S. adults have provider-diagnosed arthritis (arthritis), a number that is projected to rise to 78.4 million by 2040 (1,2). Chronic pain conditions like arthritis are associated with poorer mental health (3), especially anxiety and depression, which can impede self-care and self-management behaviors (1). Although the national prevalence of mental health conditions among adults with arthritis has been reported (3,4), little is known about state-specific prevalences, particularly of frequent mental distress, a useful public health measure that reflects perceived mental health status. An estimated 11.3% and 19% of U.S. adults overall have frequent mental distress and a history of depression, respectively (5). This analysis used 2017 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate state-specific prevalence of frequent mental distress and history of depression among adults with arthritis. The median state age-adjusted prevalences of frequent mental distress and history of depression among adults with arthritis in the 50 states and the District of Columbia (DC) were 16.8% (range = 12.9% [Hawaii] to 22.4% [Kentucky]) and 32.1% (range = 17.7% [Hawaii] to 36.6% [Oklahoma]), respectively. Health care providers have an opportunity to improve the quality of life of arthritis patients by screening for mental health problems, encouraging physical activity, and making referrals to evidence-based programs such as physical activity programs,* self-management education programs (e.g., Chronic Disease Self-Management Program), psychotherapy,§ and cognitive behavioral therapy, that can help improve management of arthritis and mental health outcomes.

BRFSS is a landline and cellular telephone survey conducted annually in all 50 states, DC, and U.S. territories that collects information on health-related behavioral risk factors, health care access, and chronic conditions among noninstitutionalized U.S. adults aged ≥18 years. The median survey response rate for all states and DC in 2017 was 45.8% and ranged from 30.6% (Illinois) to 64.1% (Wyoming).** For this analysis, 2017 BRFSS data were restricted to those for 147,288 adults with arthritis, defined as a “yes” response to the question “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” Frequent mental distress, a commonly used indicator of mental health, was defined as a response of ≥14 days 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?” The rationale for selecting the 14-day minimum period was based on evidence showing that clinicians and clinical researchers use a similar period 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.†† History of depression was defined as an affirmative response to the question “Have you ever been told you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?”

For adults with arthritis, the unadjusted, age-specific, and age-adjusted prevalences of frequent mental distress and history of depression were estimated overall, by state, and by sociodemographic characteristics. Estimates were age-adjusted using logistic regression modeling to produce predicted marginal probabilities. Differences in mental health outcomes across subgroups among adults with arthritis were tested using chi-squared tests; all differences reported were significant at α<0.05. All analyses were conducted using SAS software (version 9.4; SAS Institute) and SAS-callable SUDAAN (version 11.0.1; Research Triangle Institute) to account for the complex survey sampling design.

Overall, the nationwide unadjusted prevalence estimates of frequent mental distress and history of depression among adults with arthritis were 19.0% (95% confidence interval [CI] = 18.6–19.5) and 32.1% (95% CI = 31.5–32.6), respectively. Among adults with arthritis, the age-adjusted prevalence of frequent mental distress was significantly higher among women than among men (19.9% versus 14.6%) and persons who were lesbian/gay/bisexual compared with those who were heterosexual (28.0% versus 16.8%); it also varied by education level (Table 1). The age-adjusted prevalence of a history of depression was significantly higher among women (36.3%) than among men (24.0%), differed by race/ethnicity and education level, and was higher among lesbian/gay/bisexual adults (46.7%) than among heterosexual adults (30.5%).

Age-adjusted prevalence of both mental health measures among adults with arthritis varied widely by state (Table 2). The median state age-adjusted prevalence of frequent mental distress and history of depression among adults with arthritis in all 50 states and DC was 16.8% (range = 12.9% [Hawaii] to 22.4% [Kentucky]) and 32.1% (range = 17.7% [Hawaii] to 36.6% [Oklahoma]), respectively. States with high prevalences of frequent mental distress clustered in the Appalachian and southern states, whereas a similar geographic clustering was not observed for prevalence of a history of depression (Figure).

Discussion

Frequent mental distress and history of depression are common features among adults with arthritis in all states, with considerable variability across states. These findings are supported by previous studies that estimated anxiety and current depression among adults with and without arthritis (3,4). Similar to findings in an earlier report (6), states with high prevalences of frequent mental distress were geographically clustered, with eight of the 10 states in the highest quintile in the Appalachian and southern states. This report also provides further evidence of poorer mental health status among lesbian/gay/bisexual adults with arthritis compared with their heterosexual peers with arthritis (4).

A meta-analysis of 12 studies reported that persons with chronic conditions (e.g., cancer, end stage renal disease, rheumatoid arthritis, and angina) who reported current depression were three times more likely to have a reduced adherence to medical treatment recommendations (i.e., medication adherence, diet, exercise, and follow-up appointments) than were those who did not report depression (7). In addition, among persons with rheumatoid arthritis, symptoms of anxiety and current depression are associated with reduced response to treatment and poorer quality of life (8). Therefore, actively engaging adults with arthritis in evidence-based programs such as the Arthritis Self-Management Program§§ or the more widely available Chronic Disease Self-Management Program¶¶ can help address the physical and psychological needs in tandem; these programs have shown to reduce depression and improve self-efficacy in adults with arthritis (9). The higher prevalences of poor mental health outcomes among specific subgroups in this study, including those who are lesbian/gay/bisexual, suggests that organizations serving these persons can be important partners for promoting and increasing access to these evidence-based interventions.

The Community Preventive Services Task Force (Community Guide) recommends active screening for depression for all adults, use of trained depression care managers, and educating both patients and providers.*** Home-based supports, such as the use of community health workers, can support culturally appropriate care and further patient engagement in treatment goal-setting and self-management. Using community health workers can result in greater improvements in participant behavior and health outcomes (e.g., improvement in diabetes control) when compared with usual care.†††

Because of shortages in mental health care providers,§§§ multidisciplinary and population-based strategies that include both clinical and community approaches to addressing mental health service needs are needed for adults with arthritis. For example, allied professionals could use technology such as telemedicine in collaboration with mental health professionals, especially in rural areas (10) and in the delivery of care in community-based settings. The Program to Encourage Active, Rewarding Lives (PEARLS), for example, is a national evidence-based program for late-life depression that brings high quality mental health care into community-based settings that reach vulnerable older adults including those with arthritis.¶¶¶

The findings in this report are subject to at least five limitations. First, BRFSS data are self-reported and susceptible to recall and social desirability biases. Second, low response rates for individual states might bias findings, but sampling weights can help adjust for nonresponse bias. Third, a history of depression overestimates current depression or depressive symptoms. Fourth, the depression question does not capture adults with undiagnosed depression, and thus, might underrepresent the true proportion of respondents who are currently depressed. Finally, the arthritis question includes many types of arthritis, and prevalences of frequent mental distress and history of depression might vary among those with arthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia; however, the same strategies can be used to address mental health issues for all of these conditions.

The findings from this report can be used to monitor state-specific trends in mental health among adults with arthritis. Although variation by sociodemographic and geographic characteristics exist, the prevalences of both frequent mental distress and history of depression among adults with arthritis suggests that all adults with arthritis might benefit from systematic mental health screening by their provider and, if indicated, referral to mental health services and self-management education programs and engagement with mental health and allied professionals in a variety of clinical and community settings. In addition, the use of innovative delivery models, such as employment of community health workers and telemedicine, might prove beneficial and could augment current shortages in mental health services. To further understand geographic and sociodemographic variation in characteristics among adults with arthritis, it might be beneficial to examine at the local or community level other psychosocial and access characteristics, such as employment, physical and social environmental factors, and access to social or health care services.

Corresponding author: Kamil E. Barbour, iyk1@cdc.gov, 770-488-5145.


1Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Office of Health Promotion, Division of Chronic Disease Prevention and Control, Illinois Department of Public Health, Springfield, Illinois; 3Colorado Department of Public Health and Environment; 4Arizona Department of Health Services; 5Indiana State Department of Health.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.


References

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TABLE 1. Age-specific and age-adjusted prevalence* of frequent mental distress and history of depression among U.S. adults aged ≥18 years with arthritis, by selected characteristics — Behavioral Risk Factor Surveillance System, 50 states and District of Columbia, 2017Return to your place in the text
Characteristic No. of respondents Weighted population (x1,000) Unadjusted prevalence, % (95% CI) Age-adjusted prevalence, % (95% CI)
Arthritis and frequent mental distress
Overall 23,059 11,483 19.0 (18.6–19.5) 17.8 (17.3–18.3)
Age group (yrs)
18–44 3,663 2,844 30.9 (29.3–32.5)
45–64 11,939 5,951 23.1 (22.3–23.8)
≥65 7,457 2,687 10.6 (10.1–11.2)
Sex
Men 7,174 3,913 16.1 (15.4–16.8) 14.6 (13.9–15.3)
Women 15,874 7,566 21.0 (20.4–21.7) 19.9 (19.3–20.6)
Race/Ethnicity
White, non-Hispanic 17,264 7,785 18.0 (17.5–18.5) 17.1 (16.7–17.6)
Black, non-Hispanic 2,043 1,487 21.2 (19.5–22.9) 18.9 (17.3–20.5)
Hispanic 1,506 1,235 21.8 (19.8–23.9) 19.0 (17.1–21.1)
Other/Multiracial, non-Hispanic 1,748 711 22.0 (19.1–25.1) 19.5 (16.8–22.4)
Education level
Less than high school diploma 3,099 2,612 27.4 (25.8–29.1) 26.3 (24.6–28.0)
High school or equivalent 7,786 3,579 20.1 (19.3–20.9) 19.0 (18.2–19.8)
Some college 7,378 3,820 19.2 (18.3–20.0) 17.4 (16.6–18.3)
College graduate 4,737 1,431 11.1 (10.5–11.7) 10.3 (9.7–10.9)
Sexual orientation
Heterosexual 9,736 6,083 17.6 (16.9–18.3) 16.8 (16.1–17.5)
Lesbian/Gay/Bisexual 581 438 33.6 (29.7–37.8) 28.0 (24.5–31.8)
Arthritis and history of depression
Overall 43,433 19,658 32.1 (31.5–32.6) 31.3 (30.8–31.9)
Age group (yrs)
18–44 5,684 4,322 46.4 (44.7–48.1)
45–64 20,727 9,666 37.0 (36.1–37.8)
≥65 17,022 5,670 21.9 (21.2–22.7)
Sex
Men 12,391 6,244 25.3 (24.5–26.1) 24.0 (23.2–24.8)
Women 31,023 13,394 36.6 (35.9–37.4) 36.3 (35.5–37.0)
Race/Ethnicity
White, non-Hispanic 34,356 13,965 31.8 (31.2–32.4) 31.5 (31.0–32.1)
Black, non-Hispanic 3,092 2,171 30.3 (28.3–32.3) 28.4 (26.4–30.4)
Hispanic 2,536 2,032 34.8 (32.5–37.1) 32.4 (30.0–34.8)
Other/Multiracial, non-Hispanic 2,693 1,158 35.5 (32.3–38.9) 33.5 (30.3–36.9)
Education level
Less than high school diploma 4,712 3,797 38.5 (36.7–40.2) 38.1 (36.3–39.9)
High school or equivalent 12,998 5,633 31.1 (30.1–32.0) 30.6 (29.7–31.6)
Some college 13,885 6,789 33.7 (32.6–34.7) 32.4 (31.4–33.5)
College graduate 11,740 3,384 26.0 (25.2–26.9) 25.5 (24.6–26.4)
Sexual orientation
Heterosexual 18,551 10,755 30.8 (29.9–31.6) 30.5 (29.6–31.3)
Lesbian/Gay/Bisexual 1,038 678 51.5 (47.3–55.6) 46.7 (42.5–51.0)

Abbreviation: CI = confidence interval.
* Estimates for all characteristics except age group were age-adjusted using logistic regression modeling to produce predicted marginal probabilities.

TABLE 2. Age-specific and age-adjusted prevalence* of frequent mental distress and history of depression among U.S. adults aged ≥18 years with arthritis, by state — Behavioral Risk Factor Surveillance System, 50 states and District of Columbia (DC), 2017Return to your place in the text
State Arthritis and frequent mental distress Arthritis and history of depression
No. of respondents Weighted population (x1,000) Unadjusted prevalence, % (95% CI) Age-adjusted prevalence, % (95% CI) No. of respondents Weighted population (x1,000) Unadjusted prevalence, % (95% CI) Age-adjusted prevalence, % (95% CI)
Alabama 526 263 22.0 (19.8–24.3) 19.7 (17.7–22.0) 892 433 35.2 (32.7–37.7) 33.5 (31.1–36.0)
Alaska 131 22 18.2 (13.9–23.5) 15.4 (11.7–20.1) 238 37 30.3 (25.4–35.8) 27.6 (23.0–32.7)
Arizona 757 237 18.7 (17.3–20.3) 17.7 (16.2–19.2) 1,430 407 31.9 (30.2–33.6) 31.4 (29.7–33.2)
Arkansas 369 159 23.2 (19.9–26.8) 20.9 (17.8–24.4) 695 262 37.6 (33.9–41.5) 35.8 (32.1–39.5)
California 333 948 16.4 (14.2–18.9) 15.6 (13.4–18.1) 692 1,789 30.6 (27.8–33.5) 30.4 (27.4–33.5)
Colorado 351 135 15.0 (13.4–16.8) 13.8 (12.2–15.5) 673 243 26.7 (24.6–28.8) 25.7 (23.7–27.8)
Connecticut 427 97 15.5 (13.8–17.4) 14.9 (13.2–16.8) 858 177 27.8 (25.7–30.1) 27.8 (25.7–30.0)
Delaware 216 34 18.2 (15.3–21.5) 16.9 (14.2–20.1) 385 62 32.8 (29.2–36.6) 32.1 (28.6–35.9)
DC 131 13 16.7 (13.8–20.0) 15.9 (13.1–19.2) 189 19 23.4 (19.9–27.3) 22.9 (19.5–26.7)
Florida 1,337 779 19.5 (17.4–21.7) 19.6 (17.4–21.9) 2,325 1,329 32.5 (30.0–35.0) 33.5 (30.9–36.2)
Georgia 269 298 17.5 (15.2–20.1) 16.0 (13.8–18.5) 480 482 27.9 (25.3–30.7) 26.6 (24.0–29.4)
Hawaii 269 32 13.7 (11.6–16.0) 12.9 (10.9–15.1) 411 42 18.3 (16.1–20.7) 17.7 (15.6–20.2)
Idaho 224 51 17.2 (14.6–20.3) 16.1 (13.6–19.0) 506 103 33.9 (30.7–37.3) 33.3 (30.0–36.6)
Illinois 233 383 16.0 (13.7–18.7) 14.7 (12.5–17.2) 436 689 28.8 (25.8–31.9) 27.8 (25.0–30.9)
Indiana 873 298 21.3 (19.8–22.9) 19.2 (17.7–20.7) 1,644 522 36.8 (35.0–38.6) 35.2 (33.4–37.0)
Iowa 307 96 16.7 (14.8–18.7) 15.7 (13.9–17.7) 678 189 32.2 (30.0–34.6) 31.9 (29.7–34.2)
Kansas 968 92 18.1 (16.8–19.4) 16.7 (15.5–18.0) 2,019 178 34.4 (32.9–35.9) 33.6 (32.1–35.1)
Kentucky 671 268 25.0 (22.5–27.7) 22.4 (20.0–25.0) 1,145 420 38.6 (35.8–41.4) 36.4 (33.7–39.2)
Louisiana 318 217 23.2 (20.5–26.1) 21.1 (18.5–23.8) 549 344 35.9 (32.9–39.0) 34.3 (31.3–37.5)
Maine 593 62 18.8 (16.8–20.9) 17.3 (15.4–19.3) 1,228 120 36.2 (33.8–38.6) 35.3 (32.8–37.8)
Maryland 689 198 17.5 (15.7–19.5) 16.2 (14.5–18.1) 1,293 324 28.4 (26.4–30.5) 27.5 (25.5–29.6)
Massachusetts 310 200 16.3 (13.7–19.4) 15.3 (12.7–18.3) 575 364 28.9 (25.6–32.4) 28.4 (25.1–31.9)
Michigan 650 466 20.3 (18.6–22.1) 18.8 (17.2–20.6) 1,262 797 34.3 (32.4–36.3) 33.3 (31.4–35.3)
Minnesota 550 115 14.1 (12.7–15.5) 13.2 (11.9–14.6) 1,234 244 29.5 (27.7–31.3) 29.1 (27.4–31.0)
Mississippi 338 152 23.9 (21.0–27.1) 21.5 (18.8–24.5) 588 227 34.7 (31.6–37.9) 32.9 (29.9–36.1)
Missouri 494 251 19.7 (17.6–22.0) 18.4 (16.4–20.6) 867 436 33.7 (31.3–36.3) 33.0 (30.5–35.6)
Montana 293 36 17.8 (15.3–20.5) 16.4 (14.0–19.0) 557 66 31.8 (28.9–34.9) 30.7 (27.8–33.8)
Nebraska 609 51 15.0 (13.4–16.8) 14.0 (12.4–15.7) 1,266 105 30.6 (28.5–32.8) 30.0 (27.9–32.2)
Nevada 189 82 18.0 (14.5–22.1) 17.1 (13.6–21.3) 298 129 28.1 (24.0–32.5) 27.6 (23.4–32.2)
New Hampshire 286 44 16.0 (13.7–18.7) 14.8 (12.6–17.3) 638 95 33.9 (31.0–36.9) 33.1 (30.2–36.1)
New Jersey 571 284 18.5 (16.3–20.9) 17.3 (15.2–19.7) 957 413 26.2 (23.8–28.8) 25.5 (23.1–28.1)
New Mexico 406 92 23.4 (20.7–26.3) 21.6 (19.1–24.4) 679 143 36.0 (33.0–39.1) 34.9 (31.9–38.0)
New York 524 587 17.6 (15.6–19.7) 16.7 (14.8–18.8) 914 907 26.4 (24.3–28.6) 26.0 (23.9–28.3)
North Carolina 297 441 23.4 (20.4–26.6) 22.0 (19.1–25.3) 476 644 33.7 (30.4–37.1) 32.9 (29.7–36.4)
North Dakota 255 21 15.2 (13.1–17.6) 13.3 (11.4–15.5) 580 44 31.7 (28.9–34.6) 29.8 (27.2–32.6)
Ohio 790 501 19.7 (17.9–21.7) 18.3 (16.6–20.1) 1,406 838 32.4 (30.3–34.5) 31.4 (29.4–33.5)
Oklahoma 437 179 22.5 (20.3–24.9) 20.3 (18.2–22.6) 805 309 38.2 (35.7–40.8) 36.6 (34.1–39.3)
Oregon 284 167 20.3 (17.9–22.9) 18.8 (16.5–21.4) 557 305 36.4 (33.6–39.2) 35.5 (32.7–38.4)
Pennsylvania 357 525 18.2 (16.0–20.7) 17.3 (15.1–19.8) 639 875 30.1 (27.5–32.9) 29.6 (27.0–32.4)
Rhode Island 319 46 20.1 (17.5–23.0) 18.5 (16.0–21.2) 652 79 34.5 (31.5–37.7) 33.3 (30.4–36.4)
South Carolina 709 223 21.4 (19.6–23.3) 20.3 (18.5–22.2) 1,257 366 34.1 (32.0–36.2) 33.7 (31.6–35.8)
South Dakota 272 23 16.5 (13.4–20.1) 15.2 (12.3–18.7) 484 41 28.6 (24.9–32.6) 27.6 (24.1–31.5)
Tennessee 429 315 21.2 (18.8–23.8) 19.2 (17.0–21.7) 772 551 36.0 (33.2–38.9) 34.6 (31.8–37.5)
Texas 618 923 21.3 (18.0–24.9) 19.7 (16.6–23.3) 1,091 1,560 35.4 (31.6–39.5) 34.6 (30.7–38.8)
Utah 359 63 15.5 (13.7–17.5) 13.7 (12.1–15.6) 835 146 35.4 (33.0–37.9) 33.9 (31.4–36.3)
Vermont 327 24 17.3 (15.2–19.6) 16.3 (14.2–18.5) 726 48 35.1 (32.5–37.8) 34.7 (32.1–37.5)
Virginia 471 272 17.2 (15.3–19.2) 15.7 (14.0–17.6) 935 497 30.8 (28.6–33.1) 29.7 (27.5–32.0)
Washington 631 246 18.5 (16.8–20.3) 16.8 (15.2–18.5) 1,381 499 36.9 (34.9–39.0) 35.7 (33.7–37.8)
West Virginia 526 130 23.6 (21.5–25.8) 21.5 (19.6–23.6) 869 200 35.8 (33.5–38.1) 34.2 (32.0–36.5)
Wisconsin 256 184 16.3 (13.9–19.1) 15.0 (12.8–17.7) 487 320 28.5 (25.6–31.5) 27.6 (24.8–30.5)
Wyoming 179 17 15.3 (12.9–18.0) 13.5 (11.4–16.1) 403 36 31.9 (28.8–35.1) 30.2 (27.2–33.4)
State median N/A N/A 18.2 16.8 N/A N/A 32.5 32.1
Range N/A N/A 13.7–25.0 12.9–22.4 N/A N/A 18.3–38.6 17.7–36.6

Abbreviations: CI = confidence interval; N/A = not applicable.
* Estimates were age-adjusted using logistic regression modeling to produce predicted marginal probabilities.

Return to your place in the textFIGURE. Age-adjusted prevalence* of frequent mental distress and history of depression among adults aged ≥18 years with arthritis — Behavioral Risk Factor Surveillance System, 2017
The figure is a map showing the age-adjusted prevalence of frequent mental distress and history of depression among adults aged ≥18 years with arthritis, using data from the Behavioral Risk Factor Surveillance System, during 2017.

Abbreviation: DC = District of Columbia.

* The percentage intervals for the quintile cutoffs vary because of variations in the distribution of frequent mental distress and history of depression.


Suggested citation for this article: Price JD, Barbour KE, Liu Y, et al. State-Specific Prevalence and Characteristics of Frequent Mental Distress and History of Depression Diagnosis Among Adults with Arthritis — United States, 2017. MMWR Morb Mortal Wkly Rep 2020;68:1173–1178. DOI: http://dx.doi.org/10.15585/mmwr.mm685152a1.

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