Major mental and emotional distress has long been recognized as a precipitating factor in interpersonal difficulties, mental health problems, alcohol and drug use, need for behavioral healthcare, and even early death. That is why recent work by Blanchflower and Oswald (American Journal of Public Health, October 2020, Vol. 110, No. 10, Pp. 1538-1544) is so important. These authors examined major mental and emotional stress (defined as experiencing these stresses in all 30 of the last 30 days) for the period from 1993 to 2019. Clearly, this is a very extreme measure of distress that is experienced virtually every day.
The data derive from 8.1 million randomly sampled Americans surveyed through the CDC Behavioral Risk Factor Surveillance System.
The findings are quite disconcerting. Major distress almost doubled from 3.6% to 6.4% of Americans between 1993 and 2019. In each year, females showed higher rates than males, beginning with 4.1% vs. 3.2% in 1993, and growing to 7.0% vs. 5.3% in 2019. Rates were high and increasing for those with less than a high school education: 4.5% in 1993 increasing to 8.6% in 2019. For white and non-white persons between ages 35 and 54, rates increased over time: white individuals increased from 3.9% to 6.8% in a linear way, and non-white individuals increased from 4.9% to 5.5% in an erratic pattern. Also, the balance reversed over time, with non-white individuals higher in 1993, and white individuals higher in 2019. The latter findings are cited as evidence of the emerging problem of despair in less educated white males in recent years.
These findings have clear implications for behavioral healthcare in the United States. The current figure of 6.4% adults in major distress translates into about 13.4 million Americans. Since only about half of those with behavioral conditions actually receive specialty care, we would estimate that no more than 6.7 million of these persons are currently receiving care. That leaves the important question of what is happening to the remaining 6.7 million, and whether they will be seeking specialty care at some time in the future.
Further, since the entire specialty system serves only about 6.5% of the adult population, slightly less than half of our current national effort is expended on these 6.7 million people. Thus, we will need to learn much more about their clinical and social needs. A second implication is that we will need to learn much more about the remaining persons currently served by our specialty system and the ways in which they differ from this group.
Major stress also is a clear precipitant of increased drug use and suicide. Since a very high prevalence of major stress existed in the pre-COVID-19 period, it is quite reasonable to assume that many, if not most, of these persons have much more severe stress now than they did even just six months ago. Recent dramatic increases in levels of alcohol and drug use, and in the incidence of suicide contemplation support this assertion.
A key avenue for future work is prevention: How can we reduce the number of persons who will experience major distress? Clearly, changes in our economy, including economic downturns, play a major role. How can we dampen these effects? Similarly, racism, sexism and discrimination also play a role in fostering major distress, as we are currently witnessing with recent events. These problems also demand remediation as we go forward.
It always is better to prevent than to treat. Here, this means that it is better to dismantle negative social determinants in the community before they exert their adverse consequences. Undoubtedly, this will be a major task for us going forward.