Issue Brief #1:

What Do the Data Tell Us? The State of Mental Health

In recognition of the essential role mental health
plays in overall health, the Healthy Aging Program
and Aging in America
at the Centers for Disease Control and Prevention
(CDC) and the National Association of Chronic
Disease Directors (NACDD) are releasing two issue
briefs focused on the mental health of older adults in
the United States.

This first issue brief reviews existing data and lays

the foundation for understanding key issues related
to mental health in adults over 50. The second brief
will focus on depression, an important and
emerging public health issue. Recent public health
efforts to develop, test, and disseminate programs
that address depression in older adults have led to
practical information on this topic; the second issue
brief will examine interventions to address
depression that communities can use to improve the
mental health and quality of life of older
Americans.

Why is Mental Health a Public Health Issue?

The World Health Organization defines health as “a state of complete physical,
mental, and social well-being and not merely the absence of disease or
infirmity” (1). Because mental health is essential to overall health and
well-being, it must be recognized and treated in all Americans, including older
adults, with the same urgency as physical health. For this reason, mental health
is becoming an increasingly important part of the public health mission. In fact,
the mental health of older Americans has been identified as a priority by the
Healthy People 2010 objectives (2), the 2005 White House Conference on
Aging (3), and the 1999 Surgeon General’s report on mental health (4).

The goals and traditions of public health and health promotion can be
applied just as usefully in the field of mental health as they have been in the
prevention of both infectious and chronic diseases. Public health agencies can
incorporate mental health promotion into chronic disease prevention efforts,
conduct surveillance and research to improve the mental health evidence base,
and collaborate with partners to develop comprehensive mental health plans and
to enhance coordination of care. The challenges for public health are to identify
risk factors, increase awareness about mental disorders and the effectiveness of
treatment, remove the stigma associated with mental disorders and receiving
treatment for them, eliminate health disparities, and improve access to mental
health services, particularly among populations that are
disproportionately affected (5).

The State of Mental Health and Aging in America

 Mental Health Problems in Older Adults
It is estimated that 20% of people age 55 years or older experience some type of
mental health concern (6). The most common conditions include anxiety, severe
cognitive impairment, and mood disorders (such as depression or bipolar disorder) (6).
Mental health issues are often implicated as a factor in cases of suicide. Older men
have the highest suicide rate of any age group (7). Men aged 85 years or older have a
suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000
The presence of depressive disorders for all ages (7).
often adversely affects the course
The Significance of Depression
and complicates the treatment Depression, a type of mood disorder, is the most prevalent mental health problem
of other chronic diseases. among older adults. It is associated with distress and suffering (4). It also can lead to
impairments in physical, mental, and social functioning (4). The presence of
depressive disorders often adversely affects the course and complicates
the treatment of other chronic diseases (8). Older adults with
depression visit the doctor and emergency room more often, use more
medication, incur higher outpatient charges, and stay longer in the
hospital (4).

Although the rate of older adults with depressive symptoms tends to

increase with age (4), depression is not a normal part of growing older.
Rather, in 80% of cases it is a treatable condition (8). Unfortunately,
depressive disorders are a widely under-recognized condition and often
are untreated or undertreated among older adults (4).

The Behavioral Risk Factor Surveillance

System and Indicators
As described earlier, a core public health function related to mental health is the col-
lection of surveillance data that can be used for priority setting and as the foundation
for developing public health programs.

Through CDC’s Behavioral Risk Factor Surveillance System (BRFSS—see

Technical Information), states collect data on the mental health of older adults. The
BRFSS questionnaire consists of three parts: 1) core questions asked to all 50 states,
the District of Columbia and three territories, 2) supplemental modules which are
a series of questions on specific topics (e.g. mental health, adult asthma history, inti-
mate partner violence), and 3) state-added questions that are selected by individual
Unfortunately, depressive disorders states.
are a widely under-recognized condition There are BRFSS core questions related to mental health that collect information on
and often are untreated or under-treated the prevalence of social and emotional support, life satisfaction, and the number of

among older adults. mentally unhealthy days.

An Anxiety and Depression module was developed for the BRFSS to collect
additional information on mental health conditions. In 2006, 38 states and three
territories used this module to determine the prevalence of current depression, life-
time diagnosis of depression, and lifetime diagnosis of anxiety.
This issue brief reports on six indicators related to mental health that were part of
the 2006 BRFSS survey, both from core questions and the Anxiety and Depression
module. Data are provided for the U.S. population age 50 years or older, with a
focus on age, racial/ethnic differences, and sex.

Page 2 The State of Mental Health and Aging in America

 Social and Emotional Support

Percentage of adults aged 50 or older

who reported that they ‘rarely’ or ‘never’
received the social support that they
needed
0 - 7.87% 9.42 - 11.18%
7.88 - 9.41% 11.19 - 17.74%

US Virgin Islands
District of Columbia Source: CDC, Behavioral Risk Factor Surveillance System, 2006

• Social support serves major support functions, including emotional

support (e.g., sharing problems or venting emotions), informational
support (e.g., advice and guidance), and instrumental support (e.g.,
providing rides or assisting with housekeeping) (9).

• Adequate social and emotional support is associated with reduced risk of

mental illness, physical illness, and mortality (9).

• The majority (nearly 90%) of adults age 50 or older indicated that they are
receiving adequate amounts of support.

• Adults age 65 or older were more likely than adults age 50–64 to
report that they “rarely” or “never” received the social and emotional
support they needed (12.2% compared to 8.1%, respectively).

• Approximately one-fifth of Hispanic and other, non-Hispanic adults age

65 years or older reported that they were not receiving the support they
BRFSS Question need, compared to about one-tenth of older white adults.

“How often do you get the social and • Among adults age 50 or older, men were more likely than women to
emotional support you need?” report they “rarely” or “never” received the support they needed (11.39%
compared to 8.49%).
The response options included: “always”,
“usually”, “sometimes”, “rarely”, or “never.”

Page 3 The State of Mental Health and Aging in America

 Life Satisfaction

Percentage of adults aged 50 or older who

responded that they were “dissatisfied” or
“very dissatisfied” with their lives.

0 - 4.06% 4.58 - 5.04%

4.07 - 4.57% 5.05 - 7.16%

US Virgin Islands
District of Columbia Source: CDC, Behavioral Risk Factor Surveillance System, 2006

• Life satisfaction is the self-evaluation of one’s life as a whole, and is

influenced by socioeconomic, health, and environmental factors (10).

• Life dissatisfaction is associated with obesity and risky health behaviors

such as smoking, physical inactivity, and heavy drinking (10).

• Nearly 95% of adults age 50 or older reported being “satisfied” or “very

satisfied” with their lives, with approximately 5% indicating that they were
“dissatisfied” or “very dissatisfied” with their lives.

• Adults age 50–64 were more likely than adults age 65 or older to report
that they were “dissatisfied” or “very dissatisfied” with their lives (5.8%
compared to 3.5%, respectively).

• Other, non-Hispanic adults age 50–64 were the group most likely to
report that they were “dissatisfied” or “very dissatisfied” with their lives
BRFSS Question (9.7% compared to 7.0% of Hispanics, 7.2% of black, non-Hispanic
adults, and 5.25% of white, non-Hispanic adults in the same age group).
“In general, how satisfied are you with
your life?” • Men and women age 50 or older reported similar rates of life satisfaction
(4.7% to 5.0%, respectively).
The response options included: “very
satisfied”, “satisfied”, “dissatisfied”, or “
very dissatisfied.”

Page 4 The State of Mental Health and Aging in America

 Frequent Mental Distress

Percentage of adults aged 50 years or older

who in the past 30 days experienced
frequent mental distress

0 - 7.23% 8.53 - 9.82%

7.24 - 8.52% 9.83 - 14.45%

US Virgin Islands
District of Columbia Source: CDC, Behavioral Risk Factor Surveillance System, 2006

BRFSS Question
“Now thinking about your mental health,
• Frequent mental distress (FMD) may interfere with major life activities, which includes stress, depression and
problems with emotions, for how many
such as eating well, maintaining a household, working, or sustaining days during the past 30 days was your
personal relationships. mental health not good?”

• FMD can also affect physical health. Older adults with FMD were more People who reported 14 or more days of
likely to engage in behaviors that can contribute to poor health, such as poor mental health were defined as having
frequent mental distress (FMD).
smoking, not getting recommend amounts of exercise, or eating a diet
with few fruits and vegetables (11).

• The overwhelming majority of older adults did not experience FMD __ in

fact, in 2006, the prevalence of FMD was only 9.2% among U.S. adults
age 50 or older and 6.5% among those age 65 or older.

• Hispanics had a higher prevalence of FMD (13.2%) compared to white,

non-Hispanics (8.3%) or black, non-Hispanics (11.1%).

• Women aged 50-64 and 65 or older reported more FMD than men in
the same age groups (13.2% and 7.7% compared to 9.1% and 5.0%,
respectively).

Page 4 The State of Mental Health and Aging in America

 Current Depression

Percentage of adults aged 50 or older who

had current depression.

0 - 5.41% 6.67 - 8.57%

5.42 - 6.66% 8.58 - 12.43%
No data

US Virgin Islands
Source: CDC, Behavioral Risk Factor Surveillance System, 2006:
District of Columbia Depression and Anxiety Module administered in 38 states and 3 territories.

• Depression is more than just a passing mood. Rather, it is a condition in

which one may experience persistent sadness, withdrawal from previously
enjoyed activities, difficulty sleeping, physical discomforts, and feeling
“slowed down” (12).

• Risk factors for late-onset depression included widowhood, physical illness,

low educational attainment (less than high school), impaired functional
status, and heavy alcohol consumption (4).
BRFSS Question • Depression is one of the most successfully treated illnesses. There are
Current Depression highly effective treatments for depression in late life, and most depressed
A PHQ-8 score of 10 or greater (see techni- older adults can improve dramatically from treatment (12).
cal information).
• Contrary to popular belief, most adults age 50 or older were not currently
depressed __ only 7.7% in this age group reported current depression, and
15.7% reported a lifetime diagnosis of depression.

Page 6 The State of Mental Health and Aging in America

 Lifetime Diagnosis of Depression

Percentage of adults aged 50 or older with a

lifetime diagnosis of depression.

0 - 14.22% 15.87 - 18.06%

14.23 - 15.86% 18.07 - 23.19%
No data

US Virgin Islands
Source: CDC, Behavioral Risk Factor Surveillance System, 2006:
District of Columbia Depression and Anxiety Module administered in 38 states and 3 territories.

• In 2006, adults age 50–64 reported more current depression and lifetime
diagnosis of depression than adults age 65 or older (9.4% compared with
5.0% for current depressive symptoms and 19.3% compared with 10.5%
for lifetime diagnosis of depression, respectively).

• Hispanic adults age 50 or older reported more current depression than

white, non-Hispanic, black, non-Hispanic adults, or other, non-Hispanic
adults (11.4% compared to 6.8%, 9.0%, and 11%, respectively).

• Women age 50 or older reported more current and lifetime diagnosis of

BRFSS Question
depression than men (8.9% compared to 6.2% for current depressive Lifetime Diagnosis of Depression
symptoms; 19.1% compared to 11.7% for lifetime diagnosis). “Has a doctor or other healthcare provider
EVER told you that you have a depressive
disorder (including depression, major
depression, dysthymia, or minor
depression)?”

Depression is one
of the most successfully
treated illnesses
The State of Mental Health and Aging in America Page 7
 Lifetime Diagnosis of Anxiety Disorder

Percentage of adults aged 50 or older with a

lifetime diagnosis of anxiety disorder.

0 - 9.38% 10.60 - 12.06%

9.39 - 10.59% 12.07 - 17.62%
No data

US Virgin Islands
Source: CDC, Behavioral Risk Factor Surveillance System, 2006:
District of Columbia Depression and Anxiety Module administered in 38 states and 3 territories.

• Anxiety, like depression, is among the most prevalent mental health

problems among older adults (6). The two conditions often go hand in
hand, with almost half of older adults who are diagnosed with a major
depression also meeting the criteria for anxiety (13).

• Late-life anxiety is not well understood, but is believed to be as common in

older adults as in younger age groups (although how and when it appears
is distinctly different in older adults). Anxiety in this age group may be
underestimated because older adults are less likely to report psychiatric
symptoms and more likely to emphasize physical complaints (13).

• More than 90% of adults age 50 or older did not report a lifetime
BRFSS Question diagnosis of anxiety.
“Has a doctor or other healthcare provider
• Adults age 50–64 reported a lifetime diagnosis of an existing anxiety
EVER told you that you have an anxiety
disorder more than adults age 65 or older (12.7% compared to 7.6%).
disorder (including acute stress disorder,
anxiety, generalized anxiety disorder,
• Hispanic adults age 50 or older were slightly more likely to report a
obsessive-compulsive disorder, panic attacks,
lifetime diagnosis of an anxiety disorder compared to white,
panic disorder, phobia, posttraumatic stress
non-Hispanic, black, non-Hispanic, or other, non-Hispanic adults (14.5%
disorder, or social anxiety disorder)?”
compared to 12.6%, 11% and 14.2%, respectively).

• Women age 50–64 years report a lifetime diagnosis of an anxiety disorder

Older adults are less likely to report more often than men in this age group (16.1% compared to 9.2%,
psychiatric symptoms and more respectively.)
likely to emphasize physical complaints

Page 8 The State of Mental Health and Aging in America

 Next Steps
Most older adults are experiencing the life satis- Technical Information
faction, social and emotional support, and good
mental health that are essential to healthy aging. For the past two decades, CDC’s Behavioral Risk Factor Surveillance System
For those who do need assistance, programs and (BRFSS) has helped states survey U.S. adults regarding a wide range of health
services should be accessible and tailored to meet issues and behaviors that affect their health. The crucial information gathered
the unique needs of older adults. Public health through this state-based telephone surveillance system is used by national, state,
professionals, while relative newcomers to the and local public health agencies to identify populations that might be most at
field, have an essential role to fulfill in assuring risk and to monitor the need for and the effectiveness of various public health
that the mental health status of the older adult interventions.
population is monitored through surveillance
systems such as the BRFSS. This information A subset of BRFSS survey questions assess how many people are experiencing
then can be used to support evidence-based mental health issues, including frequent mental distress, current depression,
programs and interventions. lifetime diagnoses of both depression or an anxiety disorder, as well as the
availability of social and emotional support, which may reduce risk of
This issue brief lays the foundation for examin- emotional distress. BRFSS’s Anxiety and Depression Module used the PHQ-8,
ing a select group of mental health indicators a well-validated, brief, self-reported measure for detecting current depression.
among older adults. Future work will focus on The PHQ-8 asked 8 questions about depressive symptoms. This questionnaire is
connecting this information to programmatic based on criteria from the Diagnostic and Statistical Manual of Mental
efforts and other resources that public health, Disorders (fourth edition) diagnosis of depressive disorders (14). The PHQ-8 has
aging services, and mental health professionals been shown to be effective for detecting current depression in various
can use to improve the health and quality of life race/ethnicities (15) as well as in older adults (16). For the BRFSS, PHQ-8
of older Americans. questions were modified to be comparable to other BRFSS questions by
assessing the number of days in the past 2 weeks the respondent experienced a
particular depressive symptom (12, 17). Each question asked about
number of days the symptom occurred in the past two weeks and
a score was assigned based on the number of days (0 to 1 days=0
points, 2 to 6 days=1 point, 7 to 11 days= 3 points, and 12 to 14
days=4 points). The scores for each item were summed to produce a
total score between 0 and 24 points. A respondent with a total score
of ≥10 was defined as having current depression.

While the BRFSS is a useful tool for assessing the mental health of
the older adult population, it has some limitations: It excludes people
who do not have telephones or are in institutions, such as nursing
homes; it may under-represent people who are severely impaired
because of the functional capacity required to participate in the
survey; and responses to BRFSS are self-reported and therefore have not been
confirmed by a healthcare provider. Despite these limitations, the BRFSS is a
uniquely powerful tool to provide the prevalence of mental health issues among
older community-dwelling U.S. adults, due to its large sample size and proven
reliability and validity (18).

The BRFSS is administered and supported by the Division of Adult and

Community Health, National Center for Chronic Disease Prevention and
Health Promotion, CDC. For more information, please visit
http://www.cdc.gov/brfss.

Page 9 The State of Mental Health and Aging in America

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References
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Page 9 The State of Mental Health and Aging in America

 Acknowledgments
Healthy Aging Program, CDC

Adults and Older Adults Goal Team, CDC

Behavioral Surveillance Branch, CDC

Healthy Aging Council, NACDD

Lisa Jeannotte, Consultant

For more information, please visit

www.cdc.gov/aging and www.chronicdisease.org

Suggested Citation:
Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America
Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.