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Chapter 17
Mood Disorder Prevalence Among Young Men and Women in the United States
Bruce S. Jonas, Sc.M., Ph.D.
Debra Brody, M.P.H.
National Center for Health Statistics
Centers for Disease Control and Prevention
Margaret Roper, M.S.
National Institute of Mental Health
William Narrow, M.D., M.P.H.
American Psychiatric Association
Address correspondence to Bruce S. Jonas, Sc.M., Ph.D., Centers
for Disease Control and Prevention, National Center for Health Statistics, Office
of Analysis and Epidemiology, Room 6433, 3311 Toledo Road, Hyattsville, MD 20782
This report investigates lifetime prevalence estimates of major depressive episode,
dysthymia, and bipolar disorder using the Third National Health and Nutrition
Examination Survey (NHANES III) among young men and women.
NHANES III, conducted from 1988 to 1994, is a large, nationally representative
cross-sectional sample of the
United States. A population-based
sample of 8,602 men and women 17 to 39 years of age completed interviews, of
whom 7,667 (89.1 percent) also completed mood disorder assessments. Mood disorder
assessments came from the Diagnostic Interview Schedule (DIS) administered as
one component of the NHANES III examination. Lifetime prevalence estimates were
assessed for young men and women by selected sociodemographic and health characteristics.
Lifetime prevalence estimates of any mood disorder were 14.5 percent among
young women and 8.4 percent among young
men. Lifetime prevalence of major depressive episode (MDE), major depressive
episode with severity (MDE-s),
dysthymia, and MDE-s with dysthymia
were all higher among young women. Lifetime prevalence
of any bipolar disorder was similar for men and women. The associations between
prevalence of mood disorders and sociodemographic and health characteristics,
including race-ethnicity, education,
income, marital status, self-reported
health status, smoking status, hypertension, and asthma, were generally similar
for men and women. Prevalence estimates of any mood disorder were over 20 percent
among women with asthma or hypertension; men and women who were widowed, separated,
or divorced; and those reporting fair or poor health.
These data provide national prevalence estimates on mood disorders for young
American men and women by selected sociodemographic and health characteristics,
and identify subgroups for whom estimates are particularly
high.
Introduction
The 1999 Surgeon General’s Report on Mental Health recognized the magnitude
of the problem associated with mental illness (U.S. Department of Health and
Human Services, 1999). In 2002, the president created the New Freedom Commission
on Mental Health (President’s New Freedom Commission on Mental Health,
2003), which reported that the United States spent $71 billion on treating mental
illnesses in 1997 (Coffey et al., 2000). The report further found that persons
with mental illness have unmet health care needs and experience barriers to
care. Unipolar major depressive disorder (MDD), dysthymia, and bipolar I-II
disorders comprise mood disorders. MDD
is a chronic illness (Angst, 1986; Keller et al., 1984, 1992; Judd et al., 1998)
and is one of the most prevalent psychiatric disorders (Kessler et al., 1994).
In the National Co-morbidity Survey-Replication
(NCS-R) (Kessler et al., 2005),
conducted in 2001 to 2003, the lifetime prevalence of any mood disorder among
persons aged 18 years and older was nearly 21 percent.
Besides the NCS-R, there are
few population-based surveys in
the United States that use structured psychiatric interviews to identify mood
disorders. The Epidemiologic Catchment Area Study (ECA) (Robins & Regier,
1991), conducted from 1980 to 1985, the National Comorbidity Survey (NCS) Kessler
et al., 1994), conducted from 1990 to 1992, and the Third National Health and
Nutrition Examination Survey (NHANES III) (Jonas, Brody, Roper, & Narrow,
2003), conducted from 1988 to 1994, are surveys of this type. Prior to the ECA,
NCS, NCS-R, and NHANES III, prevalence
data on mood disorders were largely based on patient samples (Boyd & Weiss-man,
1981) or community samples (Dean, Surtees, & Sashidharian, 1993; Surtees,
Sashidarian, & Dean, 1986; Weissman & Myers, 1978).
This chapter expands on a study of the lifetime prevalence of selected mood
disorders, including major depressive episode, dysthymia, and bipolar disorder
in young adults 17–39 years of age using the NHANES III (Jonas, Brody,
Roper, & Narrow, 2003). It presents lifetime prevalence estimates of mood
disorders for young men and women, focusing on the differences associated with
sociodemographic and health characteristics.
Methods
Survey Sample
The National Center for Health Statistics, Centers for Disease Control and
Prevention, conducted the NHANES III from 1988 to 1994. NHANES III used a complex,
multistage sampling design of the civilian, noninstitutionalized U.S. population.
Survey sample weights were used to produce estimates representative of the noninstitutionalized
civilian U.S. population. Non-Hispanic
Blacks and Mexican-Americans were
oversampled. Further details about the survey and its methods have been published
elsewhere (National Center for Health Statistics, 1994). During a household
interview, 8,602 persons who were 17–39 years of age completed a series
of questionnaires administered by trained interviewers. Respondents were then
invited to undergo extensive physical examinations and further health assessments
in special mobile examination trailers. Of these 8,602 persons, 7,968 participated
in the examination that included the Diagnostic Interview Schedule (DIS) administered
in a private room. Valid assessments for the DIS were obtained for 7,667 subjects.
The overall examination response rate
(7,968/8,602) was 92.6 percent. The response rate for the DIS (7,667/7,968)
was 96.2 percent, yielding a cumulative
rate of 89.1 percent. Comparisons of the distributions of age, sex, and race-ethnicity
were virtually identical between the 8,602 persons with completed questionnaires
and the 7,667 persons with valid DIS assessments. These 7,667 persons (3,493
men and 4,174 women) were used as the study sample for these analyses.
Mood Disorders
The DIS (Robins, Helzer, Croghan, Williams, & Spitzer, 1981), administered
as one component of the NHANES III (Jonas et al., 2003), is a structured psychiatric
interview schedule. The depression and mania modules from the DIS were administered.
Both the depressive and manic syndromes consist of symptoms that tend to jointly
occur and can persist from weeks to years. The DIS was developed for use by
trained lay interviewers in two versions: one that employs the same criteria
used by clinicians as found in the Diagnostic and Statistical Manual of
Mental Disorders, Third Edition (DSM-III)
(American Psychiatric Association, 1980) and another that employs the same criteria
used by clinicians as found in the Diagnostic and Statistical Manual of
Mental Disorders, Revised Edition (DSM-III-R)
(American Psychiatric Association, 1987). There were several changes in diagnostic
criteria in the DSM-III-R.
A criterion was added for bipolar disorder, which required impairment in occupational
or usual social contexts. For dysthymia, the number of persistent symptoms required
was reduced from three to two. Additional exclusionary criteria for dysthymia
specified that there must not have been evidence for MDE during the first 2
years of the disturbance or any evidence of mania. The DSM-III
version of the DIS was used in the NHANES III.
Lifetime prevalence estimates were assessed for six mood measures: (1) major
depressive episode (MDE), (2) major depressive episode with severity (MDE-s),
(3) dysthymia, (4) MDE-s with dysthymia, (5) any bipolar disorder, and (6) any
mood disorder. Lifetime prevalence was defined as the proportion of the sample
that ever experienced a given disorder. Descriptions and a brief synopsis of
DSM-III definitions for these disorders follow:
- Unlike transient moods of sadness or elation that are considered normal
and occur frequently in the general population, MDE was defined as persistent
(for at least 2 weeks) lowered mood plus at least four of the following eight
symptom groups: change in appetite or weight, sleep disturbance, changes in
psychomotor activity, loss of ability
to experience pleasure and interest, fatigue, feelings of worthlessness or
guilt, difficulty in concentrating, and preoccupation with death or a wish
to die. If MDE criteria were met but solely due to bereavement, then the respondent
was not classified as having MDE.
- Severity criteria were also applied to MDE. The condition was defined as
severe if the respondent answered "yes" to at least one of the
following questions concerning the episode: Did you tell a doctor? Did you
tell any other professional? Did you take medicine more than once? Did symptoms
interfere with your life or activities a lot? A respondent was classified
as having MDE-s if the MDE and
severity criteria defined above were
both met.
- Dysthymia is a chronic (of at least 2 years’ duration) disturbance
of mood involving either depressed mood or loss of interest or pleasure in
most activities along with some of the symptoms used to diagnose major depressive
episode. While the depressed mood may be interrupted by periods of normal
mood for up to a few weeks, the essential aspect is its chronicity. Dysthymia
was defined as a chronic (depressed mood plus at least three of seven symptom
groups (see second through eighth MDE symptoms).
- Respondents could be diagnosed with both conditions (MDE-s and dysthymia).
- "Any bipolar disorder" was defined as having Bipolar Disorder,
Type I or Bipolar Disorder, Type II (Atypical Bipolar Disorder). "Any
bipolar disorder" is diagnosed when the criteria for MDE have been met
but in addition an episode of mania has ever occurred. The essential feature
of mania is a distinct period when the predominant mood is either elevated,
expansive, or irritable and there are associated symptoms, including
hyperactivity, pressure of speech, flight of ideas, inflated self-esteem,
decreased need for sleep, destructibility, and excessive involvement in activities
that have a high potential for painful consequences. Often the activities
are flamboyant, bizarre, or disorganized. In the NHANES III, the majority
of cases of any bipolar disorder (86.3 percent) met the criteria for Bipolar
Disorder, Type I.
- Respondents could meet the criteria for one or more of MDE, dysthymia,
or any bipolar disorder. Thus, any mood disorder was defined as the diagnosis
of one or more of MDE, dysthymia, or any bipolar disorder. Further details
regarding the diagnosis of these mood disorders have been published elsewhere
(Robins et al., 1981).
Sociodemographic and Health Characteristics
Selected sociodemographic and health characteristics potentially associated
with mood disorders were assessed: age
(17–19 years, 20–29 years, 30–39 years), gender, race-ethnicity
(non-Hispanic White, non-Hispanic
Black, Mexican-American), completed
years of education (11 years or less, 12 years, 13 or more years), marital status
(married, widowed/separated/divorced, never married), current smoking status
(smoker, nonsmoker), and self-reported
health status (excellent/very good, good, fair/poor). A history of asthma and
hypertension was based on self-report
of ever being diagnosed by a doctor.
Race-ethnicity was categorized
according to the NHANES III analytic guidelines (Jonas et al., 2003) as non-Hispanic
White, non-Hispanic Black, Mexican-American,
and other. This latter group (other) includes all other race/ethnic groups not
captured in the first three categories (e.g., Asian, non-Mexican-American
Hispanics). For the race-ethnicity
variable specifically, only the first three categories were included due to
the small sample size in the "other" group. The "other"
race-ethnicity group was included
in the totals for the remaining sociodemographic and health measures. Income
categories were defined using the poverty
income ratio (PIR), which was the ratio of the total family income to the poverty
threshold for the year of the interview (low: PIR < 1.3, middle: PIR >
= 1.3 and < 3.5, high: PIR > = 3.5). Details on the other sociodemographic
and health characteristics have been published elsewhere (National Center for
Health Statistics, 1994). Table 17.1 shows sample
sizes of these sociodemographic and health characteristics for men and women.
Statistical Analysis
SAS (SAS Institute, 1985) and SUDAAN (Shah, Barnwell, & Biegler, 21) were
used to perform statistical analysis. Survey sampling weights were used in all
the analyses reported to produce estimates that were repre-sentative
of the civilian, noninstitutionalized U.S. population. SUDAAN incorporates the
sample weights and ad-justs for
the survey’s stratified multistage sample design in calculating the appropriate
standard errors (SEs). Lifetime prevalence estimates, expressed as percentages,
are reported for all respondents and by gender for the six mood disorders described
above. Gender-specific prevalence
estimates are reported for selected mood disorders by sociodemographic and health
characteristics. Significance testing was conducted employing t tests (paired
contrasts) and used SUDAAN. All contrasts described are significant at the p
< .05 level unless otherwise noted.
Results
Lifetime Prevalence of Mood Disorders
The overall lifetime prevalence estimates for each mood disorder are shown
in Figure 17.1. The most common diagnoses in
the NHANES III were MDE (8.6 percent), MDE-s
(7.7 percent), and dysthymia (6.2 percent). Compared to these conditions, any
bipolar disorder was less common (1.6 percent). The proportion with a history
of both dysthymia and MDE-s (3.4
percent) was roughly half that of either disorder individually. More than one
in nine persons had a history of any mood disorder.
The prevalence of all mood disorders was considerably higher among women than
among men, with the exception of any bipolar disorder (figure
17.2). For the overall sample, prevalence estimates observed for age of
respondent, race-ethnicity, education, income, marital status, self-reported
health status, smoking status, asthma status, and hypertension status have been
reported elsewhere (Jonas et al., 2003).
Selected Mood Disorders for Men and Women by Sociodemographic and Health Characteristics
In addition to gender, sociodemographic and health characteristics are associated
with the prevalence of mood disorders. Race and ethnicity, for example, are
important factors. Prevalence of MDE was lower for non-Hispanic
Black and Mexican-American women
than for non-Hispanic White women
(figure 17.3). In contrast, non-Hispanic
Black women had a higher prevalence of dysthymia than non-Hispanic
Whites. Similar results were found among men: non-Hispanic
Blacks and Mexican-Americans had
lower prevalence of MDE and higher prevalence of dysthymia than non-Hispanic
Whites.
Education levels are also associated with the prevalence of mood disorders.
Thus, women with 13 or more years’ education had lower prevalence rates
of dysthymia than those with less education (figure
17.4). Prevalence of any mood disorder was also higher among women with
less than 12 years of education compared to those with 13 or more years of education.
Similar patterns were found among men for dysthymia and for any mood disorder.
However, no associations were found among these educational groups with respect
to major depressive episode.
The prevalence of mood disorders varies too by PIR. Women from low-PIR
families had a greater prevalence of
MDE, dysthymia, and any mood disorder than those from higher-PIR
families (figure 17.5) Prevalence patterns for
men were generally similar.
Men and women who were widowed, separated, or divorced were more likely to
experience any mood disorder than their married counterparts (figure
17.6). In addition, never-married
men had higher prevalence of any mood disorder than married men.
Turning to health status characteristics, prevalence of any mood disorder was
higher among men and women who rated their health as "good" and
"fair/poor" as compared to the reference group "excellent,
very good" (figure 17.7). Prevalence of
any mood disorder was also greater among smokers than nonsmokers (figure
17.8), and among asthmatics than nonasthmatics (figure
17.9). Similarly, men and women with hypertension had higher prevalence
of any mood disorder than normotensives (figure
17.10).
Discussion
The lifetime prevalence estimates of mood disorders found in this report show
a sizeable number of significant prevalence
differences by the sociodemographic and health characteristics examined. The
gender-stratified analyses presented
here generally confirm findings from other studies using structured psychiatric
interviews and have been discussed elsewhere (Jonas et al., 2003). There are
some notable pockets of high prevalence of mood disorder among men and women
where the prevalence is greater than 20.0 percent. For example, regarding marital
status, the prevalence of any mood disorder for widowed, separated, and divorced
men and women was 21.5 percent and 23.1 percent, respectively. The prevalence
of any mood disorder among men and women reporting fair or poor health was 25.6
percent and 27.6 percent, respectively. Among women with a history of asthma
or hypertension, prevalence estimates for any mood disorder were 20.7 percent
and 22.3 percent, respectively. These pockets of high prevalence may indicate
subgroups particularly at risk.
This investigation has several strengths. The NHANES III is a large and carefully
constructed, nationally representative
survey. The oversampling of Non-Hispanic
Blacks and Mexican Americans provided more stable estimates for these race-ethnicity
subgroups. The selected sociodemographic and health subgroups provide stable
estimates of prevalence for the mood disorders analyzed. The gender-specific
mood disorder prevalence estimates and differences by the sociodemographic and
health characteristics presented may give insight into subgroups that are particularly
at risk. The DIS, as a diagnostic assessment instrument, has been shown to be
reliable and has evidence of concurrent validity (Wittchen, Semler, & Von
Zerssen, 1985). The structured psychiatric interview format of the DIS enabled
the diagnosis of these mood disorders based on criteria specified in DSM-III
(Robins et al., 1981).
Several methodological limitations must be noted in the estimation of prevalence.
Most notably, the NHANES III mood disorder assessment was available only for
adults 17–39 years of age. The NHANES III is a cross-sectional
survey that relies solely on retrospective reports to assess the lifetime prevalence
of mood disorders. These reports were
subject to recall bias that could have been magnified due to retrospective time
frames that included ever experiencing a given symptom. Diagnostic assessment
was based on a single structured interview
administered by nonclinicians. On the other hand, even clinical diagnoses are
made by assess-ment of symptoms
in an interview, and there is some evidence that clinical diagnoses in community
settings may overestimate prevalence (Wittchen et al., 1985). Improved precision
in prevalence estimation would also have been possible if ancillary information
from significant family and friends in addition to institutional records could
have been obtained. In addition, lack of some specific markers among the sociodemographic
and health sub-groups (e.g., single
parenthood) limits the ability of these analyses to pinpoint clusters of high-prevalence
mood disorders. Furthermore, because of the cross-sectional
design of NHANES III, no conclusions can be drawn about the causality of the
relationships observed.
Despite these limitations, the NHANES III provides a comprehensive picture
of the prevalence of mood disorders in
a large, nationally representative sample of young men and women. The gender-specific
prevalence estimates show that certain population subgroups may be at excess
risk. These mood disorders can have concurrent
emotional, social, and cognitive complications as well as potentially increase
comorbid chronic disease and disability and diminish productivity. Continued
investigation of their prevalence and related sociodemographic
and health characteristics is recommended. Of particular interest is whether
the higher prevalence of mood disorders among young women relative to young
men continues in later life.
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