National, State-Level, and County-Level Prevalence Estimates of Adults Aged ≥18 Years Self-Reporting a Lifetime Diagnosis of Depression — United States, 2020

Depression is a major contributor to mortality, morbidity, disability, and economic costs in the United States (1). Examining the geographic distribution of depression at the state and county levels can help guide state- and local-level efforts to prevent, treat, and manage depression. CDC analyzed 2020 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate the national, state-level, and county-level prevalence of U.S. adults aged ≥18 years self-reporting a lifetime diagnosis of depression (referred to as depression). During 2020, the age-standardized prevalence of depression among adults was 18.5%. Among states, the age-standardized prevalence of depression ranged from 12.7% to 27.5% (median = 19.9%); most of the states with the highest prevalence were in the Appalachian* and southern Mississippi Valley^† regions. Among 3,143 counties, the model-based age-standardized prevalence of depression ranged from 10.7% to 31.9% (median = 21.8%); most of the counties with the highest prevalence were in the Appalachian region, the southern Mississippi Valley region, and Missouri, Oklahoma, and Washington. These data can help decision-makers prioritize health planning and interventions in areas with the largest gaps or inequities, which could include implementation of evidence-based interventions and practices such as those recommended by The Guide to Community Preventive Services Task Force (CPSTF) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

BRFSS is an ongoing, state-based, random-digit–dialed landline and cell phone survey of the U.S. adult population aged ≥18 years in all 50 states, the District of Columbia (DC), and participating U.S. territories.^§ The combined (landline and cellular) median response rate for the 2020 BRFSS (excluding territories) was 47.6% and ranged among states from 34.5% to 67.2%.^¶ A lifetime diagnosis of depression was defined as a “yes” response to the question, “Has a doctor, nurse, or other health professional ever told you that you had a depressive disorder, including depression, major depression, dysthymia, or minor depression?” Among the 2020 BRFSS respondents surveyed in all 50 U.S. states and DC, 392,746 (98.9%) responded to the depression question.

This report presents national, state-level, and county-level point estimates and 95% CIs for the prevalence of depression. National values were directly estimated from weighted BRFSS 2020 data for groups defined by age, sex, race or ethnicity, and education, and state-level estimates were directly estimated from weighted BRFSS 2020 data for each state and DC. Point estimates from survey data were estimated as weighted means and pairwise t-tests were used to determine differences (compared with a reference category) by age group, sex, race or ethnicity, and education level. Differences with p<0.05 were considered statistically significant. Because BRFSS is not designed to provide estimates at the county level, county-level estimates were obtained for all 3,143 U.S. counties using multilevel logistic regression and post-stratification.** The multilevel logistic regression model included depression as the binary dependent variable. The model’s independent variables included each respondent’s age group, sex, race and ethnicity, and education level from BRFSS 2020 data, county-level poverty data (<150% of the poverty level) from the 2016–2020 American Community Survey,^†† and random effects for state and county. The model parameters were then applied to the U.S. Census Bureau Vintage 2020 county population data to generate model-based county-level estimates of depression prevalence.^§§ A Monte Carlo simulation was used to generate 95% CIs for county-level estimates. These model-based county-level estimates were validated by comparing them with the weighted direct survey estimates from counties with sample size ≥500 (183) in BRFSS (Pearson correlation coefficient = 0.88). All national and state-level analyses were conducted using SAS-callable SUDAAN software (version 11; RTI International) to account for the BRFSS complex sample design and weighting, and county-level estimation was conducted using SAS software (version 9.4; SAS Institute). All prevalence estimates were age standardized to the 2000 U.S. Census Bureau population.^¶¶ This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.***

The age-standardized prevalence of depression among U.S. adults was 18.5% (crude = 18.4%) (Table 1). Age-specific prevalence of depression was highest among those aged 18–24 years (21.5%) and lowest among those aged ≥65 years (14.2%). The age-standardized prevalence of depression was higher among women (24.0%) compared with men (13.3%), higher among non-Hispanic White adults (21.9%) compared with non-Hispanic Black or African-American (16.2%), non-Hispanic Native Hawaiian or other Pacific Islander (14.6%), Hispanic or Latino (14.6%), and non-Hispanic Asian (7.3%) adults, and higher among adults who had attained less than a high school education (21.2%) compared with adults with a high school education or equivalent (18.5%) and college degree or higher (15.4%).

Among states, the age-standardized prevalence of depression ranged from 12.7% in Hawaii to 27.5% in West Virginia (median = 19.9%) (Table 2). The 10 states with the highest prevalence were (in descending order) West Virginia, Kentucky, Tennessee, Arkansas, Vermont, Alabama, Louisiana, Washington, Missouri, and Montana.

Among counties, the model-based age-standardized estimates ranged from 10.7% (Aleutians East Borough County, Alaska) to 31.9% (Logan County, West Virginia) (median = 21.8%) (Supplementary Table, https://stacks.cdc.gov/view/cdc/129404); most of the counties with the highest prevalence were in the Appalachian region, the southern Mississippi Valley region, and in Missouri, Oklahoma, and Washington (Figure). Estimates of depression also varied among counties within states. For example, even though all county prevalence estimates in West Virginia were in the highest quartile, estimates in the state by county ranged from 24.5% to 31.9%.

¹Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; ²Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

References

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Abbreviations: AI/AN = American Indian or Alaska Native; NA = not applicable; NH/OPI = Native Hawaiian or other Pacific Islander; Ref = referent group.
* Respondents were classified as having received a diagnosis of depression if they responded “yes” to the question, “Has a doctor, nurse, or other health professional ever told you that you had a depressive disorder, including depression, major depression, dysthymia, or minor depression?”
^† Categories might not sum to sample total because of missing responses for some variables.
^§ Weighted using the statistical weights provided in the Behavioral Risk Factor Surveillance System data set.
^¶ Except for age groups, estimates were age-standardized to the 2000 projected U.S. Census Bureau population aged ≥18 years using four groups (18–24, 25–44, 45–64, and ≥65 years). https://www.cdc.gov/nchs/data/statnt/statnt20.pdf
** Statistically significant (p<0.05) difference compared with the indicated Ref category.
^†† Respondents who identified as Hispanic or Latino might be of any race.

* Respondents were classified as having depression if they responded “yes” to the question, “Has a doctor, nurse, or other health professional ever told you that you had a depressive disorder, including depression, major depression, dysthymia, or minor depression?”
^† Weighted using the statistical weights provided in the Behavioral Risk Surveillance System data set.
^§ Age-standardized to the 2000 projected U.S. Census Bureau population aged ≥18 years using four groups (18–24, 25–44, 45–64, and ≥65 years). https://www.cdc.gov/nchs/data/statnt/statnt20.pdf

FIGURE. Model-based age-standardized* county estimates of the percentage^† of adults aged ≥18 years self-reporting a lifetime diagnosis of depression^§ — Behavioral Risk Factor Surveillance System, United States, 2020

* Age-standardized to the 2000 projected U.S. Census Bureau population aged ≥18 years using 13 age groups (18–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 50–59, 60–64, 65–69, 70–74, 75–79, and ≥80 years). https://www.cdc.gov/nchs/data/statnt/statnt20.pdf

^† By quartile.

^§ Respondents were classified as having depression if they responded “yes” to the question, “Has a doctor, nurse, or other health professional ever told you that you had a depressive disorder, including depression, major depression, dysthymia, or minor depression?”