JMIR FORMATIVE RESEARCH

Verlenden et al

Original Paper

Measuring Population-Level Adolescent Mental Health Using aSingle-Item Indicator of Experiences of Sadness andHopelessness: Cross-Sectional Study
Jorge Verlenden1, PhD; Sanjana Pampati1, MPH, PhD; Melissa Heim Viox2, MPH; Nancy Brener1, PhD; Laima
Licitis3, MPH; Patricia Dittus1, PhD; Kathleen Ethier1, PhD
1Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control andPrevention, Atlanta, GA, United States
2

NORC, University of Chicago, Chicago, IL, United States

3

Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States

Corresponding Author:
Jorge Verlenden, PhD
Division of Adolescent and School HealthNational Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Chamblee Campus
4770 Buford Highway
Atlanta, GA, 30341
United States
Phone: 1 404 498 6018
Email: nlx7@cdc.gov

Abstract
Background: Population-level monitoring of adolescent mental health is a critical public health activity used to help define
local, state, and federal priorities. The Youth Risk Behavior Surveillance System includes a single-item measure of experiencesof sadness or hopelessness as an indicator of risk to mental health. In 2021, 42% of high school students reported having felt sador hopeless for 2 weeks or more during the past 12 months. The high prevalence of US high school students with this experiencehas been highlighted in recent studies and media reports.
Objective: This study seeks to examine associations between this single-item measure of experiences of sadness or hopelessness
with other indicators of poor mental health including frequent mental distress and depressive symptoms.
Methods: We analyzed survey data from a national sample of 737 adolescents aged 15-19 years as a part of the Teen and Parent
Surveys of Health. Participants were recruited from AmeriSpeak, a probability-based panel designed to be representative of the
US household population. Feeling sad or hopeless was operationalized as a “yes” response to the item, “During the past 12 months,
did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?”
Unadjusted and adjusted prevalence ratios (aPRs) were calculated to examine associations between the single-item measure of
having felt sad or hopeless almost every day for 2 weeks with moderate to severe depressive symptoms, frequent mental distress,
and functional limitation due to poor mental health. Adjusted models controlled for age, race and ethnicity, sex assigned at birth,and sexual identity.
Results: Overall, 17.3% (unweighted: 138/735) of adolescents reported that they felt sad or hopeless for 2 weeks or more during
the past 12 months, 30.2% (unweighted: 204/716) reported moderate to severe depressive symptoms, 18.4% (unweighted: 126/732)
reported frequent mental distress, and 15.4% (unweighted: 107/735) reported functional limitation due to poor mental health.
After adjusting for demographics, adolescents who reported that they felt sad or hopeless for 2 weeks or more were 3.3 times as
likely to report moderate to severe depressive symptoms (aPR 3.28, 95% CI 2.39-4.50), 4.8 times as likely to indicate frequent
mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8 times as likely to indicate mental health usually or always interfered with
their ability to do things (aPR 7.78, 95% CI 4.88-12.41).
Conclusions: Associations between having felt sad or hopeless for 2 weeks or more and moderate to severe depressive symptoms,
frequent mental distress, and functional limitation due to poor mental health suggest the single-item indicator may represent

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relevant symptoms associated with poor mental health and be associated with unmet health needs. Findings suggest the single-item
indicator provides a population-level snapshot of adolescent experiences of poor mental health.
(JMIR Form Res 2024;8:e54288) doi: 10.2196/54288
KEYWORDS
adolescents; mental health; surveillance; teens; sadness; hopelessness

Introduction
Population-level monitoring of adolescent mental health is a
critical public health activity [1]. Data from health surveillancesystems of children and adolescents are used to track mental
health trends, identify factors that influence mental healthoutcomes, and inform public health–related decision-making[2]. National surveillance systems, such as the Youth Risk
Behavior Surveillance System (YRBSS), National Survey ofChildren’s Health, and the National Survey on Drug Use and
Health, include various measures of child and adolescent mental
health. No single surveillance system captures all aspects ofadolescent mental health (eg, disorders, mental health concerns,
or suicide), and no single indicator can summarize the many
dimensions of mental health [3]. However, by harmonizing
across data systems and furthering our understanding of what
each data system and measure captures, a more complete pictureof adolescent mental health can be established. Indeed, a numberof studies have evaluated mental health measures in publichealth surveillance systems through descriptive comparisonsof responses across items and data systems [3-5].
One such measure of poor adolescent mental health that hasreceived growing attention in recent studies and media reports
is a single-item measure of experiences of sadness orhopelessness [6,7]. Since 1999, the Centers for Disease Control
and Prevention’s (CDC) YRBSS has included this single-item
measure [8]. In 2021, 42% of high school students reported
having felt sad or hopeless for 2 weeks or more during the past
12 months, and the prevalence of this experience significantly
increased from 2011 to 2021 [9]. Further, disparities in thisexperience by sex, race/ethnicity, sexual identity, and sex ofsexual contacts have been documented [9].
This descriptive study seeks to expand the understanding of thissingle-item measure by examining its alignment with establishedmeasures of poor mental health.

Methods
Overview
We analyzed survey data from a national sample of 737
adolescents aged 15-19 years. Data were collected by NORC
at the University of Chicago, May to September 2022, as partof the Teen and Parent Surveys of Health (TAPS). Participants
were recruited from AmeriSpeak, a probability-based panel
designed to be representative of the US household population.
Selected US households are sampled using area probability andaddress-based sampling from the NORC National Sample Frame
to form the AmeriSpeak general adult panel. Recruitment occurs
by US mail, telephone, and field interviews. In addition to thegeneral adult panel, there are also subpanels of specifichttps://formative.jmir.org/2024/1/e54288

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populations, including the AmeriSpeak teen panel of adolescents
aged 13-17 years [7]. Adolescent TAPS participants wererecruited in three ways. First, adolescents aged 18-19 years weredirectly recruited from the AmeriSpeak general adult panel.
Second, adolescents aged 15-17 years were recruited from theAmeriSpeak teen panel. Third, we identified panelists who wereparents of adolescents aged 15-17 who could consent for theirchild to participate in TAPS, even if they were not members of
the AmeriSpeak teen panel. Panel recruitment and methodology
have been published elsewhere [7,8].

Ethical Considerations
Participants received the equivalent of US $20 in AmeriPoints,
redeemable for a gift card [7,8]. Teens aged 15-17 years requiredparental consent to participate. Parents also received theequivalent of US $2 in AmeriPoints for completing the screener
and consent survey. This activity was reviewed by the CDC
and conducted consistent with applicable federal law and CDC
policy; the study was also reviewed and approved by NORC’s
Institutional Review Board (IRB protocol 20.07.10, project8644). The survey was conducted confidentially.

Measures
The analysis included four indicators of poor mental health: (1)felt sad or hopeless, based on a Yes response to the YRBSS
item, “During the past 12 months, did you ever feel so sad or
hopeless almost every day for 2 weeks or more in a row thatyou stopped doing some usual activities?”; (2) depressive
symptoms, measured using the 8-item Patient Health
Questionnaire (PHQ-8) for adolescents using a cutoff score of≥10 to indicate moderate to severe depressive symptoms versus
none, minimal, or mild [9,10]; (3) frequent mental distress,
dichotomized as always or most of the time versus sometimes,
rarely, or never for the question, “During the past 30 days, howoften was your mental health not good? (Mental health includes
stress, anxiety, and depression)”; and (4) functional limitation
due to poor mental health, based on a response of always orusually versus sometimes, rarely, or never to the question,“During the past 12 months, how often has your mental healthinterfered with your ability to do things other young people
your age do?” The PHQ-8 is established as a valid diagnostic
and severity measure of depressive symptoms and is used inclinical and population studies to assess symptoms indicativeof depressive disorders [9-12]. Items 3 and 4 were derived froma health-related quality of life measure and have demonstrated
validity and reliability for population health surveillance [13,14].

Analysis
The following demographic characteristics were examined: sex
assigned at birth, age, race/ethnicity, and sexual identity. We
present the weighted prevalence of each indicator of poor mental
health overall and by demographic characteristics. Missing
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observations were excluded in calculations for each variable.
To examine associations between feeling sad or hopeless andthe other indicators of poor mental health, we used predictedmargins in logistic regression to calculate prevalence ratios andadjusted prevalence ratios (aPRs), adjusting for demographics
and accounting for the complex survey design.

Results
Overall, 17.3% (unweighted: 138/735) of adolescents reported
feeling sad or hopeless for 2 weeks or more during the past 12
months, 30.2% (unweighted: 204/716) reported moderate tohttps://formative.jmir.org/2024/1/e54288

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Verlenden et al
severe depressive symptoms, 18.4% (unweighted: 126/732)
reported frequent mental distress, and 15.4% (unweighted:
107/735) reported functional limitation due to poor mental health(Table 1).
Adolescents reporting that they had felt sad or hopeless had 3.3
times the prevalence of moderate to severe depressive symptoms(aPR 3.28, 95% CI 2.39-4.50), 4.8 times the prevalence of
frequent mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8
times the prevalence of functional limitation due to poor mental
health (aPR 7.78, 95% CI 4.88-12.41) compared to those notreporting sadness or hopelessness (Table 2).

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Table 1. Percent distribution of demographic characteristics of adolescent respondents by having felt sad or hopeless almost every day for 2 weeks(past 12 months), moderate to severe depressive symptoms (past 2 weeks), frequent mental distress (past 30 days), and functional limitation due to poor
mental health usually or always (past 12 months)a.
Overall, nFelt sad or hopeless al- Moderate to severe de- Frequent mental
most every day for 2
pressive symptoms,
distress (past 30
weeks (past 12
PHQ-8c score ≥10 (past days)e, n (%)
months)b, n (%)
2 weeks)d, n (%)

Functional limitation
due to poor mental
health usually or al-

737

138 (17.3)

204 (30.2)

126 (18.4)

107 (15.4)

Female392

96 (20.8)138 (38.5)

87 (22.8)

75 (19.4)

Male

337

39 (13.5)

63 (21.4)

39 (14.5)

32 (11.8)

15-17

529

93 (15.1)

123 (24.4)

77 (14.0)

64 (13.1)

18-19

208

45 (21.1)

81 (39.6)

49 (25.8)

43 (19.2)

White, non-Hispanic372

64 (15.5)

100 (29.8)

55 (15.5)

52 (15.9)

Black, non-Hispanic

123

21 (18.4)

30 (23.0)

19 (20.4)

15 (14.9)

Hispanic/Latino

153

36 (23.5)

53 (36.3)

35 (25.4)

25 (17.4)

All other races, non-Hispanic

89

17 (9.7)

21 (26.8)

17 (13.5)

15 (8.9)

Lesbian/gay

29

11 (36.5)

13 (41.2)

7 (18.4)

10 (31.1)

Straight/heterosexual561

77 (13.7)

124 (26.6)

79 (17.4)

61 (13.4)

Bisexual75

26 (34.0)

36 (53.2)

20 (27.1)

16 (22.5)

Another identity/unsure72

24 (21.1)

31 (32.7)

20 (17.4)

20 (18.7)

Total

ways (past 12 months)f,n (%)

Sex assigned at birthg

Age (years)

Race/ethnicityh

Sexual identityiaTable shows unweighted numbers (n) and weighted percentages (%). Missing observations were excluded in the calculation of percentages for eachvariable.
bFelt sad or hopeless is based on a “Yes” response to the question “During the past 12 months, did you ever feel so sad or hopeless almost every day
for 2 weeks or more in a row that you stopped doing some usual activities?”c

PHQ-8: 8-item Patient Health Questionnaire.

d

Having moderate to severe depressive symptoms is based on a sum score of ≥10 on the PHQ-8 and aligns with depressive symptom severity cutoff
guidelines for the PHQ, measuring number and frequency of symptoms experienced in the past 14 days.
eFrequent mental distress is based on a response of “Always” or “Most of the time” to the question “During the past 30 days, how often was your mental
health not good? (Mental health includes stress, anxiety, and depression).” Response options were “Always,” “Most of the time,” “Sometimes,” “Rarely,”and “Never.”f

Functional limitation due to poor mental health is based on response of “Always” or “Usually” to the question “During the past 12 months, how often
has your mental health interfered with your ability to do things other young people your age do?” Response options were “Always,” “Usually,”“Sometimes,” “Rarely,” or “Never.”g

Adolescents reported sex at birth in response to the survey question: “What sex were you assigned at birth, on your original birth certificate?”hAll other races category included American Indian, Alaska Native, Native Hawaiian or Pacific Islander, some other race, or selected more than one
race category.
i

Sexual identity was based on response to the question “Which of the following best represents yourself?” Adolescents selected from the following
response options: “Lesbian or gay”; “Straight, that is, not lesbian or gay”; “Bisexual”; “Something else”; “I don’t know the answer.” Responses of“Something else” or “I don’t know the answer” were coded as “Another identity/Unsure.”https://formative.jmir.org/2024/1/e54288

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Table 2. Associations between adolescent report of having felt sad or hopeless almost every day for 2 weeks (past 12 months) and moderate to severe
depressive symptoms (past 2 weeks), frequent mental distress (past 30 days), and functional limitation due to poor mental health usually or always (past12 months).
Moderate to severe depressive symptomsa(PHQ-8 score ≥10; past 2 weeks)
Weighted
percentage
(%)e
Yes

PRf (95%
CI)b

aPRg (95%
CI)

h

No

Frequent mental distress (past 30 days)c

Functional limitation due to poor mental

Weighted percentage (%)

Weighted
percentage
(%)

Yes

PR (95% CI) aPR (95%CI)

No

health usually or always (past 12 months)d

Yes

No

PR (95% CI) aPR (95%CI)

Felt sad or hopeless almost every day for two weeks, past 12 monthsi

a

Yes

74.5

25.5

3.59 (2.654.86)

3.28 (2.394.50)

55.0

45.0

5.05 (3.118.18)

4.75 (2.927.74)

56.0

44.0

8.02 (4.9313.04)

7.78 (4.8812.41)

No

20.7

79.3

Reference

Reference

10.9

89.1

Reference

Reference

7.0

93.0

Reference

Reference

PHQ-8: 8-item Patient Health Quetionnaire.

b

Having moderate to severe depressive symptoms is based on a sum score of ≥10 on the PHQ-8 and aligns with depressive symptom severity cutoff
guidelines for the PHQ, measuring number and frequency of symptoms experienced in the past 14 days.
cFrequent mental distress is based on a response of “Always” or “Most of the time” to the question “During the past 30 days, how often was your mental
health not good? (Mental health includes stress, anxiety, and depression).” Response options were “Always,” “Most of the time,” “Sometimes,” “Rarely,”and “Never.”dFunctional limitation due to poor mental health is based on response of “Always” or “Usually” to the question “During the past 12 months, how often
has your mental health interfered with your ability to do things other young people your age do?” Response options were “Always,” “Usually,”“Sometimes,” “Rarely,” or “Never.”e

Table shows weighted row percentages (%). Missing observations were excluded in calculations for each variable.

f

PR: prevalence ratio.

gaPR: adjusted prevalence ratio.

hAdjusted for age, race and ethnicity, sex assigned at birth, and sexual identity.

iFelt sad or hopeless is based on a “Yes” response to the question “During the past 12 months, did you ever feel so sad or hopeless almost every day
for 2 weeks or more in a row that you stopped doing some usual activities?”

Discussion
Our study identified strong associations between having felt
sad or hopeless and having moderate to severe depressive
symptoms, frequent mental distress, and functional limitation
due to poor mental health. Results suggest the single-item
YRBSS measure offers a depiction of poor mental health among
adolescents and support its use in population studies.
Mental health is a broad concept that includes a range offunctioning across various contexts and environments [3].
Clinical mental health assessments, especially for children andadolescents, often involve a multicomponent process that
includes structured tests and interviews with multiple informants[9,15]. However, use of single-item indicators or concise item
sets is essential to reducing respondent burden in the collectionof public health surveillance data [3-5]. Strengths of the YRBSS
measure include its brevity and plain language, along with its
association with other indicators of poor mental health thatsuggest unmet mental health needs, which together support its
utility as a population-level measure for adolescents. Future
research might examine associations between the YRBSS itemand other mental health measures as well as compare responses
by demographic characteristics.
Several limitations of our study must be acknowledged. First,
we used data from a small sample of adolescents recruited fromhttps://formative.jmir.org/2024/1/e54288

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weighted to represent the US household population,
generalizability to the US adolescent population may be limited.
Second, because the survey was administered in English,
experiences of teens with limited English proficiency may not
be represented. Third, parental consent was required for teens
aged 15-17 years to participate, which may introduce selection
bias. Fourth, recall periods varied for the sets of questions
comprising the mental health indicators thereby limiting ourability to compare experiences within the same time frame.
Population-level monitoring of adolescent health behaviors isa critical public health activity that helps ensure awareness ofchanging needs of adolescents and helps support priority-setting
for public health programming [1-3,16]. The associations
between having felt sad or hopeless for 2 weeks or more andmoderate to severe depressive symptoms, frequent mental
distress, and functional limitation due to poor mental healthsuggest the single-item indicator may represent relevant
symptoms associated with poor mental health and be associatedwith unmet health needs. Findings from this study support thevalue of this item for use in population studies of adolescentsand can enhance understanding of results of the YRBSS moving
forward.

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Acknowledgments
This study was funded, in part, by the Centers for Disease Control and Prevention (CDC) contract task order number
75D30119F06605 to NORC at the University of Chicago. This project was also supported by an appointment to the ResearchParticipation Program at the CDC, administered by the Oak Ridge Institute for Science and Education through an inter-agency
agreement between the U.S. Department of Energy and the CDC. The authors acknowledge that the copyright of this study isheld under the provisions of the U.S. Government’s contract rights.

Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of theCenters for Disease Control and Prevention (CDC).

Conflicts of Interest
None declared.

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Abbreviations
aPR: adjusted prevalence ratio

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CDC: Centers For Disease Control and Prevention
PHQ-8: 8-item Patient Health Questionnaire
TAPS: Teen and Parent Surveys of HealthYRBSS: Youth Risk Behavior Surveillance System

Edited by A Mavragani; submitted 03.11.23; peer-reviewed by D Courtney, D Levine; comments to author 22.02.24; revised version
received 29.04.24; accepted 12.06.24; published 26.07.24
Please cite as:
Verlenden J, Pampati S, Heim Viox M, Brener N, Licitis L, Dittus P, Ethier K
Measuring Population-Level Adolescent Mental Health Using a Single-Item Indicator of Experiences of Sadness and Hopelessness:
Cross-Sectional StudyJMIR Form Res 2024;8:e54288
URL: https://formative.jmir.org/2024/1/e54288
doi: 10.2196/54288
PMID:©Jorge Verlenden, Sanjana Pampati, Melissa Heim Viox, Nancy Brener, Laima Licitis, Patricia Dittus, Kathleen Ethier. Originallypublished in JMIR Formative Research (https://formative.jmir.org), 26.07.2024. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, isproperly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as wellas this copyright and license information must be included.

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