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      Mental Health and Substance Use Among Adults with Disabilities During the COVID-19 Pandemic — United States, February–March 2021

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          Adults with disabilities, a group including >25% of U.S. adults ( 1 ), experience higher levels of mental health and substance use conditions and lower treatment rates than do adults without disabilities* ( 2 , 3 ). Survey data collected during April–September 2020 revealed elevated adverse mental health symptoms among adults with disabilities ( 4 ) compared with the general adult population ( 5 ). Despite disproportionate risk for infection with SARS-CoV-2, the virus that causes COVID-19, and COVID-19–associated hospitalization and mortality among some adults with disabilities ( 6 ), information about mental health and substance use in this population during the pandemic is limited. To identify factors associated with adverse mental health symptoms and substance use among adults with disabilities, the COVID-19 Outbreak Public Evaluation (COPE) Initiative † administered nonprobability–based Internet surveys to 5,256 U.S. adults during February–March 2021 (response rate = 62.1%). Among 5,119 respondents who completed a two-item disability screener, nearly one third (1,648; 32.2%) screened as adults with disabilities. These adults more frequently experienced symptoms of anxiety or depression (56.6% versus 28.7%, respectively), new or increased substance use (38.8% versus 17.5%), and suicidal ideation (30.6% versus 8.3%) than did adults without disabilities. Among all adults who had received a diagnosis of mental health or substance use conditions, adults with disabilities more frequently (42.6% versus 35.3%; p <0.001) reported that the pandemic made it harder for them to access related care or medication. Enhanced mental health and substance use screening among adults with disabilities and improved access to medical services are critical during public health emergencies such as the COVID-19 pandemic. During February 16–March 8, 2021, among 8,475 eligible invited respondents aged ≥18 years, 5,261 (62.1%) completed nonprobability based, English-language, Internet-based Qualtrics surveys for COPE. § Participants provided informed consent electronically. Quota sampling and survey weighting were used to match U.S. Census Bureau’s 2019 American Community Survey adult U.S. population estimates for sex, age, and race/ethnicity to enhance the representativeness of this nonrandom sample. Among 5,256 respondents who answered questions for weighting variables, 5,119 (97.4%) completed a two-question disability screener. ¶ Respondents completed clinically validated self-screening instruments for symptoms of anxiety and depression** and reported past-month new or increased substance use to cope with stress or emotions and serious suicidal ideation. †† Respondents also indicated prepandemic and past-month use of seven classes §§ of substances to cope with stress or emotions. Adults with diagnosed anxiety, depression, posttraumatic stress disorder, or substance use disorders indicated whether their ability to access care or medications for these conditions was easier, harder, or unaffected because of the pandemic. Prevalence estimates for adverse mental health symptoms and substance use were compared among adults with and without disabilities using chi-square tests. Multivariable Poisson regression models with robust standard error estimators were used to estimate adjusted prevalence ratios (aPRs) by symptom type among adults with and without disabilities. To calculate associations between disability status and adverse mental health symptoms or substance use over time, aPRs were estimated for symptoms among unique participants in previous COPE survey waves (June, September, and December 2020). Covariates ¶¶ included sex, age group, race/ethnicity, income, U.S. Census region, urbanicity, and parental or unpaid caregiving roles.*** McNemar’s test assessed prepandemic and past-month substance use among adults with and without disabilities. Analyses were conducted using Python software (version 3.7.8; Python Software Foundation) and R statistical software (version 4.0.2; R Foundation) using the R survey package (version 3.29; R Foundation). The Monash University Human Research Ethics Committee reviewed and approved the study. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy. ††† Among a total of 5,119 respondents, 1,648 (32.2%) respondents reported living with disabilities (778 [47.2%] with limiting physical, mental, or emotional conditions only; 171 [10.4%] with health conditions requiring special equipment only; and 669 [42.4%] with both types of conditions) (Table). Overall, 64.1% of adults with disabilities reported adverse mental health symptoms or substance use compared with 36.0% of adults without disabilities; past-month substance use was higher among adults with disabilities (40.6%) than among adults without disabilities (24.5%). Prevalence estimates of each of the following were higher among adults with disabilities than among adults without disabilities: symptoms of anxiety or depression (56.6% versus 28.7%, respectively), new or increased substance use (38.8% versus 17.5%), and serious suicidal ideation (30.6% versus 8.3%) (Supplementary Table, https://stacks.cdc.gov/view/cdc/108999). At all timepoints, aPRs for all symptom types were significantly higher among adults with disabilities than among adults without disabilities (Figure 1). During February 16–March 8, 2021, among adults with disabilities, aPRs for symptoms of anxiety or depression and new or increased substance use were approximately 1.5 times as high, and the aPR for serious suicidal ideation was approximately 2.5 times as high as in adults without disabilities. Comparing subgroups of adults with and without disabilities, symptoms of anxiety or depression were approximately twice as prevalent among adults with disabilities who were aged ≥50 years (aPR = 2.4; 95% confidence interval [CI] = 1.7–3.2), those of non-Hispanic Asian race/ethnicity (2.4; 95% CI = 1.3–4.8), those of Hispanic or Latino (Hispanic) ethnicity (2.1; 95% CI = 1.4–3.0), and those who were not in parental or caregiver roles (2.1; 95% CI = 1.7–2.6). New or increased substance use was approximately twice as prevalent among adults with disabilities in parental roles only (2.4; 95% CI = 1.5–3.9) and among essential workers (2.3; 95% CI = 2.0–2.7). Suicidal ideation was also more prevalent among adults with disabilities aged ≥50 years (4.0; 95% CI = 2.1–7.8), those of Hispanic ethnicity (3.4; 95% CI = 1.9–6.0), adults in unpaid caregiving roles (3.4; 95% CI = 1.5–7.7), and essential (3.5; 95% CI = 2.8–4.4) or nonessential (5.3; 95% CI = 2.8–10.1) workers. TABLE Prevalence of symptoms of anxiety or depression, substance use, and suicidal ideation among adults with disabilities, by disability status and other characteristics — United States, February 16–March 8, 2021 Characteristic No. (%) Adults with disabilities, No. (%)* All respondents Adults with disabilities Symptoms of anxiety or depression† New or increased substance use to cope§ Seriously considered suicide¶ One or more of these symptoms Total 5,119 (100) 1,648 (32.2) 932 (56.6) 640 (38.8) 504 (30.6) 1,057 (64.1) Disability screener** Limited by a physical, mental, or emotional condition 778 (15.2) 778 (47.2) 417 (53.7) 218 (28.0) 148 (19.0) 465 (59.8) Limited by a health condition that requires special equipment 171 (3.3) 171 (10.4) 104 (60.5) 88 (51.5) 65 (38.2) 123 (71.8) Both of above 699 (13.7) 669 (42.4) 411 (58.8) 334 (47.8) 291 (41.5) 469 (67.1) Neither of above 3,471 (67.8) 0 (—) N/A N/A N/A N/A Sex †† Female 2,499 (48.8) 789 (47.9) 445 (56.5) 260 (32.9) 178 (22.6) 501 (63.5) Male 2,583 (50.5) 838 (50.8) 469 (55.9) 369 (44.0) 314 (37.4) 537 (64.1) Age group, yrs 18–29 938 (18.3) 314 (19.0) 250 (79.8) 185 (59.1) 136 (43.3) 276 (87.8) 30–39 967 (18.9) 325 (19.7) 259 (79.8) 198 (60.9) 166 (51.1) 281 (86.6) 40–49 818 (16.0) 253 (15.4) 180 (70.9) 137 (54.0) 125 (49.5) 202 (79.6) 50–59 972 (19.0) 309 (18.8) 132 (42.6) 80 (25.9) 54 (17.5) 158 (51.2) 60–69 790 (15.4) 235 (14.2) 59 (25.2) 21 (8.9) 4 (1.8) 72 (30.7) ≥70 634 (12.4) 213 (12.9) 52 (24.7) 19 (8.8) 19 (8.8) 68 (31.9) Race/Ethnicity White, non-Hispanic 3,103 (60.6) 975 (59.2) 522 (53.6) 327 (33.5) 266 (27.3) 585 (60.0) Black, non-Hispanic 638 (12.5) 181 (11.0) 99 (54.6) 68 (37.9) 35 (19.3) 110 (60.9) Asian, non-Hispanic 289 (5.6) 65 (3.9) 39 (61.1) 18 (27.8) 14 (21.0) 47 (72.1) Multiple/other race, non-Hispanic§§ 188 (3.7) 70 (4.3) 32 (45.2) 16 (23.3) 13 (18.3) 32 (45.8) Hispanic or Latino, any race 902 (17.6) 357 (21.7) 240 (67.2) 210 (58.8) 177 (49.5) 283 (79.3) 2020 Household income, USD ¶¶ <25,000 1,182 (23.1) 544 (33.0) 286 (52.6) 151 (27.8) 107 (19.7) 327 (60.0) 25,000–49,999 1,203 (23.5) 355 (21.5) 179 (50.4) 110 (30.9) 82 (23.2) 202 (56.9) 50,000–99,999 1,306 (25.5) 350 (21.2) 191 (54.6) 134 (38.2) 103 (29.5) 218 (62.1) ≥100,000 1,204 (23.5) 341 (20.7) 253 (74.1) 232 (68.1) 205 (60.1) 286 (83.8) Education High school diploma or less 1,379 (26.9) 485 (29.4) 264 (54.4) 155 (31.8) 135 (27.9) 309 (63.7) College or some college 2,876 (56.2) 865 (52.5) 463 (53.5) 312 (36.0) 213 (24.6) 520 (60.1) After bachelor's degree 865 (16.9) 298 (18.1) 206 (69.0) 174 (58.2) 156 (52.3) 228 (76.4) Employment status Employed (essential employee) 1,797 (35.1) 605 (36.7) 475 (78.6) 448 (74.2) 371 (61.4) 542 (89.6) Employed (nonessential employee) 941 (18.4) 151 (9.1) 87 (57.9) 53 (35.2) 38 (25.4) 103 (68.3) Unemployed 936 (18.3) 349 (21.2) 190 (54.5) 77 (22.2) 55 (15.9) 207 (59.3) Retired 1,263 (24.7) 493 (29.9) 142 (28.8) 45 (9.1) 24 (4.8) 167 (33.8) Student 182 (3.6) 51 (3.1) 38 (73.7) 16 (31.9) 15 (29.8) 38 (74.5) Parental role and unpaid caregiving status*** Neither parent nor caregiver 2,882 (56.3) 741 (44.9) 294 (39.7) 90 (12.2) 70 (9.4) 323 (43.6) Parent only 611 (11.9) 189 (11.5) 97 (51.3) 48 (25.1) 21 (11.3) 110 (58.0) Caregiver role of adults only 426 (8.3) 117 (7.1) 57 (48.6) 39 (33.1) 24 (20.9) 71 (60.5) Parental and caregiver roles 1,201 (23.5) 602 (36.5) 485 (80.5) 463 (77.0) 389 (64.6) 553 (92.0) U.S. Census region ††† Northeast 899 (17.6) 267 (16.2) 177 (66.0) 119 (44.7) 109 (40.6) 188 (70.5) Midwest 1,069 (20.9) 349 (21.1) 208 (59.8) 126 (36.0) 94 (27.1) 222 (63.6) South 2,074 (40.5) 700 (42.5) 367 (52.4) 262 (37.4) 195 (27.9) 442 (63.1) West 1,077 (21.0) 333 (20.2) 180 (54.2) 133 (40.1) 106 (31.8) 205 (61.7) Urbanicity (n = 5,091)§§§ Urban 4,241 (83.3) 1,313 (79.6) 761 (58.0) 544 (41.4) 440 (33.5) 866 (66.0) Rural 850 (16.7) 322 (19.5) 158 (49.1) 87 (27.1) 56 (17.4) 178 (55.2) Abbreviations: N/A = not applicable; USD = U.S. dollars. * Weighted rounded counts and percentages might not sum to expected values. † Symptoms of anxiety and depression were assessed via the four-item Patient Health Questionnaire (PHQ-4). Respondents who scored ≥3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for these respective conditions. § New or increased substance use was assessed by using the question, “Have you started or increased using substances to help you cope with stress or emotions during the COVID-19 pandemic? Substance use includes alcohol, legal or illegal drugs, or prescription drug use in any way not directed by a doctor.” ¶ Suicidal ideation was assessed by using an item from the National Survey on Drug Use and Health (https://nsduhweb.rti.org/respweb/homepage.cfm) adapted to refer to the previous 30 days, “At any time in the past 30 days, did you seriously think about trying to kill yourself?” ** Adults who had a disability were defined as such based on a qualifying response to either one of two questions: “Are you limited in any way in any activities because of physical, mental, or emotional condition?” and “Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?” Respondents who completed only one of the two disability screening questions (limited by a physical, mental, or emotional condition: 17); limited by a health condition that requires special equipment: 12) were classified as living with only that disability. https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf †† Gender responses of “Transgender” (22; 0.4%) and “None of these” (15; 0.3%) are not shown because of small counts. §§ The non-Hispanic, multiple/other race or multiple races category includes respondents who identified as not Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or any other race. ¶¶ Household income responses of “Prefer not to say” (225) are not shown because of an inability to sufficiently characterize these responses. *** Adults who were in parental or unpaid caregiving roles were self-identified. For this analysis, the definition of unpaid caregivers of adults was having provided unpaid care to a relative or friend ≥18 years to help them take care of themselves at any time during the 3 months before the survey. The definition of someone in a parental role was having provided unpaid care to a relative or friend <18 years. Respondents answered these questions separately. During analysis, all respondents were categorized as being in a parental role only, caregivers of adults only, having both parental and caregiving roles, or having neither parental nor caregiving roles. Adults in parenting roles might not have been natural or legal parents of children in their care. ††† https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf §§§ Invalid postcodes were provided by 28 respondents, for whom urbanicity was not categorized. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html FIGURE 1 Adjusted prevalence ratios* and 95% confidence intervals † for ≥1 symptoms of adverse mental health or substance use (A), symptoms of anxiety or depression (B), new or increased substance use (C), and suicidal ideation (D) among adults with disabilities, compared with adults without disabilities (referent group) § — United States, February 16–March 8, 2021¶ Abbreviations: aPR = adjusted prevalence ratio; CI = confidence interval. * With 95% CIs indicated by error bars. Multivariable Poisson regression models included sex, age group in years, race/ethnicity, income, U.S. Census region, urbanicity, and parental or unpaid caregiving roles (parental roles were not assessed in June 2020; only unpaid caregiving roles were considered for this variable in the June 2020 models). Separate, additional models were run to estimate aPRs for the following employment statuses: essential worker, nonessential worker, and unemployed. Estimates were not made for retired or student employment statuses because of collinearity between these employment statuses and age. † For panels A, B, and C, the y-axis range for aPR estimates is 0–5, which contains all aPRs and 95% CIs for these panels with maximal view of differences in model estimates. For panel D, given the relative rarity of suicidal ideation among some demographic subgroups that results in wide CIs for aPR estimates, the y-axis range is 0–10. § Within each subgroup, adults without disabilities are the reference group used to estimate aPRs for outcomes among adults with disabilities. ¶ Estimated aPRs are during February 16–March 8, 2021, except for the “over time” estimates, which also include estimates based on data collected during June 24–30, 2020, August 28–September 6, 2020, and December 6–27, 2020. Figure consists of four bar graphs that show adjusted prevalence ratios and 95% confidence intervals for mental health and substance use among adults with disabilities versus adults without disabilities, United States, February 16 through March 8, 2021. The prevalence of substance use to cope with stress or emotions among adults with disabilities was higher than that among adults without disabilities, both prepandemic (39.7% versus 25.3%, respectively) and in the past month (40.6% versus 24.5%; both p<0.001) (Figure 2). Among adults with disabilities, the past-month prevalence of methamphetamine use (8.4%), nonopioid prescription drug misuse (4.9%), and polysubstance use (16.9%) was approximately twice as high, and the prevalence of cocaine use (6.4%) and prescription or illicit opioid use (9.1%) were nearly three times as high compared with those among adults without disabilities (methamphetamine use 3.4%; nonopioid prescription drug misuse 2.0%; polysubstance use 7.9%; cocaine use 2.2%; prescription or illicit opioid use 3.2%). Past-month methamphetamine use prevalence increased significantly compared with prepandemic use prevalence among all respondents (with disabilities, 45.6% increase, p<0.001; without disabilities, 40.6% increase, p = 0.003). Among respondents who reported a diagnosed mental health or substance use condition, a higher percentage of adults with (versus without) disabilities reported that accessing care or medication was harder because of the COVID-19 pandemic (42.6% versus 35.3%, respectively, p<0.001). FIGURE 2 Prevalence of prepandemic and past-month substance use to cope with stress or emotions among adults, by disability status and type of substance — United States, February 16–March 8, 2021* , † , § * Overall, prepandemic and past-month use of any of these substances were reported by 39.7% and 40.6%, respectively, of adults with disabilities, and by 25.3% and 24.5%, respectively, of adults without disabilities. † All differences between adults with disabilities and adults without disabilities were significant (chi-square p-value <0.05). § Circles for use of marijuana (among adults with disabilities), use of prescription drugs (among adults without disabilities), and polysubstance use (among adults with disabilities) might appear overlapping because of very small changes in reported prevalence (<1% in all cases). Figure shows the prevalence of prepandemic and past-month substance use to cope with stress or emotions among adults by disability and substance type, United States, February 16–March 8, 2021. Discussion Nearly two thirds of surveyed adults with disabilities (who represented approximately 32% of the sample) reported adverse mental health symptoms or substance use in early 2021, compared with approximately one third of adults without disabilities. Serious suicidal ideation was approximately 2.5 times as high among adults with disabilities, and methamphetamine use, opioid use, nonopioid prescription drug misuse, and polysubstance use were at least twice as prevalent among adults with disabilities. These findings suggest value in enhanced mental health screening among adults with disabilities and in ensuring accessibility of routine and crisis services, particularly given that many adults reported that the COVID-19 pandemic had reduced mental health and substance use care or medication accessibility. Mental health disparities among adults with disabilities were observed across demographic groups, highlighting the importance of ensuring access to disaster distress §§§ and suicide prevention ¶¶¶ resources in this population. Important strategies to prevent persons from becoming suicidal include strengthening economic supports, promoting connectedness, and teaching coping skills.**** Health care providers could incorporate trauma-informed care, because adults with disabilities might have encountered stigma and trauma in previous health care interactions. Adults with disabilities more frequently reported prepandemic and past-month substance use to cope with stress or emotions compared with adults without disabilities. The substance with the largest increase in use was methamphetamine, which is particularly concerning given the increase in amphetamine overdoses †††† ( 7 ). Drug overdose deaths rose in 2020, driven by synthetic opioids. §§§§ Consistent with previous research, adults with disabilities disproportionately reported opioid use and nonopioid prescription drug misuse ( 8 ), highlighting the importance of educating patients and ensuring clinician access to prescription drug monitoring programs. ¶¶¶¶ Nearly one in ten adults with disabilities reported past-month opioid use, and opioid use among adults without disabilities increased. Policies that reduce barriers to evidence-based treatment, including recently updated buprenorphine practice guidelines,***** might improve access. The findings in this report are subject to at least four limitations. First, self-reported mental health and substance use might be subject to social desirability biases and stigma, which could lead to underreporting. Second, because the surveys were English-language only and data were obtained using nonprobability–based sampling, despite quota sampling and survey weighting, the findings from this nonrandom sample might not be generalizable. However, the proportion and demographics of surveyed adults with disabilities were similar to those of recent samples from other sources with the same or similar screening questions ( 1 , 2 , 4 ), and prevalence estimates of symptoms of anxiety and depression were largely consistent with those from other sources for the U.S. adult population ( 9 ) and adults with disabilities ( 4 ) including the U.S. Census Bureau’s probability-based Household Pulse Survey (64.3% among adults with disabilities compared with 27.4% among adults without disabilities in April 2021). ††††† Third, the respondents with disabilities might not be representative of all adults with disabilities, some of whom might lack access to hardware or assistive technologies required to independently complete the survey. Finally, adverse mental health symptoms might, in some cases, represent respondents’ disabling mental health conditions, which could confound associations with other comorbid disabling conditions (e.g., physical, cognitive, sensory); however, sensitivity analyses excluding adults with disabilities who had mental health or substance use diagnoses yielded consistent findings. Adults with disabilities have been disproportionately affected by adverse mental health symptoms and substance use during the COVID-19 pandemic, highlighting the importance of improved access to treatment for this population. Clinicians might consider screening all patients for mental health and substance use conditions during and after the pandemic. §§§§§ Behavioral health care providers might also consider facility, policy, and procedural pathway analyses to ensure accessibility for clients with physical, sensory, or cognitive disabilities.¶¶¶¶¶ Strategies designed to increase access to care and medication during public health emergencies, such as telehealth, might consider telemedicine platform and system accessibility for adults with disabilities ( 10 ); further research to identify and address health disparities among adults with disabilities could help guide additional evidence-based strategies. Summary What is already known about this topic? Adults with disabilities experience higher levels of mental health conditions and substance use than do adults without disabilities. What is added by this report? During February–March 2021, 64.1% of surveyed U.S. adults with disabilities reported adverse mental health symptoms or substance use; past-month substance use was higher than that among adults without disabilities (40.6% versus 24.5%, respectively). Among adults with a diagnosis of mental health or substance use conditions, adults with disabilities more frequently (43% versus 35%) reported pandemic-related difficulty accessing related care and medications. What are the implications for public health practice? During public health emergencies, including the COVID-19 pandemic, enhanced mental health and substance use screening among adults with disabilities and improved access to related health care services are critical.

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          Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults — United States, 2016

          Persons with disabilities face greater barriers to health care than do those without disabilities ( 1 ). To identify characteristics of noninstitutionalized adults with six specific disability types (hearing, vision, cognition, mobility, self-care, and independent living),* and to assess disability-specific disparities in health care access, CDC analyzed 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalences of disability overall and by disability type, and access to health care by disability type, were estimated. Analyses were stratified by three age groups: 18–44 years (young adults), 45–64 years (middle-aged adults), and ≥65 years (older adults). Among young adults, cognitive disability (10.6%) was the most prevalent type. Mobility disability was most prevalent among middle-aged (18.1%) and older adults (26.9%). Generally, disability prevalences were higher among women, American Indians/Alaska Natives (AI/AN), adults with income below the federal poverty level (FPL), and persons in the South U.S. Census region. Disability-specific disparities in health care access were prevalent, particularly among young and middle-aged adults. These data might inform public health programs of the sociodemographic characteristics and disparities in health care access associated with age and specific disability types and guide efforts to improve access to care for persons with disabilities.
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            Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020–February 2021

            The spread of disease and increase in deaths during large outbreaks of transmissible diseases is often associated with fear and grief ( 1 ). Social restrictions, limits on operating nonessential businesses, and other measures to reduce pandemic-related mortality and morbidity can lead to isolation and unemployment or underemployment, further increasing the risk for mental health problems ( 2 ). To rapidly monitor changes in mental health status and access to care during the COVID-19 pandemic, CDC partnered with the U.S. Census Bureau to conduct the Household Pulse Survey (HPS). This report describes trends in the percentage of adults with symptoms of an anxiety disorder or a depressive disorder and those who sought mental health services. During August 19, 2020–February 1, 2021, the percentage of adults with symptoms of an anxiety or a depressive disorder during the past 7 days increased significantly (from 36.4% to 41.5%), as did the percentage reporting that they needed but did not receive mental health counseling or therapy during the past 4 weeks (from 9.2% to 11.7%). Increases were largest among adults aged 18–29 years and among those with less than a high school education. HPS data can be used in near real time to evaluate the impact of strategies that address mental health status and care of adults during the COVID-19 pandemic and to guide interventions for groups that are disproportionately affected. HPS is a rapid-response online survey using a probability-based sample design to measure the social and economic impact of the COVID-19 pandemic on U.S. households ( 3 ). This experimental data product* was developed by the U.S. Census Bureau in partnership with CDC’s National Center for Health Statistics (NCHS) and several other federal statistical agencies. The sample is drawn from the U.S. Census Bureau’s Master Address File. † E-mail addresses and mobile telephone numbers associated with randomly selected housing units are used to invite participants. Analytic files include self-reported data from one adult aged ≥18 years at each address. Data collection began on April 23, 2020, and is ongoing (phase 1 = April 23–July 21, 2020; phase 2 = August 19–October 26, 2020; phase 3 = October 28, 2020–present, with a break during December 22, 2020–January 5, 2021). HPS response rates averaged 2.9%, 9.3%, and 6.5% during phase 1, phase 2, and phase 3 (through February 1, 2021), respectively. Questions on mental health symptoms were based on the validated four-item Patient Health Questionnaire (PHQ-4) for depression and anxiety and included how often, during the past 7 days, respondents had been bothered by 1) feeling nervous, anxious, or on edge; 2) not being able to stop or control worrying; 3) having little interest or pleasure in doing things; and 4) feeling down, depressed, or hopeless. Adults who had symptoms that generally occurred more than one half of the days or nearly every day were classified as having symptoms, consistent with published scoring recommendations § ( 4 ). Questions about mental health care use included whether, during the past 4 weeks, respondents had 1) taken prescription medication for their mental health, 2) received counseling or therapy from a mental health professional, or 3) needed but did not receive counseling or therapy from a mental health professional (i.e., had an unmet mental health need). Because of methodological differences between phases 1 and 2, trend analyses were limited to phases 2 and 3. ¶ Estimates** are presented for each 2-week data collection period for August 19, 2020–February 1, 2021 (unweighted sample size = 431,656 for phase 2 and 358,977 for phase 3, total = 790,633). Trends were assessed using joinpoint regression. †† In addition, changes in estimates of symptoms of an anxiety or a depressive disorder and the two mental health care measures were compared between August 19–31, 2020, and January 20–February 1, 2021, according to selected respondent characteristics. SAS-callable SUDAAN (version 11.0; RTI International) was used to conduct these analyses. Estimates were weighted to adjust for nonresponse and number of adults in the household and to match U.S. Census Bureau estimates of the population by age, sex, race/ethnicity, and educational attainment. During August 19–31, 2020, through December 9–21, 2020, significant increases were observed in the percentages of adults who reported experiencing symptoms of an anxiety disorder (from 31.4% to 36.9%), depressive disorder (from 24.5% to 30.2%), and at least one of these disorders (from 36.4% to 42.4%) (Figure 1). Estimates for all three mental health indicators through January 2021 were similar to those in December 2020. FIGURE 1 Percentage of adults aged ≥18 years with symptoms of anxiety disorder, depressive disorder, or anxiety or depressive disorder during past 7 days, by data collection period — Household Pulse Survey, United States, August 19, 2020–February 1, 2021* * Household Pulse Survey data collection included a 1-day break between the conclusion of one data collection period and the start of the next, as well as a 2-week break during December 22, 2020–January 5, 2021. This figure is a line graph showing the percentage of adults aged ≥18 years with symptoms of anxiety disorder, depressive disorder, or anxiety or depressive disorder during the past 7 days in the United States during August 19, 2020 through February 1, 2021. During August 19–31, 2020, through November 25–December 7, 2020, a significant increase was observed in the percentage of adults who reported taking prescription medication or receiving counseling for their mental health (from 22.4% to 25.0%) (Figure 2). Similarly, during August 19–31, 2020, through December 9–21, 2020, a significant increase was observed in the percentage of adults who reported needing but not receiving counseling or therapy for their mental health (from 9.2% to 12.4%). Estimates through January 2021 were similar to those in December 2020. FIGURE 2 Percentage of adults aged ≥18 years who took prescription medication for mental health or received counseling or therapy during past 4 weeks and percentage who needed but did not receive counseling or therapy during past 4 weeks, by data collection period — Household Pulse Survey, United States, August 19, 2020–February 1, 2021* * Household Pulse Survey data collection included a 1-day break between the conclusion of one data collection period and the start of the next, as well as a 2-week break during December 22, 2020–January 5, 2021. This figure is a line graph showing the percentage of adults aged ≥18 years who took prescription medication for mental health or received counseling or therapy during past 4 weeks and percentage who needed but did not receive counseling or therapy during past 4 weeks in the United States during August 19, 2020 through February 1, 2021. During August 19–31, 2020, through January 20–February 1, 2021, symptoms of an anxiety or a depressive disorder increased significantly from 36.4% to 41.5% (Table). Significant increases were observed for all demographic subgroups presented, except adults aged ≥80 years and non-Hispanic adults reporting races other than White, Black, or Asian. The largest increases (8.0 and 7.8 percentage points) were among those aged 18–29 years and those with less than a high school education, respectively. During this time, mental health care treatment increased significantly from 22.4% to 24.8%. Significant increases were observed for adults aged 18–29, 30–39, and 60–69 years; men and women; non-Hispanic White and non-Hispanic Black adults; adults with at least a high school education; and adults who had not experienced symptoms of an anxiety or a depressive disorder during the past 7 days. TABLE Weighted* percentage of adults aged ≥18 years with symptoms of anxiety or depressive disorder during past 7 days, percentage who took prescription medication for mental health or received counseling or therapy during past 4 weeks, and percentage who needed but did not receive counseling or therapy during past 4 weeks, by selected characteristics — Household Pulse Survey, United States, August 19, 2020–February 1, 2021 Characteristic % (95% CI) Symptoms of anxiety or depressive disorder during past 7 days Took prescription medication for mental health or received counseling or therapy during past 4 weeks Needed but did not receive counseling or therapy during past 4 weeks Aug 19–31, 2020 Jan 20–Feb 1, 2021 Aug 19–31, 2020 Jan 20–Feb 1, 2021 Aug 19–31, 2020 Jan 20–Feb 1, 2021 Total 36.4 (35.9–36.9) 41.5 (40.7–42.2)† 22.4 (22.0–22.9) 24.8 (24.2–25.4)† 9.2 (8.8–9.6) 11.7 (11.1–12.2)† Age group, yrs 18–29 49.0 (47.5–50.5) 57.0 (54.2–59.8)† 23.3 (21.5–25.2) 26.9 (24.9–29.0)† 15.6 (14.5–16.7) 22.8 (20.3–25.4)† 30–39 42.5 (40.8–44.1) 45.9 (44.5–47.3)† 23.1 (22.1–24.1) 27.1 (25.8–28.4)† 12.9 (11.9–13.9) 16.1 (14.8–17.5)† 40–49 37.6 (36.3–39.0) 41.1 (38.9–43.2)† 23.6 (22.8–24.5) 25.0 (23.7–26.3) 10.0 (9.3–10.7) 11.0 (10.0–11.9) 50–59 34.9 (33.6–36.3) 41.2 (39.8–42.6)† 23.9 (22.8–25.1) 25.4 (24.0–26.9) 7.7 (6.9–8.5) 9.5 (8.6–10.4)† 60–69 29.3 (28.0–30.6) 33.4 (31.6–35.4)† 21.2 (20.2–22.2) 23.3 (22.0–24.6)† 5.3 (4.8–5.9) 5.4 (4.8–6.0) 70–79 23.2 (21.6–25.0) 26.3 (24.6–28.0)† 19.6 (18.1–21.1) 19.8 (18.3–21.3) 2.9 (2.2–3.6) 3.1 (2.4–3.9) ≥80 19.4 (16.3–22.9) 22.5 (18.5–27.0) 14.8 (12.0–17.9) 17.3 (14.1–21.0) 1.4 (0.9–2.0) 2.3 (1.3–3.7) Sex Male 31.8 (30.8–32.8) 38.0 (36.9–39.1)† 16.3 (15.6–17.1) 19.1 (18.1–20.1)† 6.8 (6.2–7.3) 9.1 (8.3–9.8)† Female 40.7 (39.9–41.5) 44.8 (43.8–45.8)† 28.0 (27.3–28.7) 30.0 (29.3–30.7)† 11.4 (10.9–11.9) 14.1 (13.4–14.8)† Race/Ethnicity Hispanic or Latino 40.2 (38.0–42.3) 47.1 (44.7–49.4)† 17.2 (15.8–18.6) 19.5 (17.3–21.9) 9.6 (8.6–10.6) 12.8 (10.9–14.9)† White, non-Hispanic 35.4 (34.8–35.9) 39.8 (38.9–40.7)† 25.6 (25.0–26.1) 28.1 (27.3–28.8)† 9.1 (8.7–9.5) 11.7 (11.2–12.1)† Black, non-Hispanic 37.7 (35.7–39.8) 44.5 (41.6–47.5)† 15.6 (14.2–17.1) 18.7 (16.7–20.8)† 9.3 (8.3–10.3) 12.2 (10.4–14.1)† Asian, non-Hispanic 30.5 (28.2–32.8) 37.4 (33.4–41.5)† 11.1 (9.7–12.5) 12.9 (10.7–15.4) 4.8 (3.9–5.8) 5.8 (4.5–7.3) Other/Multiple races, non-Hispanic 43.1 (40.2–46.1) 44.8 (41.0–48.6) 25.0 (22.3–27.9) 23.8 (20.9–26.9) 14.2 (12.1–16.4) 13.8 (11.4–16.5) Education level Less than high school diploma 41.8 (38.4–45.2) 49.6 (45.7–53.5)† 20.0 (17.3–22.9) 20.6 (17.5–24.0) 7.0 (5.4–8.8) 11.3 (8.8–14.2)† High school diploma or GED certificate 36.3 (35.0–37.7) 41.1 (39.3–42.9)† 20.1 (19.1–21.2) 22.2 (20.9–23.4)† 7.0 (6.3–7.8) 8.7 (7.4–10.2)† Some college or associate’s degree 39.4 (38.5–40.3) 46.4 (45.2–47.6)† 23.5 (22.7–24.4) 27.7 (26.8–28.7)† 11.2 (10.6–11.9) 14.9 (13.9–15.9)† Bachelor’s degree or higher 32.4 (31.7–33.0) 35.5 (34.7–36.3)† 24.0 (23.4–24.6) 25.4 (24.6–26.1)† 9.7 (9.2–10.1) 11.4 (10.9–12.0)† Symptoms of anxiety or depressive disorder during past 7 days Did not experience symptoms NA NA 13.9 (13.4–14.4) 15.6 (14.9–16.4)† 2.4 (2.2–2.7) 3.1 (2.8–3.5)† Experienced symptoms NA NA 37.5 (36.5–38.5) 37.7 (36.6–38.8) 21.0 (20.2–21.8) 23.8 (22.8–24.9)† Abbreviations: CI = confidence interval; GED = general educational development; NA = not applicable. * Estimates were weighted to adjust for nonresponse and number of adults in the household and to match U.S. Census Bureau estimates of the population by age, sex, race/ethnicity, and educational attainment. † Significant difference between percentages at two time points (August 19–31, 2020, versus January 20–February 1, 2021) based on two-sided significance tests at the 0.05 level. Unmet mental health needs also increased significantly from 9.2% to 11.7%. Subgroups with significant increases included adults aged 18–29, 30–39, and 50–59 years; men and women; Hispanic, non-Hispanic White, and non-Hispanic Black adults; adults at all education levels; and adults regardless of whether they experienced symptoms of an anxiety or a depressive disorder or both during the past 7 days. The largest increases in unmet mental health needs (7.2 percentage points and 4.3 percentage points) were among adults aged 18–29 years and those with less than a high school education, respectively. During January 20, 2021–February 1, 2021, 23.8% of persons with symptoms of an anxiety or a depressive disorder had unmet mental health needs, and this percentage increased by 2.8 percentage points from August 2020 to February 2021. Discussion The percentage of adults who had symptoms of an anxiety or a depressive disorder during the past 7 days and those with unmet mental health needs during the past 4 weeks increased significantly from August 2020 to February 2021, with the largest increases among those aged 18–29 years and those with less than a high school education. During January 20, 2021–February 1, 2021, more than two in five adults aged ≥18 years experienced symptoms of an anxiety or a depressive disorder during the past 7 days. One in four adults who experienced these symptoms reported that they needed but did not receive counseling or therapy for their mental health. These findings are consistent with results from surveys conducted early in the COVID-19 pandemic (March–June 2020) that showed an increased prevalence of mental health symptoms, especially among young adults ( 5 – 7 ). The more recent results indicate an increasing prevalence over time later in 2020, which remained increased in early 2021. The trends in symptoms of an anxiety or a depressive disorder from HPS have been shown to be consistent with trends in the weekly number of reported COVID-19 cases, and it has been theorized that increases in these mental health indicators correspond with pandemic trends ( 8 ). The findings in this report are subject to at least four limitations. First, these data are based on self-report and were not confirmed by health professionals. Questions about mental health symptoms might be predictive of but do not necessarily reflect a clinical diagnosis. In addition, the predictive validity of the scales used in this report have not been confirmed when adapted from a 2-week to a 1-week time frame. Second, HPS did not assess the cause of these symptoms; therefore, a direct association with COVID-19 events could not be determined with certainty. Third, changes in mental health symptoms from the summer to the winter months might reflect symptoms associated with seasonal affective disorder ( 9 ). However, data from the 2019 National Health Interview Survey (NHIS), §§ measured using the unmodified PHQ-4, did not demonstrate statistically significant changes from August to December 2019 for symptoms of an anxiety disorder (8.1% to 8.6%); a depressive disorder (7.0% to 6.7%); or an anxiety disorder, a depressive disorder, or both (11.0% to 11.3%) ( 10 ). Finally, these estimates are intended to represent all adults aged ≥18 years living in housing units in the United States. However, representativeness might be limited by the indirect exclusion of persons without Internet access and by low response rates. Some households were not eligible to participate because the U.S. Census Bureau was unable to match a mobile telephone number or e-mail address. The sampling weights that were applied to all analyses were likely to have reduced some of the potential bias. Nevertheless, these data might not fully meet the U.S. Census Bureau’s quality standards and as such, the bureau labeled these data as experimental. Despite these limitations, the survey’s timeliness and relevance are strengths of HPS. The U.S. Census Bureau releases data tables to the public 9 days after the close of each data collection period. ¶¶ Simultaneously, NCHS updates online visualizations of trends in key health indicators.*** Several measures have been initiated to address increased mental health risks associated with COVID-19, ††† and a previous report outlines additional strategies, including expanded use of telehealth, to address mental health conditions during the pandemic ( 6 ). Continued near real-time monitoring of mental health trends by demographic characteristics is critical during the COVID-19 pandemic. These trends might be used to evaluate the impact of strategies that address mental health status and care of adults during the pandemic and to guide interventions for groups that are disproportionately affected. Summary What is already known about this topic? Large disease outbreaks have been associated with mental health problems. What is added by this report? During August 2020–February 2021, the percentage of adults with recent symptoms of an anxiety or a depressive disorder increased from 36.4% to 41.5%, and the percentage of those reporting an unmet mental health care need increased from 9.2% to 11.7%. Increases were largest among adults aged 18–29 years and those with less than a high school education. What are the implications for public health practice?  Trends in mental health can be used to evaluate the impact of strategies addressing adult mental health status and care during the pandemic and to guide interventions for disproportionately affected groups.
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              Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020

              This survey study compared patterns of mental health concerns, substance use, and suicidal ideation during June and September 2020 of the COVID-19 pandemic and examined at-risk demographic groups.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb Mortal Wkly Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                27 August 2021
                27 August 2021
                : 70
                : 34
                : 1142-1149
                Affiliations
                Turner Institute for Brain and Mental Health and School of Psychological Sciences, Monash University, Melbourne, Australia; Austin Health, Melbourne, Australia; Brigham and Women’s Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; CDC COVID-19 Response Team; National Center for Injury Prevention and Control, CDC; Epidemic Intelligence Service, CDC; University of Melbourne, Melbourne, Australia.
                Author notes
                Corresponding author: Amy Board, aboard@ 123456cdc.gov .
                Article
                mm7034a3
                10.15585/mmwr.mm7034a3
                8389385
                34437518
                051f5b37-bf52-4c9f-9775-742e222063c7

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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