Frequent Mental Distress Among Adults, by Disability Status, Disability Type, and Selected Characteristics – United States, 2018

Frequent mental distress, defined as 14 or more self-reported mentally unhealthy days in the past 30 days,· is associated with adverse health behaviors, increased use of health services, mental disorders (e.g., diagnosis of major depressive disorder), chronic diseases, and functional limitations (1). Adults with disabilities more often report depression and anxiety (2), reduced health care access (3), and health-related risk behaviors (4) than do adults without disabilities. CDC analyzed 2018 Behavioral Risk Factor Surveillance System (BRFSS) data to compare the prevalence of frequent mental distress among adults with disabilities with that among adults without disabilities and to identify factors associated with mental distress among those with disabilities. Nationwide, an estimated 17.4 million adults with disabilities reported frequent mental distress; the prevalence of reported mental distress among those with disabilities (32.9%) was 4.6 times that of those without disabilities (7.2%). Among adults with disabilities, those with both cognitive and mobility disabilities most frequently reported mental distress (55.6%). Adults with disabilities who reported adverse health-related characteristics (e.g., cigarette smoking, physical inactivity, insufficient sleep, obesity, or depressive disorders) or an unmet health care need because of cost also reported experiencing more mental distress than did those with disabilities who did not have these characteristics. Adults living below the federal poverty level reported mental distress 70% more often than did adults in higher income households. Among states, age-adjusted prevalence of mental distress among adults with disabilities ranged from 25.2% (Alaska) to 42.9% (New Hampshire). Understanding the prevalence of mental distress among adults with disabilities could help health care providers, public health professionals, and policy makers target interventions and inform programs and policies to ensure receipt of mental health screening, care, and support services to reduce mental distress among adults with disabilities.

BRFSS is an annual, landline and cellular telephone-based self-reported survey of noninstitutionalized U.S. adults aged >18 years.! In 2018, the BRFSS unweighted sample size was 430,949. The combined (landline and cellular telephone) median response rate among the 50 states and the District of Columbia in 2018 was 49.9% (range = 38.8%-67.2%). Adults were considered to have a disability if they reported having one or more of six disability types: hearing, vision, cognition, mobility, self-care, or independent living.^·· Mutually exclusive disability categories were created for each disability type and for adults reporting more than one disability. The latter were further categorized into four groups, based on cognition or mobility, two of the most prevalent disability types: cognition-only, mobility-only, both, or neither. Adults were considered to have frequent mental distress if they reported 14 or more days 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?

CDC compared the prevalence of mental distress among adults with and without disabilities by disability type and selected demographic characteristics that included sex, age, race/ethnicity, veteran status, marital status, employment status, sexual identity,!"! federal poverty level, and urban/rural designation. CDC calculated age-standardized^ prevalences, 95% confidence intervals, and age-adjusted··· prevalence ratios (PRs) to compare mental distress among adults with disabilities with that among those without disabilities. Among adults with disabilities, CDC compared age-standardized prevalences of mental distress by disability type and healthrelated characteristics, including health care access,!"!"! healthrelated behaviors, obesity,^ and a diagnosed depressive disorder.···· Age-standardized prevalence estimates and ageadjusted PRs of mental distress were calculated among adults with disabilities by state of residence. Missing responses to questions about disability and mental distress were excluded from analyses, resulting in a total unweighted analytic sample size of404,973. For all comparisons, statistical significance at a level of a = 0.05 was determined using a two-sided t-test in SAS-callable SUDAAN (version 11.0.1; RTI International).

Overall, 26.2% of U.S. adults who responded to questions about disability and mental distress reported having a disability. Nearly one third of adults with disabilities (32.9%) reported experiencing frequent mental distress, compared with 7.2% of adults without disabilities (PR = 4.6) (Table 1). Frequent mental distress was reported by 55.6% of those with disability in both mobility and cognition, 8.8 times that reported among those without disabilities. Demographic differences in PRs of mental distress were generally similar among adults with and without disabilities, except for veteran and employment status. Mental distress was more commonly reported among females and persons who were unmarried; unemployed; identified as lesbian or gay, bisexual, or something else; and lived in lowerincome households compared with males and those who were married, employed, identified as straight or not gay, and lived in higher-income households. Persons identifying as nonHispanic Asian, Hispanic, and middle-aged or older reported mental distress less often than did those who identified as nonHispanic white, and who were younger. Among adults without disabilities, both veterans and retirees were 20% less likely to report mental distress than were nonveterans and adults who were employed; no differences were found by veteran and employment status for adults with disabilities.

Among adults with disabilities, those who reported adverse health-related behaviors or conditions (i.e., cigarette smoking, insufficient sleep, physical inactivity, obesity, and diagnosed depressive disorder) or an unmet health care need because of cost more often had frequent mental distress than did those without these characteristics (Table 2). In general, patterns were similar across disability types. All health-related factors were associated with mental distress for adults without disabilities (Supplementary Table 1, https://stacks.cdc.gov/ view/cdc/92748). Among adults with disabilities, the highest prevalences of frequent mental distress were in New Hampshire (42.9%), South Carolina (39.2%), and Maine (38.7%); the median prevalence (32.5%) was in Louisiana; and the lowest prevalences were in Alaska (25.2%), Hawaii (26.7%), and Illinois (26.9%) (Figure) (Supplementary Table 2, https://stacks. cdc.gov/view/cdc/92748). Adults with disabilities in Minnesota, Kansas, Georgia, Iowa, and Delaware were 5.4-5.7 times more likely to report frequent mental distress than were adults without disabilities, whereas in Illinois and West Virginia, the PRs were 3.5 and 3.6, respectively (Figure) (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/92748).

Discussion

In 2018, an estimated 17.4 million U.S. adults with disabilities reported frequent mental distress across a range of demographic characteristics (including poverty and marital status), 4.6 times as often than did adults without disabilities. Having a diagnosed depressive disorder was associated with experiencing frequent mental distress, with approximately one half of adults with disabilities and a diagnosed depressive disorder reporting distress. One in six adults with disabilities who did not have a diagnosed depressive disorder reported frequent mental distress, possibly representing adults with undiagnosed mental disorders. Health care providers caring for adults with disabilities might focus on the primary disability but miss opportunities to identify and treat co-occurring mental health conditions (5). Furthermore, symptoms associated with some physical disabilities and chronic conditions, as well as overall level of functional impairment, might be exacerbated by mental distress and might improve with mental health treatment (6). To ensure recommended clinical management and referral, providers could consider screening their clients for mental health symptoms, even if mental health concerns are unrelated to the primary condition for which adults are being seen. To promote overall well-being, health care providers and public health professionals can also focus on promoting healthy lifestyles, such as maintaining a healthy weight, meeting physical activity recommendations, quitting smoking, and getting sufficient sleep,!"!!"! given that these findings indicate unhealthy lifestyles are associated with mental distress.

In one 6-year longitudinal study, increases in social support were associated with decreases in depressive symptoms among adults with physical disabilities (7). Adults with disabilities might have fewer opportunities for high-quality social engagement because of physical limitations (8) or reduced ability to communicate (9), placing them at increased risk for experiencing mental distress. The findings of reduced mental distress among adults with disabilities who are married and employed, two factors known to correlate with social ties and support (10), suggest that programs aimed at increasing social connectedness might help reduce the large disparity in mental distress between adults with and without disabilities.

Because health care access concerns are prevalent among adults with disabilities (3), the finding that adults with a costrelated unmet health care need during the past 12 months more often reported mental distress is particularly concerning. Policies, such as the Affordable Care Act, put into place to improve health care access among adults with disabilities (particularly those living in lower-income households) might help address disparities in mental distress.

The findings in this report are subject to at least four limitations. First, causality cannot be inferred from data in this cross-sectional survey; disability or adverse health-related behaviors might cause mental distress, and such distress might worsen disability or increase risk. Second, social desirability bias can result in underreporting of mental health symptoms in survey data. Third, prevalence of mental distress might be underestimated if adults with severe functional and cognitive disabilities (with potentially higher distress) are underrepresented in BRFSS data. Finally, disability categories captured in BRFSS are broad, and the primary disabling condition was unknown. Considering that 4.6% of the noninstitutionalized U.S. population had a serious mental illness in 2018, diagnosed mental disorders not assessed in BRFSS might explain in part the high prevalence of frequent mental distress among adults reporting cognitive disabilities.

This report highlights disparities in prevalence of frequent mental distress by disability status, disability type, and several demographic and health-related risk factors associated with mental and physical health. Public health professionals, policy makers, and health care providers can consider recommending strategies that increase social cohesion, encourage community participation, and improve access to quality mental health screening and care, as well as promoting healthy lifestyle recommendations and inclusion in evidence-based programs to address disparities in mental distress. Increasing provider awareness of the importance of mental health screening could help improve identification and treatment of co-occurring mental health conditions, especially among adults with cognitive and mobility disabilities who are approximately nine times as likely to have frequent mental distress as are adults without disabilities. Future work to better understand mental distress among adults with disabilities could help target interventions, whether as stand-alone approaches or components of existing disease prevention and health promotion strategies.

Acknowledgments

NaTasha Hollis, Coleen Boyle, Stuart Shapira, Marshalyn YearginAllsopp, National Center on Birth Defects and Developmental Disabilities, CDC; staff members, Population Health Surveillance Branch, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; state coordinators, Behavioral Risk Factor Surveillance System.

Corresponding author: Robyn A. Cree, [email protected], 404-498-5300.