Mental Health Surveillance Among Children - United States, 2013-2019.

Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor. Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children's mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators of children's mental health, particularly mental disorders. The 2013-2019 data from these data systems show that mental disorders begin in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders diagnosed among U.S. children and adolescents aged 3-17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting approximately one in 11 (9.4%-9.8%) children. Among children and adolescents aged 12-17 years, one fifth (20.9%) had ever experienced a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and 18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10-19 years died by suicide in 2018 and 2019. Among children and adolescents aged 3-17 years, 9.6%-10.1% had received mental health services, and 7.8% of all children and adolescents aged 3-17 years had taken medication for mental health problems during the past year, based on parent report. Approximately one in four children and adolescents aged 12-17 years reported having received mental health services during the past year. In federal data systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children's mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

Secondhand Smoke Exposure Among Nonsmoking Adults: United States, 2015-2018.

Secondhand smoke (SHS) exposure results when smoke from burning tobacco products is inhaled by nonsmokers (1,2). Acute respiratory effects, coronary heart disease, stroke, lung cancer, and premature death are associated with SHS exposure (2,3). There is no risk-free level of SHS exposure (1). The prevalence of SHS exposure declined by 71.2% from 1988 to 2014 (4). This report examines the prevalence of SHS exposure among nonsmoking U.S. adults in 2015-2018 based on blood levels of cotinine, a metabolite of nicotine. Trends in SHS exposure are also presented.

Antidepressant Use Among Adults: United States, 2015-2018.

In 2018, an estimated 7.2% of American adults had a major depressive episode in the past year (1). Depression is associated with diminished quality of life and increased disability (2). Antidepressants are one of the primary treatments for depression (3) and are among the most frequently used therapeutic medications in the United States (4). This data brief provides recent prevalent estimates for antidepressant use among U.S. adults aged 18 and over, by age, sex, race and Hispanic origin, and education. Trends in antidepressant use over the decade from 2009-2010 through 2017-2018 are described.

Cognitive Performance in Adults Aged 60 and Over: National Health and Nutrition Examination Survey, 2011-2014.

Objective-This report describes cognitive performance in the U.S. noninstitutionalized population of older adults. The association of sociodemographic factors and self-reported cognitive and health status with low cognitive performance is also investigated. Methods-During 2011-2014, the cognitive performance of participants aged 60 and over was assessed during the National Health and Nutrition Examination Survey (NHANES). Cognitive assessment was based on scores from established objective cognitive tests (word list learning with immediate and delayed recall, animal naming, and a digit symbol substitution test). Mean scores and percentile distributions were described by sociodemographic characteristics. Logistic regression modeling was conducted to evaluate the relationship of sociodemographic and self-reported health factors with low cognitive performance, defined by scores in the lowest 25th percentile. The relationship between objective cognitive functioning measures and subjective cognitive decline also was evaluated by calculating sensitivity and specificity measures. Results-A total of 3,181 adults completed at least one of four objective cognitive tests. Mean scores for men were lower than for women in three of four assessments. Mean scores decreased with increasing age and with decreasing level of income and education. Persons reporting poorer health status and subjective cognitive decline were more likely to have low performance on the four assessments. The subjective cognitive decline question had low sensitivity (22.9%-26.7%) in identifying low cognitive performers, but had high specificity in identifying those who did not score low on the cognitive assessments (89.3%-90.9%). Conclusions-Cognitive performance has important implications for the U.S. aging population. Subjective cognitive decline along with older age, low income, low educational attainment, and fair or poor self-reported health were independently associated with lower cognitive performance in a representative sample of U.S. older adults.

Secondhand Smoke Exposure Among Nonsmoking Youth: United States, 2013-2016.

Secondhand smoke (SHS) exposure comes from the inhalation of smoke from burning cigarettes, cigars, and pipes (1). SHS can cause sudden infant death syndrome, respiratory and ear infections, and asthma attacks in youth (1,2). Decreases in tobacco smoking, awareness of SHS health risks, and smokefree policies may have contributed to a reduction in SHS exposure since the late 1980s (3,4). However, in recent years, the percentage of youth with SHS exposure has remained steady (5). This report describes the prevalence of SHS exposure among nonsmoking youth in 2013-2016, as defined by serum cotinine, a metabolite of nicotine.

WIC Participation and Blood Lead Levels among Children 1-5 Years: 2007-2014.

BACKGROUND: The CDC recommends a targeted strategy for childhood blood lead screening based on participation in federal programs, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Yet, there is scarcity of data on blood lead levels (BLLs) among WIC participants. OBJECTIVE: Our objective was to investigate whether children participating in WIC and not enrolled in Medicaid, who have not been targeted in the historical Medicaid-focused screening strategy, have higher BLLs than children in neither of these programs. METHODS: The analysis included 3,180 children 1-5 y of age in the National Health and Nutrition Examination Surveys conducted in 2007-2014. Log-binomial regression, which allows direct estimation of prevalence ratios, was used to examine associations between WIC participation (in conjunction with Medicaid enrollment) and having BLLs ≥5 µg/dL with adjustment for age (1-2 vs. 3-5 y). RESULTS: The percentage of children participating in "WIC only," "Medicaid only," "both WIC and Medicaid," and "neither" were 18.9%, 10.8%, 25.4%, and 44.9%, respectively. "WIC only," "Medicaid only," and "both WIC and Medicaid" children were more likely to have BLLs ≥5 µg/dL than children who were not enrolled in either program, with adjusted prevalence ratios of 3.29 [95% confidence interval (CI): 1.19, 9.09], 4.56 (95% CI: 2.18, 9.55), and 2.58 (95% CI: 1.18, 5.63). CONCLUSIONS: Children participating in WIC but not Medicaid were more likely to have BLLs ≥5 µg/dL than children who were not enrolled in either program. These findings may inform public health recommendations and clinical practice guidelines. https://doi.org/10.1289/EHP2384

Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016.

Major depression is a common and treatable mental disorder characterized by changes in mood, and cognitive and physical symptoms over a 2-week period (1). It is associated with high societal costs (2) and greater functional impairment than many other chronic diseases, including diabetes and arthritis (3). Depression rates differ by age, sex, income, and health behaviors (4). This report provides the most recent national estimates of depression among adults. Prevalence of depression is based on scores from the Patient Health Questionnaire (PHQ-9), a symptom-screening questionnaire that allows for criteria-based diagnoses of depressive disorders (5). Estimates for non-Hispanic Asian persons are presented for the first time.

Antidepressant Use Among Persons Aged 12 and Over:United States,2011-2014.

Antidepressants are one of the three most commonly used therapeutic drug classes in the United States (1). While the majority of antidepressants are taken to treat depression, antidepressants can also be taken to treat other conditions, like anxiety disorders. This Data Brief provides the most recent estimates of antidepressant use in the U.S. noninstitutionalized population, including prevalence of use by age, sex, race and Hispanic origin, and length of use. This report also describes trends in the prevalence of antidepressant use from 1999­2002 to 2011­2014.

Blood Lead and Other Metal Biomarkers as Risk Factors for Cardiovascular Disease Mortality.

Analyses of the Third National Health and Nutrition Examination Survey (NHANES III) in 1988 to 1994 found an association of increasing blood lead levels < 10 µg/dL with a higher risk of cardiovascular disease (CVD) mortality. The potential need to correct blood lead for hematocrit/hemoglobin and adjust for biomarkers for other metals, for example, cadmium and iron, had not been addressed in the previous NHANES III-based studies on blood lead-CVD mortality association. We analyzed 1999 to 2010 NHANES data for 18,602 participants who had a blood lead measurement, were ≥ 40 years of age at the baseline examination and were followed for mortality through 2011. We calculated the relative risk for CVD mortality as a function of hemoglobin- or hematocrit-corrected log-transformed blood lead through Cox proportional hazard regression analysis with adjustment for serum iron, blood cadmium, serum C-reactive protein, serum calcium, smoking, alcohol intake, race/Hispanic origin, and sex. The adjusted relative risk for CVD mortality was 1.44 (95% confidence interval = 1.05, 1.98) per 10-fold increase in hematocrit-corrected blood lead with little evidence of nonlinearity. Similar results were obtained with hemoglobin-corrected blood lead. Not correcting blood lead for hematocrit/hemoglobin resulted in underestimation of the lead-CVD mortality association while not adjusting for iron status and blood cadmium resulted in overestimation of the lead-CVD mortality association. In a nationally representative sample of U.S. adults, log-transformed blood lead was linearly associated with increased CVD mortality. Correcting blood lead for hematocrit/hemoglobin and adjustments for some biomarkers affected the association.

Lung obstruction among adults aged 40-79: United States, 2007-2012.

During 2007-2012, 14.7% of U.S. adults aged 40­79 had lung obstruction, with almost two-thirds having mild lung obstruction (9.4%) and one-third having moderate or worse obstruction (5.3%). A similar percentage of men and women had any lung obstruction, a pattern that persisted at each level of severity. There were notable differences in lung obstruction by race and Hispanic origin. Overall and at both levels of severity, rates of lung obstruction were higher for non-Hispanic white and non- Hispanic black adults compared with Hispanic adults. Overall and at the mild lung obstruction level, the percentage of non-Hispanic white adults with lung obstruction was significantly higher than that of non-Hispanic black adults. Lung obstruction also varied by education level. Adults who had attended college had a significantly lower percentage of moderate or worse lung obstruction compared with adults with less education. Among adults with mild lung obstruction, percentages were similar by education level. More than one-half of adults aged 40­79 with lung obstruction reported having at least one respiratory symptom. Reporting rates for each symptom and for one or more symptoms were all higher for those adults with moderate or worse lung obstruction than for those with mild obstruction. Among adults with moderate or worse lung obstruction, more than 80% reported having at least one respiratory symptom.

Cigarette smoking and lung obstruction among adults aged 40-79: United States, 2007-2012.

During 2007-2012, about 46% of U.S. adults aged 40-79 with lung obstruction currently smoked cigarettes. This was more than double the smoking rate for those without lung obstruction (19.8%). In the United States, a greater percentage of men (20.5%) than women (15.3%) were current cigarette smokers in 2013. Some studies have suggested that women are more susceptible than men to the effects of tobacco smoke. Since 2000, the number of women dying from COPD has exceeded the number of men dying from the disease. In the present report, a similar percentage of men and women overall, and at each level of lung obstruction severity, currently smoked cigarettes. Notable differences were seen in smoking rates by race and Hispanic origin. Among adults aged 40-79 with mild lung obstruction, a significantly greater percentage of non-Hispanic black adults currently smoked cigarettes compared with the two other race and Hispanic origin groups. With moderate or worse lung obstruction, however, a significantly greater percentage of non-Hispanic white adults currently smoked cigarettes compared with those in the other race and Hispanic origin groups. Smoking rates among those with lung obstruction also varied by education, with progressively higher rates of smoking among those with decreasing levels of education. This inverse relationship between smoking and education level is consistent across all severity levels of lung obstruction. Smoking tobacco can increase respiratory symptoms, loss of lung function, and the progression of COPD. The data presented here show that during 2007-2012, almost one-half of U.S. adults aged 40-79 with lung obstruction currently smoked cigarettes.

Depression in the U.S. household population, 2009-2012.

KEY FINDINGS: Data from the National Health and Nutrition Examination Survey, 2009-2012. During 2009-2012, 7.6% of Americans aged 12 and over had depression (moderate or severe depressive symptoms in the past 2 weeks). Depression was more prevalent among females and persons aged 40-59. About 3% of Americans aged 12 and over had severe depressive symptoms, while almost 78% had no symptoms. Persons living below the poverty level were nearly 2½ times more likely to have depression than those at or above the poverty level. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home, and social activities. Of those with severe symptoms, 35% reported having contact with a mental health professional in the past year. Depression is a serious medical illness with mood, cognitive, and physical symptoms (1). Depression is associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (2,3). Rates of treatment remain low, and the treatment received is often inadequate (1). This data brief examines both depression and depressive symptom severity in the past 2 weeks from a symptom-based questionnaire, by demographic characteristics, functioning difficulties, and recent contact with a mental health professional. Severity is categorized as severe, moderate, mild, or no depressive symptoms. Current depression is defined as severe or moderate symptoms; no depression is defined as mild or no symptoms.

Depression and obesity in the U.S. adult household population, 2005-2010.

Forty-three percent of adults with depression were obese as compared with 33% of adults without depression. Women with depression were more likely to be obese than women without depression. The relationship was consistent across all age groups among women and was also seen in men aged 60 and over. Non-Hispanic white women with depression were more likely to be obese than non-Hispanic white women without depression. This relationship was not seen in non-Hispanic black or Hispanic women or among men of any racial or ethnic background. As the severity of depression increased, the percentage of all adults and of women with obesity increased as well. Both moderate to severe depressive symptoms and antidepressant use were associated with increased obesity. Moderate to severe depressive symptoms were associated with a higher rate of obesity both in persons who were taking antidepressant medication and those who were not, and antidepressant use was associated with a higher rate of obesity in persons with moderate to severe depressive symptoms and those with mild or no depressive symptoms. Of the four categories, the highest prevalence of obesity (54.6%) was found in persons who had moderate or severe depressive symptoms and took antidepressant medication. In this study, it is not clear whether depression or obesity occurred first because they were both measured at the same time. Other studies have shown a bidirectional relationship, meaning obesity increases risk of depression and depression increases risk of obesity . Knowledge of these risks may help general medical practitioners and mental health professionals plan prevention and treatment.

Implications of two-stage depression screening for identifying persons with thoughts of self-harm.

OBJECTIVE: Persons with thoughts of self-harm may need evaluation for suicide risk. We examine the prevalence of thoughts of self-harm and whether persons with thoughts of self-harm are identified when two-stage depression screening is used. METHODS: Data are from the 2005-2010 National Health and Nutrition Examination Surveys. Persons responding positively to question nine of the Patient Health Questionnaire-9 (PHQ-9) are identified as having thoughts of self-harm. We compare two depression cutoff scores for the Patient Health Questionnaire-2 (PHQ-2) to see what percentage of persons with thoughts of self-harm would be identified as needing further screening with the PHQ-9. RESULTS: The prevalence of thoughts of self-harm was 3.5%. Persons 12-17 years old, poor and reporting fair or poor health were more likely to report thoughts of self-harm. A cutoff score of three on the PHQ-2 identified 49% of persons with thoughts of self-harm for further screening with the PHQ-9. A cut point of two increased the proportion of persons with thoughts of self-harm continuing for further screening to 76%. CONCLUSIONS: Using a lower cutoff score, two, the PHQ-2 captures more persons with thoughts of self-harm. One quarter of persons with self-harm thoughts may not be identified for further screening when two-stage screening is used.

Reference values and factors associated with exhaled nitric oxide: U.S. youth and adults.

BACKGROUND: Normative values for fractional exhaled nitric oxide (FeNO) and the associated co-factors are important in understanding the role of FeNO as a biomarker in airway disease. The objective of this study is to establish reference FeNO values for youth and adult asymptomatic, lifetime nonsmokers in the United States, and to describe the factors affecting these levels. METHODS: Cross-sectional analyses of the National Health and Nutrition Examination Survey from 2007 to 2010. The analytic sample consisted of 4718 youth and adults, ages 6-79 years, who were lifelong nonsmokers, and free of asthma, and other respiratory conditions and symptoms. Loge FeNO values were used as dependent variables to test associations of demographic and health related-covariates. Multivariable regression models were used to assess the independent effect and covariate-adjusted contribution of the factors. RESULTS: The geometric mean FeNO level was 8.3, 12.1, and 16.2 ppb for males 6-11, 12-19, and 20-79 years, and 8.4, 10.9, and 12.6 ppb for females in the corresponding age groups. Overall, FeNO levels increased with increasing age (p < 0.001), and height (p < 0.001). In all age groups, FeNO levels were positively associated with eosinophil counts, and with testing in the morning. Among youths 6-11 and 12-19 years, non-Hispanics whites had lower FeNO values than non-Hispanic blacks and Hispanic youths. No race-ethnic difference in FeNO levels was evident for adults 20-79 years. Among adolescents and adults, FeNO levels were higher for males than for females, controlling for all other factors. CONCLUSIONS: These reference values and associated attributes in youths and adults are useful in evaluating the role of FeNO in airway diseases.

US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma.

OBJECTIVE: To examine exposure to tobacco smoke products (TSPs), environmental tobacco smoke (ETS), and in-home smoke among youth with asthma in the United States. METHODS: Nationally representative, cross-sectional data from 2250 youth aged 4 to 19 years with current asthma in the 1988-1994, 1999-2004, and 2005-2010 National Health and Nutrition Examination Survey (NHANES) were analyzed. Outcomes were use of TSPs (serum cotinine level >10 ng/mL or self-reported recent use of cigarettes, cigars, or pipes) and, among non-TSP users, ETS exposure (serum cotinine ≥0.05 ng/mL) and in-home smoke exposure (reported). Multiple logistic regression analyses assessed the associations between the outcomes and age, gender, race/ethnicity, and family income. RESULTS: Among adolescents (aged 12-19 years) with asthma in 2005-2010, 17.3% reported TSP use. Among youth (aged 4-19 years) with asthma who did not use TSPs, 53.2% were exposed to ETS and 17.6% had in-home smoke exposure. Among low-income youth, 70.1% and 28.1% had exposure to ETS and in-home smoke, respectively. After controlling for sociodemographic factors, higher prevalence of exposure to ETS and in-home smoke persisted among low-income youth. Between 1988-1994 and 2005-2010, there was a decline in ETS and in-home smoke exposure (both P < .001). CONCLUSIONS: ETS exposure among youth with asthma declined between 1988-1994 and 2005-2010, but a majority remained exposed in 2005-2010, with higher exposure among low-income youth. More than 1 in 6 youth with asthma in 2005-2010 were exposed to in-home smoke and a similar portion of adolescents used TSPs.

Physical activity and screen-time viewing among elementary school-aged children in the United States from 2009 to 2010.

OBJECTIVES To describe the percentage of children who met physical activity and screen-time recommendations and to examine demographic differences. Recommendations for school-aged children include 60 minutes of daily moderate-to-vigorous physical activity and no more than 2 hours per day of screen-time viewing. DESIGN Cross-sectional study. SETTING Data from the 2009-2010 National Health and Nutrition Examination Survey, a representative sample of the US population. PARTICIPANTS Analysis included 1218 children 6 to 11 years of age. MAIN EXPOSURES Age, race/ethnicity, sex, income, family structure, and obesity status. MAIN OUTCOME MEASURES Proxy-reported adherence to physical activity and screen-time recommendations, separately and concurrently. RESULTS Based on proxy reports, overall, 70% of children met physical activity recommendations, and 54% met screen-time viewing recommendations. Although Hispanics were less likely to meet physical activity recommendations (adjusted odds ratio [aOR], 0.60 [95% CI, 0.38-0.95]), they were more likely to meet screen-time recommendations compared with non-Hispanic whites (aOR, 1.69 [95% CI, 1.18-2.43]). Only 38% met both recommendations concurrently. Age (9-11 years vs 6-8 years: aOR, 0.57 [95% CI, 0.38-0.85]) and obesity (aOR, 0.53 [95% CI, 0.38-0.73]) were inversely associated with concurrent adherence to both recommendations. CONCLUSIONS Fewer than 4 in 10 children met both physical activity and screen-time recommendations concurrently. The prevalence of sedentary behavior was higher in older children. Low levels of screen-time viewing may not necessarily predict higher levels of physical activity.

Antidepressant use in persons aged 12 and over: United States, 2005-2008.

In 2005­2008, 11% of Americans aged 12 and over took antidepressant medication. There were significant differences in antidepressant medication usage rates between groups. Females were 2½ times as likely as males to take antidepressants. Antidepressant use was higher in persons aged 40 and over than in those aged 12­39. Non-Hispanic white persons were more likely to take antidepressants than other race and ethnicity groups. Other studies have shown similar age, gender, and race and ethnicity patterns (2,3). There was no variation in antidepressant use by income group. Among persons taking antidepressants overall, there was no significant difference in length of use between males and females. Among persons taking antidepressants, males were more likely than females to have seen a mental health professional in the past year. About 8% of persons aged 12 and over with no current depressive symptoms took antidepressant medication. This group may include persons taking antidepressants for reasons other than depression and persons taking antidepressants for depression who are being treated successfully and do not currently have depressive symptoms.Slightly over one-third of persons aged 12 and over with current severe depressive symptoms were taking antidepressants. According to American Psychiatric Association guidelines, medications are the preferred treatment for moderate to severe depressive symptomatology (4). The public health importance of increasing treatment rates for depression is reflected in Healthy People 2020, which includes national objectives to increase treatment for depression in adults and treatment for mental health problems in children (5).

Depression and smoking in the U.S. household population aged 20 and over, 2005-2008.

KEY FINDINGS: Data from the National Health and Nutrition Examination Surveys, 2005-2008. Adults aged 20 and over with depression were more likely to be cigarette smokers than those without depression. Women with depression had smoking rates similar to men with depression, while women without depression smoked less than men. The percentage of adults who were smokers increased as depression severity increased. Among adult smokers, those with depression smoked more heavily than those without depression. They were more likely to smoke their first cigarette within 5 minutes of awakening and to smoke more than one pack of cigarettes per day. Adults with depression were less likely to quit smoking than those without depression.

Secondhand tobacco smoke exposure among children and adolescents: United States, 2003-2006.

OBJECTIVE: The implementation of policies that prohibit tobacco smoking in public places has resulted in a significant reduction in secondhand smoke (SHS) exposure in the US population; however, such policies do not extend to private homes, where children continue to be exposed. Our objective was to assess SHS exposure among US children and adolescents by using serum cotinine measures to compare those who were exposed to SHS in the home and those without home exposure. METHODS: We analyzed serum cotinine data from the 2003-2006 National Health and Nutrition Examination Survey for 5518 children (3-11 years) and nonsmoking adolescents (12-19 years). We calculated geometric mean serum cotinine levels by sociodemographic and household characteristics according to self-reported home SHS exposure. Multiple regression analysis was conducted to evaluate independent predictors of serum cotinine levels. RESULTS: Geometric mean serum cotinine levels were 1.05 ng/mL among those with home SHS exposure and 0.05 ng/mL among those without home exposure. Among children who were exposed to SHS at home, serum cotinine levels were inversely associated with age and were similar for non-Hispanic black and non-Hispanic white children. Conversely, among children without SHS exposure at home, serum cotinine levels were higher among non-Hispanic black compared with non-Hispanic white children, and there was no relationship with age. Mexican American children had the lowest level of SHS exposure. CONCLUSIONS: Serum cotinine levels were an order of magnitude higher among children with reported SHS exposure at home compared with those with no exposure in the home.