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

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

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

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

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

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

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

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

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

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

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

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

Household demographics and perceived insufficient sleep among US adults.

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

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

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

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

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

Prevalence and correlates of depressive symptoms among United States adults with disabilities using assistive technology.

OBJECTIVES: To estimate the prevalence of current depressive symptoms (CDS) among adults that reported disabilities requiring the use of assistive technology (AT) and those that did not, and to examine the sociodemographic, comorbidity, health behavior, and social support correlates of this condition in adults who use AT. METHODS: Data from the 2006 Behavioral Risk Factor Surveillance System, a standardized telephone survey among U.S. adults, were analyzed (n=195,033). The Patient Health Questionnaire diagnostic algorithm was used to identify CDS. RESULTS: AT users were significantly more likely than AT non-users to have CDS (age-standardized: 30.4% vs. 7.4%). Among AT users, there was a dose-response relationship between depression severity and increased prevalence of health conditions, obesity, smoking, and physical inactivity. In the full covariate logistic regression model, the strongest sociodemographic variables associated with CDS among AT users were age and employment status. Other variables strongly associated with CDS were lack of social support and anxiety. CONCLUSIONS: An integrated approach to health care should be taken with adults who use AT. AT service providers, primary health care providers, and other care givers should be alert to the possibility of depression in AT users; and opportunities to prevent, detect, and treat depression among this population should not be missed.

Public health surveillance for mental health.

Public health systems have relied on public health surveillance to plan health programs, and extensive surveillance systems exist for health behaviors and chronic disease. Mental health has used a separate data collection system that emphasizes measurement of disease prevalence and health care use. In recent years, efforts to integrate these systems have included adding chronic disease measures to the Collaborative Psychiatric Epidemiology Surveys and depression measures to the Behavioral Risk Factor Surveillance System; other data collection systems have been similarly enhanced. Ongoing challenges to integration include variations in interview protocols, use of different measures of behavior and disease, different interval reference periods, inclusion of substance abuse disorders, dichotomous vs continuous variables, and approaches to data collection. Future directions can address linking surveillance efforts more closely to the needs of state programs, increasing child health measurements in surveys, and improving knowledge dissemination from survey analyses.

Evolving definitions of mental illness and wellness.

Understanding of the definitions of wellness and illness has changed from the mid-20th century to modern times, moving from a diagnosis-focused to a person-focused definition of mental illnesses, and from an "absence of disease" model to one that stresses positive psychological function for mental health. Currently, wellness refers to the degree to which one feels positive and enthusiastic about oneself and life, whereas illness refers to the presence of disease. These definitions apply to physical as well as mental illness and wellness. In this article, we build on the essential concepts of wellness and illness, discuss how these definitions have changed over time, and discuss their importance in the context of health reform and health care reform. Health reform refers to efforts focused on health, such as health promotion and the development of positive well-being. Health care reform refers to efforts focused on illness, such as treatment of disease and related rehabilitation efforts.

The Patient Health Questionnaire 8: current depressive symptoms among U.S. older adults, 2006 Behavioral Risk Factor Surveillance System.

OBJECTIVES: To examine the prevalence and sociodemographic predictors of current depressive symptoms among adults aged 65 years and older. DESIGN AND SETTING: Participants were obtained from the 2006 Behavioral Risk Factor Surveillance System, a population-based list-assisted random-digit-dialed telephone survey of the noninstitutionalized U.S. adults. PARTICIPANTS: A total of 45,534 participants aged 65 years and older were interviewed. MEASUREMENTS: Participants completed the Patient Health Questionnaire 8. Those with a Patient Health Questionnaire 8 score >or=10 were considered to have current depressive symptoms. RESULTS: Our findings indicated that 95.1% of people >or=65 years old did not report current depressive symptoms and 4.9% reported current depressive symptoms. Younger adults (65-74 years), those with a high school education or less, those with an income of less than $50,000, those with good to fair self-rated health, and those with a disability were more likely to have current depressive symptoms. When stratified by age (65-74, >or=75), there was no difference in the prevalence of current depressive symptoms between the age groups. However, when the authors stratified by age group both adults 65-74 years olds and those >or=75 years old, only people with worse self-rated health and those who reported a disability were more likely to have indicated current depressive symptoms. CONCLUSION: The continued collection of data on current depressive symptoms from a population-based sample of older adults can be used by policymakers and public health officials to identify local health needs and burdens that can assist in planning, directing, implementing, and monitoring the effectiveness of strategies.

Associations between health-related quality of life and smoking status among a large sample of U.S. adults.

OBJECTIVE: To examine the association between self-perceived health-related quality of life (HRQoL) and smoking status. METHODS: We used data from 2006 Behavioral Risk Factor Surveillance System, USA participants in four states (n=17,800) to compare the HRQoL of current smokers who unsuccessfully attempted to quit (unsuccessful quitters), former smokers, and never smokers with the HRQoL of current smokers who made no attempts to quit (non-quitters). RESULTS: Overall, unsuccessful quitters were more likely than non-quitters to report frequent mental distress, physical distress, and pain but not frequent depressive symptoms; former and never smokers were less likely than non-quitters to report frequent depressive symptoms. When study subjects were stratified by sex, these associations held true for men, but not for women. Among women, the prevalence of frequent mental and physical distress among former smokers and never smokers was not significantly different from the prevalence among non-quitters, whereas unsuccessful quitters were 2.4 times more likely to report frequent mental distress and 2.1 times more likely to report frequent physical distress than were non-quitters. CONCLUSIONS: Certain HRQoL characteristics were worse among smokers who unsuccessfully attempted to quit and better among former smokers than among smokers who made no attempts to quit.

The associations between depression, health-related quality of life, social support, life satisfaction, and disability in community-dwelling US adults.

The purpose of this manuscript is to describe the associations among current depression, as measured by the Patient Health Questionnaire 8, health-related quality of life, social support, life satisfaction, and disability status, using the 2006 Behavioral Risk Factor Surveillance System. A dose-response relationship exists between depression severity and mean number of days in the past 30 days of physical distress, pain, anxiety symptoms, and activity limitations as well as the prevalence of fair/poor general health, life dissatisfaction, inadequate social support, and disability. These profound associations underscore the need for recognition and treatment of depression in all healthcare settings.

Self-rated depression and physician-diagnosed depression and anxiety in Florida adults: Behavioral Risk Factor Surveillance System, 2006.

INTRODUCTION: Our purpose was to determine the prevalence and correlates of self-reported symptoms of depression and physician-diagnosed depression and anxiety in Florida adults by using the 2006 Florida Behavioral Risk Factor Surveillance System (BRFSS). METHODS: The BRFSS is an ongoing, state-based telephone health survey of noninstitutionalized adults that uses random-digit dialing. In 2006, an Anxiety and Depression Module was administered in Florida. Eight questions were used to examine current depression. Two additional questions assessed health care provider diagnosis of depressive and anxiety disorders. We used SUDAAN version 9.0 to evaluate the data to accommodate the complex sampling design. RESULTS: Approximately 9% of Florida adults experienced current depression; about 13% had had a diagnosis of depression in their lifetime and 11% had a diagnosis of anxiety in their lifetime. Approximately 44% of respondents with current depression had not had a diagnosis of depression. Current depression and lifetime diagnosis of depression and anxiety were independently associated with sociodemographic variables (being a woman, young, previously married or never married, or unemployed or unable to work), adverse health behaviors (current or former smoking, physical inactivity, or obesity), and chronic health conditions (history of a stroke, diabetes, or asthma). Although the prevalence of depression among non-Hispanic blacks and people with low education levels is higher, members of these groups are less likely than members of other sociodemographic groups to have had depression diagnosed by a physician. CONCLUSION: Depression and anxiety are associated with sociodemographic disadvantages and chronic conditions and risk factors. Knowing the prevalence of depression and anxiety, both self-rated and physician-diagnosed, is useful in identifying unmet mental health needs among subpopulations.

The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults.

OBJECTIVE: The aim of this study was to examine the extent to which depression and anxiety are associated with smoking, obesity, physical inactivity and alcohol consumption in the US population using the Patient Health Questionnaire 8 (PHQ-8) and two questions on lifetime diagnosis of anxiety and depression. METHODS: Data were analyzed in 38 states, the District of Columbia and two territories using the 2006 Behavioral Risk Factor Surveillance System (n=217,379), a large state-based telephone survey. RESULTS: Overall, adults with current depression or a lifetime diagnosis of depression or anxiety were significantly more likely than those without each diagnosis to smoke, to be obese, to be physically inactive, to binge drink and drink heavily. There was a dose-response relationship between depression severity and the prevalence of smoking, obesity and physical inactivity and between history of depression (never depressed, previously depressed, currently depressed) and the prevalence of smoking, obesity, physical inactivity, binge drinking and heavy drinking. Lifetime diagnosis of depression and anxiety had an additive association with smoking prevalence. CONCLUSION: The associations between depression, anxiety, obesity and unhealthy behaviors among US adults suggest the need for a multidimensional and integrative approach to health care.

The prevalence of depression in older U.S. women: 2006 behavioral risk factor surveillance system.

Depression, a type of mood disorder, is associated with psychological distress and suffering, and it can lead to impairments in physical, mental, and social functioning. The goal of this commentary is to provide an estimate of the prevalence of current depression and lifetime diagnosis for 14,425 community-dwelling U.S. women aged 65 and older. Using information from the 2006 Behavioral Risk Factor Surveillance System (BRFSS), participants reported their lifetime diagnosis of depression and completed the Patient Health Questionnaire 8 to assess current depression and its severity. Our findings indicate that 5.9% of women 65 years old and older have current depression, 94.1% reported either no depressive symptoms or mild depressive symptoms, and 12.3% reported a lifetime diagnosis of depression. Mental health is integral to overall health and well-being and should be treated in older women with the same urgency as physical health. Depression is a mental health issue of particular concern for women, given their increasing numbers, higher proportion in the US population, and role as caregivers. Continued surveillance from a system such as the BRFSS is needed to track changes in the mental health of older adults.

Gender differences in coronary heart disease and health-related quality of life: findings from 10 states from the 2004 behavioral risk factor surveillance system.

BACKGROUND: Our objective was to examine differences in health-related quality of life (HRQOL) between people with coronary heart disease (CHD) and those without this condition in a population-based sample of U.S. adults and to examine the interaction between CHD and diabetes on HRQOL. METHODS AND RESULTS: We performed a cross-sectional analysis of data from 50,573 participants aged >or=18 years from 10 states of the 2004 Behavioral Risk Factor Surveillance System (BRFSS). Data were self-reported. HRQOL was assessed with the Centers for Disease Control and Prevention (CDC) HRQOL-4 measures. After adjusting for age, gender, race or ethnicity, educational status, marital status, employment status, smoking status, body mass index (BMI), and alcohol use, the percentages of women without CHD who, during the previous 30 days, reported experiencing >or=14 physically unhealthy days, >or=14 mentally unhealthy days, and >or=14 activity-limitation days were 7.5%, 10.4%, and 3.6%, respectively, compared with 16.5% (odds ratio [OR] = 2.49, 95% confidence interval [CI] 2.02, 3.07), 14.5% (OR = 1.58, 95%, CI 1.22, 2.04), and 8.4% (OR = 2.56, 95% CI 1.98, 3.30) for women with CHD. The adjusted percentages of men without CHD who reported experiencing >or=14 physically unhealthy days, >or=14 mentally unhealthy days, and >or=14 activity-limitation days were 5.6%, 6.0%, and 3.0%, respectively, compared with 10.1% (OR = 1.85, 95% CI 1.47, 2.32), 8.7% (OR = 1.32, 95% CI 1.00, 1.74), and 6.4% (OR = 1.99, 95% CI 1.49, 2.66) for men with CHD. A higher adjusted percentage of women with CHD reported experiencing >or=14 physically unhealthy days (p < 0.001) and >or=14 mentally unhealthy days (p = 0.002) but not >or=14 activity-limitation days (p = 0.090) than men with CHD. CONCLUSIONS: People with CHD have significantly impaired HRQOL compared with those without CHD. HRQOL among women with CHD is worse than that among men with CHD.

Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the United States with asthma, 2006.

BACKGROUND: Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma. METHODS: We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma). RESULTS: Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety. CONCLUSION: This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.