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

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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 statespecific 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 statespecific 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. * https://www.cdc.gov/arthritis/interventions/physical-activity.html. † https://www.cdc.gov/arthritis/interventions/self_manage.htm. § https://www.nami.org/Learn-More/Treatment/Psychotherapy. 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 † † https://www.cdc.gov/hrqol/faqs.htm#10.
(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 ( ), 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). Abbreviation: CI = confidence interval. * Estimates for all characteristics except age group were age-adjusted using logistic regression modeling to produce predicted marginal probabilities.

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 Abbreviations: CI = confidence interval; N/A = not applicable. * Estimates were age-adjusted using logistic regression modeling to produce predicted marginal probabilities.
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 § § https://www.cdc.gov/arthritis/docs/ASMP-executive-summary.pdf. ¶ ¶ https://www.selfmanagementresource.com/programs/.

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.
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. ¶ ¶ ¶ *** https://www.thecommunityguide.org/topic/mental-health.
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 statespecific 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.