Indicators of poor mental health and stressors during the COVID-19 pandemic, by disability status: A cross-sectional analysis.

BACKGROUND: Evidence from previous public health emergencies indicates that adults with disabilities have higher risk for morbidity (physical and mental) and mortality than adults without disabilities. OBJECTIVE: To provide estimates of mental health indicators and stressors for US adults by disability status during April and May 2020, shortly following the emergence of the COVID-19 pandemic. METHODS: We analyzed data from Porter Novelli View 360 opt-in Internet panel survey conducted during the weeks of April 20th and May 18th, 2020 among 1004 English-speaking adults aged ≥18 years without and with disabilities (serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living). Weighted logistic regression was used to test for significant differences between calculated prevalence estimates at the P ≤ .05 level. RESULTS: One in four adults reported any disability. Adults with any disability were significantly more likely than adults without disability to report current depressive symptoms, frequent mental distress, suicidal ideation, and COVID-19-related initiated or increased substance use (all p values < .0001). Adults with disabilities also reported significantly higher levels of stressors, such as access to health care services (p < .0001), difficulty caring for their own (or another's) chronic condition (p < .0001), emotional or physical abuse from others (p < .001), and not having enough food (p < .01). CONCLUSIONS: The disproportionately high levels of poor mental health indicators among adults with disabilities as compared to those without highlight the importance of delivering timely mental health screening and treatment/intervention during and after the COVID-19 pandemic to persons with disabilities.

Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic - United States, April and May 2020.

In 2019, approximately 51 million U.S. adults aged ≥18 years reported any mental illness,* and 7.7% reported a past-year substance use disorder† (1). Although reported prevalence estimates of certain mental disorders, substance use, or substance use disorders are not generally higher among racial and ethnic minority groups, persons in these groups are often less likely to receive treatment services (1). Persistent systemic social inequities and discrimination related to living conditions and work environments, which contribute to disparities in underlying medical conditions, can further compound health problems faced by members of racial and ethnic minority groups during the coronavirus disease 2019 (COVID-19) pandemic and worsen stress and associated mental health concerns (2,3). In April and May 2020, opt-in Internet panel surveys of English-speaking U.S. adults aged ≥18 years were conducted to assess the prevalence of self-reported mental health conditions and initiation of or increases in substance use to cope with stress, psychosocial stressors, and social determinants of health. Combined prevalence estimates of current depression, initiating or increasing substance use, and suicidal thoughts/ideation were 28.6%, 18.2%, and 8.4%, respectively. Hispanic/Latino (Hispanic) adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups. These estimates highlight the importance of population-level and tailored interventions for mental health promotion and mental illness prevention, substance use prevention, screening and treatment services, and increased provision of resources to address social determinants of health. How Right Now (Qué Hacer Ahora) is an evidence-based and culturally appropriate communications campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by COVID-19-related stress, grief, and loss (4).

Racial and Ethnic Differences in Parental Attitudes and Concerns About School Reopening During the COVID-19 Pandemic - United States, July 2020.

In light of the disproportionate risk of hospitalization and death attributable to coronavirus disease 2019 (COVID-19) among racial and ethnic minority groups, parental attitudes and concerns regarding school reopening were assessed by race and ethnicity using data from three online CARAVAN omnibus surveys conducted during July 8-12, 2020, by ENGINE Insights.* Survey participants included 858 parents who had children and adolescents in kindergarten through grade 12 (school-aged children) living in their household. Overall, 56.5% of parents strongly or somewhat agreed that school should reopen this fall, with some differences by race/ethnicity: compared with 62.3% of non-Hispanic White (White) parents, 46.0% of non-Hispanic Black or African American (Black) parents (p = 0.007) and 50.2% of Hispanic parents (p = 0.014) agreed that school should reopen this fall. Fewer White parents (62.5%) than Hispanic (79.5%, p = 0.026) and non-Hispanic parents of other racial/ethnic groups (66.9%, p = 0.041) were supportive of a mask mandate for students and staff members. Understanding parental attitudes and concerns is critical to informing communication and messaging around COVID-19 mitigation. Families' concerns also highlight the need for flexible education plans and equitable resource provision so that youth education is not compromised.

Comparing the historical limits method with regression models for weekly monitoring of national notifiable diseases reports.

To compare the performance of the standard Historical Limits Method (HLM), with a modified HLM (MHLM), the Farrington-like Method (FLM), and the Serfling-like Method (SLM) in detecting simulated outbreak signals. We used weekly time series data from 12 infectious diseases from the U.S. Centers for Disease Control and Prevention's National Notifiable Diseases Surveillance System (NNDSS). Data from 2006 to 2010 were used as baseline and from 2011 to 2014 were used to test the four detection methods. MHLM outperformed HLM in terms of background alert rate, sensitivity, and alerting delay. On average, SLM and FLM had higher sensitivity than MHLM. Among the four methods, the FLM had the highest sensitivity and lowest background alert rate and alerting delay. Revising or replacing the standard HLM may improve the performance of aberration detection for NNDSS standard weekly reports.

Preparedness Perceptions, Sociodemographic Characteristics, and Level of Household Preparedness for Public Health Emergencies: Behavioral Risk Factor Surveillance System, 2006-2010.

Our objective was to inform state and community interventions focused on increasing household preparedness by examining the association between self-reported possession of household disaster preparedness items (ie, a 3-day supply of food and water, a written evacuation plan, and a working radio and flashlight) and perceptions of household preparedness on a 3-point scale from "well prepared" to "not at all prepared." Data were analyzed from 14 states participating in a large state-based telephone survey: the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS) (n = 104,654). Only 25.3% of the population felt they were well prepared, and only 12.3% had all 5 of the recommended items. Fewer than half the households surveyed had 4 or more of the recommended preparedness items (34.1%). Respondents were more likely to report their households were well prepared as the number of preparedness items possessed by their household increased. Risk factors for having no preparedness items were: younger age, being female, lower levels of education, and requesting the survey to be conducted in Spanish. To increase household disaster preparedness, more community-based preparedness education campaigns targeting vulnerable populations, such as those with limited English abilities and lower reading levels, are needed.

Excess burden of depression among HIV-infected persons receiving medical care in the united states: data from the medical monitoring project and the behavioral risk factor surveillance system.

BACKGROUND: With increased life expectancy for HIV-infected persons, there is concern regarding comorbid depression because of its common occurrence and association with behaviors that may facilitate HIV transmission. Our objectives were to estimate the prevalence of current depression among HIV-infected persons receiving care and assess the burden of major depression, relative to that in the general population. METHODS AND FINDINGS: We used data from the Medical Monitoring Project (MMP) and the Behavioral Risk Factors Surveillance System (BRFSS). The eight-item Patient Health Questionnaire was used to identify depression. To assess the burden of major depression among HIV-infected persons receiving care, we compared the prevalence of current major depression between the MMP and BRFSS populations using stratified analyses that simultaneously controlled for gender and, in turn, each of the potentially confounding demographic factors of age, race/ethnicity, education, and income. Each unadjusted comparison was summarized as a prevalence ratio (PR), and each of the adjusted comparisons was summarized as a standardized prevalence ratio (SPR). Among HIV-infected persons receiving care, the prevalence of a current episode of major depression and other depression, respectively, was 12.4% (95% CI: 11.2, 13.7) and 13.2% (95% CI: 12.0%, 14.4%). Overall, the PR comparing the prevalence of current major depression between HIV-infected persons receiving care and the general population was 3.1. When controlling for gender and each of the factors age, race/ethnicity, and education, the SPR (3.3, 3.0, and 2.9, respectively) was similar to the PR. However, when controlling for gender and annual household income, the SPR decreased to 1.5. CONCLUSIONS: Depression remains a common comorbidity among HIV-infected persons. The overall excess burden among HIV-infected persons receiving care is about three-times that among the general population and is associated with differences in annual household income between the two populations. Relevant efforts are needed to reduce this burden.

Physical activity patterns among U.S. adults with and without serious psychological distress.

OBJECTIVE: A physically active lifestyle is recommended for overall health--both physical and mental. Serious psychological distress (SPD) is associated with adverse health behaviors. We compared patterns of physical activity (PA) among adults with and without SPD using current public health guidelines for PA and examined whether adults with SPD were physically active at recommended levels. METHODS: We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to assess SPD using the Kessler 6 (K6) scale of nonspecific psychological distress and PA categories based on the 2008 U.S. Department of Health and Human Services guidelines. Complete data were available for 78,886 adults in 16 states that used an optional BRFSS mental illness and stigma module containing the K6 scale. We performed multiple logistic regression analyses to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: The unadjusted prevalence of SPD was 3.9% (95% CI 3.6, 4.2), and the age-adjusted prevalence of SPD was 3.8% (95% CI 3.5, 4.1). After adjusting for age, sex, race/ethnicity, education, employment, body mass index, smoking status, and heavy drinking, adults with SPD were significantly less likely to be physically active at recommended levels than adults without SPD. PRs were attenuated but remained significant after further adjustment for limitations to PA. CONCLUSION: Adults with SPD are less likely to meet current PA recommendations than adults without SPD, highlighting the need for targeted interventions.

Chronic conditions and household preparedness for public health emergencies: Behavioral Risk Factor Surveillance System, 2006-2010.

INTRODUCTION: Individuals with chronic conditions often experience exacerbation of those conditions and have specialized medical needs after a disaster. Less is known about the level of disaster preparedness of this particular population and the extent to which being prepared might have an impact on the risk of disease exacerbation. The purpose of this study was to examine the association between self-reported asthma, cardiovascular disease, and diabetes and levels of household disaster preparedness. METHODS: Data were analyzed from 14 US states participating in the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS), a large state-based telephone survey. Chi-square statistics and adjusted prevalence ratios were calculated. RESULTS: After adjusting for sociodemographic characteristics, as compared to those without each condition, persons with cardiovascular disease (aPR = 1.09; 95% CI, 1.01-1.17) and diabetes (aPR = 1.13; 95% CI, 1.05-1.22) were slightly more likely to have an evacuation plan and individuals with diabetes (aPR = 1.04; 95% CI, 1.02-1.05) and asthma (aPR = 1.02; 95% CI, 1.01-1.04) were slightly more likely to have a 3-day supply of prescription medication. There were no statistically significant differences in the prevalence for all other preparedness measures (3-day supply of food and water, working radio and flashlight, willingness to leave during a mandatory evacuation) between those with and those without each chronic condition. CONCLUSION: Despite the increased morbidity and mortality associated with chronic conditions, persons with diabetes, cardiovascular disease, and asthma were generally not more prepared for natural or man-made disasters than those without each chronic condition.

Change in health insurance coverage in Massachusetts and other New England States by perceived health status: potential impact of health reform.

OBJECTIVES: We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health. METHODS: We used 2003-2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform. RESULTS: The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states--from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs. CONCLUSIONS: On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.

Association between perceived insufficient sleep, frequent mental distress, obesity and chronic diseases among US adults, 2009 behavioral risk factor surveillance system.

BACKGROUND: Although evidence suggests that poor sleep is associated with chronic disease, little research has been conducted to assess the relationships between insufficient sleep, frequent mental distress (FMD ≥14 days during the past 30 days), obesity, and chronic disease including diabetes mellitus, coronary heart disease, stroke, high blood pressure, asthma, and arthritis. METHODS: Data from 375,653 US adults aged ≥ 18 years in the 2009 Behavioral Risk Factor Surveillance System were used to assess the relationships between insufficient sleep and chronic disease. The relationships were further examined using a multivariate logistic regression model after controlling for age, sex, race/ethnicity, education, and potential mediators (FMD and obesity). RESULTS: The overall prevalence of insufficient sleep during the past 30 days was 10.4% for all 30 days, 17.0% for 14-29 days, 42.0% for 1-13 days, and 30.6% for zero day. The positive relationships between insufficient sleep and each of the six chronic disease were significant (p < 0.0001) after adjustment for covariates and were modestly attenuated but not fully explained by FMD. The relationships between insufficient sleep and both diabetes and high blood pressure were also modestly attenuated but not fully explained by obesity. CONCLUSIONS: Assessment of sleep quantity and quality and additional efforts to encourage optimal sleep and sleep health should be considered in routine medical examinations. Ongoing research designed to test treatments for obesity, mental distress, or various chronic diseases should also consider assessing the impact of these treatments on sleep health.

Health-related quality of life domains and household preparedness for public health emergencies: Behavioral Risk Factor Surveillance System, 2006-2010.

BACKGROUND: This study examined the association between self-reported levels of household disaster preparedness and a range of physical and mental health quality of life outcomes. METHODS: Data collected from 14 states participating in a large state-based telephone survey were analyzed (n = 104 654). Household disaster-preparedness items included having a 3-day supply of food, water, and prescription medications; a working battery-powered radio and flashlight; an evacuation plan; and a willingness to evacuate when instructed to do so. Quality-of-life items were categorized into 2 domains: physical health (general health, unhealthy physical days, and activity-limited days) and mental health (unhealthy mental days, social and emotional support, and life satisfaction). RESULTS: Persons with self-reported impaired mental health were generally less likely to report being prepared for a disaster than those who did not report impairment in each domain. Persons with low life satisfaction were among the least likely to be prepared, followed by those with inadequate social and emotional support, and then by those with frequent mental distress. Persons reporting physical impairments also reported deficits in many of the preparedness items. However, after adjusting for sociodemographic characteristics, some of the associations were attenuated and no longer significant. CONCLUSION: Persons reporting impaired quality of life are vulnerable to increased mental and physical distress during a disaster, and their vulnerability is compounded if they are ill-prepared. Therefore, persons reporting impaired quality of life should be included in the list of vulnerable populations that need disaster preparedness and response outreach.

The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults.

BACKGROUND: Research suggests that ACEs have a long-term impact on the behavioral, emotional, and cognitive development of children. These disruptions can lead to adoption of unhealthy coping behaviors throughout the lifespan. The present study sought to examine psychological distress as a potential mediator of sex-specific associations between adverse childhood experiences (ACEs) and adult smoking. METHOD: Data from 7,210 Kaiser-Permanente members in San Diego California collected between April and October 1997 were used. RESULTS: Among women, psychological distress mediated a significant portion of the association between ACEs and smoking (21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, 10% for parental separation or divorce). Among men, the associations between ACEs and smoking were not significant. CONCLUSIONS: These findings suggest that for women, current smoking cessation strategies may benefit from understanding the potential role of childhood trauma.

Associations between adverse childhood experiences, psychological distress, and adult alcohol problems.

OBJECTIVE: To examine the mediating role of psychological distress on the relationship between adverse childhood experiences and adult alcohol problems by gender. METHODS: Linear and logistic regression analyses were conducted on 7279 Kaiser-Permanente members, aged >18 years. RESULTS: Psychological distress mediated significant proportions of alcohol problems associated with childhood emotional abuse and neglect, physical abuse and neglect, mental illness in the household, parental separation or divorce, sexual abuse, and household drug use among women and mental illness in the household, emotional neglect, physical abuse, household drug use, and sexual abuse among men. CONCLUSION: It may be important to identify early childhood trauma and adult psychological distress in programs that focus on reducing alcohol abuse.

Potential moderating role of seat belt law on the relationship between seat belt use and adverse health behavior.

OBJECTIVE: To determine the potential moderating effect of seat belt law on seat belt compliance among persons who engage in adverse health behaviors. METHODS: Self-reported use of seat belts and adverse health behaviors in a 2008 US state-based population survey. RESULTS: Seat belt law moderates the use of seat belts among males and females who smoked, males who were physically inactive, and males and females who engaged in multiple risk behaviors. CONCLUSION: There is a need to supplement legislative interventions with more focused behavioral approaches to further increase seat belt compliance among persons who engage in adverse risk behaviors.

The association between depression and anxiety and use of oral health services and tooth loss.

OBJECTIVE: The purpose of this study is to examine the associations among depression, anxiety, use of oral health services, and tooth loss. METHODS: Data were analysed for 80 486 noninstitutionalized adults in 16 states who participated in the 2008 Behavioral Risk Factor Surveillance System. Binomial and multinomial logistic regression analyses were used to estimate predicted marginals, adjusted prevalence ratios, adjusted odds ratios (AOR) and their 95% confidence intervals (CI). RESULTS: The unadjusted prevalence for use of oral health services in the past year was 73.1% [standard error (SE), 0.3%]. The unadjusted prevalence by level of tooth loss was 56.1% (SE, 0.4%) for no tooth loss, 29.6% (SE, 0.3%) for 1-5 missing teeth, 9.7% (SE, 0.2%) for 6-31 missing teeth and 4.6% (SE, 0.1%) for total tooth loss. Adults with current depression had a significantly higher prevalence of nonuse of oral health services in the past year than those without this disorder (P < 0.001), after adjustment for age, sex, race/ethnicity, education, marital status, employment status, adverse health behaviours, chronic conditions, body mass index, assistive technology use and perceived social support. In logistic regression analyses employing tooth loss as a dichotomous outcome (0 versus ≥1) and as a nominal outcome (0 versus 1-5, 6-31, or all), adults with depression and anxiety were more likely to have tooth loss. Adults with current depression, lifetime diagnosed depression and lifetime diagnosed anxiety were significantly more likely to have had at least one tooth removed than those without each of these disorders (P < 0.001 for all), after fully adjusting for evaluated confounders (including use of oral health services). The adjusted odds of being in the 1-5 teeth removed, 6-31 teeth removed, or all teeth removed categories versus 0 teeth removed category were increased for adults with current depression versus those without (AOR = 1.35; 95% CI = 1.14-1.59; AOR = 1.83; 95% CI = 1.51-2.22; and AOR = 1.44; 95% CI = 1.11-1.86, respectively). The adjusted odds of being in the 1-5 teeth removed and 6-31 teeth removed categories versus 0 teeth removed category were also increased for adults with lifetime diagnosed depression or anxiety versus those without each of these disorders. CONCLUSIONS: Use of oral health services and tooth loss was associated with depression and anxiety after controlling for multiple confounders.

Household demographics and perceived insufficient sleep among US adults.

It has become increasingly recognized that insufficient sleep is associated with adverse health outcomes. Studies have observed that sleep duration and daytime sleepiness varies by sex and marital status. Few studies have examined the impact of the number of children on sleep. To evaluate the association of marital status and number of children with insufficient sleep and in a large national sample. We analyzed data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) survey, a population-based telephone survey of non-institutionalized US adults (N = 395,407), in which respondents were asked, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?" We used sex-specific, multivariate logistic regression analyses to assess the associations of marital status (married, previously married, never married) and the number of children in the household with frequent insufficient sleep (≥14 days in past 30 days) after adjusting for age, race/ethnicity, and education. In this study population, 23% were never married, 60% were married, and 17% were previously married. Forty-three percent reported having children aged <18 years in the household. Married men (24.3%) were less likely to report frequent insufficient sleep than never married men (28.0%) or previously married men (28.8%). Never married women (33.4%) were more likely to report frequent insufficient sleep than currently married (29.0%) or previously married women (29.0%). The likelihood of frequent insufficient sleep increased in a linear fashion with the number of children in the household for all subgroups (P < 0.05) except among never married men. These findings suggest that the presence of children in the household often increases the frequency of insufficient rest or sleep among the adults with whom they reside. Thus, health care providers may wish to consider the presence of children under 18 years of age a potential "risk factor" for insufficient sleep when counseling adults in the household about the importance of sleep to overall health.

Uninsurance among nonelderly adults with and without frequent mental and physical distress in the United States.

OBJECTIVES: This research describes uninsurance rates over time among nonelderly adults in the United States with or without frequent physical and mental distress and provides estimates of uninsurance by frequent mental distress status and sociodemographic characteristics nationally and by state. METHODS: Data from the 1993 through 2009 Behavioral Risk Factor Surveillance System, a telephone survey that uses random-digit dialing, were used to examine the prevalence of uninsurance among nearly 3 million respondents by self-report of frequent physical and frequent mental distress and sociodemographic characteristics, response year, and state of residence. RESULTS: After adjustment for sociodemographic characteristics, uninsurance among adults aged 18 to 64 years was markedly higher among those with frequent mental distress only (22.6%) and those with both frequent mental and frequent physical distress (21.8%) than among those with frequent physical distress only (17.7%). The prevalence of uninsurance did not differ markedly between those with only frequent mental distress and those with both frequent mental distress and frequent physical distress. The prevalence of uninsurance among those with frequent mental distress only and those with neither frequent mental distress nor frequent physical distress increased significantly over time. CONCLUSIONS: Uninsurance rates among nonelderly adults with frequent mental distress were disproportionately high. The results of this analysis can be used as baseline data to assess whether implementation of the Affordable Care Act is accompanied by changes in health care access, utilization, and self-reported measures of health, particularly among those with mental illness.

Mental illness surveillance among adults in the United States.

Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previous year. The economic cost of mental illness in the United States is substantial, approximately $300 billion in 2002. Population surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug abuse) and chronic conditions, and use of mental health-related care and clinical services. Population-based surveys and surveillance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and treatment programs. This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental illness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005-2008 National Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007-2008, approximately 5% of ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depression, psychoses, or anxiety disorders. Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and use of mental health treatment services could substantially reduce the associated morbidity.

Surveillance of certain health behaviors and conditions among states and selected local areas --- Behavioral Risk Factor Surveillance System, United States, 2009.

PROBLEM: Chronic diseases and conditions (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors and conditions (e.g., smoking, physical inactivity, poor diet, excessive drinking, and obesity) and using preventive health-care services (e.g., physical examination, vaccination, screening for high blood pressure and high cholesterol, consumption of fruits and vegetables, and participation in regular leisure-time physical activity) can reduce morbidity and mortality from chronic diseases. REPORTING PERIOD: January 2009--December 2009. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based random-digit--dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors and conditions, chronic diseases and conditions, access to health care, and use of preventative health services and practices related to the leading causes of death and disabilities in the United States. This report presents results for 2009 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 180 metropolitan and micropolitan statistical areas (MMSAs), and 283 selected counties. RESULTS: In 2009, the estimated prevalence of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairments and disabilities varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topics. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior, as reported by the survey respondent. Adults who reported having fair or poor health: 10.1%--30.9% for states and territories, 7.9%--25.8% for MMSAs, and 4.5%--26.1% for counties. Adults with health-care coverage: 71.4%--94.7% for states and territories, 52.7%--96.3% for MMSAs, and 52.7%--97.6% for counties. Annual routine physical checkup among adults aged ≥18 years: 55.8%--79.3% for states and territories, 51.8%--80.7% for MMSAs, and 49.2%--83.5% for counties. Annual influenza vaccination among adults aged ≥65 years: 26.8%--76.8% for states and territories, 55.4%--81.4% for MMSAs, and 50.5%--83.5% for counties. Pneumococcal vaccination among adults aged ≥65 years: 19.1%--73.9% for states and territories, 52.9%--81.3% for MMSAs, and 41.9%--82.0% for counties. Adults who had their cholesterol checked within the preceding 5 years: 67.5%--85.3% for states and territories, 58.2%--88.8% for MMSAs, and 58.2%--92.4% for counties. Adults who consumed at least five servings of fruits and vegetables per day: 14.6%--31.5% for states and territories, 12.6%--33.0% for MMSAs, and 13.4%--34.9% for counties. Adults who engaged in moderate or vigorous physical activity: 28.0%--60.7% for states and territories, 34.6%--64.9% for MMSAs, and 33.6%--67.3% for counties. Adults who engaged in only vigorous physical activity: 13.7%--40.1% for states and territories, 13.8%--43.3% for MMSAs, and 14.2%--50.0% for counties. Current cigarette smoking among adults: 6.4%--25.6% for states and territories, 5.7%--29.0% for MMSAs, and 5.6%--29.8% for counties. Binge drinking among adults: 6.8%--23.9% for states and territories, 3.5%--23.2% for MMSAs, and 3.4%--26.3% for counties. Heavy drinking among adults: 1.9%--8.1% for states and territories, 1.0%--11.1% for MMSAs, and 0.9%--11.1% for counties. Adults who reported no leisure-time physical activity: 15.8%--45.6% for states and territories, 13.3%--40.2% for MMSAs, and 10.5%--40.2% for counties. Adults aged ≥18 years who were overweight: 31.6%--38.7% for states and territories, 28.7%--44.1% for MMSAs, and 25.6%--46.7% for counties. Adults aged ≥20 years who were obese: 19.7%--36.0% for states and territories, 15.4%--43.6% for MMSAs, and 13.8%--45.7% for counties. Adults aged ≥18 years who did not get enough rest or sleep: 34.3%--52.6% for states and territories, 28.2%--54.8% for MMSAs, and 24.5%--55.6% for counties. Adults who had received a high blood pressure diagnosis: 22.1%--38.5% for states and territories, 18.8%--43.9% for MMSAs, and 17.2%--43.6% for counties. Adults who had a high blood cholesterol diagnosis: 24.9%--42.2% for states and territories, 27.5%--47.8% for MMSAs, and 26.7%--51.4% for counties. Adults who had received a diagnosis of coronary heart disease: 2.5%--10.3% for states and territories, 2.6%--11.6% for MMSAs, and 1.6%--12.3% for counties. Adults who had received a stroke diagnosis: 1.4%--3.9% for states and territories, 0.8%--5.9% for MMSAs, and 0.8%--6.6% for counties. Adults who had received a diabetes diagnosis: 5.8%--12.9% for states and territories, 2.8%--15.4% for MMSAs, and 2.8%--14.7% for counties. Adults who had received a cancer diagnosis: 3.0%--12.6% for states and territories, 5.8%--15.1% for MMSAs, and 3.9%--16.2% for counties. Adults who had asthma: 4.4%--11.1% for states and territories, and 3.2%--15.3% for MMSAs, and 3.2%--15.7% for counties. Adults who had arthritis: 10.7%--35.6% for states and territories, 16.2%--36.0% for MMSAs, and 12.6%--39.4% for counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10.2%--27.1% for states and territories, 13.1%--33.7% for MMSAs, and 10.4%--36.1% for counties. Adults who required special equipment because of health problems: 3.6%--10.2% for states and territories, 3.4%--11.5% for MMSAs, and 1.7%--13.0% for counties. INTERPRETATION: The findings in this report indicate substantial variations in self-rated general health status, health-care coverage, use of preventive health-care services, health risk behaviors and health conditions, cardiovascular conditions, other chronic diseases, and health impairments and disabilities among U.S. adults at the state and territory, MMSA, and county levels. The findings show that Healthy People 2010 objectives had not been met in many areas by 2009, which underscores the continued need for surveillance of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairment and disability. PUBLIC HEALTH ACTION: Data on health risk behaviors, chronic health conditions, preventive care practices, and chronic diseases are used to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels.. The overarching goals of Healthy People 2010 are to increase quality and years of healthy life and to eliminate health disparities. Local and state health departments and federal agencies should continue to use BRFSS data to identify populations at high risk for certain health risk behaviors and conditions, cardiovascular conditions, and other chronic diseases and to evaluate the use of preventive health-care services. In addition, BRFSS data can be used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality.

PHQ-8 Days: a measurement option for DSM-5 Major Depressive Disorder (MDD) severity.

BACKGROUND: Proposed draft diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) suggest that dimensional assessments can supplement dichotomous diagnoses by incorporating measures of severity, frequency, and duration, providing the ability to monitor changes in symptoms over time and to guide appropriate treatment. METHODS: This report is based on data from the Behavioral Risk Factor Surveillance System 2006 from 198,678 survey participants who responded to all eight Patient Health Questionnaire (PHQ-8) items. We evaluated use of the days version of the PHQ-8 to determine an optimal cut-point for identifying respondents with depression and to evaluate the performance characteristics of the PHQ-8 at this cut-point. RESULTS: A PHQ-8 score of 55 or more days was determined to be the optimal cut-point when compared to the DSM-derived PHQ-8 algorithm for a major depressive episode (five or more symptoms present "more than half the days," at least one of which must be anhedonia or depression). In the full sample, the sensitivity and the specificity of this cut-point were 0.91 (0.90-0.93) and 0.99 (0.99-0.99), respectively. CONCLUSION: The days version of the PHQ-8 may be a valuable dimensional alternative to the traditional PHQ-8 by offering finer granularity of dimensionality (a score of 0 to 112).