Results from the 2021 National Survey on Drug Use and Health: Detailed Tables

Appendix A: Key Definitions for the 2021 National Survey on
Drug Use and Health

This glossary is a resource to provide definitions for many of the commonly used measures and terms in tables and reports from the 2021 National Survey on Drug Use and Health (NSDUH). Where relevant, cross-references to details in the 2021 National Survey on Drug Use and Health (NSDUH): Methodological Summary and Definitions report also are provided.¹ In addition, some definitions contain cross-references (indicated by “SEE”) to refer data users to the correct entry in the glossary or to aid data users in understanding the meaning of the current definition. For example, if data users search on “Any Mental Illness” or “AMI,” they are referred to the “Mental Illness” definition for the definition of any mental illness. As an example of the second kind of cross-reference, the “Alcohol Use Disorder (AUD)” definition includes cross-references to “Alcohol Use” and “Substance Use Disorder (SUD)” to aid data users in understanding the AUD definition. However, these cross-references to other definitions are not intended to provide an exhaustive index of all related terms that might apply.

For some key terms, specific question wording is provided for clarity. In some situations, information also is included about specific gate questions. In many instances, a gate question is the first question in a series of related questions. How a respondent answers the gate question affects whether the respondent is asked additional questions in that section of the interview or is routed to the next section of the interview. In some sections of the interview, respondents may be asked more than one gate question to determine whether they are asked additional questions in that section or are routed to the next section.²

Because of changes to data collection procedures and other methodological changes for 2021, estimates between 2021 and prior years should not be compared. See Chapters 2, 3, and 6 in the 2021 Methodological Summary and Definitions report for additional information on these changes.

Abbreviated WHODAS

SEE: “World Health Organization Disability Assessment Schedule (WHODAS).”

ACASI

ACASI stands for audio computer-assisted self-interviewing and applies to in-person NSDUH data collection. ACASI questions appear on a laptop computer screen while an audio recording of the questions plays on headphones. Respondents enter their answers directly into the computer without the interviewer knowing how they answered. ACASI is designed to provide the respondent with a highly private and confidential mode for responding to questions about illicit drug use and other sensitive behaviors. The audio also is helpful for respondents with limited reading skills. For information on in-person interview sections administered using ACASI, see the list of the content of the 2021 NSDUH in-person instruments.³

SEE: “CAPI” and “Interview Mode.”

Access to Medical Care Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “Because of the COVID-19 pandemic in the U.S., did you experience any of the following in your access to medical care?” Respondents were asked whether they experienced the following: (1) appointments moved from in person to telehealth, (2) delays or cancellations in appointments, (3) delays in getting prescriptions, and (4) inability to access needed care resulting in moderate to severe impact on health. Respondents could indicate that these situations did not apply to them.

SEE: “COVID-19.”

Access to Mental Health Care Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “Because of the COVID-19 pandemic in the U.S., did you experience any of the following in your access to mental health treatment?” Respondents were asked whether they experienced the following: (1) appointments moved from in person to telehealth, (2) delays or cancellations in appointments, (3) delays in getting prescriptions, and (4) inability to access needed care resulting in moderate to severe impact on health. Respondents could indicate that these situations did not apply to them.

SEE: “COVID-19.”

Access to Substance Use Treatment Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “Because of the COVID-19 pandemic in the U.S., did you experience any of the following in your access to substance use treatment?” Respondents were asked whether they experienced the following: (1) appointments moved from in person to telehealth, (2) delays or cancellations in appointments, (3) delays in getting prescriptions, and (4) inability to access needed care resulting in moderate to severe impact on health. Respondents could indicate that these situations did not apply to them.

SEE: “COVID-19.”

Age

Age of the respondent was defined as “age at time of interview.” The interview program calculated the respondent’s age from the interview date and the date of birth reported to the interviewer. The interview program prompts the interviewer to confirm the respondent’s age after it has been calculated.

AIAN

SEE: “American Indian or Alaska Native (AIAN).”

Alcohol Use

Measures of use of alcohol in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the alcohol section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, had a drink of any type of alcoholic beverage?” and “How long has it been since you last drank an alcoholic beverage?”). The question about recency of use was asked if respondents previously reported any use of alcohol in their lifetime.

The following definitional information preceded the question about lifetime alcohol use: “The next questions are about alcoholic beverages, such as beer, wine, brandy, and mixed drinks. Listed on the next screen are examples of the types of beverages we are interested in. Please review this list carefully before you answer these questions. These questions are about drinks of alcoholic beverages. Throughout these questions, by a ‘drink,’ we mean a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it. We are not asking about times when you only had a sip or two from a drink.”

SEE: “Binge Use of Alcohol,” “Current Use or Misuse,” “Heavy Use of Alcohol,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Underage Alcohol Use.”

Alcohol Use Disorder (AUD)

Alcohol use disorder (AUD) was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁴). Respondents who used alcohol on 6 or more days in the past 12 months were classified as having an AUD if they met two or more of the following criteria: (1) used alcohol in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on alcohol use; (3) spent a great deal of time in activities to obtain, use, or recover from alcohol use; (4) felt a craving or strong desire to use alcohol; (5) engaged in recurrent alcohol use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use alcohol despite social or interpersonal problems caused by the effects of alcohol; (7) gave up or reduced important social, occupational, or recreational activities because of alcohol use; (8) continued to use alcohol in physically hazardous situations; (9) continued to use alcohol despite physical or psychological problems caused by alcohol use; (10) increased the amount of alcohol needed to achieve same effect or noticed that the same amount of alcohol use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping alcohol use or (11b) used alcohol or a related substance to get over or avoid alcohol withdrawal symptoms. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use” and “Substance Use Disorder (SUD).”

Alcohol Use in Combination with Illicit Drug Use

Respondents who used alcohol in the past 30 days were classified as using alcohol in combination with illicit drugs if they reported in the consumption of alcohol section of the questionnaire that they used one or more of six selected illicit drugs with their most recent use of alcohol or within a couple of hours of drinking alcohol. The selected illicit drugs respondents were asked about using in combination with alcohol were marijuana, cocaine or crack, heroin, hallucinogens, inhalants, and methamphetamine. Respondents who used both alcohol and selected illicit drugs in the past month were asked about this behavior. Respondents could report the use of more than one selected illicit drug in combination with alcohol. The definition does not include alcohol use in combination with prescription pain relievers, prescription tranquilizers, prescription stimulants, or prescription sedatives because respondents were asked about misuse of these prescription psychotherapeutic drugs in combination with alcohol at any point in the past 30 days (i.e., not just the last time they used alcohol).

SEE: “Alcohol Use,” “Cocaine Use,” “Crack Use,” “Hallucinogen Use,” “Heroin Use,” “Inhalant Use,” “Marijuana Use,” and “Methamphetamine Use.”

Alternative Service Professional

The alternative service professional measure from the adult depression and adolescent depression sections of the questionnaire was defined as a (1) religious or spiritual advisor (e.g., minister, priest, or rabbi) or (2) herbalist, chiropractor, acupuncturist, or massage therapist seen because of sadness, discouragement, or lack of interest (for adults) or sadness, discouragement, or boredom (for adolescents). Respondents could report they received treatment from more than one of these categories of alternative service professionals.

SEE: “Health Professional,” “Major Depressive Episode (MDE),” and “Treatment for Depression.”

American Indian or Alaska Native (AIAN)

American Indian or Alaska Native only, not of Hispanic, Latino, or Spanish origin, including North American, Central American, or South American Indian as reported in the core demographics section at the beginning of the questionnaire. This definition does not include respondents reporting two or more races. Respondents reporting they were American Indians or Alaska Natives and of Hispanic, Latino, or Spanish origin were classified as Hispanic.

SEE: “Hispanic or Latino,” “Race/Ethnicity,” and “Two or More Races.”

Analysis Weight

Person-level analysis weights were created for analyses of NSDUH data so that the estimates from respondents’ data represented the national population of interest for a given survey year. In each year, person-level analysis weights reflected probabilities of selection, adjustment for nonresponse, poststratification to known population control totals, and controls for extreme weights when necessary. See Section 2.3.4 in the 2021 Methodological Summary and Definitions report for additional details on how the weights are created.

For 2021, two person-level weights were produced. In addition to the main analysis weight, a person-level break-off analysis weight was produced to adjust for the relatively high number of web respondents who did not complete the interview (i.e., break-offs). The break-off analysis weight was used to analyze unimputed outcomes based on questions that occurred in the mental health or later sections of the questionnaire. See Chapters 2, 3, and 6 in the 2021 Methodological Summary and Definitions report for details on when the break-off analysis weights were used to produce estimates for 2021.

SEE: “Interview Mode.”

Any Excluding Serious Mental Illness

SEE: “Mental Illness.”

Any Mental Illness (AMI)

SEE: “Mental Illness.”

Any Use of Prescription Psychotherapeutics

Any use of psychotherapeutics refers to use of prescription psychotherapeutic medication (pain relievers, tranquilizers, stimulants, or sedatives) for any reason. This could include use of prescriptions of one’s own as directed by a doctor or misuse of these medications. Respondents were asked in the respective questionnaire sections whether they used a series of specific prescription psychotherapeutic drugs in the past 12 months. For pain relievers, stimulants, and sedatives, respondents were instructed not to include the use of over-the-counter (OTC) drugs (e.g., aspirin, Tylenol^®, Advil^®, Aleve^®, Dexatrim^®, No-Doz^®, Hydroxycut^®, 5-Hour Energy^®, Sominex^®, Unisom^®, Benadryl^®, Nytol^®). This instruction not to include OTC drugs was not included for tranquilizers because all tranquilizers in the United States currently require a prescription. The questions about any use in the past 12 months included electronic images of pills or other forms of the drugs (where applicable) to aid respondents in recalling whether they used a specific prescription drug in the past 12 months. Respondents who did not report use in the past 12 months of any specific prescription psychotherapeutic drug within a category (e.g., prescription pain relievers) were asked whether they ever, even once, used any prescription psychotherapeutic drug within that category (e.g., any prescription pain reliever). Respondents were not asked about any use of prescription psychotherapeutic drugs in the past 30 days.

SEE: “Benzodiazepine Use or Misuse,” “Lifetime Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Pain Reliever Use or Misuse,” “Past Year Use or Misuse,” “Psychotherapeutic Drugs,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” “Stimulant Use or Misuse,” “Tranquilizer or Sedative Use or Misuse,” and “Tranquilizer Use or Misuse.”

Any Vaping

Any vaping includes vaping of any substance with an e-cigarette or vaping device. Measures of any vaping in the respondent’s lifetime, past year, and past month were derived from lifetime and recency questions in the emerging issues section of the questionnaire (i.e., “Have you ever, even once, vaped anything with an e-cigarette or other vaping device?” and “How long has it been since you last vaped anything with an e-cigarette or other vaping device?”). Respondents were informed that these devices might also be called vape pens, personal vaporizers, or mods and that people can vape nicotine or tobacco, marijuana, flavoring, or other substances. See Section 3.4.10.1 in the 2021 Methodological Summary and Definitions report for additional details.

Asian

Asian only, not of Hispanic, Latino, or Spanish origin, in accordance with federal standards for reporting race and ethnicity data.⁵ This definition is based on reports in the core demographics section at the beginning of the interview in which respondents described themselves as being Asian. The definition does not include respondents reporting two or more races. Respondents reporting they were Asian and of Hispanic, Latino, or Spanish origin were classified as Hispanic. Specific Asian groups asked about were Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian.

SEE: “Hispanic or Latino,” “Race/Ethnicity,” and “Two or More Races.”

At Risk for Initiation

Individuals were classified as being at risk for initiation in the past 12 months if they did not use a given substance in their lifetime or if they used it for the first time in the past year. Individuals who first used the substance more than 12 months ago were no longer considered to be at risk for initiation. NSDUH can identify individuals at risk for initiation of use of marijuana, cocaine, crack, heroin, hallucinogens, lysergic acid diethylamide (LSD), phencyclidine (PCP), Ecstasy, inhalants, methamphetamine, cigarettes, smokeless tobacco, cigars, and alcohol and also those at risk for initiation of daily cigarette use based on responses from the respective substance use questionnaire sections.

NSDUH cannot identify individuals at risk for initiation of illicit drug use, misuse of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives), benzodiazepines, misuse of opioids, and use of illicit drugs other than marijuana. For these measures, the Results from the 2021 National Survey on Drug Use and Health: Detailed Tables do not show percentages for initiation among those at risk for initiation because of the structure of the prescription drug questions.⁶ With the focus of questions on the past year misuse of specific psychotherapeutic drugs, respondents who last misused any prescription psychotherapeutic drug in a category (e.g., pain relievers) more than 12 months ago may underreport misuse. These respondents who did not report misuse that occurred more than 12 months ago would be misclassified as still being at risk for initiation. This change also affected aggregate risk for initiation measures such as those listed earlier in this paragraph (e.g., illicit drugs) that include prescription psychotherapeutic drugs.

Additionally, NSDUH cannot identify individuals at risk for initiation of use of any tobacco product. Aggregate measures for the use of tobacco products include the use of cigarettes, smokeless tobacco, cigars, or pipe tobacco. However, respondents are not asked initiation questions for pipe tobacco; therefore, the aggregate risk for initiation of use of any tobacco product cannot be determined.

In addition, respondents are not asked questions about the initiation of use or misuse of GHB, nonprescription cough and cold medicines, kratom, nicotine vaping, marijuana vaping, vaping of flavoring, synthetic marijuana, or synthetic stimulants. Therefore, there are no risk for initiation measures for these substances.

See Section 3.4.2 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Initiation of Substance Use or Misuse.”

Benzodiazepine Use or Misuse

Measures of the use or misuse of benzodiazepines in the past year were derived from questions in the tranquilizer and sedative sections of the questionnaire that asked respondents about any use (i.e., for any reason) in the past 12 months of specific prescription tranquilizers or sedatives classified as benzodiazepines (see below). Respondents who reported they used specific benzodiazepines were asked for each drug whether they used it in the past 12 months in any way not directed by a doctor. Examples of use in any way a doctor did not direct respondents to use prescription tranquilizers or sedatives (including benzodiazepines) were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug.

Questions about the past year use and misuse of benzodiazepines covered the following subcategories of benzodiazepines prescribed as tranquilizers: alprazolam products (Xanax^®, Xanax^® XR, generic alprazolam, or generic extended-release alprazolam), lorazepam products (Ativan^® or generic lorazepam), clonazepam products (Klonopin^® or generic clonazepam), or diazepam products (Valium^® or generic diazepam). Questions covered the following subcategories of benzodiazepines prescribed as sedatives: flurazepam (also known as Dalmane^®), temazepam products (Restoril^® or generic temazepam), or triazolam products (Halcion^® or generic triazolam). These drugs were specified in the questionnaire but are not an exhaustive list of benzodiazepines. The benzodiazepine category also includes benzodiazepines that respondents specified that they misused as other tranquilizers or sedatives.

Respondents were asked about their use and misuse of benzodiazepines only for the past year; therefore, there are no lifetime or past month measures for benzodiazepines. See Section 4.5 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Past Year Use or Misuse,” “Sedative Use or Misuse,” and “Tranquilizer Use or Misuse.”

Binge Use of Alcohol

Binge use of alcohol was defined for females as drinking four or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) and for males as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days. Respondents were asked in the alcohol section of the questionnaire about the number of days they had five or more drinks (for males) or four or more drinks (for females) on the same occasion if they reported last using any alcohol in the past 30 days based on the following question: “How long has it been since you last drank an alcoholic beverage?”

SEE: “Alcohol Use” and “Heavy Use of Alcohol.”

Black

Black/African American only, not of Hispanic, Latino, or Spanish origin. This definition is based on reports in the core demographics section at the beginning of the interview in which respondents described themselves as being Black or African American. The definition does not include respondents reporting two or more races. Respondents reporting they were Black or African American and of Hispanic, Latino, or Spanish origin were classified as Hispanic.

SEE: “Hispanic or Latino,” “Race/Ethnicity,” and “Two or More Races.”

Blunts

Blunts were defined as cigars with marijuana in them. Measures of use of blunts in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the blunts section of the questionnaire about lifetime and recency of use (i.e., “Have you ever smoked part or all of a cigar with marijuana in it?” and “How long has it been since you last smoked part or all of a cigar with marijuana in it?”). The question about recency of use was asked if respondents previously reported any use of cigars with marijuana in them in their lifetime.

The following definitional information preceded the question about lifetime use of cigars with marijuana in them: “Sometimes people take tobacco out of a cigar and replace it with marijuana. This is sometimes called a ‘blunt’.”

SEE: “Cigar Use,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Marijuana Use,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Tobacco Product Use.”

CAPI

CAPI stands for computer-assisted personal interviewing and applies to in-person NSDUH data collection. CAPI questions in NSDUH are interviewer administered. Interviewers read these questions to respondents, then enter the respondents’ answers into a laptop computer. For information on interview sections administered in person using CAPI, see the list of the content of the 2021 NSDUH in-person instrument.⁷

SEE: “ACASI” and “Interview Mode.”

Central Nervous System Stimulant Use or Misuse

Central nervous system (CNS) stimulants in NSDUH refer to cocaine, methamphetamine, or prescription stimulants. Measures were created for any use of CNS stimulants and misuse of CNS stimulants. See Section 3.4.12 in the 2021 Methodological Summary and Definitions report for additional details.

Any Use

Respondents were classified as using CNS stimulants for any reason in the past year (i.e., any use) if they reported using cocaine or methamphetamine in the past year or they reported any use of prescription stimulants in the past year (i.e., not necessarily misuse). (Respondents were not asked about any use of prescription stimulants in the past month.)

Misuse

Respondents were classified as misusing CNS stimulants in the past year or past month if they reported using cocaine or methamphetamine or misusing prescription stimulants in these periods. (Respondents who reported the misuse of specific prescription stimulants in the past year were asked if they misused any prescription stimulant in the past month.)

SEE: “Current Use or Misuse,” “Cocaine Use,” “Methamphetamine Use,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Stimulant Use or Misuse.”

Central Nervous System Stimulant Use Disorder

Respondents were classified as having a central nervous system (CNS) stimulant use disorder if they met criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁸). Two measures of CNS stimulant use disorder were created for 2021: (1) CNS stimulant use disorder due to any use of CNS stimulants and (2) CNS stimulant use disorder due to the misuse of CNS stimulants.

Disorder Due to Any Use

CNS stimulant use disorder due to any use was defined as having a cocaine use disorder, methamphetamine use disorder, or a prescription stimulant use disorder. Respondents who reported any use of prescription stimulants in the past year and met DSM-5 criteria for stimulant use disorder were classified as having a prescription stimulant use disorder.

Disorder Due to Misuse

CNS stimulant use disorder due to misuse was defined as having a cocaine use disorder, methamphetamine use disorder, or a prescription stimulant use disorder among past year misusers of prescription stimulants. Respondents who reported the misuse of prescription stimulants in the past year and met DSM-5 criteria for stimulant use disorder were classified as having a prescription stimulant use disorder due to misuse.

Respondents were not counted as having a CNS stimulant use disorder if they did not meet the full substance use disorder criteria individually for either cocaine, methamphetamine, or prescription stimulants. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Cocaine Use,” “Cocaine Use Disorder,” “Methamphetamine Use,” “Methamphetamine Use Disorder,” “Stimulant Use Disorder,” and “Stimulant Use or Misuse.”

Cigar Use

Measures of use of cigars, including big cigars, cigarillos, and little cigars that look like cigarettes, in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the tobacco section of the questionnaire about lifetime cigar use, use in the past 30 days, and the recency of use (if not in the past 30 days) (i.e., “Have you ever smoked part or all of a cigar?” “During the past 30 days, have you smoked part or all of any type of cigar?” and “How long has it been since you last smoked part or all of any type of cigar?”). Responses to questions in a later section about use of cigars with marijuana in them (blunts) were not included in these measures to maintain the comparability of estimates over time. Questions about use of cigars in the past 30 days or the most recent use of cigars (if not in the past 30 days) were asked if respondents previously reported any use of cigars in their lifetime.

SEE: “Blunts,” “Cigarette Use,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Cigarette Use

Measures of use of cigarettes in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the tobacco section of the questionnaire about lifetime cigarette use, use in the past 30 days, and the recency of use (if not in the past 30 days) (i.e., “Have you ever smoked part or all of a cigarette?” “During the past 30 days, have you smoked part or all of a cigarette?” and “How long has it been since you last smoked part or all of a cigarette?”). Questions about use of cigarettes in the past 30 days or the most recent use of cigarettes (if not in the past 30 days) were asked if respondents previously reported they smoked part or all of a cigarette in their lifetime.

SEE: “Cigar Use,” “Current Use or Misuse,” “Daily Cigarette Use,” “Lifetime Use or Misuse,” “Nicotine (Cigarette) Dependence,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Classified as Needing Alcohol Use Treatment

Respondents were classified as needing treatment for an alcohol use problem if they met the criteria for an alcohol use disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁹), or they received treatment at a specialty facility (i.e., drug and alcohol rehabilitation facility [inpatient or outpatient], hospital [inpatient only], or mental health center) for the use of alcohol. Reports of substance use treatment in some other place for the use of alcohol were included as treatment at a specialty facility if the other place respondents specified was considered to be a specialty facility. Questions for the receipt of virtual (telehealth) services were not associated with a specific provider, location, or facility type. Therefore, receipt of these services was not grouped into the NSDUH measure for substance use treatment at a specialty facility. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use Disorder (AUD),” “Specialty Facility for Substance Use Treatment,” and “Substance Use Treatment.”

Classified as Needing Illicit Drug Use Treatment

Respondents were classified as needing treatment for an illicit drug use problem if they met the criteria for an illicit drug use disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5¹⁰), or they received treatment at a specialty facility (i.e., drug and alcohol rehabilitation facility [inpatient or outpatient], hospital [inpatient only], or mental health center) for the use of illicit drugs. Reports of substance use treatment in some other place for the use of illicit drugs were included as treatment at a specialty facility if the other place respondents specified was considered to be a specialty facility. Questions for the receipt of virtual (telehealth) services were not associated with a specific provider, location, or facility type. Therefore, receipt of these services was not grouped into the NSDUH measure for substance use treatment at a specialty facility. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Illicit Drug Use Disorder (IDUD),” “Illicit Drugs,” “Specialty Facility for Substance Use Treatment,” and “Substance Use Treatment.”

Classified as Needing Substance Use Treatment

Respondents were classified as needing substance use treatment (i.e., treatment for an illicit drug or alcohol use problem) if they met the criteria for an illicit drug or alcohol use disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5¹¹), or they received treatment at a specialty facility (i.e., drug and alcohol rehabilitation facility [inpatient or outpatient], hospital [inpatient only], or mental health center) for the use of illicit drugs or alcohol. Reports of substance use treatment in some other place for the use of illicit drugs or alcohol were included as treatment at a specialty facility if the other place respondents specified was considered to be a specialty facility. Questions for the receipt of virtual (telehealth) services were not associated with a specific provider, location, or facility type. Therefore, receipt of these services was not grouped into the NSDUH measure for substance use treatment at a specialty facility. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use Disorder (AUD),” “Illicit Drug Use Disorder (IDUD),” “Illicit Drugs,” “Specialty Facility for Substance Use Treatment,” “Illicit Drug or Alcohol Use Disorder,” and “Substance Use Treatment.”

Cocaine Use

Measures of use of cocaine, including powder, crack, free base, and coca paste, in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the cocaine section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used any form of cocaine?” and “How long has it been since you last used any form of cocaine?”). The question about recency of use was asked if respondents previously reported any use of cocaine in their lifetime.

SEE: “Crack Use,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Cocaine Use Disorder

Cocaine use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5¹²). Respondents who used cocaine in the past 12 months (including those who reported using crack or cocaine with a needle in that period) were classified as having a cocaine use disorder in that period if they met two or more of the following criteria: (1) used cocaine in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on cocaine use; (3) spent a great deal of time in activities to obtain, use, or recover from cocaine use; (4) felt a craving or strong desire to use cocaine; (5) engaged in recurrent cocaine use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use cocaine despite social or interpersonal problems caused by the effects of cocaine; (7) gave up or reduced important social, occupational, or recreational activities because of cocaine use; (8) continued to use cocaine in physically hazardous situations; (9) continued to use cocaine despite physical or psychological problems caused by cocaine use; (10) increased the amount of cocaine needed to achieve same effect or noticed that the same amount of cocaine use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping cocaine use or (11b) used cocaine or a related substance to get over or avoid cocaine withdrawal symptoms. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Cocaine Use” and “Crack Use.”

College Enrollment Status

This measure was developed only for respondents aged 18 to 22 based on answers to questions in the education section later in the interview about current or upcoming enrollment in school and (if applicable) about whether respondents were full- or part-time students and the year of school they were or will be attending. Respondents in this age group were classified either as full-time college students or as some other status, which included respondents not enrolled in school, enrolled in college part time, enrolled in other grades either full time or part time, or enrolled with no other information available. Respondents were classified as full-time college students if they reported they were attending or will be attending their first through fifth or higher year of college or university and they were or will be a full-time student. Respondents whose current enrollment status was unknown were excluded from this measure.

County Type

County type was based on the “Rural/Urban Continuum Codes” developed in 2013 by the U.S. Department of Agriculture (USDA).¹³ All U.S. counties and county equivalents were grouped based on revised definitions of metropolitan statistical areas (MSAs) and definitions of micropolitan statistical areas as defined by the Office of Management and Budget (OMB) as of February 2013.¹⁴

The classifications are partially based on population counts from the 2010 census representing the resident population. Data from the 2006 to 2010 American Community Surveys were also used by OMB and USDA to define these county type levels. Large MSAs (large metro) have a total population of 1 million or more. Small MSAs (small metro) have a total population of fewer than 1 million and are classified further as having either a total population of 250,000 to 1 million or less than 250,000. Nonmetropolitan (nonmetro) counties were classified according to the aggregate size of their urban population and whether they were adjacent to a metro area.

Nonmetropolitan areas include counties in micropolitan statistical areas as well as counties outside of both metropolitan and micropolitan statistical areas and are classified into three overall categories: (1) urban population of 20,000 or more are classified as “urbanized” for counties adjacent to a metro area or not adjacent to a metro area, (2) urban population of at least 2,500 but fewer than 20,000 are classified as “less urbanized” for counties adjacent to a metro area or not adjacent to a metro area, and (3) rural area with population fewer than 2,500 are classified as “completely rural” for counties adjacent to a metro area or not adjacent to a metro area. The terms “urbanized,” “less urbanized,” and “completely rural” for counties are not based on the relative proportion of the county population in urbanized areas but rather on the absolute size of the population in urbanized areas. For example, some counties classified as “less urbanized” had over 50 percent of the county population residing in urbanized areas, but this represented fewer than 20,000 people in the county. See Section 3.4.5 in the 2021 Methodological Summary and Definitions report for additional details.

COVID-19

COVID-19 is the abbreviation for coronavirus disease 2019, the term approved by the World Health Organization and the Centers for Disease Control and Prevention.¹⁵ In the abbreviation, CO = corona, VI = virus, and D = disease.

Crack Use

Crack was defined as cocaine used in rock or chunk form. Measures of use of crack cocaine in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the cocaine section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used ‘crack’?” and “How long has it been since you last used ‘crack’?”). The question about recency of use was asked if respondents previously reported use of cocaine in any form and specifically any use of crack in their lifetime. Respondents who reported they never used any form of cocaine were logically classified as never having used crack.

SEE: “Cocaine Use,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Current Use or Misuse

For substances other than prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, or sedatives), current use refers to any reported use of a specific substance in the past 30 days (also referred to as “past month use”). For prescription psychotherapeutic drugs, current misuse refers to misuse of psychotherapeutics in the past 30 days. Respondents were not asked about any use of psychotherapeutics in the past 30 days.

SEE: “Lifetime Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Daily Cigarette Use

Respondents who smoked cigarettes in the past 30 days were classified as being past month daily cigarette users if they reported in the tobacco section of the questionnaire that they smoked part or all of a cigarette on all 30 days in that period. Respondents were classified as being lifetime daily cigarette users if they reported daily cigarette use in the past month or they reported a period in their lifetime when they smoked cigarettes every day for at least 30 days.

SEE: “Cigarette Use.”

Daily or Almost Daily Use

Respondents who used or misused a substance other than cigarettes on 20 or more days in the past month were classified as daily or almost daily users in the past month. Respondents who reported in the respective substance use questionnaire sections that they used a substance on 300 or more days in the past year were classified as daily or almost daily users in the past year. Those who met the criterion for being a daily or almost daily user in the past year may not have met the criterion for being a daily or almost daily user in the past month. Respondents were not asked about the number of days in the past year they used tobacco products or misused prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, or sedatives). Those who reported smoking cigarettes on each of the past 30 days were classified as daily smokers.

SEE: “Daily Cigarette Use.”

Delinquent Behavior

Youths aged 12 to 17 were asked a series of six questions in the youth experiences section of the questionnaire: “During the past 12 months, how many times have you … gotten into a serious fight at school or work?” “taken part in a fight where a group of your friends fought against another group?” “carried a handgun?” “sold illegal drugs?” “stolen or tried to steal anything worth more than $50?” and “attacked someone with the intent to seriously hurt them?” Response options were (1) 0 times, (2) 1 or 2 times, (3) 3 to 5 times, (4) 6 to 9 times, or (5) 10 or more times. Respondents were classified as having engaged in a specific delinquent behavior if they reported engaging in that behavior at least one time in the past 12 months. In addition, respondents were classified as having engaged in physical delinquent behaviors if they reported they got in a serious fight at school or work, took part in a fight against another group, or attacked someone with the intent to seriously hurt them at least one time in the past 12 months. Respondents were classified as having engaged in nonphysical delinquent behaviors if they reported they carried a handgun, sold illegal drugs, or stole or tried to steal anything worth more than $50 at least one time in the past 12 months.

Depression

SEE: “Major Depressive Episode (MDE).”

Distress

SEE: “Kessler-6 (K6) Scale” and “Serious Psychological Distress (SPD).”

DMT, AMT, or 5-MeO-DIPT (“Foxy”) Use

Measures of the use of dimethyltryptamine (DMT), alpha-methyltryptamine (AMT), or N, N-diisopropyl-5-methoxytryptamine (5-MeO-DIPT or “Foxy”) in the respondent’s lifetime, the past year, and the past month were derived from responses to questions in the hallucinogens section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used any of the following: DMT, AMT, or Foxy?” and “How long has it been since you last used DMT, AMT, or Foxy?”).

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Driving Under the Influence

Respondents who reported the use of alcohol or selected illicit drugs in the past 12 months were asked individual questions in the special topics section of the questionnaire about driving a vehicle in the past 12 months while under the influence of alcohol, marijuana, cocaine or crack, heroin, hallucinogens, inhalants, or methamphetamine. Respondents who reported driving under the influence of alcohol and one or more of these illicit drugs were asked an additional question about driving under the influence of only alcohol.

Respondents were classified as driving under the influence of one or more selected illicit drugs if they reported driving under the influence of marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine. Respondents were classified as driving under the influence of one or more selected illicit drugs other than marijuana if they reported driving under the influence of cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine, regardless of whether they also reported driving under the influence of marijuana.

SEE: “Alcohol Use,” “Cocaine Use,” “Crack Use,” “Hallucinogen Use,” “Heroin Use,” “Inhalant Use,” “Marijuana Use,” and “Methamphetamine Use.”

Drug Use

Drug use includes marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine use in the past year, or any use in the past 12 months of prescription psychotherapeutics, which include pain relievers, tranquilizers, stimulants, and sedatives. This definition differs from the illicit drug use definition because it includes any use of prescription drugs. NSDUH does not consider the use (but not misuse) of prescription psychotherapeutic drugs to be illicit drug use.

SEE: “Drug Use Disorder” and “Illicit Drugs.”

Drug Use Disorder

Drug use disorder is defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5¹⁶), for one or more of the following drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or any use of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, and sedatives). The DSM-5 SUD criteria for prescription drugs applies to people who used prescription drugs for any reason in the past year (i.e., not just misuse). A reduced set of criteria are used to define prescription drug use disorder for respondents who used prescription drugs but did not misuse them in the past year. See Section 3.4.3 and Table 3.7 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Cocaine Use Disorder,” “Hallucinogen Use Disorder,” “Heroin Use Disorder,” “Drug Use,” “Inhalant Use Disorder,” “Marijuana Use Disorder,” “Methamphetamine Use Disorder,” “Pain Reliever Use Disorder,” “Sedative Use Disorder,” “Stimulant Use Disorder,” “Substance Use Disorder (SUD),” and “Tranquilizer Use Disorder.”

Ecstasy Use

Measures of use of Ecstasy or MDMA (methylenedioxy-methamphetamine) in the respondent’s lifetime, the past year, and the past month were derived from responses to questions in the hallucinogens section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used ‘Ecstasy’ or ‘Molly’, also known as MDMA?” and “How long has it been since you last used ‘Ecstasy’ or ‘Molly’, also known as MDMA?”). The question about recency of use was asked if respondents previously reported any use of Ecstasy or MDMA in their lifetime.

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Education Level

Educational attainment among adult respondents aged 18 or older was based on respondents’ reports in the core demographics section at the beginning of the interview about the highest grade or level of school they completed, including the highest degree they completed. Response options for respondents who completed the 11th grade or lower were presented in terms of single years of education, ranging from 0 if respondents never attended school up to the 11th grade. Response options for higher levels of education than the 11th grade indicated whether respondents received a high school diploma, completed the 12th grade without receiving a diploma, received a general educational development (GED) certificate, obtained some college credit but did not receive a degree, or received some kind of college degree (i.e., associate’s, bachelor’s, master’s, doctoral, or professional).

Adult respondents were classified into four categories based on their answers: (1) less than high school, (2) high school graduate, (3) some college or associate’s degree, and (4) college graduate. Adults who indicated they completed the 12th grade but did not receive a high school diploma were classified as having less than a high school education. Adults who indicated they received a high school diploma or GED were classified as high school graduates. Adults who received an associate’s degree were classified in the “some college” category, along with adults who received some college credit but had not obtained a degree. Adults who indicated they received a bachelor’s degree or higher were classified as being college graduates.

Employment Status

Respondents were asked to report in the employment section of the questionnaire whether they worked in the week prior to the interview and, if not, whether they had a job despite not working in the past week. Respondents who worked in the past week or who reported having a job despite not working were asked whether they usually work 35 hours or more per week. Respondents who did not work in the past week but had a job were asked to report why they did not work in the past week despite having a job. Respondents who did not have a job in the past week were asked to report why they did not have a job in the past week.

Full-time

“Full-time” includes respondents who usually work 35 or more hours per week and who worked in the past week or had a job despite not working in the past week.

Part-time

“Part-time” includes respondents who usually work fewer than 35 hours per week and who worked in the past week or had a job despite not working in the past week.

Unemployed

“Unemployed” refers to respondents who did not have a job and were looking for work or who were on layoff. For consistency with the Current Population Survey definition of unemployment, respondents who reported they did not have a job but were looking for work needed to report making specific efforts to find work in the past 30 days, such as sending out resumes or applications, placing ads, or answering ads.

Other

“Other” includes all responses defined as not being in the labor force, including being a student, keeping house or caring for children full time, retired, disabled, or other miscellaneous work statuses. Respondents who reported they did not have a job and did not want one also were classified as not being in the labor force. Similarly, respondents who reported not having a job and looking for work also were classified as not being in the labor force if they did not report making specific efforts to find work in the past 30 days. Those respondents who reported having no job and provided no additional information could not have their labor force status determined and were therefore assigned to the Other employment category.

Ethnicity

SEE: “Hispanic or Latino” and “Race/Ethnicity.”

Ever Used

SEE: “Lifetime Use or Misuse.”

Exposure to Drug Education and Prevention

The following measures were created for exposure to drug education and prevention among youths aged 12 to 17: (1) exposure to prevention messages in school, (2) participation in a prevention program outside of school, (3) seeing or hearing prevention messages from sources outside of school, and (4) conversations with parents about the dangers of substance use.

Youths who reported in the youth experiences section of the questionnaire that they attended any type of school at any time in the past 12 months were asked: “During the past 12 months … Have you had a special class about drugs or alcohol in school?” “Have you had films, lectures, discussions, or printed information about drugs or alcohol in one of your regular classes such as health or physical education?” “Have you had films, lectures, discussions, or printed information about drugs or alcohol outside of one of your regular classes such as in a special assembly?” Youths who reported having had any of these were classified as having seen or heard prevention messages in school.

Youths who reported they were home schooled in the past 12 months also were asked these questions. Youths who reported they were home schooled were instructed to think about their home schooling as “school.”

Youths also were asked: “During the past 12 months … Have you participated in an alcohol, tobacco or drug prevention program outside of school, where you learn about the dangers of using, and how to resist using, alcohol, tobacco, or drugs?” “Have you seen or heard any alcohol or drug prevention messages from sources outside school such as posters, pamphlets, radio, or TV?” “Have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use?” Youths who answered these questions as “yes” were classified as having been exposed to prevention messages from these sources outside of school.

Family Income

Family income was estimated by asking respondents about their total personal income and total family income, based on the following questions in the income section of the questionnaire: “Of these income groups, which category best represents [your/SAMPLE MEMBER’s] total personal income during [the previous calendar year]?” and “Of these income groups, which category best represents [your/SAMPLE MEMBER’s] total combined family income during [the previous calendar year]?” Family was defined as any related member in the household, including all foster relationships and unmarried partners (including same-sex partners). It excluded roommates, boarders, and other nonrelatives. Categories for family income ranged from less than $1,000 to $150,000 or more.

NOTE: If no other family members were living with the respondent, total family income was based on information about the respondent’s total personal income. For youths aged 12 to 17 and those respondents who were unable to respond to the health insurance or income questions, proxy responses were accepted from a household member identified as being better able to give the correct information about health insurance and income.

Functional Impairment

Functional impairment refers to interference in a person’s daily functioning or limitations in carrying out one or more major life activities. The Global Assessment of Functioning (GAF) allows mental health clinicians to assess a person’s level of impairment because of a diagnosable mental, behavioral, or emotional disorder.¹⁷ In follow-up interviews conducted in 2008 to 2012 with a subset of adult NSDUH respondents, mental health clinicians used the GAF and rated respondents’ worst period of functioning in the past 12 months because of a mental disorder. See Section 3.4.6 in the 2021 Methodological Summary and Definitions report for additional details about how functional impairment is assessed for adults in NSDUH.

SEE: “Global Assessment of Functioning (GAF),” “Mental Illness,” “Sheehan Disability Scale (SDS),” and “World Health Organization Disability Assessment Schedule (WHODAS).”

Gate Question

A gate question is an initial question that asks whether the behavior or characteristic of interest is applicable to the respondent. Thus, these questions function to open or close a “gate” in the interview by governing whether respondents are asked additional questions about the topic of interest or skip remaining questions about that topic. Sections of the questionnaire about specific topics may include a single gate question or more than one gate question (e.g., hallucinogens, inhalants). An affirmative response to a question leads to respondents being asked a series of other related questions. A response other than an affirmative one (or no affirmative responses to all gate questions in sections with more than one gate question) results in respondents skipping additional questions on that topic and being routed to the next set of topics in the interview.¹⁸

SEE: “Module.”

Geographic Division

In the United States, nine geographic divisions are within four geographic regions based on classifications developed by the U.S. Census Bureau.¹⁹ Within the Northeast Region are the New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) and the Middle Atlantic Division (New Jersey, New York, Pennsylvania). Within the Midwest Region are the East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) and the West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota). Within the South Region are the South Atlantic Division (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia), the East South Central Division (Alabama, Kentucky, Mississippi, Tennessee), and the West South Central Division (Arkansas, Louisiana, Oklahoma, Texas). Within the West Region are the Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) and the Pacific Division (Alaska, California, Hawaii, Oregon, Washington).

SEE: “Region.”

GHB Use

Measures of use of gamma hydroxybutyrate (GHB) in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the special drugs section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used GHB?” and “How long has it been since you last used GHB?”).

The following definitional information preceded the question about lifetime use of GHB: “The next question is about GHB, also called ‘G,’ ‘Georgia Home Boy,’ ‘Grievous Bodily Harm,’ ‘Liquid G,’ or gamma hydroxybutyrate.”

SEE: “Current Use or Misuse,” “Illicit Drugs,” “Illicit Drugs Other Than Marijuana,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Global Assessment of Functioning (GAF)

As indicated in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV²⁰), mental health clinicians use the Global Assessment of Functioning (GAF) to consider a person’s psychological, social, and occupational functioning on a hypothetical continuum. Clinicians do not include impairment in functioning due to physical or environmental limitations. When adequate information is available, numeric ratings for the GAF range from 1 to 100. Lower values on the rating scale indicate a greater extent of impairment due to the presence of a diagnosable mental, behavioral, or emotional disorder. In follow-up interviews conducted in 2008 to 2012 with a subset of adult NSDUH respondents, mental health clinicians used the GAF and rated respondents’ worst period of functioning in the past 12 months because of a mental disorder. See Section 3.4.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Mental Illness,” “Sheehan Disability Scale (SDS),” and “World Health Organization Disability Assessment Schedule (WHODAS).”

Hallucinogen Use

Measures of use of hallucinogens in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the hallucinogens section of the questionnaire about lifetime and recency of use (e.g., “How long has it been since you last used any hallucinogen?”).²¹ The question about recency of use was asked if respondents previously reported any use of hallucinogens in their lifetime (see below).

Respondents were asked a series of gate questions about any use of specific hallucinogens in their lifetime. These gate questions were preceded by the following definitional information about hallucinogens: “The next questions are about substances called hallucinogens. These drugs often cause people to see or experience things that are not real.”

Gate questions asked whether respondents ever used the following hallucinogens, even once: (1) LSD, also called “acid”; (2) PCP, also called “angel dust” or phencyclidine; (3) peyote; (4) mescaline; (5) psilocybin, found in mushrooms; (6) “Ecstasy” or “Molly,” also called MDMA; (7) ketamine, also called “Special K” or “Super K”; (8) DMT, also called dimethyltryptamine, AMT, also called alpha-methyltryptamine, or Foxy, also called 5-MeO-DIPT; (9) Salvia divinorum; and (10) any other hallucinogen besides the ones that have been listed.

SEE: “Current Use or Misuse,” “DMT, AMT, or 5-MeO-DIPT (“Foxy”) Use,” “Ecstasy Use,” “Gate Question,” “Ketamine Use,” “Lifetime Use or Misuse,” “LSD Use,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “PCP Use,” “Recency of Use or Misuse,” and “Salvia divinorum Use.”

Hallucinogen Use Disorder

Hallucinogen use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5²²). Respondents who used hallucinogens in the past 12 months were classified as having a hallucinogen use disorder in that period if they met two or more of the following criteria: (1) used hallucinogens in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on hallucinogen use; (3) spent a great deal of time in activities to obtain, use, or recover from hallucinogen use; (4) felt a craving or strong desire to use hallucinogens; (5) engaged in recurrent hallucinogen use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use hallucinogens despite social or interpersonal problems caused by the effects of hallucinogens; (7) gave up or reduced important social, occupational, or recreational activities because of hallucinogen use; (8) continued to use hallucinogens in physically hazardous situations; (9) continued to use hallucinogens despite physical or psychological problems caused by hallucinogen use; and (10) increased the amount of hallucinogens needed to achieve same effect or noticed that the same amount of hallucinogen use had less effect than before. Hallucinogen use disorder does not have a withdrawal criterion. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Hallucinogen Use.”

Health Insurance Status

A series of questions was asked in the health insurance section of the questionnaire to identify whether respondents currently were covered by Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), military health care (such as TRICARE or CHAMPUS), private health insurance, or any kind of health insurance (if respondents reported not being covered by any of the above). If respondents did not currently have health insurance coverage, questions were asked to determine the length of time they were without coverage and the reasons for not being covered.

NOTE: For youths aged 12 to 17 and those respondents who were unable to respond to the health insurance or income questions, proxy responses were accepted from a household member identified as being better able to give the correct information about health insurance and income.

SEE: “Medicaid” and “Medicare.”

Health Professional

The health professional measure from the adult depression and adolescent depression sections of the questionnaire included any of the following types of medical doctors or other professionals respondents saw because of sadness, discouragement, or lack of interest (for adults) or sadness, discouragement, or boredom (for adolescents): general practitioner or family doctor; other medical doctor (e.g., cardiologist, gynecologist, urologist, or other medical doctors that are not general practitioners or family doctors); psychologist; psychiatrist or psychotherapist; social worker; counselor; other mental health professional (e.g., mental health nurse or other therapist where type is not specified); and nurse, occupational therapist, or other health professional. Respondents could report they saw more than one type of health professional for these feelings.

SEE: “Alternative Service Professional,” “Major Depressive Episode (MDE),” and “Treatment for Depression.”

Heavy Use of Alcohol

Heavy use of alcohol was defined for males as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) and for females as drinking four or more drinks on the same occasion on each of 5 or more days in the past 30 days. Heavy alcohol users also were classified as binge users of alcohol. Respondents were asked in the alcohol section of the questionnaire about the number of days they had five or more drinks (for males) or four or more drinks (for females) on the same occasion if they reported last using any alcohol in the past 30 days based on the following question: “How long has it been since you last drank an alcoholic beverage?”

SEE: “Alcohol Use” and “Binge Use of Alcohol.”

Heroin Use

Measures of use of heroin in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the heroin section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used heroin?” and “How long has it been since you last used heroin?”). The question about recency of use was asked if respondents previously reported any use of heroin in their lifetime.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Heroin Use Disorder

Heroin use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5²³). Respondents who used heroin in the past 12 months (including those who reported smoking, sniffing, or using heroin with a needle in that period) were classified as having a heroin use disorder in that period if they met two or more of the following criteria: (1) used heroin in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on heroin use; (3) spent a great deal of time in activities to obtain, use, or recover from heroin use; (4) felt a craving or strong desire to use heroin; (5) engaged in recurrent heroin use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use heroin despite social or interpersonal problems caused by the effects of heroin; (7) gave up or reduced important social, occupational, or recreational activities because of heroin use; (8) continued to use heroin in physically hazardous situations; (9) continued to use heroin despite physical or psychological problems caused by heroin use; (10) increased the amount of heroin needed to achieve same effect or noticed that the same amount of heroin use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping heroin use or (11b) used heroin or a related substance to get over or avoid heroin withdrawal symptoms. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Heroin Use.”

Hispanic or Latino

Hispanic or Latino was defined as anyone of Hispanic, Latino, or Spanish origin. Respondents were classified as Hispanic or Latino in the race/ethnicity measure regardless of race, in accordance with federal standards for reporting race and ethnicity data.²⁴ This definition is based on reports in the core demographics section at the beginning of the interview that respondents were of Hispanic, Latino, or Spanish origin or descent.

SEE: “American Indian or Alaska Native (AIAN),” “Asian,” “Black,” “Native Hawaiian or Other Pacific Islander (NHOPI),” “Race/Ethnicity,” “Two or More Races,” and “White.”

Illicit Drug Use Disorder (IDUD)

Illicit drug use disorder (IDUD) is defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5²⁵), for one or more of the following illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutic drugs that were misused (i.e., pain relievers, tranquilizers, stimulants, and sedatives). Illicit drug use disorder does not include prescription drug use disorder data from past year users of prescription drugs who did not misuse them in the past year. See Section 3.4.3 and Table 3.7 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Cocaine Use Disorder,” “Drug Use Disorder,” “Hallucinogen Use Disorder,” “Heroin Use Disorder,” “Illicit Drugs,” “Inhalant Use Disorder,” “Marijuana Use Disorder,” “Methamphetamine Use Disorder,” “Pain Reliever Use Disorder,” “Sedative Use Disorder,” “Stimulant Use Disorder,” “Substance Use Disorder (SUD),” and “Tranquilizer Use Disorder.”

Illicit Drugs

Illicit drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutics that were misused, which include pain relievers, tranquilizers, stimulants, and sedatives. Illicit drug use refers to use of any of these drugs based on responses to questions for these substances in the respective questionnaire. NSDUH does not consider the use (but not misuse) of prescription psychotherapeutic drugs to be illicit drug use. Responses to questions about the use of the following drugs were not included in these measures: GHB (gamma hydroxybutyrate), nonprescription cough or cold medicines, synthetic marijuana, and synthetic stimulants. Kratom was not included as an illicit drug because it is not a controlled substance nationally. However, some states may prohibit the possession and use of kratom.²⁶

SEE: “Cocaine Use,” “Crack Use,” “Current Use or Misuse,” “Hallucinogen Use,” “Heroin Use,” “Inhalant Use,” “Lifetime Use or Misuse,” “Marijuana Use,” “Methamphetamine Use,” “Pain Reliever Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” “Stimulant Use or Misuse,” and “Tranquilizer Use or Misuse.”

Illicit Drugs Other Than Marijuana

These drugs include cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutics that were misused, which include pain relievers, tranquilizers, stimulants, and sedatives. This measure includes marijuana users who used any of the above drugs in addition to using marijuana, as well as users of those drugs who have not used marijuana. This measure excludes respondents who used only marijuana. The measure for illicit drugs other than marijuana is defined based on responses to questions for these substances in the respective questionnaire. NSDUH does not consider the use (but not misuse) of prescription psychotherapeutic drugs to be illicit drug use. Responses to questions about the use of the following drugs also were not included in these measures: GHB (gamma hydroxybutyrate), nonprescription cough or cold medicines, synthetic marijuana, and synthetic stimulants. Kratom was not included as an illicit drug because it is not a controlled substance nationally. However, some states may prohibit the possession and use of kratom.²⁷

SEE: “Cocaine Use,” “Crack Use,” “Current Use or Misuse,” “Hallucinogen Use,” “Heroin Use,” “Inhalant Use,” “Lifetime Use or Misuse,” “Methamphetamine Use,” “Pain Reliever Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Psychotherapeutic Drugs,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” “Stimulant Use or Misuse,” and “Tranquilizer Use or Misuse.”

Income

SEE: “Family Income.”

Inhalant Use

Measures of use of inhalants in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the inhalants section of the questionnaire about lifetime and recency of use (e.g., “How long has it been since you last used any inhalant for kicks or to get high?”). The question about recency of use was asked if respondents previously reported any use of inhalants in their lifetime (see below).

Respondents were asked a series of gate questions about any use of specific inhalants in their lifetime. These gate questions were preceded by the following definitional information about inhalants: “These next questions are about liquids, sprays, and gases that people sniff or inhale to get high or to make them feel good. We are not interested in times when you inhaled a substance accidentally—such as when painting, cleaning an oven, or filling a car with gasoline.”

Gate questions asked whether respondents ever inhaled the following substances, even once, for kicks or to get high: (1) amyl nitrite, “poppers,” locker room odorizers, or “rush”; (2) correction fluid, degreaser, or cleaning fluid; (3) gasoline or lighter fluid; (4) glue, shoe polish, or toluene; (5) halothane, ether, or other anesthetics; (6) lacquer thinner or other paint solvents; (7) lighter gases, such as butane or propane; (8) nitrous oxide or “whippits”; (9) felt-tip pens, felt-tip markers, or magic markers; (10) spray paints; (11) computer keyboard cleaner, also known as air duster; (12) some other aerosol spray; and (13) any other inhalant besides the ones that have been listed.

SEE: “Current Use or Misuse,” “Gate Question,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Inhalant Use Disorder

Inhalant use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5²⁸). Respondents who used inhalants in the past 12 months were classified as having an inhalant use disorder in that period if they met two or more of the following criteria: (1) used inhalants in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on inhalant use; (3) spent a great deal of time in activities to obtain, use, or recover from inhalant use; (4) felt a craving or strong desire to use inhalants; (5) engaged in recurrent inhalant use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use inhalants despite social or interpersonal problems caused by the effects of inhalants; (7) gave up or reduced important social, occupational, or recreational activities because of inhalant use; (8) continued to use inhalants in physically hazardous situations; (9) continued to use inhalants despite physical or psychological problems caused by inhalant use; and (10) increased the amount of inhalants needed to achieve same effect, developed tolerance, or noticed that the same amount of inhalant use had less effect than before. Inhalant use disorder does not have a withdrawal criterion. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Inhalant Use.”

Initiation of Substance Use or Misuse

Substance use initiation refers to the use of a substance for the first time (new use).²⁹ Initiation statistics in NSDUH reflect first use or misuse occurring within the 12 months prior to the interview. This is referred to as “past year initiation.”

Initiation estimates were based on retrospective questions asked of lifetime users in the respective substance use questionnaire sections about the age at first use of substances and the year and month of first use for recent initiates, along with the respondent’s date of birth and the interview date. However, questions about first misuse of prescription psychotherapeutic drugs were asked only of respondents who reported they misused prescription psychotherapeutic drugs in the past 12 months. Respondents who misused prescription psychotherapeutic drugs in the past 12 months were classified as past year initiates if they reported only past year initiation of the drugs they misused in that period in the respective substance use sections and they reported they did not misuse any prescription psychotherapeutic drug in that category prior to the past 12 months.

Past year initiates can be identified in NSDUH for the use of marijuana, cocaine, crack, heroin, hallucinogens, lysergic acid diethylamide (LSD), phencyclidine (PCP), Ecstasy, inhalants, methamphetamine, cigarettes (including daily cigarette use), smokeless tobacco, cigars, and alcohol. Past year initiates also can be identified for the specific misuse of prescription pain relievers, tranquilizers, stimulants, and sedatives. Past year initiates cannot be identified in NSDUH for the aggregate substance use measures of use of illicit drugs, use of illicit drugs other than marijuana, the misuse of any prescription psychotherapeutic drug, tranquilizer or sedative, benzodiazepines, and opioids. Additionally, estimates cannot be identified for past year initiation of use of any tobacco product because respondents are not asked an initiation question for pipe tobacco. For all initiation estimates, respondents who are immigrants were included regardless of whether their first use or misuse occurred inside or outside the United States.

Respondents are not asked initiation questions about the use or misuse of GHB, nonprescription cough and cold medicines, kratom use, nicotine vaping, marijuana vaping, vaping of flavoring, synthetic marijuana use, or synthetic stimulant use. Therefore, respondents cannot be identified as past year initiates for the use of these substances.

See Section 3.4.2 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “At Risk for Initiation.”

Inpatient Mental Health Service Use among Adults

SEE: “Mental Health Service Use among Adults.”

Interview Mode

Interview mode refers to the method for collecting NSDUH data. For 2021, there were two interview modes used for data collection due to the public health emergency related to COVID-19. See Section 2.2 in the 2021 Methodological Summary and Definitions report for additional details on the two interview modes.

In-person

For in-person data collection, field interviewers (FIs) visited households to determine whether zero, one, or two individuals aged 12 or older would be selected for the interview. If household members were selected, FIs conducted interviews in person with respondents either in their homes or at another suitable location (e.g., outdoors in a private setting). Questions about less sensitive topics were administered by FIs using computer-assisted personal interviewing (CAPI), but most NSDUH questions for in-person data collection were self-administered using audio computer-assisted self- interviewing (ACASI).

Web-based

Web-based data collection in NSDUH involved the use of the Internet to select and interview eligible household members, without FIs visiting households. Hence, all questions for web-based data collection were self-administered.

SEE: “ACASI,” “CAPI,” and “COVID-19.”

Kessler-6 (K6) Scale

The Kessler-6 (K6) scale consists of six questions that gather information on how frequently adult respondents experienced symptoms of psychological distress during the past month or the 1 month in the past year when they were at their worst emotionally.³⁰ These questions ask about the frequency of feeling (1) nervous, (2) hopeless, (3) restless or fidgety, (4) sad or depressed, (5) that everything was an effort, and (6) no good or worthless. Adult respondents are first asked in the mental health section of the questionnaire about these symptoms for the past 30 days. Adults are then asked if they had a period in the past 12 months when they felt more depressed, anxious, or emotionally stressed than they felt during the past 30 days. If so, they are asked the K6 questions for the 1 month in the past 12 months when they felt the worst.

Imputation-revised responses to these six questions for the past 30 days and (if applicable) the past 12 months are recoded and summed to produce a score ranging from 0 to 24. If respondents are asked the K6 questions for both the past 30 days and past 12 months, the higher of the two scores is chosen as the final score for the past year reference period. Higher K6 total scores indicate greater distress. The K6 scale provides a measure of psychological distress and does not directly measure the presence of a diagnosable mental, behavioral, or emotional disorder, nor does it capture information on functional impairment due to having psychological distress or a mental disorder. The K6 and scales for measuring functional impairment using the World Health Organization Disability Assessment Schedule [WHODAS]^31,32 are used in models that predict whether a respondent can be categorized as having serious mental illness (SMI). See Section 3.4.6 in the 2021 Methodological Summary and Definitions report for more information about the K6 and its scoring, as well as the development of SMI prediction models.

SEE: “Global Assessment of Functioning (GAF),” “Mental Illness,” “Serious Psychological Distress (SPD),” “Sheehan Disability Scale (SDS),” and “World Health Organization Disability Assessment Schedule (WHODAS).”

Ketamine Use

Measures of the use of ketamine in the respondent’s lifetime, the past year, and the past month were derived from responses to the hallucinogen section questions about lifetime and recency of use (i.e., “Have you ever, even once, used Ketamine, also called ‘Special K’ or ‘Super K’?” and “How long has it been since you last used Ketamine?”).

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Kratom Use

Measures of use of kratom in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used kratom?” and “How long has it been since you last used kratom?”). The questions about kratom in the emerging issues section of the questionnaire were not incorporated in estimates of use of illicit drugs or illicit drugs other than marijuana because kratom is not a controlled substance nationally.³³

The following definitional information preceded the question about lifetime use of kratom: “This next question is about kratom, which can come in forms such as powder, pills, or leaf.”

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Large Metro

SEE: “County Type.”

Latino

SEE: “Hispanic or Latino.”

Lifetime Use or Misuse

These measures indicate use or misuse of a specific substance at least once in the respondent’s lifetime and include respondents who also reported last using substances other than prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, or sedatives) or last misusing prescription psychotherapeutic drugs in the past 30 days or past 12 months. For prescription psychotherapeutic drugs, any lifetime use includes respondents who also reported any use in the past 12 months.

SEE: “Any Use of Prescription Psychotherapeutics,” “Current Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Location of Most Recent Underage Alcohol Use

Respondents aged 12 to 20 who reported in the alcohol section of the questionnaire drinking at least one alcoholic beverage within the past 30 days were asked in the consumption of alcohol section to indicate where they drank alcoholic beverages the last time they drank. The possible locations were (1) in a car or other vehicle; (2) at the respondent’s home; (3) at someone else’s home; (4) at a park, on a beach, or in a parking lot; (5) in a restaurant, bar, or club; (6) at a concert or sports game; (7) at school; or (8) some other place. Those who reported “some other place” were asked to type in a response indicating the specific location. Estimates for commonly reported other locations are included in the 2021 Detailed Tables. Respondents could report more than one location.

SEE: “Alcohol Use” and “Underage Alcohol Use.”

Location of Outpatient Mental Health Services among Adults

Respondents aged 18 or older who reported in the adult mental health utilization section of the questionnaire they received outpatient mental health services in the past year were asked where they received the mental health services. Response options for the location of outpatient mental health services were as follows: (1) an outpatient mental health clinic or center, (2) office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic; (3) a doctor’s office that was not part of a clinic; (4) an outpatient medical clinic; (5) a partial day hospital or day treatment program; or (6) some other place. Respondents who reported “some other place” were asked to type in a response indicating the specific location. Estimates for commonly reported other locations are included in the 2021 Detailed Tables. Respondents could report more than one location for services. Questions for the receipt of virtual (telehealth) services were not associated with a specific provider or location. Therefore, information on adults’ receipt of virtual (telehealth) mental health services was not included as a specific location for outpatient mental health services.

SEE: “Mental Health Service Use among Adults” and “Source of Payment for Mental Health Services among Adults.”

Location of Substance Use Treatment

Respondents who reported in the drug treatment section of the questionnaire that they received treatment in the past 12 months for their use of alcohol or illicit drugs were asked if they received the treatment at any of the following locations: (1) a hospital overnight or longer as an inpatient, (2) a residential drug or alcohol rehabilitation facility where they stayed overnight or longer, (3) a drug or alcohol rehabilitation facility as an outpatient, (4) a mental health center or facility as an outpatient, (5) an emergency room, (6) a private doctor’s office, (7) a prison or jail, (8) a self-help group (e.g., Alcoholics Anonymous or Narcotics Anonymous), (9) virtual (telehealth) services; and (10) some other place.

SEE: “Substance Use Treatment.”

Loss of Permanent Housing Because of the COVID-19 Pandemic

A measure of the loss of permanent housing because of the COVID-19 pandemic was derived from responses to the question in the COVID-19 section of the questionnaire asking respondents aged 12 or older, “Were you homeless, living on the street, in a vehicle, or in some type of makeshift housing like a tent or empty building at any time because of the COVID-19 pandemic?”

SEE: “COVID-19.”

Low Precision

Estimates based on a relatively small number of respondents or with relatively large standard errors were not presented in NSDUH reports and tables; they have been replaced with an asterisk (*) in the 2021 Detailed Tables and noted as “low precision.” These estimates have been omitted because one cannot place a high degree of confidence in their accuracy. Table 3.2 in the 2021 Methodological Summary and Definitions report includes a complete list of the rules used to determine low precision.

SEE: “Suppression of Estimates.”

LSD Use

Measures of use of lysergic acid diethylamide (LSD) in the respondent's lifetime, the past year, and the past month were derived from responses to the questions in the hallucinogens section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used LSD, also called ‘acid’?” and “How long has it been since you last used LSD?”). The question about recency of use was asked if respondents previously reported any use of LSD in their lifetime.

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Major Depressive Episode (MDE)

Individuals were classified as having had a lifetime major depressive episode (MDE) if they reported in the adult or adolescent depression sections of the questionnaire at least five or more of the following nine symptoms nearly every day (except where noted) in the same 2-week period in their lifetime, in which at least one of the symptoms was a depressed mood or loss of interest or pleasure in daily activities: (1) depressed mood most of the day; (2) markedly diminished interest or pleasure in all or almost all activities most of the day; (3) significant weight loss when not dieting or weight gain or decrease or increase in appetite; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness; (8) diminished ability to think or concentrate or indecisiveness; and (9) recurrent thoughts of death or recurrent suicide ideation. Unlike the other symptoms listed previously, recurrent thoughts of death or suicidal ideation did not need to have occurred nearly every day.

This definition is based on the definition found in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5³⁴). Individuals were classified as having an MDE in the past year if they (1) had a lifetime MDE, (2) had a period of time in the past 12 months when they felt depressed or lost interest or pleasure in daily activities for 2 weeks or longer, and (3) reported during this period of 2 weeks or longer in the past 12 months they had “some of the other problems” they reported for a lifetime MDE. Consistent with the DSM-5 criteria, NSDUH does not exclude MDEs that occurred exclusively in the context of bereavement.

To make the questions developmentally appropriate for youths, some questions in the adolescent depression section are worded differently than the question in the adult depression section. Therefore, the adult and youth measures for MDE should not be combined or compared. See Section 3.4.7 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Severe Impairment Due to Major Depressive Episode.”

Major Depressive Episode (MDE) with Severe Impairment

Severe impairment was defined by the level of role interference for adults or the level of problems for youths with a past year major depressive episode (MDE) when their depression symptoms were most severe (for adults) or worst (for youths). Impairment was defined based on the role domains for adults aged 18 or older and for youths aged 12 to 17 in the Sheehan Disability Scale (SDS). Respondents with a past year MDE and ratings of 7 or greater for interference (for adults) or problems (for youths) in one or more role domains were classified as having an MDE with severe impairment. The severe impairment measures asked about in the respective depression questionnaire sections are defined using different role domains for adults and youths. Therefore, the adult and youth measures should not be combined or compared. See Section 3.4.7 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Major Depressive Episode (MDE)” and “Sheehan Disability Scale (SDS).”

Marijuana Use

Measures of use of marijuana in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the marijuana section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used marijuana or hashish?” and “How long has it been since you last used marijuana or hashish?”). The question about recency of use was asked if respondents previously reported any use of marijuana or hashish in their lifetime. Responses to separate questions about use of cigars with marijuana in them (blunts) were not included in these measures. Creation of these measures did not take into account responses to questions about use of marijuana in the past 12 months that was recommended by a doctor or other health care professional.

The following definitional information preceded the question about lifetime use of marijuana: “The next questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called ‘hash.’ It is usually smoked in a pipe. Another form of hashish is hash oil.”

Additional questions about marijuana vaping were asked in the emerging issues section of the questionnaire, and the overall marijuana measures for 2021 took data into account for marijuana vaping. See Section 2.3.2 in the 2021 Methodological Summary and Definitions report for more information.

SEE: “Blunts,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Marijuana Vaping,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Marijuana Use Disorder

Marijuana use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5³⁵). Respondents who used marijuana on 6 or more days in the past 12 months were classified as having a marijuana use disorder in that period if they met two or more of the following criteria: (1) used marijuana in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on marijuana use; (3) spent a great deal of time in activities to obtain, use, or recover from marijuana use; (4) felt a craving or strong desire to use marijuana; (5) engaged in recurrent marijuana use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use marijuana despite social or interpersonal problems caused by the effects of marijuana; (7) gave up or reduced important social, occupational, or recreational activities because of marijuana use; (8) continued to use marijuana in physically hazardous situations; (9) continued to use marijuana despite physical or psychological problems caused by marijuana use; (10) increased the amount of marijuana needed to achieve same effect or noticed that the same amount of marijuana use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping marijuana use or (11b) used marijuana or a related substance to get over or avoid marijuana withdrawal symptoms. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Marijuana Use.”

Marijuana Vaping

Measures of marijuana vaping in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of marijuana vaping (i.e., “Have you ever, even once, vaped marijuana with an e-cigarette or other vaping device?” and “How long has it been since you last vaped marijuana with a vaping device?”). Respondents first were asked whether they ever vaped any substance with e-cigarettes or another vaping device in their lifetime. Respondents who reported that they ever vaped any substance in their lifetime were asked whether they ever used e-cigarettes or another vaping device to vape marijuana. The question about recency of marijuana vaping was asked if respondents reported that they vaped marijuana in their lifetime.

In the question about vaping anything with an e-cigarette or other vaping device, respondents were informed that these devices might also be called vape pens, personal vaporizers, or mods. However, these alternate terms were not repeated in the questions for marijuana vaping.

Questions about marijuana vaping were incorporated into the marijuana use measures and related measures that include marijuana. See Section 3.4.10.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Any Vaping” and “Marijuana Use.”

Medicaid

Medicaid is a public assistance program that pays for medical care for low-income and disabled people. Respondents were asked in the health insurance section of the questionnaire specifically about the Medicaid program in the state where they lived. Respondents aged 12 to 19 were asked specifically about the Children’s Health Insurance Program (CHIP) in their state. Respondents aged 12 to 19 who reported they were covered by the CHIP in their state also were classified as being covered by Medicaid. Respondents aged 65 or older who reported they were covered by Medicaid were asked to verify their answer was correct.

NOTE: For youths aged 12 to 17 and those respondents who were unable to respond to the health insurance or income questions, proxy responses were accepted from a household member identified as being better able to give the correct information about health insurance and income.

SEE: “Health Insurance Status” and “Medicare.”

Medicare

Medicare is a health insurance program for people aged 65 or older and for certain disabled people. Respondents younger than the age of 65 who reported in the health insurance section of the questionnaire they were covered by Medicare were asked to verify their answer was correct.

NOTE: For youths aged 12 to 17 and those respondents who were unable to respond to the health insurance or income questions, proxy responses were accepted from a household member identified as being better able to give the correct information about health insurance and income.

SEE: “Health Insurance Status” and “Medicaid.”

Medication-Assisted Treatment (MAT) for Alcohol Use

Respondents who reported that they ever used alcohol and that they received treatment in the past 12 months for their use of illicit drugs or alcohol were asked in the emerging issues section of the questionnaire whether they used medication prescribed by a doctor or other health professional in the past 12 months to help reduce or stop the use of alcohol. Medications shown to respondents included acamprosate, also known as Campral^®; disulfiram, also known as Antabuse^®; naltrexone pills, also known as ReVia^® or Trexan^®; and injectable naltrexone, also known as Vivitrol^®. Respondents who reported using any prescription medication to help reduce or stop their use of alcohol were classified as having received medication-assisted treatment (MAT) in the past year for alcohol use. Respondents were classified as not having received MAT in the past year if the only substances they reported using to reduce or stop their use of alcohol were illicit drugs, alcohol, marijuana, nicotine products (tobacco products or nicotine vaping), or over-the-counter drugs.

Because the MAT questions were asked only of respondents who reported that they received treatment in the past 12 months for their use of illicit drugs or alcohol, respondents who did not receive substance use treatment in the past 12 months (or in their lifetime) for their use of illicit drugs or alcohol were classified as not having received MAT. Respondents who never used alcohol were also classified as not having received MAT for their use of alcohol. See Section 3.4.9 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use” and “Substance Use Treatment.”

Medication-Assisted Treatment (MAT) for Opioid Misuse

Respondents who reported having ever used heroin or ever misused prescription pain relievers and reported receiving treatment in the past 12 months for their use of illicit drugs or alcohol were asked in the emerging issues section of the questionnaire whether they used medication prescribed by a doctor or other health professional in the past 12 months to help reduce or stop the use of opioids. The examples of opioids were tailored according to whether respondents (1) ever used heroin and ever misused prescription pain relievers, (2) ever used heroin but did not report misuse of prescription pain relievers, or (3) ever misused prescription pain relievers but did not report heroin use. Medications shown to respondents included buprenorphine or buprenorphine-naloxone pills or film taken by mouth, also known as Suboxone^®, Zubsolv^®, Bunavail^®, or Subutex^®; injectable buprenorphine, also known as Sublocade^®; a buprenorphine implant placed under the skin, also known as Probuphine^®; methadone; naltrexone pills, also known as ReVia^® or Trexan^®; and injectable naltrexone, also known as Vivitrol^®.

Respondents who reported using any prescription medication other than prescription pain relievers³⁶ to help reduce or stop their use of opioids were classified as having received medication-assisted treatment (MAT) in the past year for opioid misuse. Respondents were classified as not having received MAT in the past year if the only substances they reported using to reduce or stop their use of opioids were prescription pain relievers, illicit drugs, alcohol, marijuana, nicotine products (tobacco products or nicotine vaping), or over-the-counter drugs.

Because the MAT questions were asked only of respondents who reported that they received treatment in the past 12 months for their use of illicit drugs or alcohol, respondents who did not receive substance use treatment in the past 12 months (or in their lifetime) for their use of illicit drugs or alcohol were classified as not having received MAT. Respondents who never used heroin and never misused prescription pain relievers were also classified as not having received MAT for their misuse of opioids. See Section 3.4.9 in the 2021 Methodological Summary and Definitions report for additional details.

The following definitional information preceded the question about the receipt of MAT for opioids (example given for respondents who ever used heroin and ever misused prescription pain relievers): “The next question is about medication-assisted treatment prescribed by a doctor or other health professional to help reduce or stop your use of heroin or prescription pain relievers. It is different from medications given to stop a drug overdose.”

SEE: “Heroin Use,” “Opioid Misuse,” “Pain Reliever Use or Misuse,” “Past Year Use or Misuse,” and “Substance Use Treatment.”

Medication-Assisted Treatment (MAT) for Alcohol Use or Opioid Misuse

Respondents were classified as having received medication-assisted treatment (MAT) in the past year for alcohol use or opioid misuse if they reported receiving MAT for alcohol use or opioid misuse. See Section 3.4.9 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Medicated Assisted Treatment (MAT) for Alcohol Use,” “Medicated Assisted Treatment (MAT) for Opioid Misuse,” and “Past Year Use or Misuse.”

Mental Health Care

SEE: “Mental Health Service Settings for Youths,” “Mental Health Service Use among Adults,” and “Treatment for Depression.”

Mental Health Service Settings for Youths

For youths aged 12 to 17, mental health service settings refer to locations or types of providers where youths received treatment or counseling for any emotional or behavioral problem (not caused by the use of alcohol or drugs) in the past 12 months.

Mental health services settings, differentiated by the type of setting, were defined as follows:

Specialty

Specialty mental health settings for youths include outpatient, inpatient, or residential mental health settings. The outpatient settings include (1) private therapists, psychologists, psychiatrists, social workers, or counselors; (2) mental health clinics or centers; (3) partial day hospitals or day treatment programs; and (4) in-home therapists, counselors, or family preservation workers. The inpatient settings include (1) hospitals and (2) residential treatment centers. Youths were classified as having received mental health services at a specialty setting if they reported receiving treatment or counseling in any of these settings for emotional or behavioral problems. Youths could report receiving services in more than one specialty setting.

Nonspecialty

Nonspecialty mental health settings for youths include the education, general medical, juvenile justice, and child welfare settings. The education setting includes mental health services from (1) school social workers, school psychologists, or school counselors; and (2) special schools or school programs (within a regular school) for students with emotional or behavioral problems. The general medical setting includes mental health services from pediatricians or other family doctors. The juvenile justice setting includes services in a juvenile detention center, prison, or jail provided by psychiatrists, psychologists, social workers, or counselors who work for the court system. The child welfare setting includes foster care or therapeutic foster care. Youths could report receiving services in more than one nonspecialty setting.

Virtual (Telehealth)

Virtual mental health service settings for youths include services delivered over the phone, by email, or through video calling.

Youths could report in the youth mental health service utilization section of the questionnaire that they received mental health services in all three types of service settings. The receipt of virtual (telehealth) services was not associated with a specific provider, location, or facility type. Therefore, receipt of these services was not grouped into the NSDUH measures for the specialty or nonspecialty youth mental health service settings.

An aggregate measure was not created for any mental health service use among youths for multiple reasons. First, questions about specific settings did not apply to all NSDUH respondents aged 12 to 17. Therefore, youths had different opportunities to report that they received mental health services, depending on the setting. Specifically, only those youths who previously reported that they attended any type of school in the past 12 months were asked whether they received mental health services in education settings; school dropouts and youths who reported that they were homeschooled were not asked about mental health services in education settings. Also, only those youths who reported staying in a juvenile detention center in the past 12 months were asked whether they received services in juvenile justice settings. Second, SAMHSA considered that the types of services and level of care in nonspecialty settings, such as education settings, would be qualitatively different from services received in specialty settings. For these reasons, SAMHSA decided to present separate estimates for youths’ receipt of services in specialty and nonspecialty settings.

Measures of the receipt of mental health services for youths in the nonspecialty or specialty service settings include different service settings from those included in the measures for the receipt of adult mental health services. Data on the use of prescription medication to treat any emotional or behavioral problem also are not collected from youths. In addition to the differences in service settings included in the youth and adult mental health service measures, aggregate measures for any mental health service use were not created for youths for the reasons mentioned previously. Therefore, the adult and youth mental health service measures should not be combined or compared.

Mental Health Service Use among Adults

For adults aged 18 or older, use of mental health services was defined as the receipt of treatment or counseling for any problem with emotions, nerves, or mental health in the 12 months prior to the interview. Respondents were asked in the adult mental health utilization section of the questionnaire to report whether they received mental health services in the past 12 months in an inpatient or outpatient setting, they used prescription medication, or they received virtual telehealth services to treat a mental or emotional condition. Respondents also were asked not to report inpatient or outpatient treatment for the use of alcohol or drugs. Mental health services, differentiated by the type of service, were defined as follows:

Inpatient

Respondents were classified as having received mental health services as an inpatient in the past 12 months if they reported staying overnight or longer in any of the following locations to receive treatment or counseling for any problem they were having with their emotions, nerves, or mental health: (1) private or public psychiatric hospital, (2) psychiatric unit of a general hospital, (3) medical unit of a general hospital, (4) another type of hospital, (5) residential treatment center, and (6) some other facility. Respondents could report receiving services in more than one inpatient setting.

Outpatient

Respondents were classified as having received mental health services as an outpatient in the past 12 months if they reported receiving outpatient treatment or counseling for any problem they were having with their emotions, nerves, or mental health at any of the following locations: (1) outpatient mental health clinic or center; (2) office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic; (3) doctor’s office that was not part of a clinic; (4) outpatient medical clinic; (5) partial day hospital or day treatment program; and (6) some other place. Respondents who reported “some other place” were asked to type in a description of this other place. Estimates for commonly reported other places are included in the 2021 Detailed Tables. Respondents could report receiving services in more than one outpatient setting.

Prescription Medication

Respondents were classified as having used prescription medication as a mental health service if they reported taking prescription medications prescribed for them to treat a mental or emotional condition.

Virtual (Telehealth)

Respondents were classified as having received virtual (telehealth) mental health services if they reported receiving services delivered over the phone, by email, or through video calling.

Adults could report in the adult mental health service utilization section of the questionnaire that they received all four of these types of mental health services. The receipt of virtual (telehealth) services was not associated with a specific provider, location, or facility type. Respondents also were not asked whether the prescription medication that they took to treat a mental or emotional condition was prescribed to them through virtual services. Therefore, receipt of virtual services was not grouped into the NSDUH measures for the inpatient or outpatient adult mental health service settings or the receipt of prescription medication to treat a mental or emotional condition.

Two aggregate measures of mental health service use in the past 12 months among adults were created for the 2021 Detailed Tables. The first included the receipt of inpatient or outpatient services or the use of prescription medication in the past 12 months, but it did not include virtual services. The second included the receipt of inpatient or outpatient services, the use of prescription medication, or the receipt of virtual services in the past 12 months.

Measures of mental health service use for adults are defined using different criteria from the measures for the receipt of youth mental health services. Also, an aggregate measure for any mental health service use was created for adults but not for youths aged 12 to 17 because (1) all youths were not asked questions for every setting where they could have received services and (2) the types of services and level of care would differ in the settings that were presented to youths (and compared with the settings that were presented to adults). Therefore, the adult and youth mental health service measures should not be combined or compared.

SEE: “Location of Outpatient Mental Health Services among Adults,” “Perceived Unmet Need for Mental Health Services among Adults,” “Reasons for Not Receiving Mental Health Services among Adults,” and “Source of Payment for Mental Health Services among Adults.”

Mental Health Treatment

SEE: “Mental Health Service Settings for Youths,” “Mental Health Service Use among Adults,” “Reasons for Receiving Mental Health Services among Youths,” and “Treatment for Depression.”

Mental Illness

The definition of mental illness among adults aged 18 or older has two dimensions: (1) the presence of a diagnosable mental, behavioral, or emotional disorder in the past year (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV³⁷); and (2) the level of interference with or limitation of one or more major life activities resulting from a disorder (functional impairment). A statistical model predicting the likelihood of having mental illness was developed based on a subsample of adult NSDUH respondents from 2008 to 2012 who completed a clinical follow-up interview after the main NSDUH interview. The follow up interviews consisted of detailed mental health assessments administered by trained mental health clinicians. The dependent variable for mental illness in the model was established through the clinical interviews using modules from the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non patient Edition (SCID-I/NP)³⁸ for the following past year disorders or symptoms: major depressive disorder (including major depressive episode [MDE]), dysthymic disorder, bipolar I disorder (including manic episode), specific phobia, social phobia, generalized anxiety disorder, panic disorder (with and without agoraphobia), agoraphobia (without history of panic disorder), obsessive-compulsive disorder, posttraumatic stress disorder, anorexia nervosa, bulimia nervosa, adjustment disorder, and psychotic symptoms (i.e., hallucinations or delusions). The clinical interviews also included the Global Assessment of Functioning scale to measure functional impairment. This model was used to predict adult NSDUH respondents’ mental illness status based on their responses to questions in the main NSDUH interview on psychological distress (Kessler-6 scale), functional impairment (an abbreviated version of the World Health Organization Disability Assessment Schedule), past year MDE, past year suicidal thoughts, and age. See Section 3.4.6 in the 2021 Methodological Summary and Definitions report for additional details on the model and specifications.

Mental illness, differentiated by the level of functional impairment, was defined as follows for adults:

Any

Any mental illness (AMI) among adults was defined as adults aged 18 or older who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder as defined above, regardless of the level of impairment in carrying out major life activities. AMI was estimated based on a statistical model of a clinical diagnosis and responses to questions in the main NSDUH interview on distress (Kessler-6 scale), impairment (truncated version of the World Health Organization Disability Assessment Schedule), past year major depressive episode, past year suicidal thoughts, and age.

Any Excluding Serious

Any mental illness (AMI) excluding serious mental illness (SMI) was defined to include adults aged 18 or older who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder as defined above and resulting in less than substantial impairment in carrying out major life activities, based on clinical interview Global Assessment of Functioning scores of greater than 50. AMI excluding SMI was estimated based on a statistical model of a clinical diagnosis and responses to questions in the main NSDUH interview on distress (Kessler-6 scale), impairment (truncated version of the World Health Organization Disability Assessment Schedule), past year major depressive episode, past year suicidal thoughts, and age.

Serious

Serious mental illness (SMI) among adults was defined in Public Law 102-321 as adults aged 18 or older who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder and resulting in substantial impairment in carrying out major life activities.³⁹ In NSDUH, a diagnosable mental, behavioral, or emotional disorder was defined as for the other mental illness categories described previously (i.e., based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV⁴⁰] and excluding developmental and substance use disorders); substantial impairment was defined based on clinical interview Global Assessment of Functioning scores of 50 or below. SMI was estimated based on a statistical model of a clinical diagnosis and responses to questions in the main NSDUH interview on distress (Kessler 6 scale), impairment (truncated version of the World Health Organization Disability Assessment Schedule), past year major depressive episode, past year suicidal thoughts, and age. All adults with SMI were also classified as having AMI.

SEE: “Global Assessment of Functioning (GAF),” “Kessler-6 (K6) Scale,” “Major Depressive Episode (MDE),” “Suicidal Thoughts and Behavior,” and “World Health Organization Disability Assessment Schedule (WHODAS).”

Methamphetamine Use

Measures of use of methamphetamine in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the methamphetamine section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used methamphetamine?” and “How long has it been since you last used methamphetamine?”). The question about recency of use was asked if respondents previously reported any use of methamphetamine in their lifetime.

The following definitional information preceded the question about lifetime use of methamphetamine: “Methamphetamine, also known as crank, ice, crystal meth, speed, glass, and many other names, is a stimulant that usually comes in crystal or powder forms. It can be smoked, ‘snorted,’ swallowed or injected.” The methamphetamine section does not include the prescription form of methamphetamine (Desoxyn^®) as an example.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Stimulant Use or Misuse.”

Methamphetamine Use Disorder

Methamphetamine use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁴¹). Respondents who used methamphetamine in the past 12 months (including those who reported using methamphetamine with a needle in that period) were classified as having a methamphetamine use disorder in that period if they met two or more of the following criteria: (1) used methamphetamine in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on methamphetamine use; (3) spent a great deal of time in activities to obtain, use, or recover from methamphetamine use; (4) felt a craving or strong desire to use methamphetamine; (5) engaged in recurrent methamphetamine use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use methamphetamine despite social or interpersonal problems caused by the effects of methamphetamine; (7) gave up or reduced important social, occupational, or recreational activities because of methamphetamine use; (8) continued to use methamphetamine in physically hazardous situations; (9) continued to use methamphetamine despite physical or psychological problems caused by methamphetamine use; (10) increased the amount of methamphetamine needed to achieve same effect or noticed that the same amount of methamphetamine use had less effect than before); and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping methamphetamine use or (11b) used methamphetamine or a related substance to get over or avoid methamphetamine withdrawal symptoms. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Methamphetamine Use.”

Midwest Region

The states included are those in the East North Central Division (Illinois, Indiana, Michigan, Ohio, and Wisconsin) and the West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota).

SEE: “Geographic Division” and “Region.”

Misuse of Prescription Psychotherapeutics

Misuse of prescription psychotherapeutics (prescription pain relievers, prescription tranquilizers, prescription stimulants, or prescription sedatives) was defined as use “in any way a doctor did not direct you to use [it or them]” and focused on behaviors that constitute misuse of prescription drugs. Examples of misuse were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug.

Respondents who reported in the respective prescription drug questionnaire sections that they used specific prescription psychotherapeutic drugs for any reason in the past 12 months were shown a list of the drugs they used in the past 12 months and were asked for each drug whether they used it (or them) in the past 12 months in any way not directed by a doctor. Respondents were reminded not to include over-the-counter drugs when they were asked whether they used any other prescription pain reliever, stimulant, or sedative in the past 12 months in any way not directed by a doctor. This reminder was not included for prescription tranquilizers because no tranquilizers were available over the counter.

If respondents reported misuse of one or more specific drugs within a category in the past 12 months, they were asked whether they used any drug in that category (e.g., prescription pain relievers) in the past 30 days in any way a doctor did not direct the respondent to use it or them. Respondents who reported any use of prescription psychotherapeutics in the past 12 months but did not report misuse in the past 12 months or who reported any use in their lifetime but not in the past 12 months were asked whether they ever, even once, used any prescription psychotherapeutic drug within that category (e.g., any prescription pain reliever) in a way a doctor did not direct them to use it. Consequently, estimates of misuse in the lifetime or past month periods were available only for an overall prescription psychotherapeutic drug category (e.g., pain relievers) and not for specific prescription drugs within that category.

SEE: “Any Use of Prescription Psychotherapeutics,” “Benzodiazepine Use or Misuse,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Pain Reliever Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Psychotherapeutic Drugs,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” “Source of Prescription Psychotherapeutic Drugs,” “Stimulant Use or Misuse,” “Tranquilizer or Sedative Use or Misuse,” and “Tranquilizer Use or Misuse.”

Mode

SEE: “Interview Mode.”

Module

In some NSDUH publications, modules in the NSDUH questionnaire refer to sections of the interview that are organized together by content and interviewing logic for determining which questions respondents were asked. For in-person interviews, sections also were organized according to whether they were interviewer-administered (i.e., using computer-assisted personal interviewing [CAPI]) or self-administered (i.e., using audio computer-assisted self interviewing [ACASI]).

SEE: “ACASI,” “CAPI,” “Gate Question,” and “Interview Mode.”

Native Hawaiian or Other Pacific Islander (NHOPI)

Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific Islander, not of Hispanic, Latino, or Spanish origin, in accordance with federal standards for reporting race and ethnicity data.⁴² This definition is based on reports in the core demographics section at the beginning of the interview in which respondents described themselves as being Native Hawaiian, Guamanian or Chamorro, Samoan, or an Other Pacific Islander. The definition does not include respondents reporting two or more races. Respondents reporting they were Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific Islander and of Hispanic, Latino, or Spanish origin were classified as Hispanic.

SEE: “Hispanic or Latino,” “Race/Ethnicity,” and “Two or More Races.”

Need for Alcohol Use Treatment

SEE: “Classified as Needing Alcohol Use Treatment.”

Need for Illicit Drug Use Treatment

SEE: “Classified as Needing Illicit Drug Use Treatment.”

Need for Substance Use Treatment

SEE: “Classified as Needing Substance Use Treatment.”

NHOPI

SEE: “Native Hawaiian or Other Pacific Islander (NHOPI).”

Nicotine (Cigarette) Dependence

Respondents who reported they smoked cigarettes in the past month were classified as having nicotine (cigarette) dependence if they met either the dependence criteria derived from the Nicotine Dependence Syndrome Scale (NDSS)^43,44 or the Fagerstrom Test of Nicotine Dependence (FTND).^45,46 Nicotine (cigarette) dependence is based only on the use of cigarettes according to questions in the substance dependence or abuse section of the questionnaire. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Cigarette Use” and “Nicotine Vaping.”

Nicotine Vaping

Measures of nicotine vaping in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of nicotine or tobacco vaping (i.e., “Have you ever, even once, vaped nicotine or tobacco with an e-cigarette or other vaping device?” and “How long has it been since you vaped nicotine or tobacco with an e-cigarette or other vaping device?”). Respondents first were asked whether they ever vaped any substance with e-cigarettes or another vaping device in their lifetime. Respondents who reported that they ever vaped any substance in their lifetime were asked whether they ever used e-cigarettes or another vaping device to vape nicotine. The question about recency of nicotine vaping was asked if respondents reported that they vaped nicotine or tobacco in their lifetime. See Section 3.4.10.2 in the 2021 Methodological Summary and Definitions report for additional details.

In the question about vaping anything with an e-cigarette or other vaping device, respondents were informed that these devices might also be called vape pens, personal vaporizers, or mods. However, these alternate terms were not repeated in the questions for nicotine vaping.

Questions about nicotine vaping in the emerging issues section were asked later in the questionnaire than the questions on nicotine (cigarette) dependence. Therefore, information on nicotine vaping in the past month was not used to create estimates for nicotine (cigarette) dependence.

SEE: “Any Vaping” and “Tobacco Product Use or Nicotine Vaping.”

Nonmetro

SEE: “County Type.”

Nonphysical Delinquent Behavior

SEE: “Delinquent Behavior.”

Nonprescription Cough or Cold Medicine Use

Measures of use of nonprescription cough or cold medicine to get high in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the special drugs section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, taken a non-prescription cough or cold medicine just to get high?” and “How long has it been since you last took one of these cough or cold medicines to get high?”). The questions about nonprescription cough or cold medicine use are not incorporated in estimates of either use of illicit drugs or use of illicit drugs other than marijuana.

The following definitional information preceded the question about lifetime use: “The next question is about non-prescription cough or cold medicines, also known as ‘over-the-counter’ medicines.”

SEE: “Current Use or Misuse,” “Illicit Drugs,” “Illicit Drugs Other Than Marijuana,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Nonspecialty Mental Health Service Settings for Youths

SEE: “Mental Health Service Settings for Youths.”

Northeast Region

The states included are those in the New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and the Middle Atlantic Division (New Jersey, New York, and Pennsylvania).

SEE: “Geographic Division” and “Region.”

Opioid Use or Misuse

Opioids in NSDUH refer to heroin and prescription pain relievers. Measures were created for both any use of opioids and misuse of opioids. See Section 4.3 in the 2021 Methodological Summary and Definitions report for additional details.

Any Use

Respondents were classified as using opioids for any reason in the past year (i.e., any use) if they reported using heroin in the past year or they reported any use of prescription pain relievers in the past year (i.e., not necessarily misuse). (Respondents were not asked about any use of prescription stimulants in the past month.)

Although the majority of any past year use of prescription pain relievers in 2021 consisted of the use of prescription opioids in the NSDUH questionnaire, respondents who reported any use of only “other” prescription pain relievers in the past year may not necessarily have used prescription opioids. Respondents who reported any past year use of only “other” pain relievers and also reported past year heroin use were unambiguously opioid users by virtue of their reported heroin use. However, respondents who reported any past year use of only “other” prescription pain relievers were still classified as past year opioid users, even if they did not report heroin use in the past year.

Misuse

Respondents were classified as misusing opioids in the past year or past month if they reported using heroin or misusing prescription pain relievers in these periods. (Respondents who reported the misuse of specific prescription pain relievers in the past year were asked whether they misused any prescription pain reliever in the past month.)

Although most misuse of prescription pain relievers in 2021 consisted of the use of prescription opioids (either prescription opioids in the NSDUH questionnaire or other opioids that respondents specified that they misused), respondents who reported the misuse of only “other” prescription pain relievers in the past year may not necessarily have misused prescription opioids. Respondents who reported the past year misuse of only “other” pain relievers and also reported past year heroin use were unambiguously opioid misusers by virtue of their reported heroin use. However, respondents who reported the past year misuse of only “other” prescription pain relievers were still classified as past year opioid users, even if they did not report heroin use in the past year.

Respondents were classified as having past year or past month opioid misuse if they reported using heroin or misusing prescription pain relievers.

SEE: “Current Use or Misuse,” “Heroin Use,” “Pain Reliever Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Opioid Use Disorder

Respondents were classified as having an opioid use disorder if they met criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁴⁷). Two measures of opioid use disorder were created for 2021: (1) opioid use disorder due to any use of opioids and (2) opioid use disorder due to the misuse of opioids.

Disorder Due to Any Use

Opioid use disorder due to any use was defined as having a heroin use disorder or a pain reliever use disorder. Respondents who reported any use of prescription pain relievers in the past year and met DSM-5 criteria for pain reliever use disorder were classified as having a pain reliever use disorder.

Disorder Due to Misuse

Opioid use disorder due to misuse was defined as having a heroin use disorder or a pain reliever use disorder among past year misusers of prescription pain relievers. Respondents who reported the misuse of prescription pain relievers in the past year and met DSM-5 criteria for pain reliever use disorder were classified as having a pain reliever use disorder due to misuse.

Respondents were not counted as having an opioid use disorder if they did not meet the full substance use disorder criteria for heroin or prescription pain relievers individually. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

In 2021, the majority of people aged 12 or older who had an opioid use disorder in the past year consisted of people who used prescription opioids in that period. However, respondents who may have used or misused only nonopioid drugs in the past year could be misclassified as having an opioid use disorder. See Section 4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Heroin Use,” “Heroin Use Disorder,” “Pain Reliever Use Disorder,” and “Pain Reliever Use or Misuse.”

Outpatient Mental Health Service Use among Adults

SEE: “Mental Health Service Use among Adults.”

OxyContin^® Use or Misuse

Information about any use and misuse of the prescription pain reliever OxyContin^® was obtained for the past year. Measures of use or misuse of OxyContin^® were derived from reports in the pain relievers section of the questionnaire for any use and misuse of this specific pain reliever in the past 12 months. If respondents reported any use of OxyContin^® in the past 12 months, they were asked the following question: “In the past 12 months, did you use OxyContin in any way a doctor did not direct you to use it?”

SEE: “Pain Reliever Use or Misuse” and “Past Year Use or Misuse.”

Pain Reliever Use Disorder

Pain reliever use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁴⁸). Respondents who reported any use of prescription pain relievers in the past 12 months were asked questions about the following criteria for pain reliever use disorder: (1) used pain relievers in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on pain reliever use; (3) spent a great deal of time in activities to obtain, use, or recover from pain reliever use; (4) felt a craving or strong desire to use pain relievers; (5) engaged in recurrent pain reliever use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use pain relievers despite social or interpersonal problems caused by the effects of pain relievers; (7) gave up or reduced important social, occupational, or recreational activities because of pain reliever use; (8) continued to use pain relievers in physically hazardous situations; (9) continued to use pain relievers despite physical or psychological problems caused by pain reliever use; (10) increased the amount of pain relievers needed to achieve same effect or noticed that the same amount of pain reliever use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping pain reliever use or (11b) used prescription pain relievers or a related substance to get over or avoid pain reliever withdrawal symptoms.

The number of criteria for classifying respondents who reported any use of prescription pain relievers in the past 12 months differed according to whether respondents misused pain relievers, or they used pain relievers but did not misuse them in that period.

Disorder Due to Misuse

Respondents who misused prescription pain relievers in the past 12 months were classified as having a pain reliever use disorder if they had 2 or more of the 11 criteria mentioned previously.

Disorder Due to Use but Not Misuse

Respondents who used prescription pain relievers in the past 12 months but did not misuse them were classified as having a pain reliever use disorder if they met two or more of the first nine criteria mentioned previously. Criteria 10 and 11 do not apply to people who did not misuse prescription pain relievers because these criteria can occur as normal physiological adaptations when people use pain relievers appropriately under medical supervision.⁴⁹

The overall measure of pain reliever use disorder was based on whether respondents in either of these two groups were classified as having a pain reliever use disorder in the past year. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

In 2021, the majority of people aged 12 or older who had a pain reliever use disorder in the past year consisted of people who used prescription opioids in that period. However, respondents who may have used or misused only nonopioid drugs in the past year could be misclassified as having pain reliever use disorder. See Section 4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Opioid Use Disorder” and “Pain Reliever Use or Misuse.”

Pain Reliever Use or Misuse

Measures of use or misuse of prescription pain relievers in the respondent’s lifetime and past year were derived from a series of questions in the screener and main sections of the questionnaire for pain relievers that first asked respondents about any use (i.e., for any reason) of specific prescription pain relievers in the past 12 months. Respondents were instructed not to include the use of over-the-counter (OTC) pain relievers, such as aspirin, Tylenol^®, Advil^®, or Aleve^®. Respondents who did not report use of any pain reliever in the past 12 months were asked whether they ever, even once, used prescription pain relievers.

Respondents who reported they used specific prescription pain relievers in the past 12 months for any reason were shown a list reminding them of the drugs they used in the past 12 months. For each of these drugs, respondents were asked whether they misused it (or them) in the past 12 months (i.e., use in any way a doctor did not direct them to use it). Examples of misuse were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug. Respondents were reminded not to include OTC drugs when they were asked if they misused any other prescription pain reliever in the past 12 months. If respondents reported misuse of one or more specific prescription pain relievers in the past 12 months, they were asked whether they misused prescription pain relievers in the past 30 days. Respondents who reported any use of prescription pain relievers in the past 12 months but did not report misuse in the past 12 months or who reported any use in their lifetime but not in the past 12 months were asked whether they ever, even once, misused any prescription pain reliever. Consequently, lifetime and past month estimates of the misuse of prescription pain relievers are available only for the overall pain reliever category and not for specific pain relievers.

Questions about past year use and misuse in the 2021 NSDUH covered the following subcategories of pain relievers: hydrocodone products (Vicodin^®, Lortab^®, Norco^®, Zohydro^® ER, or generic hydrocodone); oxycodone products (OxyContin^®, Percocet^®, Percodan^®, Roxicodone^®, or generic oxycodone); tramadol products (Ultram^®, Ultram^® ER, Ultracet^®, generic tramadol, or generic extended-release tramadol); codeine products (Tylenol^® with codeine 3 or 4, or generic codeine pills); morphine products (Avinza^®, Kadian^®, MS Contin^®, generic morphine, or generic extended-release morphine); fentanyl products (Duragesic^®, Fentora^®, or generic fentanyl); buprenorphine products (Suboxone^®, generic buprenorphine, or generic buprenorphine plus naloxone); oxymorphone products (Opana^®, Opana^® ER, generic oxymorphone, or generic extended-release oxymorphone); Demerol^®; hydromorphone products (Dilaudid^® or generic hydromorphone, or Exalgo^® or generic extended-release hydromorphone); methadone; or any other prescription pain reliever. Other prescription pain relievers could include products similar to the specific pain relievers listed previously. Questions were not asked about past month pain reliever use or misuse for the specific subtype categories.

Because the specific pain relievers listed above are classified as opioids, use or misuse of any of these specific pain relievers indicates prescription opioid use or misuse. If respondents reported the use or misuse of only “other” pain relievers, however, respondents could have used or misused drugs that are not opioids. If respondents reported that they used or misused other pain relievers in the past year, they may not have known the specific other pain relievers they used or misused. Some of these other pain relievers could have been prescription opioids. See Section 4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Lifetime Use or Misuse,” “Opioid Misuse,” “OxyContin^® Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Source of Prescription Psychotherapeutic Drugs.”

Past Month Use or Misuse

These measures indicate use of a substance other than prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, or sedatives) or misuse of prescription psychotherapeutic drugs in the 30 days prior to the interview. Respondents were not asked about any use of prescription psychotherapeutic drugs in the past 30 days. Respondents who indicated past month use or misuse of a specific substance also were classified as lifetime and past year users or misusers.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Past Year Use or Misuse

These measures indicate use or misuse of a specific substance in the 12 months prior to the interview. For prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, or sedatives), measures include any use or misuse in the past 12 months. Measures for prescription psychotherapeutic drugs are determined from respondents’ answers to questions about any use or misuse in the past 12 months. For tobacco products, past year use measures were determined from respondents’ answers to questions about use in the past 30 days or most recent use. For all other substances (alcohol through methamphetamine), past year use measures were determined from questions about respondents’ most recent use of that substance. Respondents who indicated past year use or misuse of a specific substance also were classified as lifetime users or misusers.

SEE: “Any Use of Prescription Psychotherapeutics,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Past Month Use or Misuse,” “Recency of Use or Misuse,” and “Tobacco Product Use.”

PCP Use

Measures of use of phencyclidine (PCP) in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the hallucinogens section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used PCP, also called ‘angel dust’ or phencyclidine?” and “How long has it been since you last used PCP?”). The question about recency of use was asked if respondents previously reported any use of PCP in their lifetime.

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Perceived Availability

Respondents were asked in the risk and availability section of the questionnaire to assess how difficult or easy it would be for them to get various illicit drugs if they wanted these drugs. The drugs include marijuana, lysergic acid diethylamide (LSD), cocaine, crack, and heroin. Response options were (1) probably impossible, (2) very difficult, (3) fairly difficult, (4) fairly easy, and (5) very easy.

SEE: “Cocaine Use,” “Crack Use,” “Heroin Use,” “LSD Use,” and “Marijuana Use.”

Perceived Effects on Alcohol Use Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “How much, if at all, has the COVID-19 pandemic affected the amount of alcohol you drink?” Respondents could indicate that they drank alcohol much less, a little less, about the same amount, a little more, or much more than they did before the COVID-19 pandemic began. This question on perceived effects on alcohol use because of the COVID-19 pandemic was asked only of past year alcohol users.

SEE: “COVID-19.”

Perceived Effects on Use of Drugs Other Than Alcohol Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “How much, if at all, has the COVID-19 pandemic affected your drug use other than alcohol?” Respondents could indicate they used drugs other than alcohol much less, a little less, about the same amount, a little more, or much more than before the COVID-19 pandemic began. This question on perceived effects on drug use was asked only of respondents who reported using marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine in the past year or who reported any use (i.e., not necessarily misuse) of prescription pain relievers, tranquilizers, stimulants, or sedatives in the past year. Drugs other than alcohol did not include tobacco products or nicotine vaping. Respondents were reminded that drugs meant cannabis, which included marijuana and hashish; cocaine; methamphetamine; heroin; fentanyl; hallucinogens such as LSD; and prescription medications including benzodiazepines such as Xanax and Ativan, stimulants such as Ritalin and Adderall, and opioids such as hydrocodone or oxycodone.

SEE: “COVID-19.”

Perceived Need for Alcohol Use Treatment

Respondents who reported using alcohol in their lifetime were classified as perceiving a need for alcohol use treatment if they reported in the drug treatment section of the questionnaire that they felt a need for alcohol use treatment when asked, “During the past 12 months, did you need treatment or counseling for your use of alcohol?” or if they indicated feeling a need for additional treatment specifically for alcohol use when asked, “During the past 12 months, for which of the following drugs did you need additional treatment or counseling?” See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Substance Use Treatment.”

Perceived Need for Illicit Drug Use Treatment

Respondents were classified as perceiving a need for illicit drug use treatment if they reported in the drug treatment section of the questionnaire that they felt a need for treatment for the use of one or more drugs when asked specifically about each of the individual drugs they had indicated using: “During the past 12 months, did you need treatment or counseling for your use of [drug]?” Lifetime users of the following illicit drugs were asked whether they thought they needed treatment for the use of these illicit drugs: marijuana or hashish, cocaine or crack, heroin, hallucinogens, inhalants, methamphetamine, prescription pain relievers, prescription tranquilizers, prescription stimulants, prescription sedatives, or some other drug. Respondents were asked whether they thought they needed treatment for their use of prescription pain relievers, tranquilizers, stimulants, or sedatives if they reported misuse in their lifetime.

Respondents were also classified as perceiving a need for illicit drug use treatment if they indicated feeling a need for additional treatment specifically for the use of one or more drugs when asked, “During the past 12 months, for which of the following drugs did you need additional treatment or counseling?” The response list included the same illicit drugs mentioned in the preceding paragraph, if respondents reported lifetime use (for marijuana through methamphetamine) or misuse (for prescription pain relievers, tranquilizers, stimulants, or sedatives). See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Substance Use Treatment.”

Perceived Need for Substance Use Treatment

Respondents were classified as perceiving (or feeling) a need for substance use treatment if they reported in the drug treatment section of the questionnaire that they perceived a need for illicit drug use treatment or alcohol use treatment or if they reported that they felt a need for additional treatment. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Perceived Need for Alcohol Use Treatment” and “Perceived Need for Illicit Drug Use Treatment.”

Perceived Negative Effects on Mental Health Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “Since the beginning of the COVID-19 pandemic, how much, if at all, has COVID-19 negatively affected your emotional or mental health?” Respondents could indicate the impact of the COVID-19 pandemic on their mental health as not at all, a little, some, quite a bit, or a lot. This question on perceived negative effects on mental health was asked of all respondents, regardless of their mental health status.

SEE: “COVID-19.”

Perceived Recovery from Mental Health Issues

Respondents aged 18 or older were classified as perceiving themselves to be in recovery or to have recovered from mental health issues at the time of the interview if they (1) reported they ever had a problem with their mental health and (2) considered themselves to be in recovery or recovered from their problem. Questions for perceived recovery from mental health issues were in the emerging issues section.

Perceived Recovery from Substance Use Problems

Respondents aged 18 or older were classified as perceiving themselves to be in recovery or to have recovered from substance use problems at the time of the interview if they (1) reported they ever had a problem with their drug or alcohol use and (2) considered themselves to be in recovery or recovered from their problem. Questions for perceived recovery from substance use problems were in the emerging issues section.

Perceived Risk/Harmfulness

Respondents were asked in the risk and availability section of the questionnaire to report how much they thought people risk harming themselves physically and in other ways when they use various illicit drugs, alcohol, and cigarettes with various levels of frequency. Response options were (1) no risk, (2) slight risk, (3) moderate risk, and (4) great risk.

Perceived Unmet Need for Mental Health Services among Adults

Perceived unmet need for mental health services among adults was defined as a perceived need for mental health treatment or counseling in the past 12 months that was not received. Perceived unmet need for mental health services was defined based on responses to the following question in the adult mental health service utilization section of the questionnaire asked of all adults aged 18 or older: “During the past 12 months, was there any time when you needed mental health treatment or counseling for yourself but didn’t get it?” This measure of perceived unmet need for mental health services also could include adults who received some type of mental health services in the past 12 months. If adult NSDUH respondents perceived an unmet need for mental health services but also reported that they received mental health services in the past year, the timing of the unmet need cannot be determined from respondents’ answers. For some respondents, the unmet need could refer to a need they felt before they received services. For other respondents, the unmet need could refer to the need for additional services they did not receive. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Mental Health Service Use among Adults” and “Reasons for Not Receiving Mental Health Services among Adults.”

Percentages

Estimated percentages presented in NSDUH reports and tables are based on weighted data. Analysis weights are created so that estimates are representative of the target population. See Section 2.3.4 in the 2021 Methodological Summary and Definitions report for additional details about the development of analysis weights in NSDUH.

SEE: “Analysis Weight” and “Rounding.”

Physical Delinquent Behavior

SEE: “Delinquent Behavior.”

Pipe Tobacco Use

Measures of use of pipe tobacco in the respondent’s lifetime and the past month were derived from responses to the questions in the tobacco section of the questionnaire about lifetime pipe tobacco use and use in the past 30 days (i.e., “Have you ever smoked tobacco in a pipe, even once?” and “During the past 30 days, have you smoked tobacco in a pipe, even once?”). Questions about use of pipe tobacco were asked if respondents previously reported they smoked tobacco in a pipe in their lifetime.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” and “Recency of Use or Misuse.”

Poverty Level

Poverty level was defined by comparing a respondent’s total family income with the U.S. Census Bureau’s poverty thresholds (both measured in dollar amounts) in order to determine the poverty status of the respondent and the respondent’s family. Information on family income, size, and composition (e.g., number of children) was used to determine the respondent’s poverty level. The poverty level was calculated as a percentage of the poverty threshold by dividing a respondent’s reported total family income by the appropriate poverty threshold amount. Three categories for poverty level were defined relative to the poverty threshold: (1) less than 100 percent (i.e., total family income was less than the poverty threshold); (2) 100 to 199 percent (i.e., total family income was at or above the poverty threshold but less than twice the poverty threshold); and (3) 200 percent or more (i.e., total family income was twice the poverty threshold or greater). In addition, the measure for poverty level excluded respondents aged 18 to 22 who were living in a college dormitory.

SEE: “Family Income.”

Prescription Medication Use as a Mental Health Service among Adults

SEE: “Mental Health Service Use among Adults.”

Prescription Psychotherapeutic Drugs

SEE: “Psychotherapeutic Drugs.”

Prescription Psychotherapeutic Drug Use Disorder

Respondents were classified as having a prescription psychotherapeutic drug use disorder if they met criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁵⁰). Two measures of prescription psychotherapeutic drug use disorder were created for 2021: (1) prescription psychotherapeutic drug use disorder due to any use of prescription psychotherapeutic drugs and (2) prescription psychotherapeutic drug use disorder due to the misuse of prescription psychotherapeutic drugs.

Disorder Due to Any Use

Prescription psychotherapeutic drug use disorder due to any use was defined as having any of the following substance use disorders in the past year: pain reliever use disorder, tranquilizer use disorder, stimulant use disorder, or sedative use disorder. Respondents who reported any use of prescription psychotherapeutic drugs in the past year and met DSM-5 substance use disorder criteria for any of these four categories of prescription psychotherapeutic drugs were classified as having a prescription psychotherapeutic drug use disorder.

Disorder Due to Misuse

Prescription psychotherapeutic drug use disorder due to misuse was defined as having any of the following substance use disorders in the past year because of the misuse of prescription psychotherapeutic drugs: pain reliever use disorder, tranquilizer use disorder, stimulant use disorder, or sedative use disorder. Respondents who reported the misuse of prescription psychotherapeutic drugs in the past year and met corresponding DSM-5 criteria for any of these prescription psychotherapeutic drugs were classified as having a prescription psychotherapeutic drug use disorder due to misuse.

Respondents were not counted as having a prescription psychotherapeutic drug use disorder if they did not meet the full substance use disorder criteria for any of these prescription psychotherapeutic drug categories individually. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Pain Reliever Use Disorder,” “Pain Reliever Use or Misuse,” “Sedative Use Disorder,” “Sedative Use or Misuse,” “Stimulant Use Disorder,” “Stimulant Use or Misuse,” “Tranquilizer or Sedative Use Disorder,” “Tranquilizer or Sedative Use or Misuse,” “Tranquilizer Use Disorder,” and “Tranquilizer Use or Misuse.”

Probation/Parole

Respondents were asked in the special topics section of the questionnaire if they were on probation at any time during the past 12 months or if they were on parole, supervised release, or other conditional release from prison at any time during the past 12 months. Respondents could indicate being on both probation and parole during the past 12 months; therefore, these questions are not mutually exclusive.

Psychotherapeutic Drugs

Psychotherapeutic drugs are prescription medications with legitimate medical uses as pain relievers, tranquilizers, stimulants, and sedatives. The respondent is asked to report any use and misuse of these drugs in the respective prescription drug questionnaire sections. Misuse is defined as use in any way a doctor did not direct a respondent to use the drugs, including (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug. Although methamphetamine remains available in prescription form and is occasionally prescribed, NSDUH does not explicitly include methamphetamine as a prescription stimulant.⁵¹

SEE: “Any Use of Prescription Psychotherapeutics,” “Benzodiazepine Use or Misuse,” “Lifetime Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Pain Reliever Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” “Source of Prescription Psychotherapeutic Drugs,” “Stimulant Use or Misuse,” “Tranquilizer or Sedative Use or Misuse,” and “Tranquilizer Use or Misuse.”

Quarter

Quarter is defined as one of the contiguous 3-month periods of the calendar year. Data for NSDUH are typically collected across four quarters of the year: (1) Quarter 1 from January through March, (2) Quarter 2 from April through June, (3) Quarter 3 from July through September, and (4) Quarter 4 from November through December.

Race/Ethnicity

Race/ethnicity was used to refer to the respondent’s self-classification of racial and ethnic origin and identification, in accordance with federal standards for reporting race and ethnicity data.⁵² For Hispanic origin, respondents were asked in the core demographics section at the beginning of the interview, “Are you of Hispanic, Latino, or Spanish origin or descent?” For race, respondents were asked in the core demographics section, “Which of these groups describes you?” Response options for race were (1) White, (2) Black or African American, (3) American Indian or Alaska Native, (4) Native Hawaiian, (5) Guamanian or Chamorro, (6) Samoan, (7) Other Pacific Islander, (8) Asian, and (9) Other.

Respondents were allowed to choose more than one of these groups. Categories for a combined race/ethnicity variable included Hispanic (regardless of race); non-Hispanic groups where respondents indicated only one race (White; Black or African American; American Indian or Alaska Native; Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific Islander; Asian); and non Hispanic groups where respondents reported two or more races. However, respondents choosing more than one category from among Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific Islander but no other categories were classified as being in the “Native Hawaiian or Other Pacific Islander” category instead of the “two or more races” category. These categories were based on classifications developed by the U.S. Census Bureau.

SEE: “American Indian or Alaska Native (AIAN),” “Asian,” “Black,” “Hispanic or Latino,” “Native Hawaiian or Other Pacific Islander (NHOPI),” “Two or More Races,” and “White.”

Reasons for Misusing Prescription Psychotherapeutics

Respondents who reported misuse of prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, and sedatives) in the past year were asked in the respective questionnaire sections to report the last drug they misused in the past year and the reasons why they misused it. Response options varied by psychotherapeutic category. Response options for the misuse of pain relievers were (1) to relieve physical pain, (2) to relax or relieve tension, (3) to experiment or to see what the drug is like, (4) to feel good or get high, (5) to help with sleep, (6) to help with feelings or emotions, (7) to increase or decrease the effect(s) of some other drug, (8) because the respondent is “hooked” or has to have the drug(s), or (9) for some other reason. The same response options were presented for tranquilizer misuse and sedative misuse, except that “to relieve physical pain” was not presented as an option; the first response option for both of these psychotherapeutic categories was “to relax or relieve tension.” Response options for the misuse of stimulants were (1) to help lose weight, (2) to help concentrate, (3) to help be alert or stay awake, (4) to help study, (5) to experiment or to see what the drug(s) is (or are) like, (6) to feel good or get high, (7) to increase or decrease the effect(s) of some other drug, (8) because the respondent is “hooked” or has to have the drug(s), or (9) for some other reason.

For each of the four psychotherapeutic drug categories, respondents could report more than one reason for their last misuse. Respondents who reported more than one reason were asked to report the main reason for their last misuse. If respondents reported only one reason for their last misuse, they were not asked to report their main reason; this reason was considered to be their main one.

SEE: “Pain Reliever Use or Misuse,” “Sedative Use or Misuse,” “Stimulant Use or Misuse,” and “Tranquilizer Use or Misuse.”

Reasons for Not Receiving Mental Health Services among Adults

Respondents aged 18 or older who reported in the adult mental health utilization section of the questionnaire that there was a time in the past year when they needed mental health treatment or counseling but did not get it were asked up to two questions to report why they did not get the treatment or counseling they thought they needed. Reasons in the first question were (1) could not afford the cost; (2) concerned that getting mental health treatment or counseling might cause their neighbors or community to have a negative opinion of them; (3) concerned that getting mental health treatment or counseling might have a negative effect on their jobs; (4) health insurance does not cover any mental health treatment or counseling; (5) health insurance does not pay enough for mental health treatment or counseling; (6) did not know where to go to get services; (7) concerned that the information they gave the counselor might not be kept confidential; (8) concerned that they might be committed to a psychiatric hospital or might have to take medicine; or (9) some other reason. Respondents who reported some other reason in the first question were asked a follow-up question listing additional reasons. Reasons in the second question included (1) did not think they needed treatment at the time; (2) thought they could handle the problem without treatment; (3) did not think treatment would help; (4) did not have time (because of job, childcare, or other commitments); (5) did not want others to find out that they needed treatment; (6) had no transportation, or treatment was too far away, or the hours were not convenient; or (7) some other reason. Respondents who reported “some other reason” in this second question were asked to type in a response indicating the most important other reason. Estimates for commonly reported reasons for not receiving mental health services are included in the 2021 Detailed Tables. Respondents could report more than one reason in either question.

SEE: “Mental Health Service Use among Adults” and “Perceived Unmet Need for Mental Health Services among Adults.”

Reasons for Receiving Mental Health Services among Youths

Youths aged 12 to 17 who received treatment or counseling for emotional or behavioral problems (not caused by drug or alcohol use) in different mental health service settings in the past year were asked in the youth mental health utilization section of the questionnaire to report their reasons for receiving the services in these settings. For each relevant setting, respondents were asked up to two questions to report why they received services in that setting. Reasons in the first question included (1) thought about killing self or tried to kill self, (2) felt depressed, (3) felt very afraid and tense, (4) was breaking rules and “acting out,” (5) had eating problems, or (6) some other reason. Respondents who reported some other reason in the first question were asked a follow-up question listing additional reasons. Reasons in the second question included (1) trouble controlling anger, (2) getting into physical fights, (3) problems at home or in family, (4) problems with friends, (5) problems with people other than family or friends, (6) problems at school, or (7) some other reason. Respondents who reported “some other reason” in the second question were asked to type in a response indicating the most important other reason. Estimates for commonly reported other reasons are included in the 2021 Detailed Tables. Respondents could report more than one reason in either question. Respondents were not asked to report reasons for receiving services in the following settings: a school for students with emotional or behavioral problems, a school program for students with emotional or behavioral problems, the juvenile justice setting, or virtual (telehealth) services.

SEE: “Mental Health Service Settings for Youths.”

Receipt of Treatment for Specific Substances

These measures are based on reports in the drug treatment section of the questionnaire for treatment for respondents’ use of alcohol or specific illicit drugs in the past 12 months. Questions were asked of respondents who were receiving treatment or counseling at the time of the interview or who received treatment in the past 12 months for their alcohol or illicit drug use. Respondents were asked to report the specific substances for which they received treatment in the past 12 months.

Depending on which question respondents received, they could report treatment for more than one substance. The specific substances included in these questions were alcohol, marijuana, cocaine or crack, heroin, hallucinogens, inhalants, methamphetamine, prescription pain relievers, prescription tranquilizers, prescription stimulants, prescription sedatives, and some other drug; however, respondents were not asked about a specific substance if they had not used it in their lifetime.⁵³ However, respondents who used prescription drugs for any reason in their lifetime but did not misuse prescription drugs were not asked about treatment for their misuse of prescription drugs.

SEE: “Alcohol Use,” “Illicit Drugs,” “Misuse of Prescription Psychotherapeutics,” and “Substance Use Treatment.”

Received Treatment for Alcohol Use

SEE: “Substance Use Treatment.”

Received Treatment for Illicit Drug Use

SEE: “Substance Use Treatment.”

Received Virtual (Telehealth) Substance Use Treatment

Respondents were classified as having received virtual (telehealth) treatment for their use of alcohol or illicit drugs if they reported in the substance use treatment section of the questionnaire that they received substance use treatment in the past 12 months and they reported receiving virtual (telehealth) treatment in the past 12 months for their use of alcohol or illicit drugs. Respondents were asked “During the past 12 months, have you received any professional counseling, medication or treatment for your alcohol or drug use over the phone, by email, or through video calling?” Respondents who reported receiving substance use treatment in any location for their use of both alcohol and drugs and reported receiving virtual (telehealth) substance use treatment services were asked if the service was for alcohol use only, illicit drug use only, or both alcohol and illicit drug use.

Questions for the receipt of virtual (telehealth) services were not associated with a specific provider, location, or facility type. Therefore, receipt of these services was not grouped into the NSDUH measure for substance use treatment at a specialty facility.

SEE: “Location of Substance Use Treatment.”

Recency of Use or Misuse

Respondents who previously reported any use of tobacco, alcohol, or illicit drugs other than prescription psychotherapeutic drugs in their lifetime in the respective questionnaire sections were asked about their most recent use of that substance. This information was the source for the lifetime, past year, and past month estimates of substance use or misuse. The questions “Have you ever, even once, used [substance name]?” and “How long has it been since you last used [substance name]?” were essentially the same for all substances other than tobacco products and prescription psychotherapeutic drugs.

For tobacco products (cigarettes, smokeless tobacco, cigars, or pipe tobacco), a question first was asked about use in the past 30 days if respondents indicated ever using that tobacco product in their lifetime. Lifetime users of pipe tobacco were asked only about their use in the past 30 days. For tobacco products other than pipe tobacco, if the respondents did not use the product in the past 30 days, the recency question was asked as above, with the response options (1) more than 30 days ago but within the past 12 months, (2) more than 12 months ago but within the past 3 years, and (3) more than 3 years ago. For the remaining substances, the response options were (1) within the past 30 days, (2) more than 30 days ago but within the past 12 months, and (3) more than 12 months ago.

For prescription psychotherapeutic drugs, respondents were not asked a single question about their most recent use or misuse. Most recent use of psychotherapeutic drugs for any reason was determined first from respondents’ reports of any use of specific psychotherapeutic drugs within a category (e.g., prescription pain relievers) in the past 12 months. Any use more than 12 months ago was established from follow-up questions about lifetime use that were asked if respondents did not report use in the past 12 months of any specific prescription psychotherapeutic drug within a category. Similarly, most recent misuse of psychotherapeutic drugs (i.e., use in any way not directed by a doctor) was determined first from respondents’ reports of misuse in the past 12 months of specific psychotherapeutic drugs within a category respondents reported using in that period. If respondents reported misuse of any psychotherapeutic drug in the past 12 months, misuse within the past 30 days was determined in one of two ways: (1) if respondents initiated misuse of a specific drug in the past 30 days or (2) otherwise, from a follow-up question about misuse of any drug in that category in the past 30 days. Misuse of prescription psychotherapeutic drugs more than 12 months ago was established from follow-up questions about lifetime use asked if respondents reported (1) any use of specific prescription psychotherapeutics in the past 12 months, but they did not report misuse in the past 12 months; or (2) any use of prescription psychotherapeutic drugs in an overall category in their lifetime but not in the past 12 months.

SEE: “Any Use of Prescription Psychotherapeutics,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Misuse of Prescription Psychotherapeutics,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Tobacco Product Use.”

Region

Four regions, Northeast, Midwest, South, and West, are based on classifications developed by the U.S. Census Bureau.

SEE: “Geographic Division,” “Midwest Region,” “Northeast Region,” “South Region,” and “West Region.”

Religious Service Attendance

Respondents were asked about the number of times they attended religious services in the past year. Respondents were asked not to include special occasions, such as weddings, funerals, or other special events. Response categories included (1) 0 times, (2) 1 to 2 times, (3) 3 to 5 times, (4) 6 to 24 times, (5) 25 to 52 times, or (6) more than 52 times. Although these questions were asked of adults aged 18 or older in the social environment section of the questionnaire and of youths aged 12 to 17 in the youth experiences section, only data for youths are presented in the 2021 Detailed Tables.

Rounding

The decision rules for the rounding of percentages are as follows:

1. If the second number to the right of the decimal point is greater than or equal to 5, the first number to the right of the decimal point is rounded up to the next higher number.
2. If the second number to the right of the decimal point is less than 5, the first number to the right of the decimal point remains the same.

Thus, an estimate of 16.55 percent will have been rounded to 16.6 percent, while an estimate of 16.44 percent will have been rounded to 16.4 percent. Although the percentages in the tables generally total 100 percent, the use of rounding sometimes produces a total of slightly less than or more than 100 percent. Rounding of estimates also needs to be taken into account when interpreting the results of tests for statistical significance because testing is done using unrounded estimates. Therefore, estimates rounded to the same value may not show the same results for statistical testing.

SEE: “Percentages” and “Statistical Significance.”

Salvia divinorum Use

Measures of the use of Salvia divinorum in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the hallucinogen section of the questionnaire about lifetime and recency of use (i.e., “Have you ever, even once, used Salvia divinorum?” and “How long has it been since you last used Salvia divinorum?”).

SEE: “Current Use or Misuse,” “Hallucinogen Use,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Sedative Use Disorder

Sedative use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁵⁴). Respondents who reported any use of prescription sedatives in the past 12 months were asked questions about the following criteria for sedative use disorder: (1) used sedatives in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on sedative use; (3) spent a great deal of time in activities to obtain, use, or recover from sedative use; (4) felt a craving or strong desire to use sedatives; (5) engaged in recurrent sedative use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use sedatives despite social or interpersonal problems caused by the effects of sedatives; (7) gave up or reduced important social, occupational, or recreational activities because of sedative use; (8) continued to use sedatives in physically hazardous situations; (9) continued to use sedatives despite physical or psychological problems caused by sedative use; (10) increased the amount of sedatives needed to achieve same effect or noticed that the same amount of sedative use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping sedative use or (11b) used prescription sedatives or a related substance to get over or avoid sedative withdrawal symptoms.

The number of criteria for classifying respondents who reported any use of prescription sedatives in the past 12 months differed according to whether respondents misused sedatives, or they used sedatives but did not misuse them in that period.

Disorder Due to Misuse

Respondents who misused prescription sedatives in the past 12 months were classified as having a sedative use disorder if they had 2 or more of the 11 criteria mentioned previously.

Disorder Due to Use but Not Misuse

Respondents who used prescription sedatives in the past 12 months but did not misuse them were classified as having a sedative use disorder if they met two or more of the first nine criteria mentioned previously. Criteria 10 and 11 do not apply to people who did not misuse prescription sedatives because these criteria can occur as normal physiological adaptations when people use sedatives appropriately under medical supervision.⁵⁵

See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report.

SEE: “Sedative Use or Misuse” and “Tranquilizer or Sedative Use Disorder.”

Sedative Use or Misuse

Measures of use or misuse of prescription sedatives in the respondent’s lifetime and past year were derived from a series of questions in the screener and main sections of the questionnaire for sedatives that first asked respondents about any use (i.e., for any reason) of specific prescription sedatives in the past 12 months. Respondents were informed that these drugs are also called “downers” or “sleeping pills.” Respondents also were informed that people sometimes take these drugs to help them relax or help them sleep. Respondents were instructed not to include the use of over-the-counter (OTC) sedatives, such as Sominex^®, Unisom^®, Benadryl^®, or Nytol^®. Respondents who did not report use of any sedative in the past 12 months were asked whether they ever, even once, used prescription sedatives.

Respondents who reported they used specific prescription sedatives in the past 12 months for any reason were shown a list reminding them of the drugs they used in the past 12 months. For each of these drugs, respondents were asked whether they misused it (or them) in the past 12 months (i.e., use in any way a doctor did not direct them to use it). Examples of misuse were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug. Respondents were reminded not to include OTC drugs when they were asked if they misused any other prescription sedative in the past 12 months. If respondents reported misuse of one or more specific prescription sedatives in the past 12 months, they were asked whether they misused prescription sedatives in the past 30 days. Respondents who reported any use of prescription sedatives in the past 12 months but did not report misuse in the past 12 months or who reported any use in their lifetime but not in the past 12 months were asked whether they ever, even once, misused any prescription sedative. Consequently, lifetime or past month estimates of the misuse of prescription sedatives are available only for the overall prescription sedative category and not for specific sedatives.

Questions about past year use and misuse in the 2021 NSDUH covered the following subcategories of sedatives: zolpidem products (Ambien^®, Ambien^® CR, generic zolpidem, or generic extended-release zolpidem); eszopiclone products (Lunesta^® or generic eszopiclone); zaleplon products (Sonata^® or generic zaleplon); benzodiazepine sedatives (flurazepam [also known as Dalmane^®], temazepam products [Restoril^®, or generic temazepam], or triazolam products [Halcion^® or generic triazolam]); barbiturates (Butisol^®, Seconal^®, or phenobarbital); or any other prescription sedative. Other prescription sedatives could include products similar to the specific sedatives listed previously. Questions were not asked about past month sedative use or misuse for the subtype categories.

SEE: “Benzodiazepine Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Source of Prescription Psychotherapeutic Drugs,” and “Tranquilizer or Sedative Use or Misuse.”

Self-Help Group

Respondents who reported in the drug treatment section of the questionnaire that they received treatment for their use of alcohol or drugs in the past 12 months were asked whether they received treatment in a self-help group, such as Alcoholics Anonymous or Narcotics Anonymous. Treatment received in self-help groups was not considered substance use treatment at a specialty facility. Respondents also were asked in a different question whether they attended self-help groups in the past 12 months to receive help for their alcohol or drug use, regardless of whether they previously reported receiving any treatment in the past 12 months.

SEE: “Specialty Facility for Substance Use Treatment” and “Substance Use Treatment.”

Serious Financial Worries Because of the COVID-19 Pandemic

Respondents aged 12 or older were asked in the COVID-19 section of the questionnaire, “How often have you had serious financial worries because of the COVID-19 pandemic?” Response options were (1) all the time, (2) nearly all the time, (3) some of the time, (4) rarely, and (5) never.

SEE: “COVID-19.”

Serious Mental Illness (SMI)

SEE: “Mental Illness.”

Serious Psychological Distress (SPD)

Serious psychological distress (SPD) for adults is defined as having a score of 13 or higher on the Kessler-6 (K6) scale. This scale consists of six questions that gather information on how frequently adult respondents experienced symptoms of psychological distress during the past month or the 1 month in the past year when they were at their worst emotionally. These questions in the mental health section of the questionnaire ask about the frequency of feeling (1) nervous, (2) hopeless, (3) restless or fidgety, (4) sad or depressed, (5) that everything was an effort, and (6) no good or worthless.⁵⁶ Respondents were asked the K6 questions for the past 30 days and (if applicable) the 1 month in the past year when adult respondents were at their worst emotionally. Past month and past year SPD estimates are presented in the 2021 Detailed Tables.

The maximum score of the two periods (i.e., past month and past year) was used to create the total past year score. See Section 3.4.6 of the 2021 Methodological Summary and Definitions report for more information.

SEE: “Kessler-6 (K6) Scale” and “Mental Illness.”

Sheehan Disability Scale (SDS)

The Sheehan Disability Scale (SDS)⁵⁷ consists of a series of four questions used in NSDUH to measure interference or problems in a person’s daily functioning caused by major depressive episode. The SDS role domains are assessed on a 0 to 10 visual analog scale with impairment categories of “none” (0), “mild” (1-3), “moderate” (4-6), “severe” (7-9), and “very severe” (10). For adults aged 18 or older, the SDS role domains are (1) home management, (2) work, (3) close relationships with others, and (4) social life. For youths aged 12 to 17, the SDS role domains are (1) chores at home, (2) school or work, (3) close relationships with family, and (4) social life. Because the SDS asks about different role domains for adults in the adult depression section of the questionnaire and for youths in the adolescent depression section, the adult and youth SDS data should not be combined or compared.

SEE: “Severe Impairment Due to Major Depressive Episode” and “World Health Organization Disability Assessment Schedule (WHODAS).”

Small Metro

SEE: “County Type.”

Smokeless Tobacco Use

Measures of the use of smokeless tobacco in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the tobacco section of the questionnaire about lifetime smokeless tobacco use, use in the past 30 days, and recency of use (if not in the past 30 days) (e.g., “Have you ever used ‘smokeless’ tobacco, even once?” “During the past 30 days, have you used ‘smokeless’ tobacco, even once?” and “How long has it been since you last used ‘smokeless’ tobacco?”). Questions about use of smokeless tobacco in the past 30 days or the most recent use of smokeless tobacco (if not in the past 30 days) were asked if respondents previously reported any use of smokeless tobacco in their lifetime.

The following information preceded the question about lifetime use of smokeless tobacco: “The next questions are about your use of ‘smokeless’ tobacco such as snuff, dip, chewing tobacco, or ‘snus.’”

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Social Context of Most Recent Underage Alcohol Use

Respondents aged 12 to 20 who reported drinking at least one alcoholic beverage within the past 30 days were asked in the consumption of alcohol section of the questionnaire if they were alone, with one other person, or with more than one person the last time they drank.

SEE: “Alcohol Use” and “Underage Alcohol Use.”

Source of Alcohol for Most Recent Underage Alcohol Use

Respondents aged 12 to 20 who reported drinking at least one alcoholic beverage within the past 30 days were asked questions in the consumption of alcohol section of the questionnaire pertaining to the source of the alcohol for their most recent alcohol use. The sources were (1) respondent purchased it, (2) someone else purchased it, (3) received it from a parent or guardian, (4) received it from another family member aged 21 or older, (5) received it from an unrelated person aged 21 or older, (6) received it from someone under age 21, (7) took it from own home, (8) took it from someone else’s home, or (9) got it some other way. Respondents who reported “some other way” were asked to type in a response indicating the specific source. Estimates for commonly reported other sources are included in the 2021 Detailed Tables. Respondents could report more than one source.

The questions on the source of last alcohol use were presented in two categories: (1) respondents paid (they purchased the alcohol or gave someone else money to purchase the alcohol), and (2) respondents did not pay (they received the alcohol for free from someone or took the alcohol from their own or someone else’s home).

SEE: “Alcohol Use” and “Underage Alcohol Use.”

Source of Payment for Mental Health Services among Adults

Respondents aged 18 or older who reported receiving mental health services in the past year as an inpatient or an outpatient were asked in the adult mental health service utilization section of the questionnaire who paid or will pay for the mental health services they received in that period. Response options for the source of payment were as follows: (1) self or a family member living in household, (2) a family member not living in the household, (3) private health insurance, (4) Medicare, (5) Medicaid, (6) a rehabilitation program, (7) employer, (8) VA or other military program, (9) other public source, (10) other private source, or (11) no payment because treatment was free. Respondents could report more than one source of payment. Respondents who reported taking prescription medicine in the past 12 months that was prescribed for a mental or emotional condition were not asked to report the source of payment for the prescription medication. Although these questions were asked of both adults who received mental health services as an inpatient and those who received mental health services as an outpatient, only data for the source of payment among adults who received services as an outpatient were presented in the 2021 Detailed Tables.

SEE: “Location of Outpatient Mental Health Services among Adults” and “Mental Health Service Use among Adults.”

Source of Prescription Psychotherapeutic Drugs

Respondents who reported misuse of prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, and sedatives) in the past year were asked in the respective questionnaire sections how they obtained the last drug they misused in a given category. Response options for the source of the medications were as follows: (1) got a prescription from just one doctor; (2) got prescriptions from more than one doctor; (3) stole from a doctor’s office, clinic, hospital, or pharmacy; (4) got from a friend or relative for free; (5) bought from a friend or relative; (6) took from a friend or relative without asking; (7) bought from a drug dealer or other stranger; and (8) got in some other way (includes other sources specified by respondents). Respondents who reported they obtained these drugs from a friend or relative for free were asked how the friend or relative obtained them, using the same response options 1 through 8 as the respondents’ source questions.

Respondents who reported misuse of psychotherapeutic drugs in the past 12 months were asked to report the last psychotherapeutic drug they misused in a given category and were asked the following question: “Now think again about the last time you used [fill in the name of the last prescription pain reliever, prescription tranquilizer, prescription stimulant, or prescription sedative that was misused] in any way a doctor did not direct you to use [it/them]. How did you get the [fill in the relevant drug name]? If you got the [fill in the relevant drug name] in more than one way, please choose one of these ways as your best answer.”

SEE: “Pain Reliever Use or Misuse,” “Sedative Use or Misuse,” “Stimulant Use or Misuse,” and “Tranquilizer Use or Misuse.”

South Region

The states included are those in the South Atlantic Division (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia); the East South Central Division (Alabama, Kentucky, Mississippi, and Tennessee); and the West South Central Division (Arkansas, Louisiana, Oklahoma, and Texas).

SEE: “Geographic Division” and “Region.”

Specialty Facility for Substance Use Treatment

A specialty facility for substance use treatment was defined as a drug or alcohol rehabilitation facility (inpatient or outpatient), a hospital (inpatient only), or a mental health center. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details. Questions for the receipt of virtual (telehealth) services were not associated with a specific provider, location, or facility type. Therefore, receipt of virtual substance use treatment services was not included in the NSDUH measure for substance use treatment at a specialty facility.

SEE: “Classified as Needing Substance Use Treatment,” “Self-Help Group,” and “Substance Use Treatment.”

Specialty Mental Health Service Settings for Youths

SEE: “Mental Health Service Settings for Youths.”

Statistical Significance

Statistical comparisons between members of demographic subgroups were presented in NSDUH reports and tables for 2021. When reports compare estimates between demographic subgroups (e.g., by age group), a significance level of .05 generally is used to determine whether these estimates are statistically different. If differences do not meet the criteria for statistical significance, the values of these estimates are not considered to be different from one another. Low precision estimates are not included in statistical tests. Also, testing can indicate significant differences involving seemingly identical percentages that have been rounded to the nearest tenth of a percent. See Section 3.2.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Low Precision” and “Rounding.”

Stimulant Use Disorder

Stimulant use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁵⁸). Respondents who reported any use of prescription stimulants in the past 12 months were asked questions about the following criteria for stimulant use disorder: (1) used stimulants in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on stimulant use; (3) spent a great deal of time in activities to obtain, use, or recover from stimulant use; (4) felt a craving or strong desire to use stimulants; (5) engaged in recurrent stimulant use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use stimulants despite social or interpersonal problems caused by the effects of stimulants; (7) gave up or reduced important social, occupational, or recreational activities because of stimulant use; (8) continued to use stimulants in physically hazardous situations; (9) continued to use stimulants despite physical or psychological problems caused by stimulant use; (10) increased the amount of stimulants needed to achieve same effect or noticed that the same amount of stimulant use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping stimulant use or (11b) used prescription stimulants or a related substance to get over or avoid stimulant withdrawal symptoms.

The number of criteria for classifying respondents who reported any use of prescription stimulants in the past 12 months differed according to whether respondents misused stimulants, or they used stimulants but did not misuse them in that period.

Disorder Due to Misuse

Respondents who misused prescription stimulants in the past 12 months were classified as having a stimulant use disorder if they had 2 or more of the 11 criteria mentioned previously.

Disorder Due to Use but Not Misuse

Respondents who used prescription stimulants in the past 12 months but did not misuse them were classified as having a stimulant use disorder if they met two or more of the first nine criteria mentioned previously. Criteria 10 and 11 do not apply to people who did not misuse prescription stimulants because these criteria can occur as normal physiological adaptations when people use stimulants appropriately under medical supervision.⁵⁹

Methamphetamine use disorder was asked about separately from prescription stimulant use disorder. Therefore, responses to methamphetamine use disorder questions were not considered in determining whether a respondent had a stimulant use disorder. See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report.

SEE: “Stimulant Use or Misuse.”

Stimulant Use or Misuse

Measures of use or misuse of prescription stimulants in the respondent’s lifetime and past year were derived from a series of questions in the screener and main sections of the questionnaire for stimulants that first asked respondents about any use (i.e., for any reason) of specific prescription stimulants in the past 12 months. Respondents were informed that people sometimes take stimulants for attention deficit disorder, to lose weight, or to stay awake. Respondents were instructed not to include the use of over-the-counter (OTC) stimulants, such as Dexatrim^®, No-Doz^®, Hydroxycut^®, or 5-Hour Energy^®. Respondents who did not report use of any prescription stimulant in the past 12 months were asked whether they ever, even once, used prescription stimulants.

Respondents who reported they used specific prescription stimulants in the past 12 months for any reason were shown a list reminding them of the drugs they used in the past 12 months. For each of these drugs, respondents were asked whether they misused it (or them) in the past 12 months (i.e., use in any way a doctor did not direct them to use it). Examples of misuse were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug. Respondents were reminded not to include OTC drugs when they were asked if they misused any other prescription stimulant in the past 12 months. If respondents reported misuse of one or more specific prescription stimulants in the past 12 months, they were asked whether they misused prescription stimulants in the past 30 days. Respondents who reported any use of prescription stimulants in the past 12 months but did not report misuse in the past 12 months or who reported any use in their lifetime but not in the past 12 months were asked whether they ever, even once, misused any prescription stimulant. Consequently, lifetime or past month estimates of the misuse of prescription stimulants are available only for the overall prescription stimulant category and not for specific stimulants.

Questions about past year use and misuse in the 2021 NSDUH covered the following subcategories of stimulants: amphetamines (Adderall^®, Adderall^® XR, Dexedrine^®, Vyvanse^®, generic dextroamphetamine, generic amphetamine-dextroamphetamine combinations, or generic extended-release amphetamine-dextroamphetamine combinations); methylphenidate products (Ritalin^®, Ritalin^® LA, Concerta^®, Daytrana^®, Metadate^® CD, Metadate^® ER, Focalin^®, Focalin^® XR, generic methylphenidate, generic extended-release methylphenidate, generic dexmethylphenidate, or generic extended-release dexmethylphenidate); anorectic (weight-loss) stimulants (Didrex^®, benzphetamine, Tenuate^®, diethylpropion, phendimetrazine, or phentermine); Provigil^®; or any other prescription stimulant. Other prescription stimulants could include products similar to the specific stimulants listed previously. Methamphetamine was not included as a prescription stimulant, unless respondents specified the prescription form of methamphetamine (Desoxyn^®) as another prescription stimulant they misused. Questions were not asked about past month stimulant use or misuse for the subtype categories.

SEE: “Lifetime Use or Misuse,” “Methamphetamine Use,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Source of Prescription Psychotherapeutic Drugs.”

Substance Use Disorder (SUD)

Substance use disorder (SUD) was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁶⁰), for one or more drugs or alcohol. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use Disorder (AUD),” “Cocaine Use Disorder,” “Hallucinogen Use Disorder,” “Heroin Use Disorder,” “Illicit Drug Use Disorder (IDUD),” “Inhalant Use Disorder,” “Marijuana Use Disorder,” “Methamphetamine Use Disorder,” “Pain Reliever Use Disorder,” “Sedative Use Disorder,” “Stimulant Use Disorder,” “Tranquilizer or Sedative Use Disorder,” and “Tranquilizer Use Disorder.”

Substance Use Disorder Severity

The severity of a substance use disorder (SUD) is determined by the number of individual criteria based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁶¹) recorded as positive for a particular substance (or category of substances). The number of positive criteria required for each severity level is the same for every substance.

People were classified in the mild category if they met two or three SUD criteria for that substance, in the moderate category if they met four or five SUD criteria for that substance, or in the severe category if they met six or more SUD criteria for that substance. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use Disorder (AUD),” “Cocaine Use Disorder,” “Hallucinogen Use Disorder,” “Heroin Use Disorder,” “Drug Use Disorder,” “Inhalant Use Disorder,” “Marijuana Use Disorder,” “Methamphetamine Use Disorder,” “Pain Reliever Use Disorder,” “Sedative Use Disorder,” “Stimulant Use Disorder,” “Tranquilizer or Sedative Use Disorder,” and “Tranquilizer Use Disorder.”

Substance Use Treatment

Respondents were classified as having received substance use treatment if they reported in the drug treatment section of the questionnaire that they received treatment in the past 12 months for their use of alcohol or illicit drugs at any location, such as a hospital (inpatient), a rehabilitation facility (inpatient or outpatient), a mental health center, an emergency room, a private doctor’s office, a self-help group, prison/jail, virtual (telehealth) services, or some other place. Of these locations, drug or alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient only), and mental health centers are considered specialty facilities for substance use treatment. Thus, substance use treatment received at a specialty facility is included in estimates of substance use treatment received at any location.

Substance use treatment questions in 2021 were asked of respondents who used alcohol or illicit drugs in their lifetime. Respondents who used prescription drugs in their lifetime but who did not misuse them did not receive these questions unless they reported lifetime use of alcohol or other illicit drugs. See Section 3.4.4 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Alcohol Use,” “Illicit Drugs,” “Classified as Needing Substance Use Treatment,” “Location of Substance Use Treatment,” “Receipt of Treatment for Specific Substances,” “Received Virtual (Telehealth) Substance Use Treatment,” “Self-Help Group,” and “Specialty Facility for Substance Use Treatment.”

Suicidal Thoughts and Behaviors among Adults

Adults aged 18 or older were asked in the mental health section of the questionnaire whether they had seriously thought about killing themselves, made any plans to kill themselves, or tried to kill themselves at any time during the past 12 months. Adult respondents who attempted suicide in the past 12 months were asked whether they had received medical attention from a health professional, including whether they stayed overnight in a hospital in the past 12 months because of a suicide attempt. If adult respondents reported receiving medical attention, they were asked whether they stayed overnight or longer in a hospital for their suicide attempt.

Suicidal Thoughts and Behaviors among Youths

Youths aged 12 to 17 were asked in the youth mental health service utilization section of the questionnaire whether they had seriously thought about killing themselves, made any plans to kill themselves, or tried to kill themselves at any time during the past 12 months. Youths who reported that they made a suicide attempt were asked if they received medical attention or stayed overnight in the hospital because of their suicide attempt. All respondents aged 12 to 17 were asked if they made a suicide plan or attempted suicide regardless of whether they reported serious thoughts of suicide. The questions about suicidal thoughts and behavior among adolescents included response choices for “I’m not sure” and “I don’t want to answer,” in addition to respondents having other options for answering questions as “don’t know” or “refused.”

Suicidal Thoughts and Behaviors Because of COVID-19

Adult respondents aged 18 or older who reported in the mental health section of the questionnaire that they seriously thought about killing themselves were asked, “Was this because of the COVID-19 pandemic?” Adults who reported making suicide plans in the past 12 months and making suicide attempts in the past 12 months were asked the same follow-up question about each of the suicidal behaviors.

Similarly, youths aged 12 to 17 who reported in the youth mental health service utilization section of the questionnaire that they seriously thought about killing themselves were asked, “Was this because of the COVID-19 pandemic?” Youths who reported making suicide plans in the past 12 months and making suicide attempts in the past 12 months were asked the same follow-up question about each of these suicidal behaviors.

SEE: “Suicidal Thoughts and Behaviors among Adults” and “Suicidal Thoughts and Behaviors among Youths.”

Suppression of Estimates

Estimates presented in NSDUH reports and tables are run through a suppression rule that determines the suitability of the estimates for publication according to the standard errors of the estimates and the sample sizes on which the estimates are based. Estimates that do not meet the established precision criteria are suppressed (i.e., not published) in NSDUH reports and tables. Table 3.2 in Section 3.2.2 of the 2021 Methodological Summary and Definitions report includes a full description and complete list of the rules used to determine low precision.

SEE: “Low Precision.”

Synthetic Cannabinoids

SEE: “Synthetic Marijuana.”

Synthetic Cathinones

SEE: “Synthetic Stimulants.”

Synthetic Marijuana

Measures of the use of synthetic marijuana in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of use of synthetic marijuana (i.e., “Have you ever, even once, used synthetic marijuana or fake weed?” and “How long has it been since you last used synthetic marijuana or fake weed?”) The question about recency of use was asked if respondents previously reported using synthetic marijuana in their lifetime.

The following definitional information preceded the question about lifetime use of synthetic marijuana: “The next question is about synthetic marijuana or fake weed, also called K2 or Spice.”

Technically, these substances are called synthetic cannabinoids because they are human-made chemicals that are similar to chemicals found in the marijuana plant. For simplicity, however, NSDUH questions referred to these substances as “synthetic marijuana.” The terms fake weed, K2, and Spice were included to help respondents differentiate between marijuana (i.e., cannabis) and synthetic marijuana.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Synthetic Stimulants

Measures of the use of synthetic stimulants in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of use of synthetic stimulants (i.e., “Have you ever, even once, used these synthetic stimulants?” and “How long has it been since you last used these synthetic stimulants, also called “bath salts” or flakka?”). The question about recency of use was asked if respondents previously reported using synthetic stimulants in their lifetime.

The following definitional information preceded the question about lifetime use of synthetic stimulants: “The next question is about synthetic stimulants that people use to get high, also called ‘bath salts’ or flakka.”

Technically, these substances are called synthetic cathinones because they are human-made stimulants that are chemically related to cathinone, a substance found in the khat plant. For simplicity, NSDUH questions referred to these substances as “synthetic stimulants.” The terms bath salts and flakka were included to help respondents differentiate between other stimulants and these synthetic stimulants.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” and “Recency of Use or Misuse.”

Telehealth Services

SEE: “Mental Health Service Settings for Youths,” “Mental Health Service Use among Adults,” and “Received Virtual (Telehealth) Substance Use Treatment.”

Tobacco Product Use

This measure indicates use of any of the following tobacco products: cigarettes, smokeless tobacco, cigars, or pipe tobacco. Tobacco product use in the past year includes past month pipe tobacco use; however, it does not include use of pipe tobacco more than 30 days ago but within 12 months of the interview because the survey did not capture this information. Measures of tobacco product use in the respondent’s lifetime, the past year, or the past month also do not include reports from separate questions about use of cigars with marijuana in them (blunts). Tobacco product use does not include questions for the use of e-cigarettes or another vaping device to vape nicotine.

SEE: “Cigar Use,” “Cigarette Use,” “Current Use or Misuse,” “Lifetime Use or Misuse,” “Nicotine Vaping,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Pipe Tobacco Use,” “Recency of Use or Misuse,” “Smokeless Tobacco Use,” and “Tobacco Product Use or Nicotine Vaping.”

Tobacco Product Use or Nicotine Vaping

Respondents were classified as using tobacco products or vaping nicotine in the lifetime, past year, or past month periods if they reported using tobacco products (i.e., cigarettes, smokeless tobacco, cigars, or pipe tobacco), vaping nicotine, or both in these periods.⁶² See Section 3.4.10.2 in the 2021 Methodological Summary and Definitions report for additional details on nicotine vaping.

SEE: “Nicotine Vaping” and “Tobacco Product Use.”

Total Family Income

SEE: “Family Income.”

Tranquilizer or Sedative Use Disorder

Respondents were classified as having a tranquilizer or sedative use disorder if they met criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁶³). Two measures of tranquilizer or sedative use disorder were created for 2021: (1) tranquilizer or sedative use disorder due to any use of opioids and (2) tranquilizer or sedative use disorder due to the misuse of tranquilizers or sedatives.

Disorder Due to Any Use

Tranquilizer or sedative use disorder due to any use was defined as having a tranquilizer use disorder or a sedative use disorder. Respondents who reported any use of prescription tranquilizers or sedatives in the past year and met DSM-5 criteria for tranquilizer or sedative use disorder were classified as having a tranquilizer or sedative use disorder.

Disorder Due to Misuse

Tranquilizer or sedative use disorder due to misuse was defined as having a tranquilizer use disorder or a sedative use disorder among past year misusers of prescription tranquilizers or sedatives.

Respondents were not counted as having a tranquilizer or sedative use disorder if they did not meet the full substance use disorder criteria for prescription tranquilizers or sedatives individually. See Section 3.4.3 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Sedative Use Disorder,” “Sedative Use or Misuse,” “Tranquilizer Use Disorder,” and “Tranquilizer Use or Misuse.”

Tranquilizer or Sedative Use or Misuse

Respondents were classified as having past year or past month prescription tranquilizer or sedative use or misuse if they reported using or misusing prescription tranquilizers or prescription sedatives.

SEE: “Current Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Sedative Use or Misuse,” and “Tranquilizer Use or Misuse.”

Tranquilizer Use Disorder

Tranquilizer use disorder was defined as meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5⁶⁴). Respondents who reported any use of prescription tranquilizers in the past 12 months were asked questions about the following criteria for tranquilizer use disorder: (1) used tranquilizers in larger amounts or for a longer time period than intended; (2) had a persistent desire or made unsuccessful attempts to cut down on tranquilizer use; (3) spent a great deal of time in activities to obtain, use, or recover from tranquilizer use; (4) felt a craving or strong desire to use tranquilizers; (5) engaged in recurrent tranquilizer use resulting in failure to fulfill major role obligations at work, school, or home; (6) continued to use tranquilizers despite social or interpersonal problems caused by the effects of tranquilizers; (7) gave up or reduced important social, occupational, or recreational activities because of tranquilizer use; (8) continued to use tranquilizers in physically hazardous situations; (9) continued to use tranquilizers despite physical or psychological problems caused by tranquilizer use; (10) increased the amount of tranquilizers needed to achieve same effect or noticed that the same amount of tranquilizer use had less effect than before; and (11) either of the following: (11a) experienced a required number of withdrawal symptoms after cutting back or stopping tranquilizer use or (11b) used prescription tranquilizers or a related substance to get over or avoid tranquilizer withdrawal symptoms.

The number of criteria for classifying respondents who reported any use of prescription tranquilizers in the past 12 months differed according to whether respondents misused tranquilizers, or they used tranquilizers but did not misuse them in that period.

Disorder Due to Misuse

Respondents who misused prescription tranquilizers in the past 12 months were classified as having a tranquilizer use disorder if they had 2 or more of the 11 criteria mentioned previously.

Disorder Due to Use but Not Misuse

Respondents who used prescription tranquilizers in the past 12 months but did not misuse them were classified as having a tranquilizer use disorder if they met two or more of the first nine criteria mentioned previously. Criteria 10 and 11 do not apply to people who did not misuse prescription tranquilizers because these criteria can occur as normal physiological adaptations when people use tranquilizers appropriately under medical supervision.⁶⁵

See Section 3.4.3 and Table 3.6 in the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Tranquilizer or Sedative Use Disorder” and “Tranquilizer Use or Misuse.”

Tranquilizer Use or Misuse

Measures of use or misuse of prescription tranquilizers in the respondent’s lifetime and past year were derived from a series of questions in the screener and main sections of the questionnaire for tranquilizers that first asked respondents about any use (i.e., for any reason) of specific prescription tranquilizers in the past 12 months. Respondents were informed that tranquilizers are usually prescribed to relax people, to calm people down, to relieve anxiety, or to relax muscle spasms. Respondents also were informed that some people call tranquilizers “nerve pills.” Respondents who did not report use of any tranquilizer in the past 12 months were asked whether they ever, even once, used prescription tranquilizers.

Respondents who reported they used specific prescription tranquilizers in the past 12 months for any reason were shown a list reminding them of the drugs they used in the past 12 months. For each of these drugs, respondents were asked whether they misused it (or them) in the past 12 months (i.e., in any way a doctor did not direct them to use it). Examples of misuse were presented to respondents and included (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than told to take a drug; or (3) use in any other way a doctor did not direct the respondent to use a drug. If respondents reported misuse of one or more specific prescription tranquilizers in the past 12 months, they were asked whether they misused prescription tranquilizers in the past 30 days. Respondents who reported any use of prescription tranquilizers in the past 12 months but did not report misuse in the past 12 months or who reported any use in their lifetime but not in the past 12 months were asked whether they ever, even once, misused any prescription tranquilizer. Consequently, lifetime and past month estimates of the misuse of prescription tranquilizers are available only for the overall prescription tranquilizer category and not for specific tranquilizers.

Questions about past year use and misuse in the 2021 NSDUH covered the following subcategories of tranquilizers: benzodiazepine tranquilizers (including alprazolam products [Xanax^®, Xanax^® XR, generic alprazolam, or generic extended-release alprazolam], lorazepam products [Ativan^® or generic lorazepam], clonazepam products [Klonopin^® or generic clonazepam], or diazepam products [Valium^® or generic diazepam]); muscle relaxants (cyclobenzaprine [also known as Flexeril^®] or Soma^®); or any other prescription tranquilizer. Other prescription tranquilizers could include products similar to the specific tranquilizers listed previously. Questions were not asked about past month tranquilizer use or misuse for the subtype categories.

SEE: “Benzodiazepine Use or Misuse,” “Lifetime Use or Misuse,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Source of Prescription Psychotherapeutic Drugs,” and “Tranquilizer or Sedative Use or Misuse.”

Treatment for a Mental Disorder

SEE: “Mental Health Service Settings for Youths,” “Mental Health Service Use among Adults,” and “Treatment for Depression.”

Treatment for a Substance Use Problem

SEE: “Substance Use Treatment.”

Treatment for Depression

Treatment for depression was defined based on questions in the adult and youth depression sections of the questionnaire as seeing or talking to a professional or using prescription medication in the past year for depression.⁶⁶ Treatment professionals were subdivided into “Alternative Service Professional,” “Health Professional,” and “Other.”

SEE: “Alternative Service Professional,” “Health Professional,” and “Major Depressive Episode (MDE).”

Two or More Races

Respondents were asked to report in the core demographics section of the questionnaire which racial groups describe them. Response options were (1) White, (2) Black or African American, (3) American Indian or Alaska Native, (4) Native Hawaiian, (5) Guamanian or Chamorro, (6) Samoan, (7) Other Pacific Islander, (8) Asian, and (9) Other.

Respondents were allowed to choose more than one of these groups. Respondents who chose more than one category from among Native Hawaiian, Guamanian or Chamorro, Samoan, and Other Pacific Islander (and no additional categories) were classified in a single category: Native Hawaiian or Other Pacific Islander. Otherwise, respondents reporting two or more of the above groups and that they were not of Hispanic, Latino, or Spanish origin were included in a “Two or More Races” category. People reporting two or more races do not include respondents who reported more than one Asian subgroup but who reported “Asian” as their only race. Respondents reporting two or more races and reporting that they were of Hispanic, Latino, or Spanish origin were classified as Hispanic.

SEE: “Hispanic or Latino” and “Race/Ethnicity.”

Type of Mental Health Service Use among Adults

SEE: “Mental Health Service Use among Adults.”

Underage Alcohol Use

Underage alcohol use was defined as any use of alcohol by people aged 12 to 20 in the respondent’s lifetime, past year, or past month as reported in the alcohol section of the questionnaire.

SEE: “Alcohol Use,” “Binge Use of Alcohol,” “Current Use or Misuse,” “Heavy Use of Alcohol,” “Lifetime Use or Misuse,” “Location of Most Recent Underage Alcohol Use,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” “Social Context of Most Recent Underage Alcohol Use,” and “Source of Alcohol for Most Recent Underage Alcohol Use.”

Underage Tobacco Use or Nicotine Vaping

Underage tobacco use or nicotine vaping was defined as any use of tobacco products or nicotine vaping by people aged 12 to 20 in the respondent’s lifetime, past year, or past month as reported in the tobacco and emerging issues sections of the questionnaire.

SEE: “Current Use or Misuse,” “Lifetime Use or Misuse,” “Nicotine Vaping,” “Past Month Use or Misuse,” “Past Year Use or Misuse,” “Recency of Use or Misuse,” and “Tobacco Product Use.”

Unmet Need for Mental Health Services among Adults

SEE: “Perceived Unmet Need for Mental Health Services among Adults.”

Vaping of Flavoring

Measures of vaping of flavoring in the respondent’s lifetime, the past year, and the past month were derived from responses to the questions in the emerging issues section of the questionnaire about lifetime and recency of vaping of flavoring (i.e., “Have you ever, even once, vaped only flavoring without nicotine or other substances added?” and “How long has it been since you last vaped only flavoring?”). Respondents first were asked whether they ever vaped any substance with e cigarettes or another vaping device in their lifetime. Respondents who reported that they ever vaped any substance in their lifetime were asked whether they ever used e-cigarettes or another vaping device to vape only flavoring. The question about recency of vaping of flavoring was asked if respondents reported that they vaped flavoring in their lifetime. See Section 3.4.10.4 in the 2021 Methodological Summary and Definitions report for additional details.

In the question about vaping anything with an e-cigarette or other vaping device, respondents were informed that these devices might also be called vape pens, personal vaporizers, or mods. However, these alternate terms were not repeated in the questions for vaping of flavoring.

SEE: “Any Vaping.”

Virtual (Telehealth) Mental Health Service Settings for Youths

SEE: “Mental Health Service Settings for Youths.”

Virtual (Telehealth) Mental Health Service Use among Adults

SEE: “Mental Health Service Use among Adults.”

Virtual (Telehealth) Substance Use Treatment

SEE: “Received Virtual (Telehealth) Substance Use Treatment.”

West Region

The states included are those in the Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming) and the Pacific Division (Alaska, California, Hawaii, Oregon, and Washington).

SEE: “Geographic Division” and “Region.”

White

White only, not of Hispanic, Latino, or Spanish origin. This definition is based on reports in the core demographics section at the beginning of the interview in which respondents described themselves as being White. The definition does not include respondents reporting two or more races. Respondents reporting they were White and of Hispanic, Latino, or Spanish origin were classified as Hispanic.

SEE: “Hispanic or Latino,” “Race/Ethnicity,” and “Two or More Races.”

World Health Organization Disability Assessment Schedule (WHODAS)

The World Health Organization Disability Assessment Schedule (WHODAS) consists of a series of questions used for assessing disturbances in social adjustment and behavior (i.e., functional impairment). A reduced set of WHODAS items was used in NSDUH.⁶⁷ Adult respondents were asked in the mental health section of the questionnaire if they had difficulty doing any of the following eight activities during the 1 month when their emotions, nerves, or mental health interfered most with their daily activities: (1) remembering to do things they needed to do, (2) concentrating on doing something important when other things were going on around them, (3) going out of the house and getting around on their own, (4) dealing with people they did not know well, (5) participating in social activities, (6) taking care of household responsibilities, (7) taking care of daily responsibilities at work or school, and (8) getting daily work done as quickly as needed.

The eight imputation-revised items were assessed on a 0 to 3 scale ranging from “no difficulty” (coded as 0) to “severe difficulty” (coded as 3). Some items had an additional category for respondents who did not engage in a particular activity (e.g., they did not leave the house on their own). Respondents who reported they did not engage in an activity were asked a follow-up question to determine if they did not do so because of emotions, nerves, or mental health. Respondents with an imputation-revised value of “yes” to this follow-up question were subsequently assigned to the “severe difficulty” category; otherwise, respondents were assigned to the “no difficulty” category. Summing across the eight responses resulted in a total score with a range from 0 to 24. See Section 3.4.6 of the 2021 Methodological Summary and Definitions report for additional details.

SEE: “Mental Illness,” “Severe Impairment Due to Major Depressive Episode,” and “Sheehan Disability Scale (SDS).”