CDC adds depression module to behavioral risk survey

The U.S. Centers for Disease Control and Prevention included a depression questionnaire in the Behavioral Risk Factor Surveillance System (BRFSS) survey for the first time in 2006 and again in 2008. Combined data revealed that an estimated nine percent of U.S. adults experienced depression during the two weeks preceding the survey, including 3.4 percent who met criteria for major depression. A total of 235,067 adults in 45 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands were polled in telephone surveys. The findings were reported in this past Oct. 1 CDC “Morbidity and Mortality Weekly Report.”

Depression was determined by responses to the Patient Health Questionnaire 8 (PHQ-8) that encompasses DSM-IV criteria for depression. Respondents were considered depressed if they reported “little interest or pleasure in doing things” or “feeling down, depressed or hopeless” plus five more criteria for major depression or two more criteria for other depression.

Mississippi and Puerto Rico topped the rankings of current depression with 14.8 percent and 14.7 percent respectively. North Dakota had the lowest rate at 4.8 percent. New England states clustered between 6.5 for Connecticut and 8.8 percent for Rhode Island.

“With this two-week prevalence, we got a snapshot in U.S. states of what depression looks like in adults,” says CDC researcher Lela McKnight-Eily, Ph.D., a clinical psychologist.

Major depression was higher in women, the middle-aged and the previously married. It was also more prevalent in people who were unemployed, medically uninsured, less educated and non-white.

Administering the optional depression module along with the core BRFSS questionnaire allows the CDC and state health departments to track the prevalence of depression and its relationship to co-morbid disease and risk factors more closely. Depression was more common in people with such chronic conditions as obesity, hypertension, cardiovascular disease, diabetes and asthma and in people with unhealthy behaviors, like smoking, excessive drinking and sedentary lifestyles.

Unlike most states, Maine ran the depression module in four of the last five years and will again in 2011. Elsie Freeman, M.D., M.P.H., director for integrated care projects at the Maine Department of Health and Human Services, says depression can be difficult to gauge with the PHQ-8 because it’s based on self-reporting and because it doesn’t address anger and irritability, which can be symptomatic in men. So while a snapshot in time is good, having data over time is better.

“With depression, we’re dancing around something. It’s not like a blood sugar test for diabetes,” Freeman says. “Which is why it’s so important to have this module run for five or 10 years.”

But just as important as the data is what one does with it. “It’s all very well to have surveillance, which is fabulous, but you’ve got to disseminate it; you’ve got to message it,” Freeman says.

Her messaging has resulted in some notable successes. The Department of Public Health’s Division of Chronic Disease is including a two-question depression screen on its “Keep ME Well” Web site. The non-profit Maine Health Access Foundation is funding Healthy Maine Partnerships that will educate the local public health workforce about the signs and symptoms of depression and resources for treatment. The foundation also funded integrated delivery of primary care and behavioral health services at 14 sites throughout the state.

Freeman says the key to getting public health entities to adopt mental health screening is to demonstrate the destructive link between depression and chronic disease.

“The goal is to integrate mental health in the notion of healthcare delivery whether it’s on the primary care side or the public health side. We’re starting in this state with depression,” Freeman says. “The real question is how to get more states to run the depression module.”

The CDC supports the BRFSS core questionnaire financially, but states have to pay for the optional modules, sometimes with CDC support. New Hampshire got CDC funding to run the depression module in 2006, so it now has a baseline to compare data from 2011, the next time the module will be funded, says Erik Riera, Bureau of Behavioral Health administrator.

Freeman says that as a result of lobbying by mental health advocates, including representatives from Maine, the BRFSS core questionnaire will include a depression question starting in 2011.

“The question will be: Have you ever been told by a healthcare professional that you have depression?” Freeman says. “This is a big deal. Being on the core means it will be on every survey in every state and they fund it.”