2 figures, 1 table omitted
Poor mental health is a major source of distress, disability, and social
burden1; 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
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
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%. 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).
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.
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.
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
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
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
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
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: 9 available
*According to the methodology of the Council of American Survey Research
Organizations, the response rate includes the number of completed interviews
in the numerator and an estimate of the number of all eligible interviewees
and those whose eligibility is undetermined in the denominator.
†Includes persons who did not identify as one of the following
racial/ethnic populations: white, non-Hispanic; black, non-Hispanic; Hispanic;
Asian/Pacific Islander; or American Indian/Alaska Native. These persons might
be of multiple race/ethnicity.
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