Where Depression Is Most Common: U.S. State and County Estimates, 2020

Depression is a major cause of illness, disability, death and economic cost in the United States. Knowing where it is most common helps states and counties target prevention, treatment and management.

CDC used the 2020 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of adults in every state and DC, to estimate how many had ever been told by a doctor, nurse or other health professional that they had a depressive disorder — depression, major depression, dysthymia or minor depression. 392,746 people answered the question.

Nationally

18.4% of adults — about one in five — reported a lifetime diagnosis (18.5% age-standardized).

Age-standardized except for the age groups.

By state

Prevalence ranged from 12.7% in Hawaii to 27.5% in West Virginia (median 19.9%). The ten highest, in order: West Virginia, Kentucky, Tennessee, Arkansas, Vermont, Alabama, Louisiana, Washington, Missouri and Montana. Most of the highest-prevalence states were in the Appalachian and southern Mississippi Valley regions.

By county

Model-based estimates for all 3,143 counties ranged from 10.7% (Aleutians East Borough, Alaska) to 31.9% (Logan County, West Virginia), with a median of 21.8%. The highest were mostly in Appalachia, the southern Mississippi Valley, and Missouri, Oklahoma and Washington. Counties varied within states too: every West Virginia county was in the top quarter, yet they ranged from 24.5% to 31.9%.

Model-based, age-standardized prevalence of adults reporting a lifetime diagnosis of depression, by county, United States, 2020. CDC / MMWR

Why the differences

• Young adults had the highest rates; national survey data show depression in the previous year rose fastest among adolescents and young adults from 2015 to 2019.
• Depression often accompanies chronic diseases such as diabetes, arthritis and heart disease, which are also concentrated in Appalachian states — so the map may partly reflect them.
• Social conditions matter too: Appalachian adults tend to have lower incomes, more poverty and less education, all of which can harm health.

What can help

• Physical activity, good sleep and good nutrition help manage symptoms and support mental health at every age; the American Psychological Association offers treatment guidelines by age group.
• Chronic disease self-management programs can improve both chronic conditions and mental health.
• CDC's How Right Now campaign offers resources for emotional well-being and resilience.
• The Community Preventive Services Task Force recommends, among others, collaborative care for depressive disorders, mental health benefits legislation, school-based cognitive behavioral therapy to reduce depression and anxiety, and depression care management for older adults; SAMHSA's Evidence-Based Practices Resource Center helps put proven practices in place.

How the county estimates were made

BRFSS isn't designed for county estimates, so CDC used multilevel statistical modeling with each respondent's age, sex, race and ethnicity and education, county poverty data, and Census population estimates. The results agreed well (correlation 0.88) with direct survey estimates in the 183 counties with at least 500 respondents.

Limits

• Answers are self-reported and subject to recall and other biases; willingness to discuss symptoms and access to a provider may differ by sex, culture and generation.
• People in institutions or unreachable by phone were not surveyed.
• County estimates may be imprecise, since they rest on population estimates, not census counts.

Sources

Based on Lee B, Wang Y, Carlson SA, et al., "National, State-Level, and County-Level Prevalence Estimates of Adults Aged ≥18 Years Self-Reporting a Lifetime Diagnosis of Depression — United States, 2020," MMWR Morbidity and Mortality Weekly Report, volume 72, Centers for Disease Control and Prevention; a work of the United States government in the public domain.