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

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.

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.

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).

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.

MMWR. 1998;47:365-368

DURING THE first quarter of 1998, the Texas Department of Health and the Iowa Department of Public Health notified CDC of three fatal cases of varicella (chickenpox) that occurred in children during 1997. All three children were unvaccinated. Two children contracted chickenpox from unvaccinated siblings, and the mode of exposure was unknown for the third. This report summarizes these cases and indicates that varicella-related deaths continue to occur among children in the United States despite the availability of vaccine and recommendations for its use in all susceptible children.^1- 2

On February 28, 1997, a previously healthy, unvaccinated 21-month-old boy developed a typical varicella rash. He had no reported exposure to varicella. On March 1, he was taken to a local emergency department (ED) with a high fever and was started on oral acetaminophen and diphenhydramine. On March 3, his primary-care physician prescribed oral acyclovir. On March 4, his mother noted a new petechial-like rash. The next morning, his primary-care physician noted lethargy, a purpuric rash, and poor perfusion. He was transferred to a local ED. Fluid resuscitation and intravenous ceftriaxone were initiated, but the child continued to deteriorate rapidly, requiring intubation, mechanical ventilation, and inotropic support with dopamine. Blood cultures were negative for bacterial pathogens. Laboratory tests indicated disseminated intravascular coagulation and severe dehydration. Approximately 112 hours after arrival at the ED, he was transported to a tertiary-care center. Within 10 minutes of arrival, he suffered cardiac arrest and died. The death was attributed to varicella with hemorrhagic complications.

On December 21, 1997, a 5-year-old unvaccinated boy with a history of asthma was taken to a local ED with a fever of 104.5 F (40.3 C) and a typical varicella rash in multiple stages of healing. The child was treated with antipyretic and antipruritic medications and discharged.

That evening, the boy developed mild dyspnea and was treated at home for a presumed asthma attack with metered-dose inhalers and one dose of oral prednisone. He returned to the ED on December 22 with shortness of breath and a 4-hour history of abdominal and leg pain. On presentation to the ED, one of the patient's siblings had active varicella and another had recently recovered from varicella. Physical examination revealed numerous chickenpox lesions, one of which appeared infected. He was tachypneic, and his extremities were mottled consistent with peripheral septic emboli. Chest and abdominal radiographs revealed a right pleural effusion, pneumonia, and mild ileus. Thoracostomy produced pleural fluid containing gram-positive cocci, confirmed 8 hours later to be group A Streptococcus (GAS). A peripheral blood sample revealed gram-positive cocci. He was admitted to the hospital and treated with intravenous ceftriaxone, nafcillin, and acyclovir.

After admission, his breathing became labored and his extremities increasingly mottled. He rapidly developed hypotension, obtundation, and bradycardia. Despite efforts at cardiopulmonary resuscitation, the child died 5 hours after arriving at the ED. A post-mortem examination attributed the death to GAS septicemia, pneumonia, and pleural effusion, complicating varicella infection.

On December 14, 1996, a previously healthy, unvaccinated 23-month-old boy developed fever and a typical varicella rash. Approximately 1-2 weeks earlier, his unvaccinated 4-year-old sibling had contracted varicella. He was taken to his physician on December 17 because of persistent fever and cellulitis of the left foot, and he was hospitalized on December 19 for failure to improve on an unspecified outpatient antibiotic regimen. Because his condition deteriorated despite intravenous methicillin and ceftriaxone, he was transferred to a regional hospital on December 21. Sepsis, possible viral meningoencephalitis, and mild pleural effusion were diagnosed. A cerebrospinal fluid examination revealed lymphocytic pleocytosis, and blood and urine cultures grew penicillin-resistant Staphylococcus aureus. Antibiotics were changed to nafcillin and gentamycin, and intravenous acyclovir was added on December 23. On December 24, the child developed an aortic insufficiency murmur, and an echocardiogram revealed a 9×9 mm vegetation on the aortic valve, consistent with bacterial endocarditis. Serial echocardiograms displayed growth of the vegetation and development of a pericardial effusion. He was transferred to a cardiac surgery center on December 26. While awaiting surgery, he developed refractive heart failure secondary to staphylococcal endocarditis. He became incoherent, probably secondary to a major embolic neurologic event, and died on January 8, 1997.

FA Guerra, MD, R Sanchez, San Antonio Metropolitan Health Dept, San Antonio; L Tabony, MPH, M VanEgdom, J Pelosi, MPH, DM Simpson, MD, State Epidemiologist, Texas Dept of Health. K Gerdes, MD, Blank Children's Hospital, Des Moines; MP Quinlisk, MD, State Epidemiologist, Iowa Dept of Public Health. A Bowen, MPH, Univ of Wisconsin. Child Vaccine Preventable Disease Br, Epidemiology and Surveillance Div, National Immunization Program, CDC.

The three cases described in this report indicate that healthy children continue to die from complications of varicella, a disease that is preventable through vaccination. Although commonly viewed as a benign disease of childhood, serious complications and death can occur following varicella. Varicella is the leading cause of vaccine-preventable deaths in children in the United States.

During 1990-1994, varicella was the underlying cause of death in an average of 43 children aged <15 years each year (CDC, unpublished data, 1998). During 1988-1995, up to 10,000 children were hospitalized each year for varicella or its complications (CDC, unpublished data, 1998). Ninety percent of the children who died did not have high-risk conditions for severe varicella. The most common severe complications from varicella among fatal cases in children are secondary bacterial infections and pneumonia. Other complications include encephalitis, hemorrhagic complications, hepatitis, arthritis, and Reye syndrome. Reports of severe invasive infections from GAS-complicating varicella have heightened awareness that varicella is a well-defined risk factor for GAS disease.^3- 4

Varicella vaccine was licensed in the United States in March 1995, is widely available, and is recommended for routine vaccination of children aged 12-18 months and for vaccination of susceptible older children, adolescents, and adults.^1- 2 The Vaccines For Children (VFC) program provides varicella vaccine for VFC-eligible children aged >12 months who were born on or after January 1, 1983, and for VFC-eligible children aged <19 years who are family members of an immunocompromised person.

National coverage levels among children aged 19-35 months for varicella vaccine have increased from 14% during July-September 1996 to 25% during March-June 1997.⁵ Barriers to vaccine use include the perception that varicella is a benign disease, concerns that immunity will not persist, the potential that varicella disease burden will shift to older age groups among whom the disease is more severe, and concerns about vaccine efficacy and safety.⁴ A recent study documented 100% vaccine efficacy for prevention of moderate or severe varicella and 86% for prevention of all varicella.⁶ In addition, vaccinated children who developed varicella caused by wild virus or "breakthrough disease" had very mild disease of short duration with <50 lesions.⁷ Persistence of immunity for more than 20 years post vaccination has been demonstrated.⁸ As disease incidence and exposure to wild virus declines, continuing surveillance will determine the need for and timing of additional doses of vaccine.

To monitor the impact of varicella vaccination programs throughout the United States, varicella surveillance is needed, and surveillance for varicella deaths in all states is a key first step in this process. States also are encouraged to develop additional sustainable surveillance systems, including monitoring hospitalizations and establishing statewide aggregate reporting for cases by schools, day care centers, and/or health-care provider offices, and to consider instituting vaccine requirements for day care and school entry.¹

Efforts to increase routine and catch-up varicella vaccination among children should include educating health-care providers that deaths and severe morbidity from varicella are preventable.^1- 2 Policies that delay vaccination of susceptible children until adolescence accept the considerable disease burden that occurs among children aged 2-11 years. The most effective vaccination strategy focuses on vaccinating children routinely at age 12-18 months and vaccinating all susceptible older children and adolescents. Children have the highest disease incidence and are the group that serve as the primary source of transmission of varicella to groups at higher risk for severe disease, including adults⁹ and persons who are not eligible for vaccination. Most deaths and severe morbidity from varicella in children and in adults can be prevented by implementing recommended policies for childhood vaccination.

MMWR. 1998;47:335-336

The SURGEON General's report, Tobacco Use Among U.S. Racial/Ethnic Minority Groups, was released on April 27, 1998. This report is the first to focus on tobacco use among four U.S. racial/ethnic minority groups: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics.

The five major conclusions in the report are

1. Cigarette smoking is a major cause of disease and death in each of the four population groups studied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking.

2. Tobacco use varies within and among racial/ethnic minority groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use, and African American and Southeast Asian men also have a high prevalence of smoking. Asian American and Hispanic women have the lowest prevalence.

3. Among adolescents, cigarette smoking prevalence increased in the 1990s among African Americans and Hispanics after several years of substantial decline among adolescents of all four racial/ethnic minority groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s.

4. No single factor determines patterns of tobacco use among racial/ethnic minority groups; these patterns are the result of complex interactions of multiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological elements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives.

5. Rigorous surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence tobacco use to improve our understanding of racial/ethnic smoking patterns and identify strategic tobacco control opportunities. The capacity of tobacco control efforts to keep pace with patterns of tobacco use and cessation depends on timely recognition of emerging prevalence and cessation patterns and the resulting development of appropriate community-based programs to address the factors involved.

Additional information about the report or a free copy of the executive summary is available from CDC's National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Mailstop K-50, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724; telephone (770) 488-5705 (press 2); or World-Wide Web http://www.cdc.gov/tobacco. Faxed copies of the executive summary may be obtained from the Office on Smoking and Health's fax information system, telephone (800) 232-1311 and select "hot topics." Copies of the full report (stock no. 017-001-00527-4) are available for $20 from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9328; telephone (202) 512-1800; fax (202) 512-1650. The executive summary of the report will be published as an MMWR Recommendations and Reports.

MMWR. 1998;47:287

CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) will cosponsor a statistical methods symposium, "Emerging Statistical Issues in Public Health for the 21st Century," January 28-29, 1999, in Atlanta. A short course, "Privacy, Confidentiality, and the Protection of Health Data—A Statistical Perspective," will be offered January 27, 1999, in conjunction with the symposium. The symposium and course are open to the public.

Abstracts will be considered in the following areas: (1) data collection and storage, including questionnaire and survey design, the use of data registries, and issues related to patients' rights and data privacy and confidentiality; (2) modeling and analysis of complex and/or dependent data structures, including techniques and software for spatial, clustered, longitudinal, survey, and genetic data, hierarchical and causal modeling, and data mining; (3) modeling and analysis of sparse data structures, including issues related to missing values, limits of detection, low dosages or exposures, and rare conditions; (4) design, modeling, and evaluation of public health interventions; and (5) applications of statistical methods in public health arenas including infectious and chronic disease prevention, injury and violence prevention, occupational and environmental exposures, and immunization.

Abstracts should be postmarked no later that July 1, 1998. Authors of papers accepted for presentations or posters will be notified by September 30, 1998. Registration and abstract information and additional information regarding scientific content of the symposium is available from CDC's Epidemiology Program Office, 1999 CDC and ATSDR Symposium on Statistical Methods, 1600 Clifton Road, NE, Mailstop D-01, Atlanta, GA 30333; telephone (404) 639-3806; fax (404) 639-4463; or e-mail bam6@cdc.gov.