Geographic Patterns of Frequent Mental Distress

U.S. Adults, 1993–2001 and 2003–2006


      Mental illnesses and other mental health problems often lead to prolonged, disabling, and costly mental distress. Yet little is known about the geographic distribution of such mental distress in the U.S.


      Since 1993, the CDC has tracked self-perceived mental distress through the Behavioral Risk Factor Surveillance System (BRFSS). In 2007 and 2008, analysis was performed on BRFSS data reported by 2.4 million adults from 1993–2001 and 2003–2006 to map and describe the prevalence of frequent mental distress (FMD)—defined as having ≥14 mentally unhealthy days during the previous 30 days—for all states and for counties with at least 30 respondents.


      The adult prevalence of FMD for the combined periods was 9.4% overall, ranging from 6.6% in Hawaii to 14.4% in Kentucky. From 1993–2001 to 2003–2006, the mean prevalence of FMD increased by at least 1 percentage point in 27 states and by more than 4 percentage points in Mississippi, Oklahoma, and West Virginia. Most states showed internal geographic variations in FMD prevalence. The Appalachian and the Mississippi Valley regions had high and increasing FMD prevalence, and the upper Midwest had low and decreasing FMD prevalence.


      Geographic areas were identified with consistently high and consistently low FMD prevalence, as well as areas in which FMD prevalence changed substantially. Further evaluation of the causes and implications of these patterns is warranted. Surveillance of mental distress may be useful in identifying unmet mental health needs and disparities and in guiding health-related policies and interventions.
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        • CDC
        Measuring healthy days: population assessment of health-related quality of life.
        CDC, Atlanta GA2000
        • McGuire T.
        • Wells K.B.
        • Bruce M.L.
        • et al.
        Burden of illness.
        Ment Health Serv Res. 2002; 4: 179-185
        • WHO
        The world health report—2001: mental health.
        WHO, Geneva2001
        • Druss B.G.
        • Wang P.S.
        • Sampson N.A.
        • et al.
        Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey Replication.
        Arch Gen Psychiatry. 2007; 64: 1196-1203
        • Schwartz C.
        Distinguishing distress from disorder as psychological outcomes of stressful social arrangements: can we and should we?.
        Health (London). 2007; 11: 291-299
        • Mrazek P.J.
        • Haggerty R.J.
        Reducing risks for mental disorders: frontiers for preventive intervention.
        National Academies Press, Washington DC1994
        • Mechanic D.
        Mental health policy at the millennium: challenges and opportunities.
        in: Mental health, U.S., 2000. Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Rockville MD2000
        • Horwitz A.V.
        Distinguishing distress from disorder as psychological outcomes of stressful social arrangements.
        Health (London). 2007; 11: 273-289
        • American Psychiatric Association
        Consumer & family information: distress, stress, or mental disorder?.
        Psychiatr Serv. 2002; 53: 133
        • Mueller D.P.
        • Edwards D.W.
        • Yarvis R.M.
        Stressful life events and psychiatric symptomatology: change or undesirability?.
        J Health Soc Behav. 1977; 18: 307-317
        • Ford J.D.
        • Adams M.L.
        • Dailey W.F.
        Psychological and health problems in a geographically proximate population time-sampled continuously for three months after the September 11th, 2001 terrorist incidents.
        Anxiety Stress Coping. 2007; 20: 129-146
        • Goldberg D.
        A classification of psychological distress for use in primary care settings.
        Soc Sci Med. 1992; 35: 189-193
        • Strine T.W.
        • Chapman D.P.
        • Kobau R.
        • Balluz L.I.
        • Mokdad A.H.
        Depression, anxiety, and physical impairments and quality of life in the U.S. non-institutionalized population.
        Psychiatr Serv. 2004; 55: 1408-1413
        • Brown D.W.
        • Balluz L.S.
        • Ford E.S.
        • et al.
        Associations between short- and long-term unemployment and frequent mental distress among a national sample of men and women.
        J Occup Environ Med. 2003; 45: 1159-1166
        • Zahran H.S.
        • Kobau R.
        • Moriarty D.G.
        • Zack M.M.
        • Holt J.
        • Donehoo R.
        Health-related quality of life surveillance—U.S., 1993–2002.
        MMWR Surveill Summ. 2005; 54: 1-35
        • CDC
        Health-related quality of life prevalence data.
        • Raeburn M.
        Mental distress—how to help.
        (Glasgow, Scotland: Scottish Association for Mental Health Information Service)
        • Thurston-Hicks A.
        • Paine S.
        • Hollifield M.
        Functional impairment associated with psychological distress and medical severity in rural primary care patients.
        Psychiatr Serv. 1998; 49: 951-955
        • Walker A.E.
        Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia.
        Chronic Illn. 2007; 3: 202-218
        • Hall E.
        • Johnson E.J.
        Suicide and suicidal thoughts by Oregonians.
        Oregon Center for Health Statistics, Portland OR1997
        • Lewinsohn P.M.
        • Rohde P.
        • Seeley J.R.
        Psychosocial risk factors for future adolescent suicide attempts.
        J Consult Clin Psychol. 1994; 62: 297-305
        • Cook E.L.
        • Harman J.S.
        A comparison of health-related quality of life for individuals with mental health disorders and common chronic medical conditions.
        Public Health Rep. 2008; 123: 45-51
        • Olatunji B.O.
        • Cisler J.M.
        • Tolin D.F.
        Quality of life in the anxiety disorders: a meta-analytic review.
        Clin Psychol Rev. 2007; 27: 572-581
        • Mechanic D.
        Is the prevalence of mental disorders a good measure of the need for services?.
        Health Affairs. 2003; 22: 8-20
        • Coker A.L.
        • McKeown R.E.
        • Sanderson M.
        • et al.
        Severe dating violence and quality of life among South Carolina high school students.
        Am J Prev Med. 2000; 19: 220-227
        • Bensley L.
        • Van Eenwyk J.
        • Wynkoop-Simmons K.
        Childhood family violence history and women's risk for intimate partner violence and poor health.
        Am J Prev Med. 2003; 25: 38-44
        • Schneiderman N.
        • Ironson G.
        • Siegel S.D.
        Stress and health: psychological, behavioral, and biological determinants.
        Ann Rev Clin Psychol. 2005; 1: 607-628
        • Alhuwalia I.B.
        • Mack K.A.
        • Mokdad A.H.
        Mental and physical distress and high-risk behaviors among reproductive-age women.
        Obstet Gynecol. 2004; 104: 477-483
        • Strine T.W.
        • Balluz L.I.
        • Chapman D.P.
        • Moriarty D.G.
        • Owens M.G.
        • Mokdad A.H.
        Risk behaviors and health care coverage among adults by frequent mental distress status, 2001.
        Am J Prev Med. 2004; 26: 213-216
        • Calsyn R.J.
        • Winter J.P.
        Predicting four types of service needs in older adults.
        Eval Program Plann. 2001; 24: 157-166
        • Dominick K.L.
        • Ahern F.M.
        • Gold C.H.
        • Heller D.A.
        Relationship of health-related quality of life to health care utilization and mortality among older adults.
        Aging Clin Exp Res. 2002; 14: 499-508
        • Kimerling R.
        • Baumrind N.
        Access to specialty mental health services among women in California.
        Psychiatr Serv. 2005; 56: 729-734
        • Ford J.D.
        • Adams M.L.
        • Dailey W.F.
        Factors associated with receiving help and risk factors for disaster-related distress among Connecticut adults 5–15 months after the September 11th terrorist incidents.
        Soc Psychiatry Psychiatr Epidemiol. 2006; 41: 261-270
        • Adams M.L.
        • Ford J.D.
        • Dailey W.F.
        Predictors of help seeking among Connecticut adults after September 11, 2001.
        Am J Public Health. 2004; 94: 1596-1602
        • Druss B.G.
        • Marcus S.C.
        Use of psychotropic medications before and after Sept. 11, 2001.
        Am J Psychiatry. 2004; 161: 1377-1383
        • Druss B.G.
        • Henderson K.L.
        • Rosenheck R.A.
        Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina.
        Am J Psychiatry. 2007; 164: 154-156
        • Holley H.L.
        Geography and mental health: a review.
        Soc Psychiatry Psychiatr Epidemiol. 1998; 33: 535-542
        • Durkheim E.
        Routledge and Kegan Paul, London1952
        • Mark T.L.
        • Shern D.L.
        • Bagalman J.E.
        • Cao Z.
        Ranking America's mental health: an analysis of depression across the states.
        • Giles-Sims J.
        • Lockhart C.
        Explaining cross-state differences in elderly suicide rates and identifying state-level public policy responses that reduce rates.
        Suicide Life Threat Behav. 2006; 36: 694-708
      1. Indicators of mental health.
        in: Herrman H. Saxena S. Moodie R. Promoting mental health: concepts, emerging evidence, practice. WHO, Geneva2005
        • McCarthy J.
        • Davidson I.
        Suicide as an indicator of mental health (letter).
        Br Med J. 1994; 309: 58-59
        • Straus M.A.
        • Linsky A.S.
        • Bachman-Prehn R.
        Change in the stressfulness of life in American states and regions from 1976 to 1982.
        Soc Indic Res. 1989; 21: 229-257
        • Gurin G.
        • Veroff J.
        • Feld S.
        Americans view their mental health—a nationwide interview survey.
        Basic Books, New York1960
        • Rief W.
        • Fichter M.
        The symptom check list SCL-90-R and its ability to discriminate between dysthymia, anxiety disorders, and anorexia nervosa.
        Psychopathology. 1992; 25: 128-138
        • Burvill P.W.
        • Knuiman M.W.
        Which version of the General Health Questionnaire should be used in community studies?.
        Aust N Z J Psychiatry. 1983; 17: 237-242
        • Strine T.W.
        • Kobau R.
        • Chapman D.P.
        • Thurman D.J.
        • Price P.
        • Balluz L.S.
        Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: results from the 2002 National Health Interview Survey.
        Epilepsia. 2005; 46: 1133-1139
        • Harris K.M.
        • Carpenter C.
        • Bao Y.
        The effects of state parity laws on the use of mental health care.
        Med Care. 2006; 44: 499-505
        • Hagman B.T.
        • Delnevo C.D.
        • Hrywna M.
        • Williams J.M.
        Tobacco use among those with serious psychological distress: results from the National Survey of Drug Use and Health, 2002.
        Addict Behav. 2008; 33: 582-592
        • CDC
        Health-related quality of life—Los Angeles County, California, 1999.
        MMWR Morb Mortal Wkly Rep. 2001; : 556-559
        • Community Health Improvement Partners (CHIP)
        Charting the course IV—CHIP needs assessment 2004.
        San Diego County, San Diego CA2004
        • Seattle and King County
        Health of King County 2006.
        • Boston Public Health Commission
        The health of Boston 2002.
        Boston Public Health Commission Research Office, Boston MA2002
        • Hennepin County Community Health Department
        SHAPE 2002: a preview, survey of the health of adults, the population and the environment.
        Hennepin County Community Health Department and Bloomington Division of Public Health, Minneapolis MN2003
        • Plapinger J.D.
        • Miller R.A.
        • Wunsch-Hitzig R.
        • et al.
        New York City Mental Health Local Plan—FY2007.
        New York City Department of Health and Mental Hygiene, Bureau of Planning, Evaluation, and Quality Improvement, New York2007
        • CDC
        State and community health profiles.
        • CDC and The Merck Company Foundation
        The state of aging and health in America 2007.
        The Merck Company Foundation, Whitehouse Station NJ2007
        • CDC
        Self-reported frequent mental distress among adults—U.S., 1993–1996.
        MMWR Morb Mortal Wkly Rep. 1998; 47: 325-331
        • CDC
        Self-reported frequent mental distress among adults—U.S., 1993–2001.
        MMWR Morb Mortal Wkly Rep. 2004; 53: 963-966
        • Zack M.M.
        • Moriarty D.G.
        • Stroup D.F.
        • Ford E.S.
        • Mokdad A.H.
        Worsening trends in adult health-related quality of life and self-rated health—U.S., 1993–2001.
        Public Health Rep. 2004; 119: 493-505
        • Moriarty D.G.
        • Zack M.M.
        • Kobau R.
        The Centers for Disease Control and Prevention's healthy days measures—population tracking of perceived physical and mental health over time.
        Health Qual Life Outcomes. 2003; 1: 1-8
        • CDC
        Public health surveillance for behavioral risk factors in a changing environment: recommendations from the Behavioral Risk Factor Surveillance Team.
        MMWR Recomm Rep. 2003; 52: 1-2
        • Hansen Simonson K.
        • Surveillance Research Program, NCI
        Headbang software, version 3.0.
        (Bethesda MD: National Cancer Institute, Statistical Research and Applications Branch)
        • Mungiole M.
        • Pickle L.W.
        • Simonson K.H.
        Application of a weighted head-banging algorithm to mortality data maps.
        Stat Med. 1999; 18: 3201-3209
        • Pickle L.W.
        • Yuchen S.
        Within-state geographic patterns of health insurance coverage and health risk factors in the U.S..
        Am J Prev Med. 2002; 22: 75-83
        • Buescher P.A.
        Age-adjusted death rates, statistical primer (No. 13).
        North Carolina Department of Health and Human Services, Raleigh NC1998
        • Feinleib M.
        • Zarate A.O.
        Reconsidering age adjustment procedures: workshop proceedings.
        Vital Health Stat. 1992; 4 (4): 3-83
        • Brown D.W.
        • Balluz L.S.
        • Giles W.H.
        • et al.
        Diabetes mellitus and health-related quality of life among older adults.
        Diabetes Res Clin Pract. 2004; 65: 105-115
        • Davis S.
        Requirements for population data.
        Recommended standards for mental health population data, 2006. 2006
        • CDC
        State differences in reported healthy days among adults—U.S., 1993–1996.
        MMWR Wkly Rep. 1998; 47: 239-244
        • Okoro C.A.
        • Strine T.W.
        • McGuire L.
        • Balluz L.S.
        • Mokdad A.H.
        Employment status and frequent mental distress among adults with disabilities.
        Occup Med (Lond). 2007; 57: 217-220
        • Larson R.J.
        • Welch H.G.
        Risk for increased utilization and adverse health outcomes among men served by the Veterans Health Administration.
        Mil Med. 2007; 172: 690-696
        • Mody R.R.
        • Smith M.J.
        Smoking status and health-related quality of life: findings from the 2001 Behavioral Risk Factor Surveillance System data.
        Am J Health Promot. 2006; 20: 251-258
        • OKoro C.A.
        • Mokdad A.H.
        • Brewer R.D.
        • Naimi T.S.
        • Moriarty D.G.
        • Giles W.H.
        Binge drinking and health-related quality of life: do popular perceptions match reality?.
        Am J Prev Med. 2004; 26: 230-232
        • Openshaw S.
        The modifiable areal unit problem.
        Geo Books, Norwich, England1984
        • Jia H.
        • Muennig P.
        • Lubetkin E.I.
        • Gold M.R.
        Predicting geographical variations in behavioural risk factors: an analysis of physical and mental healthy days.
        J Epidemiol Community Health. 2004; 58: 150-155