2023 National Survey on Drug Use and Health (NSDUH):
Methodological Summary and Definitions

1.1 Background on the 2023 NSDUH

Conducted by the federal government since 1971, the 2023 survey collected data with a representative sample of the population. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, and is planned and managed by SAMHSA’s Center for Behavioral Health Statistics and Quality (CBHSQ). Data collection and analysis are conducted under contract with RTI International.¹

NSDUH targets the collection of information from residents of households (e.g., individuals living in houses or townhouses, apartments, and condominiums; civilians living in housing on military bases) and individuals in noninstitutional group quarters (e.g., shelters, rooming or boarding houses, college dormitories, migratory workers’ camps, halfway houses). Not included are individuals with no fixed household address (e.g., homeless and/or transient people not in shelters), military personnel on active duty, and residents of institutional group quarters, such as jails and hospitals. People also are excluded during data collection if they cannot complete the survey in either English or Spanish or they are not physically or mentally capable of completing the interview.

The 2023 NSDUH used multimode data collection, in which respondents completed the survey in person or via the web. Methodological investigations led to the conclusion that estimates based on multimode data collection since 2021 are not comparable with estimates from 2020 or prior years. Chapter 6 in the 2021 National Survey on Drug Use and Health (NSDUH): Methodological Summary and Definitions (CBHSQ, 2022) discusses these methodological investigations in greater detail. However, the 2023 estimates are comparable with the 2021 estimates that are calculated with an adjusted weight (see Section 2.3.4.3). The 2023 estimates also are comparable with the 2022 estimates.

1.2 Organization of the Report

This report is organized into four chapters, including this introductory chapter. Chapter 2 describes the survey, including information about the sample design, data collection procedures, and key aspects of data processing (e.g., development of analysis weights). Chapter 3 presents technical details on the statistical methods and measurement, such as suppression criteria for unreliable estimates, statistical testing procedures, response rates, and issues for selected measures for substance use, mental health status, and the receipt of substance use treatment or mental health treatment. Chapter 4 discusses special topics related to prescription psychotherapeutic drugs.

1.3 Summary of Other Relevant Sources of NSDUH Information

Data and findings for the 2023 NSDUH are presented in five key products:

1. The Key Substance Use and Mental Health Indicators in the United States: Results from the 2023 National Survey on Drug Use and Health report (CBHSQ, 2024j) is a national-level report focusing on estimates among people aged 12 years or older among the civilian, noninstitutionalized population in the United States. Although estimates can be compared between 2021 and 2023, this report presents NSDUH estimates from 2023 only.
2. The 2023 Companion Infographic Report: Results from the 2021, 2022, and 2023 National Surveys on Drug Use and Health (CBHSQ, 2024e) shows comparisons of selected estimates from 2021 to 2023 among the population aged 12 or older.
3. The Behavioral Health by Race and Ethnicity: Results from the 2021‑2023 National Surveys on Drug Use and Health report (CBHSQ, 2024i) shows comparisons of selected estimates for racial or ethnic groups using pooled data from the 2021‑2023 NSDUHs to increase the precision of estimates.
4. The Results from the 2023 National Survey on Drug Use and Health: Detailed Tables (CBHSQ, 2024k) are a comprehensive set of tables on substance use and mental health issues that include estimated numbers of people with a characteristic of interest (e.g., numbers of substance users, numbers of adults with mental illness), corresponding percentages, and standard errors of estimates. These tables show estimates for 2022 and 2023 and whether there was a statistically significant change between 2022 and 2023 when applicable.
5. The 2023 Highlighted Population Slides are a forthcoming set of slides that will explore substance use and mental health measures for particular populations in the United States. Slides will be based on data from the 2023 NSDUH and will be available at https://www.samhsa.gov/data/release/2023-national-survey-drug-use-and-health-nsduh-releases. Within each slide deck for a given population, selected estimates will be presented overall, by age group, and for selected subpopulations. SAMHSA expects to release these slides in 2024.

Additional 2023 national reports and products can be found on SAMHSA’s website at https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health. State-level estimates and substate estimates for substance use and mental health outcomes² are also available on SAMHSA’s website https://www.samhsa.gov/data/.

As in previous years, CBHSQ will construct a public use data file for the 2023 NSDUH that will be available in late 2024 on the website for the Substance Abuse and Mental Health Data Archive (SAMHDA) at https://www.datafiles.samhsa.gov/data-sources. Users of NSDUH data files, including the public use file, will see important questionnaire updates for a given survey year being reflected by changes to the variable names, labels, and codebook documentation.

2.1 Sample Design

The target population for the National Survey on Drug Use and Health (NSDUH) is the civilian, noninstitutionalized population aged 12 years or older residing within the United States. The survey covers residents of households (e.g., individuals living in houses or townhouses, apartments, and condominiums; civilians living in housing on military bases) and individuals in noninstitutional group quarters (e.g., shelters, rooming or boarding houses, college dormitories, migratory workers’ camps, halfway houses). Not included in the population covered by the survey are individuals with no fixed household address (e.g., homeless and/or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as jails or hospitals. Those who are unable to take the survey in either English or Spanish are part of the eligible population but are unable to complete it.

2.1.1 Coordinated Sample Design for 2014‑2023

A coordinated sample design was developed for the 2014‑2023 NSDUHs. The coordinated sample design is state based, with an independent, multistage area probability sample within each state and the District of Columbia. In this approach, successively smaller geographic areas are selected within each state. In the smallest geographic areas, address lists are constructed and serve as the dwelling unit (DU) sampling frames, where DUs can be households or units (rooms, beds, or people) within an eligible group quarter. Then DUs and people within those DUs are randomly selected to participate. Each respondent having a known probability of selection allows NSDUH to make estimates for the population.

For the coordinated sample design, states were the first level of stratification. Each state was further stratified into approximately equally populated state sampling regions (SSRs). As shown in Figure 2.1, there were five stages of selection to create the multistage area probability sample. First, census tracts were selected within each SSR (Stage 1), then census block groups were selected within those census tracts (Stage 2), and then smaller area segments (i.e., a collection of census blocks) were selected within the census block groups (Stage 3). Next, DUs were selected within segments to receive a screener (Stage 4), and within each selected DU, up to two residents who were at least 12 years old were selected for the interview (Stage 5).

A large reserve sample of area clusters was selected at the time that the 2014‑2017 NSDUH sample was selected. This reserve sample was used to field the 2018‑2023 NSDUHs. The coordinated sample design for 2014‑2023 includes a 50 percent overlap in sampled areas within each successive 2‑year period from 2014 through 2023. Half of the sampled clusters for 2023 were carried over from the 2022 NSDUH. The other half of the sampled clusters were new for 2023. As seen in Figure 2.2, the selection of smaller area segments within census block groups (Stage 3) was eliminated for the new portion of the 2023 sample. Selecting the DU samples from larger geographic areas was expected to increase precision. The 2014‑2023 NSDUH sample design provides a sufficient number of completed interviews to support both state and national estimates.

For the overlapping sample design, DUs that were not sampled the first year are eligible for selection the following year. There is no planned overlap of sampled residents and no longitudinal follow-up for individuals. However, people may be selected in consecutive years if they move and their new residence is selected the year after their original DU was sampled.

For the 2023 NSDUH, a hybrid field enumeration and address-based sampling (ABS) approach was used to construct DU frames within sampled areas. Census block groups were evaluated using a set of ABS coverage criteria. If the census block group met all coverage criteria,³ the ABS frame was used. If the census block group failed one or more coverage criteria, field enumeration was used to construct the DU frame. For the portion of the sample carried over from the 2022 NSDUH, a smaller area (one or more census blocks) was selected for field enumeration (see Figure 2.1). For the new portion of the sample, the census block group was field enumerated (see Figure 2.2).⁴ The “segment” is the geographic area for which the DU frame is constructed, even though some segments are second-stage sampling units and some are third-stage sampling units. For the remainder of this report, “segment” refers to both census block groups and smaller area segments if no distinction is made.

To improve efficiencies and data quality, starting with the 2023 NSDUH, an electronic listing (eListing) application was used to enumerate DUs in field enumeration segments and to locate sampled DUs during data collection. For sampled areas carried over from the 2022 NSDUH, paper DU listings were converted to eListings so that only electronic maps were used to support data collection in 2023.

Table 2.1 provides the target and achieved sample allocations for the 2023 NSDUH. Adolescents aged 12 to 17 years and young adults aged 18 to 25 years were oversampled. See the 2023 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 2: Sample Design Report (Center for Behavioral Health Statistics and Quality [CBHSQ], 2024f) for more details on the sample design.

3.3 Other Information on Data Accuracy

The accuracy of survey estimates can be affected by nonresponse, coding errors, computer processing errors, errors in the sampling frame, reporting errors, and other errors not due to sampling. They are sometimes referred to as “nonsampling errors.” These types of errors and their impact can be reduced through data editing, statistical adjustments for nonresponse, close monitoring and periodic retraining of interviewers, and improvement in various quality control procedures.

Although these types of errors often can be much larger than sampling errors, measurement of most of these errors is difficult. However, the effects of some types of these errors can be examined through proxy measures, such as response rates, and from other research studies.

3.3.1 Screening and Interview Response Rate Patterns

All dwelling units (DUs³²) in the sample are screened to confirm eligibility and to select zero, one, or two members to participate in the survey. The weighted screening response rate (SRR³³) is defined as the weighted number of successfully screened DUs³⁴ divided by the weighted number of eligible DUs (as defined in Table 3.3). Of the 804,971 eligible sampled DUs in 2023, 198,246 were screened successfully, for a weighted SRR of 24.36 percent (Table 3.3).

Table 3.3 – Weighted Percentages and Sample Sizes for the 2022 and 2023 NSDUHs; by Screening Results

Screening Result	Sample Size 2022	Sample Size 2023	Weighted Percentage 20221	Weighted Percentage 20231
Total Sample	942,539	874,764	100.00	100.00
Ineligible Cases	78,254	69,793	7.90	7.76
Eligible Cases	864,285	804,971	92.10	92.24
Ineligibles	78,254	69,793	7.90	7.76
Vacant	11,488	10,571	16.91	16.61
Not a Primary Residence	2,159	1,665	6.56	3.74
Not a Dwelling Unit	1,573	1,500	2.33	2.32
All Military Personnel	544	429	0.66	0.57
Other, Ineligible2	62,490	55,628	73.54	76.76
Eligible Cases	864,285	804,971	92.10	92.24
Screening Complete3	217,457	198,246	25.46	24.36
No One Selected	111,024	102,295	13.15	12.47
One Selected	61,605	55,689	7.25	6.91
Two Selected	44,828	40,262	5.07	4.98
Screening Not Complete	646,828	606,725	74.54	75.64
No One Home/No Contact Made	217,789	201,466	24.66	24.97
Respondent Unavailable/Web Nonrespondent	297,983	273,430	33.16	34.20
Physically/Mentally Incapable	1,209	1,219	0.15	0.15
Language Barrier – Hispanic	3,483	3,504	0.43	0.47
Language Barrier – Other	2,298	2,611	0.33	0.36
Refusal	85,025	76,001	10.27	9.48
Other, Access Denied4	38,007	47,764	5.45	5.93
Other, Eligible	475	354	0.04	0.03
Segment Not Accessible	0	0	0.00	0.00
Screener Not Returned	296	237	0.03	0.03
Fraudulent Case	263	139	0.02	0.02
Electronic Screening Problem	0	0	0.00	0.00
1 Weighted percentages are computed using design-based weights and do not reflect adjustments to standardize the weighted proportion of interviews that were completed in person or via the web. 2 Examples of “Other, Ineligible” cases are those in which all residents lived in the dwelling unit for less than half of the calendar quarter and dwelling units listed in error. 3 The screening response rate (SRR) is calculated as the weighted number of successfully screened DUs divided by the weighted number of eligible DUs, , where is the inverse of the unconditional probability of selection for the DU and excludes all adjustments for nonresponse and poststratification defined in Section 2.3.4 of this report. 4 “Other, Access Denied” includes all dwelling units to which the field interviewer was denied access, including locked or guarded buildings, gated communities, and other controlled access situations. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2022 and 2023.

For the 2023 NSDUH, DU eligibility was imputed for sampled DUs whose members did not initiate the web screening interview and that were not visited by a field interviewer (i.e., DUs with unknown eligibility). Thus, the weighted SRR reflects an American Association for Public Opinion Research (AAPOR) standard definition (AAPOR, 2016), which assumes that some sampled DUs with unknown eligibility are actually eligible.

In successfully screened DUs, eligible DU members who were selected were then asked to complete the interview. The number of respondents who completed the interview and the number of people who were selected were used to calculate the unweighted interview response rate (IRR) for NSDUH. The weighted IRR is defined as the number of people represented by the respondents divided by the number of people represented by the individuals who were selected (Table 3.4). In the screened DUs, a total of 135,737 people were selected, and completed interviews were obtained from 67,679 of these sampled people, for a weighted IRR of 50.45 percent. In an effort to maximize the IRR, all respondents were offered a $30 incentive to encourage them to complete the 2023 NSDUH interview. To be considered a completed interview, a respondent for the 2023 NSDUH needed to provide enough data to pass the usability criteria described in Section 2.3.1.

Among people who were selected for the interview but did not complete it, the most common reasons for not responding were (1) refusal to participate by the respondent or by the parent or adult guardian of the adolescent respondent (26.1 percent) and (2) did not participate because the residents were not available, never at home, or did not respond to the web survey (18.9 percent) (Table 3.4). Among demographic subgroups, the weighted IRR was higher among people aged 26 or older (51.5 percent), females (53.1 percent), Black people (53.4  percent), people in the Northeast (52.5  percent), and residents of nonmetropolitan areas (52.8 percent) than among their corresponding counterparts (Table 3.5).

Table 3.5 – Interview Response Rates and Sample Sizes for the 2022 and 2023 NSDUHs; by Demographic Characteristics

Demographic Characteristic	Selected People 2022	Selected People 2023	Completed Interviews 2022	Completed Interviews 2023	Weighted Response Rate 2022	Weighted Response Rate 2023
Total	150,789	135,737	71,369	67,679	47.43%	50.45%
Age
12‑17	35,136	31,358	14,813	14,305	41.61%	46.09%
18‑25	37,571	34,315	17,255	16,285	44.66%	46.69%
26+	78,082	70,064	39,301	37,089	48.54%	51.54%
Gender
Male	73,858	66,404	32,766	31,324	44.38%	47.70%
Female	76,931	69,333	38,603	36,355	50.37%	53.05%
Race/Ethnicity
Hispanic	28,840	27,938	12,835	13,567	42.47%	47.81%
Non-Hispanic, White	88,973	78,498	42,716	39,130	48.88%	51.32%
Non-Hispanic, Black	16,828	15,034	8,341	7,985	50.47%	53.44%
Non-Hispanic, All Other Races	16,148	14,267	7,477	6,997	43.54%	46.18%
Region
Northeast	27,496	26,396	12,967	13,000	48.27%	52.45%
Midwest	35,896	31,678	16,983	15,615	48.57%	51.14%
South	50,387	43,718	24,635	22,234	48.10%	50.63%
West	37,010	33,945	17,054	16,830	44.73%	48.09%
County Type
Large Metropolitan	70,636	62,802	32,653	30,822	45.86%	49.47%
Small Metropolitan	59,461	51,748	28,561	25,925	48.68%	51.21%
Nonmetropolitan	20,692	21,187	10,155	10,932	51.02%	52.79%
NOTE: Estimates are based on demographic information obtained from screener data and are not consistent with estimates on demographic characteristics presented in the Results from the 2023 National Survey on Drug Use and Health: Detailed Tables (Center for Behavioral Health Statistics and Quality [CBHSQ], 2024k). NOTE: The weighted interview response rate (IRR) is calculated as the weighted number of respondents divided by the weighted number of selected people, defined as , where is the design-based weight or the inverse of the probability of selection for the person and includes DU-level nonresponse and poststratification adjustments (adjustments 1, 2, and 3 in Section 2.3.4.1). However, does not include person-level weight adjustments (adjustments 4, 5, 6, and 7 in Section 2.3.4.1) and does not reflect adjustments to standardize the weighted proportion of interviews that were completed in person or via the web (Section 2.3.4.2). Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2022 and 2023.

The overall weighted response rate (ORR) of 12.3 percent is defined as the product of the weighted SRR and weighted IRR, or ORR = SRR × IRR.

3.3.1.1 Bias Due to Unit Nonresponse

Maximizing NSDUH response rates is intended to minimize bias in estimates due to different characteristics of respondents and nonrespondents. Surveys on substance use and mental health may be particularly vulnerable to nonresponse bias if people are less likely to participate in the survey who recently used drugs, used drugs frequently, or had mental disorders. For example, the NSDUH response rate in 2023 among young adults aged 18 to 25 was lower than that among adults aged 26 or older (Table 3.5); young adults in 2023 were more likely than adults aged 26 or older to use many of the substances discussed in the Key Substance Use and Mental Health Indicators report (CBHSQ, 2024j) and to have AMI in the past year.

However, potential sources of nonresponse bias in one direction (e.g., bias that would decrease estimates) could be offset by corresponding sources of bias in the opposite direction (e.g., bias that would increase estimates), such that overall effects on prevalence because of nonresponse bias could be minimal. For example, the NSDUH response rate in 2023 among females was higher than that among males; NSDUH findings have shown adult females to be more likely than adult males to have a major depressive episode (MDE), AMI, or SMI in the past year. See the 2023 Detailed Tables (CBHSQ, 2024k) and Gender Differences in Past Year Mental Health among Young Adults Aged 18 to 25 (Magas & Hoenig, 2024) for more information. Further research on this important topic with recent NSDUH data would be useful.

3.3.2 Item Nonresponse and Inconsistent Responses

3.3.2.1 Item Nonresponse

Among survey participants, item response rates were generally very high for most mental health and drug use items. With the use of multimode data collection in 2023, however, item nonresponse rates were higher than what they were in survey years prior to 2020 when data were collected through in-person interviews only. The increase is due to web respondents discontinuing the survey prior to completion (i.e., breaking off). See Section 2.3.4 for details.

Prior to the introduction of the web mode of data collection in NSDUH, item nonresponse was predominantly caused by responses of “don’t know” or “refused” either in the specific question or in earlier questions that governed skip logic.³⁵ In 2023, item nonresponse for usable interviews among adults was driven by survey break-offs. Item nonresponse tended to be lower for drug use items because of the usability criteria described in Section 2.3.1 and higher for mental health items.³⁶

Occurrences of missing data in mental health items (e.g., mental health treatment, MDE) are important to examine because these questions occurred later in the NSDUH interview when respondents could break off but their interviews could remain usable. Furthermore, mental health variables were not all statistically imputed for 2023 (see Section 3.4.5).

As an example of how break-offs can introduce bias, rates of missing data for the receipt of mental health treatment in the past 12 months and the types of missing data (e.g., responses of “don’t know” or “refused,” no response because respondents broke off the interview) varied by age group and mode of interview in 2023. Among adult respondents aged 18 or older, item nonresponse was generally lower for in-person respondents for the receipt of mental health treatment at specific locations in the past 12 months or the use of prescription medication in that period to help with their mental health.³⁷ Among adult web respondents, the majority of the missing data was from interview break-offs. Break-offs contributed less to item nonresponse for respondents aged 12 to 17 than for adults. Unlike adults, item nonresponse was generally lower for youths who completed the survey via the web than it was for those who were interviewed in person.

The receipt of substance use treatment also occurred later in the NSDUH interview than the questions about substance use but earlier in the interview than the mental health items; respondents could break off before these questions and their interviews could remain usable.³⁸ In addition, respondents could have been skipped out of the substance use treatment questions because information was unknown for whether they used alcohol or drugs in their lifetime. Because not all of the substance use treatment variables were statistically imputed for 2023 (see Section 3.4.4), potential bias due to missing data is relevant to NSDUH estimates for substances for which treatment was received.

For questions that ask for an opinion or a perception, such as the perceived risk of harm from the use of different substances or the perceived availability of substances, responses of “don’t know” may be a valid indication of respondents not having an opinion or not knowing enough knowledge about these substances. Responses of “don’t know” to questions about the perceived risk of harm from substance use were the predominant source of missing data in most of these questions for 2023. Aside from issues of potential bias, discussed in Section 3.3.2.2, excluding respondents who answered “don’t know” to these questions might create the impression that all people in the population have an opinion about the perceived risk of harm from substance use or the perceived availability of different substances. However, the estimates on perceived risk and availability of substances published in the 2023 Detailed Tables (CBHSQ, 2024k) exclude respondents from analyses who answered “don’t know” to these questions; thus, this issue is a limitation to consider when data users interpret these results.

3.3.2.2 Effects of Missing Data on Estimates

When statistical imputation was not used to replace missing values with nonmissing values (see Section 2.3.3), NSDUH estimates were based on variables that have some missing data. Generally, observations with missing values are excluded from standard NSDUH analyses, including a portion (but not all) of the analyses used to create the annual detailed tables.

Since 2021, additional variables have been statistically imputed to mitigate the effect of increased rates of item nonresponse due to break-offs. See Table 2.3 for a list of measures that were statistically imputed for the 2023 NSDUH. However, some mental health or other variables in later sections of the 2023 interview were not statistically imputed. There may be bias in estimates from these variables due to the presence of missing data. Specifically, there may be bias when respondents with missing data are excluded from the analysis.

For estimated numbers of people with a given characteristic, there will always be a negative bias if there are missing values in the domain variable(s), the outcome variable, or both. For example, consider an analysis that estimates the percentage and number of youths between the ages of 12 and 17 who were exposed to school-based substance use prevention messages. This analysis includes a domain variable for youths who attended school in the past 12 months (including those who were homeschooled) and multiple outcome variables, which consist of whether youths received substance use prevention messages in various school settings. Respondents may have missing data for either the domain of school attendance or the outcomes of exposure to school-based prevention activities. Respondents with missing data who were exposed to these messages would not be included in the estimated number of exposed youths. Assuming that some of these youths with missing data were exposed to prevention messages, there would be negative bias in the population estimates.

When a population mean or proportion is estimated, there may or may not be bias, and the bias can be either negative or positive. The direction and magnitude of the bias for means and proportions depend on how different the item respondents are from the item nonrespondents with respect to the outcome of interest. For example, if the “true” sources where respondents with missing data obtained the last prescription pain relievers they misused matched the distribution among respondents who did not have missing data, then excluding missing data (and decreasing the number of respondents in the denominator) would not be expected to affect the estimated percentages of people in the population who obtained their prescription pain relievers from specific sources. However, if the source of prescription pain relievers among respondents with missing data was skewed in favor of a particular source (e.g., through prescriptions from more than one doctor), then excluding these respondents with missing data might introduce bias in published estimates.

These missing data effects are discussed in more detail in the 2022 Statistical Inference Report (CBHSQ, 2024d).

3.3.2.3 Inconsistent Responses

In order to minimize respondent confusion, inconsistent responses, and item nonresponse, the NSDUH instrument for both in-person and web-based interviews was programmed to skip respondents out of inapplicable questions based on their previous answers. This skip logic reduced the potential for inconsistent data by limiting respondents’ opportunity to provide answers that were inconsistent with previous answers. For example, if respondents did not report that they last used alcohol in the past 30 days, they were not asked questions about their use of alcohol in the past 30 days. In some situations, respondents were asked to resolve an inconsistency between two answers. However, programming within the in-person and web instruments could not eliminate all occurrences of missing or inconsistent data. For example, respondents could report they last used any form of cocaine more than 12 months ago but they last used crack cocaine at some point within the past 12 months; both answers logically cannot be true.

These missing or inconsistent responses in the substance use data are first resolved (where possible) through a logical editing process (e.g., logically inferring more recent reported use of crack cocaine applies to any cocaine). When the missing or inconsistent responses are not resolved through logical editing, they may be resolved through imputation using statistical methodology. Editing and imputation of missing responses are potential sources of measurement error.

Not all inconsistencies in the data are resolved through editing or imputation. Inconsistencies could remain when they arise between questions from different questionnaire sections. Respondents could indicate in the cocaine section that they last used cocaine more than 12 months ago and also indicate in the special drugs section that they last used a needle to inject cocaine at some point in the past 12 months. According to the general principle of not editing across sections of the interview (see Section 2.3.2), this information from the later special drugs section was not used to edit the variable for the most recent use of cocaine. In situations such as these, data users will need to decide how to handle these inconsistencies in their analyses.

For more information on editing and statistical imputation, see Sections 2.3.2 and 2.3.3. Details on the editing and imputation procedures for 2023 also will appear in the 2023 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 10: Editing and Imputation Report (CBHSQ, forthcoming b). Until that report becomes available, refer to the 2022 Editing and Imputation Report (CBHSQ, 2024b) for the most recent documentation of general principles and procedures for editing and imputation.

3.3.3 Validity of Self-Reported Substance Use

Most estimates of substance use, including those produced for NSDUH, are based on self-reports of use. This section focuses on the validity of NSDUH respondents’ self-reports of substance use and is not intended to provide a comprehensive discussion of issues associated with the validity of any self-report in NSDUH. Factors such as the length of time between an event and the interview date or respondents’ interpretation of a question also can affect respondents’ recall or reporting, independent of the potential sensitivity of the topic covered by a question. An additional factor discussed in this section is the use of multimode data collection (i.e., in person or web) in 2023.

Survey questions about topics such as substance use are considered to be sensitive because respondents may think the questions are intrusive (“none of your business”), pose risks for negative social or legal consequences if their answers were to become known, or require them to provide socially undesirable answers (Tourangeau & Yan, 2007). Although studies generally have supported the validity of self-report data for sensitive topics, the potential for these data to be biased (underreported or overreported) is well documented. The bias varies by several factors, including the mode of administration, the setting, perceptions of privacy, the population under investigation, and for substance use, the type of drug (Aquilino, 1994; Brener et al., 2006; CBHSQ, 2012; Harrison & Hughes, 1997; Lindberg & Scott, 2018; Tourangeau & Smith, 1996; Tourangeau & Yan, 2007; Turner et al., 1992). NSDUH utilizes widely accepted methodological practices for increasing the accuracy of self-reports, such as encouraging privacy through self-administration of questions about sensitive topics—including audio computer-assisted self-interviewing (ACASI) for in-person data collection—and providing assurances that individual responses will remain confidential. Comparisons using these methods within NSDUH data (collected in person) have shown they reduce reporting bias (Gfroerer et al., 2002).

A special study cosponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) examined the validity of NSDUH self-report data on drug use among people aged 12 to 25. The study found urine and hair specimens can be collected with a relatively high response rate in a general population survey, and most youths and young adults reported their recent drug use accurately in self‑reports (Harrison et al., 2007).³⁹

3.3.3.1 Reporting of Sensitive Behaviors in Web Surveys

Prior studies spanning multiple decades (e.g., Aquilino, 1994; Lindberg & Scott, 2018; Tourangeau & Smith, 1996) have established that respondents are more likely to report sensitive behaviors when questions are self-administered than when they need to report their answers to interviewers. With the use of multimode data collection in the 2023 NSDUH, including some interviews being completed via the web, it is important to examine respondent willingness to report sensitive behaviors via the web. Given the use of the web for interactions that involve the sharing of sensitive data (e.g., Social Security numbers, credit card numbers), people may be expected to accurately report information about their substance use in a web-based survey. However, the reliability of self-reports in surveys administered via the web remains an open and evolving question.

Kreuter and colleagues (2008) assessed social desirability bias in the reporting of potentially sensitive academic information using interviewer administration via computer-assisted telephone interviewing (CATI) and self-administration using interactive voice recognition (IVR) and web administration. Under a randomized experimental design, web administration increased the reporting of socially undesirable academic information such as a cumulative grade point average below 2.5 compared with CATI, with IVR yielding results between those of web administration and CATI. Web respondents also were less likely than CATI respondents to falsely deny socially undesirable outcomes relative to information from external data sources. Although this study focused on academic outcomes rather than substance use, it is consistent with other literature showing that self-administered data collection modes—including web-based data collection—yield increased reports of sensitive behaviors compared with interviewer-administered modes.

Cernat and colleagues (2016) used data from the 2010 to 2012 waves of the Health and Retirement Study to compare estimates of depression symptoms from the Center for Epidemiologic Studies Depression Scale (CES‑D) in interviewer-administered and self-administered web data collection modes. Depression estimates based on the CES‑D were lower in interviewer-administered modes than in the web mode. However, the study did not compare the web data collection mode with other self-administration modes.

The Monitoring the Future (MTF) study for 2023 used a web-based questionnaire to collect data from 8th, 10th, and 12th graders. Since the 2021 survey, students have used their own electronic devices (rather than tablets provided by the study) to connect to the web and complete the survey during class time. Analyses found that substance use trends were replicated when the sample for 2021 was restricted to students who reported that all their classes were in school (46 percent of the sample). Investigators concluded that web administration of the survey at home produced results similar to those for students who completed the web survey in school (Johnston et al., 2022).

One issue for web-based data collection in NSDUH concerns privacy in settings such as within households. As noted previously, respondents’ perceptions of privacy can influence the reporting of sensitive behaviors, as described by Brener and colleagues (2006) and in a report comparing youth substance use estimates across national surveys (CBHSQ, 2012). For the 2023 NSDUH, field interviewers asked in-person respondents to find a private location to complete the survey. Web respondents were asked to be in a private location within the home and to affirm before starting an interview that they were in a private location. Unlike in-person interviews, however, no privacy ratings were available for web-based interviews to indicate whether interviews remained private throughout the entire interview, or if not, the extent of time for which the interview was less than private and who else might have been present. It also is not known whether NSDUH web respondents perceived the web mode to be a more private method for answering sensitive questions compared with in-person data collection in a private setting using ACASI, but with a field interviewer present. As web-based interviewing is increasingly used for collecting survey data—including data on sensitive topics such as substance use—methodological research comparing data collection via the web with other modes that collect self-administered data would be useful for establishing the factors that encourage or discourage the reporting of sensitive behaviors via the web.

3.3.3.2 Issues for Self-Reporting of Prescription Drug Misuse

The emphasis on past year rather than lifetime misuse of specific prescription drugs in the NSDUH questionnaire appears to affect the validity of estimates for lifetime misuse of prescription psychotherapeutic drugs (see Section C in the 2015 Methodological Summary and Definitions report; CBHSQ, 2016). Respondents in 2023 who did not misuse prescription psychotherapeutic drugs in the past 12 months were asked only about lifetime misuse of general categories of prescription psychotherapeutic drugs (e.g., prescription pain relievers). Respondents also did not have cues for recalling misuse more than 12 months ago of drugs no longer available by prescription in the United States (e.g., sedatives containing methaqualone, such as those with the brand names Quaalude^® or Sopor^®). Field testing of these prescription drug questions suggested that the emphasis on the past year misuse of specific prescription drugs can result in underreporting of lifetime misuse of prescription psychotherapeutic drugs. For more information, see the National Survey on Drug Use and Health: 2012 Questionnaire Field Test Final Report and the National Survey on Drug Use and Health: 2013 Dress Rehearsal Final Report (CBHSQ, 2014b, 2014c). For this reason, estimates of lifetime misuse of prescription psychotherapeutic drugs are not included in the 2023 national reports and tables.

The prescription drug questions in 2023 allowed respondents to report any use or misuse in the past 12 months for specific medications within a given psychotherapeutic category (e.g., the benzodiazepine tranquilizers Xanax^®, Xanax^® XR, generic alprazolam, and generic extended-release alprazolam). These details were presented to respondents to aid them with recall and recognition. However, respondents could have difficulty knowing or remembering whether they took a generic or brand name drug or what type of formulation they took (i.e., immediate release or extended release). Therefore, recall of the use or misuse of prescription drugs containing a given active ingredient has been assumed to be more accurate than recall of the exact drugs respondents took. For example, respondents who took the generic benzodiazepine alprazolam (brand name drug Xanax^®) could recognize the drug by its brand name and report use or misuse of “Xanax.” This issue may be especially relevant for respondents who misused prescription drugs by taking them without a prescription of their own. However, self-reports of the use or misuse of Xanax^® or alprazolam are equivalent analytically for estimating the use or misuse of tranquilizers containing alprazolam, even if respondents may have misreported the exact drug they used or misused in the past year. Therefore, 2023 NSDUH estimates for the use or misuse of prescription psychotherapeutic drugs in the past year are reported for overall psychotherapeutic drug categories (e.g., tranquilizers) or for subtypes of related drugs (e.g., benzodiazepine tranquilizers, tranquilizers containing alprazolam), but they are generally not reported for specific individual prescription drugs from the NSDUH questionnaire.⁴⁰

3.3.4 Changes to Questions about Race

Starting with the 2022 NSDUH, revisions were made to question QD05, which asked respondents to report the race category that best described them. For the 2022 NSDUH, the response options for the race question were rearranged to be in alphabetical order, as per current Office of Management and Budget (OMB) guidelines. The response option for American Indian or Alaska Native was moved to the top of the list; in prior years, White had been the first response option. Also, respondents were no longer offered a response option for “other” race.⁴¹ See Section 2.2.2 in the 2022 Methodological Summary and Definitions report (CBHSQ, 2023b).

Starting with the 2023 NSDUH, the race and ethnicity questions in the in-person questionnaire became self-administered instead of being administered by an interviewer (see Section 2.2.2). The race questions were placed in a self-administered demographic section that included sensitive questions on sex at birth and gender identity. The 2022 and 2023 NSDUH data were evaluated to look for patterns for both item nonresponse and sample sizes due to these changes.

3.3.4.1 Item Nonresponse

As noted in the 2022 Methodological Summary and Definitions report, the unweighted number of respondents in 2022 who did not know or refused to answer the race question increased following the changes in the order of response options and the removal of the response option for “other” race (CBHSQ, 2023b). The change from interviewer administration to self-administration in the 2023 in-person questionnaire again increased the overall unweighted number and percentage of respondents who did not know or refused to answer the race question from about 800 respondents in 2022 (1.1 percent) to about 1,000 in 2023 (1.5 percent). Specifically, the percentage of in-person respondents with missing data for QD05 increased from 1.2 percent in 2022 to 1.9 percent in 2023, whereas about 1.0 percent of web respondents had missing data for QD05 in both years. The increase in nonresponse for the in-person mode but not for the web mode suggests that the increase for 2023 can be explained by the change to self-administration for in-person respondents. These increased numbers of respondents who did not know or refused to answer the race questions led to higher levels of imputation rates overall in 2023. More information on item nonresponse can be found in Section 3.3.2.1.

3.3.4.2 Changes to the Numbers of Non-Hispanic American Indian or Alaska Native Respondents

With the reordering of the response options in the 2022 NSDUH data, the unweighted number of non-Hispanic American Indian or Alaska Native respondents increased in 2022. The 2023 data showed further increases in the unweighted number and percentage of respondents who were non-Hispanic American Indian or Alaska Native. The number of in-person non-Hispanic American Indian or Alaska Native respondents more than doubled from 2021 to 2023 (from 460 to 1,130), and the corresponding percentage also increased over this period (from 1.5 to 2.6 percent of in-person respondents). Like item nonresponse, there was little change for web respondents between 2022 and 2023.

NSDUH data that are published in the 2023 national reports and tables are weighted to reflect U.S. Census Bureau or ACS population estimates for specific racial or ethnic groups. As noted in Section 2.3.4, the weighting process for 2023 did not change compared with the procedures for 2022 and 2021. The NSDUH weighted population counts were consistent with those from prior years. Systematic differences were not observed in published estimates for the non-Hispanic American Indian or Alaska Native population in the 2023 national reports and tables that were based on the final main analysis weight. Despite the weighted population size for non-Hispanic American Indian or Alaska Native people being consistent between years, caution is advised in comparing outcomes for this group over time due to the change in the unweighted number of respondents.

3.4 Measurement Issues

Several measurement issues for the 2023 NSDUH are discussed in this section. Issues addressed include the methods for measuring the use and misuse of fentanyl (including illegally made fentanyl [IMF]), the initiation of substance use or misuse of prescription drugs, SUDs, substance use treatment (including medication-assisted substance use treatment), mental health treatment, and the definition of county type. Additionally, this section discusses the mental health measures AMI, SMI, and MDE. Starting with Section 3.4.9, measures are discussed for recovery, nicotine vaping, central nervous system (CNS) stimulant use, suicidality, and modes of marijuana use.

This section also discusses how missing data were handled analytically to produce the estimates found in the national reports and tables for the 2023 NSDUH. Refer to Section 3.3.2 for a discussion of potential bias in estimates because of missing data.

Except where noted, estimates for measures described in this section used the main analysis weight described in Section 2.3.4. The section specifically mentions when estimates used the break-off analysis weight because the measures were not statistically imputed.

3.4.1 Use and Misuse of Fentanyl, Including Illegally Made Fentanyl

Data from the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System indicate that overdose deaths involving synthetic opioids other than methadone have been the leading drugs for opioid-involved overdose deaths since the end of 2016 (Ahmad et al., 2024). This involvement of synthetic opioids in fatal overdoses has been attributed to fentanyl and fentanyl analogues that are made illegally in clandestine laboratories rather than by the pharmaceutical industry. These forms of IMF and analogues have been mixed with heroin as an adulterant, substituted for heroin entirely, or sold as counterfeit prescription drugs (Ciccarone, 2019). From 2016 to 2021, age-adjusted rates of drug overdose deaths more than tripled for deaths involving fentanyl (Spencer et al., 2023).

From 2015 to 2021, NSDUH asked about the use and misuse of prescription forms of fentanyl but did not ask specifically about the use of IMF. However, respondents could specify in the special drugs section of the NSDUH interview that fentanyl was another drug that they injected with a needle. Because many prescription fentanyl products that are available by prescription in the United States (e.g., Duragesic^®, Fentora^®, generic fentanyl) are in forms such as skin patches or “lollipops” that would require extraction of the fentanyl before it can be injected, most reports in NSDUH of the injection of fentanyl are assumed to involve the injection of IMF. However, reports of fentanyl injection that require respondents to specify it as some other drug that they injected are likely to yield underestimates of IMF use (Kroutil et al., 2010). Moreover, heroin that contains IMF as an adulterant could be used in ways other than injection, such as sniffing (Mars et al., 2018).⁴²

Therefore, beginning with the 2022 NSDUH, questions were included in the emerging issues section that specifically asked about the use of IMF. Respondents aged 12 or older were asked whether they ever used IMF and, if so, how long it had been since they last used it. The questionnaire explained that IMF is fentanyl that people cannot get from a doctor or pharmacy and that IMF can come in forms such as powder, pills, blotter paper, or mixed with heroin or other drugs. If respondents reported that they had ever used IMF, they also were asked whether they ever used a needle to inject it. If they reported ever having used IMF with a needle, and if they had previously indicated that they used IMF in any way within the past 12 months, they were asked how long it had been since they last injected it. Respondents who reported using IMF with a needle in their lifetime and reported last using it in any way more than 12 months ago were not asked when they last used a needle to inject IMF; logically, these respondents last injected IMF more than 12 months ago.

Estimates for any use of IMF in the lifetime, past year, and past month used the main analysis weight because the variables for the lifetime and most recent use of any IMF were statistically imputed. However, estimates in the 2023 Detailed Tables (CBHSQ, 2024k) for the use of IMF with a needle used the break-off analysis weight because variables for the use of IMF with a needle were not statistically imputed.

Beginning in 2022, national reports and tables included estimates for aggregate measures that included past year use of prescription fentanyl products or IMF. The measure for any use of fentanyl in the past year included reports of any use of prescription fentanyl or use of IMF in the past year. The measure for fentanyl misuse included misuse of prescription fentanyl or use of IMF in the past year.

3.4.2 Initiation of Substance Use or Misuse

In NSDUH, initiation refers to the first use or misuse of a particular substance. For prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, and sedatives), initiation refers to the first time misuse ever occurred.⁴³ All of the initiation variables used to create published estimates for the 2023 NSDUH underwent statistical imputation to remove missing values (see Section 2.3.3). Therefore, these variables were not subject to the kinds of potential bias because of missing data described in Section 3.3.2.

The NSDUH questionnaire collected year and month of first use for recent initiates—that is, people who used a particular substance for the first time at their current age or the year before their current age. Month, day, and year of birth also were obtained directly or were statistically imputed for item nonrespondents as part of the data postprocessing. Additionally, the date of the interview was recorded for both in-person and web respondents.

Past year initiation referred to respondents whose date of first use of a substance (or misuse for psychotherapeutic drugs) was within the 12 months prior to their interview date.⁴⁴ Past year initiation was determined by self-reported past year use, the age at first use, the year and month of recent new use, and the interview date.

Calculations of estimates of past year initiation did not take into account whether respondents initiated substance use while a resident of the United States. This method of calculation allowed for direct comparability with other standard measures of substance use because the populations of interest for the measures will be the same (i.e., both measures examined all possible respondents and were not restricted to those initiating substance use only in the United States).

One important note for initiation estimates is the relationship between the main categories and subcategories of substances (e.g., hallucinogens would be a main category, and lysergic acid diethylamide [LSD], phencyclidine [PCP], and Ecstasy would be subcategories in relation to hallucinogens). As shown in Figure 3.2, an individual can initiate use of any hallucinogen, LSD, PCP, or Ecstasy only once. Respondents who initiated use of any hallucinogen more than 12 months ago by definition were not past year initiates of hallucinogen use, even if they initiated use of LSD, PCP, or Ecstasy in the past year. Similar principles applied to other main categories and subcategories, such as cocaine and crack, a main category and a subcategory, respectively.

A related issue applied to initiation estimates for the aggregate substance use categories that include prescription drug measures, such as past year initiation of the use of any illicit drug or the misuse of prescription psychotherapeutic drugs.⁴⁵ For example, people who first misused prescription stimulants in the past 12 months but who first misused prescription pain relievers more than 12 months prior to the interview date would be past year initiates for the misuse of stimulants. These people would not be past year initiates for the misuse of prescription psychotherapeutic drugs or illicit drugs because they had already misused pain relievers more than 12 months ago. Because of the potential for respondents to underreport lifetime (but not past year) misuse of prescription psychotherapeutic drugs (see Section 3.3.3.2), lifetime (but not past year) misusers of prescription drugs could be misclassified as past year initiates for illicit drugs if they reported past year initiation of another illicit drug (e.g., heroin) but failed to report their lifetime misuse of a prescription psychotherapeutic drug (e.g., pain relievers).⁴⁶ Section 4.6.3 discusses additional issues for the measurement of initiation of benzodiazepine misuse. For these reasons, the 2023 national reports and tables do not show initiation estimates for the aggregate categories of illicit drugs, prescription psychotherapeutic drugs, opioids, benzodiazepines, the aggregate category for tranquilizers or sedatives, or CNS stimulants.

Also, NSDUH does not collect initiation data for pipe tobacco. Therefore, the aggregate risk for initiation of use of any tobacco product, or initiation of any tobacco product use or nicotine vaping, cannot be determined (i.e., including pipe tobacco). NSDUH also does not collect initiation data on marijuana vaping or vaping of flavoring. Thus, the 2023 national reports and tables do not show initiation estimates for the aggregate category of any tobacco product use, any tobacco product use or nicotine vaping, marijuana vaping, or vaping of flavoring.

In addition to estimates of the number of people initiating use of a substance in the past year, 2023 NSDUH estimates were computed for the mean age at first use or misuse among past year initiates of these substances. Unless specified otherwise, estimates of the mean age at initiation in the past 12 months were restricted to people aged 12 to 49 so that these mean age estimates were not influenced by those few respondents who were past year initiates and were aged 50 or older. As a measure of central tendency, means are influenced by the presence of extreme values in the data. Therefore, constraining the mean age estimates to past year initiates aged 12 to 49 was expected to increase the utility of these results to health researchers and analysts by providing a less biased picture of the substance use initiation behaviors among the civilian, noninstitutionalized population in the United States. This constraint was applied only to estimates of mean ages at first use and did not affect estimates for the 2023 NSDUH of the numbers of new users or associated percentages (e.g., the percentage of past year users who initiated use in the past year).

3.4.2.1 Initiation of Use of Substances from the Nicotine Section through the Methamphetamine Section

For cigarettes, nicotine vaping, smokeless tobacco, cigars, alcohol, marijuana, cocaine, crack cocaine, heroin, hallucinogens, inhalants, and methamphetamine, respondents were classified as past year initiates if there were fewer than 365 days between the interview date in 2023 and the statistically imputed month, day, and year of first use of the relevant substance. (If respondents reported first use in calendar year 2022, their first use could be within 365 days of the interview date.) The total number of past year initiates can be used in the estimation of different percentages. For these substances, denominators for the percentages vary according to whether rates are being estimated for (1) all people in the population (or all people in a subgroup of the population, such as people in a given age group), (2) people who are at risk for initiation because they have not used the substance of interest prior to the past 12 months, or (3) past year users of the substance. The 2023 Detailed Tables (CBHSQ, 2024k) show all three of these percentages.

3.4.2.2 Initiation of Misuse of Prescription Psychotherapeutic Drugs

Respondents were asked about the initiation of misuse of prescription psychotherapeutic drugs only for the individual prescription drugs they misused in the past 12 months. Asking respondents to recall their first misuse of any prescription drug in an overall category (e.g., pain relievers) would require them to think about all prescription drugs that could have been available to them when they initiated misuse. However, some of these drugs may no longer have been available when respondents were interviewed.

Figure 3.3 uses prescription pain relievers as an example to illustrate the steps for identifying past year initiates of the misuse of prescription drugs. These steps are the same for the other prescription drug categories. If respondents reported they first misused one or more prescription pain relievers at an age or in a year and month more than 12 months prior to the interview date, they logically did not initiate the misuse of pain relievers in the past year. Respondents who reported that they first misused all specific pain relievers in the past 12 months were asked a general question for whether they misused any pain reliever more than 12 months ago; “any pain reliever” in this follow-up question was not necessarily limited to the specific pain relievers that respondents were asked about in the questionnaire.⁴⁷ The answers to these follow-up questions determined whether these respondents who reported initiation of misuse for all specific pain relievers they misused in the past 12 months were past year initiates for the misuse of any pain reliever or if initiation of misuse in the past year needed to be resolved through imputation (see Section 2.3.3). Further details on the editing and imputation procedures for initiation of misuse of prescription drugs for 2023 also will appear in the 2023 Editing and Imputation Report (CBHSQ, forthcoming b). Until that report becomes available, refer to the 2022 Editing and Imputation Report (CBHSQ, 2024b) for the most recent documentation of these editing and imputation procedures.

Field testing in 2013 of redesigned questions for the initiation of misuse of prescription drugs indicated that estimated numbers and percentages of people who initiated the misuse of prescription drugs in the past year were similar based on the redesigned questions and questions from the main survey that measured past year initiation. For more information, see the 2013 Dress Rehearsal Final Report (CBHSQ, 2014c). Therefore, the 2023 national reports and tables present estimated numbers of people who initiated the misuse of prescription pain relievers, tranquilizers, stimulants, or sedatives in the past year.

In addition, the total number of past year initiates of misuse of any psychotherapeutic drug in a category can be used in the estimation of percentages among (1) all people in the population (or all people in a subgroup of the population, such as those in a given age group) and (2) people who were past year users of the substance. The 2023 Detailed Tables (CBHSQ, 2024k) show estimates for these two percentages.

As noted in Section 3.3.3, however, respondents who last misused prescription psychotherapeutic drugs in a category more than 12 months ago may underreport misuse, especially if they were not presented with examples of drugs formerly available by prescription in the United States but no longer available at the time respondents were interviewed. These respondents who did not report misuse occurring more than 12 months ago would be misclassified as still being “at risk” for initiation of misuse of prescription drugs in that psychotherapeutic category.⁴⁸ For this reason, percentages for initiation of misuse of psychotherapeutic drugs among people who were at risk for initiation were not created for the 2023 Detailed Tables.

3.4.3 Substance Use Disorders

The NSDUH questionnaire included questions designed to measure dependence on nicotine in the form of cigarettes. The questionnaire also included questions to measure SUDs for alcohol and drugs. Estimates for nicotine dependence are included in the 2023 Detailed Tables. Estimates for SUD and SUD severity for alcohol and drugs are included in both national reports and tables for the 2023 NSDUH.

3.4.3.1 Nicotine Dependence

For nicotine, questions pertaining to dependence were based on the Nicotine Dependence Syndrome Scale (NDSS; Shiffman et al., 1995, 2004) and the Fagerstrom Test of Nicotine Dependence (FTND; Fagerstrom, 1978; Heatherton et al., 1991). Nicotine dependence was not measured for respondents who did not smoke cigarettes in the past month but used other products containing nicotine.

To identify patterns of nicotine dependence within the 2023 NSDUH data, questions measured dependence on nicotine through the use of cigarettes. Respondents were classified as being dependent if they met either the NDSS or the FTND classifications for dependence. The 2023 NSDUH contained 19 NDSS questions addressing five aspects of dependence: (1) smoking drive (compulsion to smoke driven by nicotine craving and withdrawal), (2) nicotine tolerance, (3) continuous smoking, (4) behavioral priority (i.e., preferring smoking over other reinforcing activities), and (5) stereotypy (i.e., fixed patterns of smoking). The 2023 NSDUH contained two mutually exclusive questions (DRCGE19a and DRCGE19b) addressing the FTND measure of dependence. These questions ask respondents who reported smoking cigarettes in the past month if the first cigarette they smoked was within 30 minutes of waking up on the days they smoked.

Missing data for nicotine dependence were statistically imputed for past month cigarette smokers. See Section 2.3.3 for more information on imputation.

3.4.3.2 Substance Use Disorder for Drugs and Alcohol

SUD estimates for drugs and alcohol in the 2023 NSDUH were based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‑5; American Psychiatric Association, 2013). Respondents were asked SUD questions separately for any drugs or alcohol they used in the 12 months prior to the survey.⁴⁹ SUD questions for drugs applied to marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, and any use of psychotherapeutic drugs, including prescription pain relievers, tranquilizers, stimulants, or sedatives. Beginning in 2021, NSDUH respondents who reported any use of prescription psychotherapeutic drugs in the past year (i.e., not just misuse of prescription drugs) were asked the respective SUD questions for that category of prescription drugs. More information on how the current SUD questions were developed based on DSM‑5 criteria can be found in the 2020 Methodological Summary and Definitions report (CBHSQ, 2021).

Users of NSDUH reports and tables also should be aware that questions about the use of IMF appeared after SUD questions in the 2023 NSDUH questionnaire (See Section 3.4.1 for additional information about the IMF questions). For this reason, overall SUD, drug use disorder, and opioid use disorder measures do not capture disorders arising solely from the use of IMF.

DSM‑5 includes the following SUD criteria (as measured in the 2023 NSDUH):

1. The substance is often taken in larger amounts or over a longer period than intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
4. There is craving, or a strong desire or urge, to use the substance.
5. There is recurrent substance use that results in a failure to fulfill major role obligations at work, school, or home.
6. There is continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of substance use.
8. There is recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. There is a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or there is a markedly diminished effect with continued use of the same amount of the substance (i.e., tolerance).
11. There are two components of withdrawal symptoms, either of which meet the overall criterion for withdrawal symptoms:
    1. There is a required number of withdrawal symptoms that occur when substance use is cut back or stopped following a period of prolonged use.⁵⁰
    2. The substance or a related substance is used to get over or avoid withdrawal symptoms.⁵¹

Table 3.6 shows how these 11 DSM‑5 SUD criteria apply to substances in NSDUH. For prescription psychotherapeutic drugs (i.e., prescription pain relievers, tranquilizers, stimulants, or sedatives), Table 3.6 also shows how these criteria apply if respondents misused prescription psychotherapeutic drugs, or if they simply used but did not misuse prescription drugs in the past year. For consistency with the DSM‑5 criteria, NSDUH respondents were classified as having an SUD if they met two or more of the applicable criteria in a 12‑month period.

For alcohol, marijuana, cocaine, heroin, and methamphetamine, all 11 criteria applied (see Table 3.6). However, for hallucinogens and inhalants, only the first 10 criteria applied; the withdrawal criterion is not applicable to hallucinogens and inhalants.

For the prescription drugs shown in Table 3.6, the applicable DSM‑5 criteria for classifying respondents as having a prescription drug use disorder depends on whether respondents misused prescription drugs or used but did not misuse prescription drugs in the past year. If respondents misused prescription drugs in the past year, all 11 criteria shown in Table 3.6 applied. However, if respondents used but did not misuse prescription drugs in the past year, only the first 9 criteria shown in Table 3.6 applied. Criteria 10 (tolerance) and 11 (withdrawal) do not apply to respondents who used but did not misuse these prescription drugs in the past year; tolerance and withdrawal can occur as normal physiological adaptations when people use these prescription drugs appropriately under medical supervision (Hasin et al., 2013).

Table 3.7 lists the substances that were included in aggregate SUD measures in the 2023 NSDUH. For example, CNS stimulant use disorder included data from past year users of cocaine, methamphetamine, or prescription stimulants. Respondents were not counted as having a CNS stimulant use disorder if they did not meet the full SUD criteria individually for either cocaine, methamphetamine, or prescription stimulants. The same principles applied to the creation of the aggregate measures for tranquilizer or sedative use disorder and for opioid use disorder.

3.4.3.2.1 Substance Use Disorder Severity

The severity of an SUD for a particular substance (or category of substances) according to DSM‑5 criteria was determined by the number of individual criteria that a respondent met for a particular substance (or category of substances). The number of criteria required for each severity level was the same for every substance, regardless of how many criteria were applicable for the substance.

• People were classified in the mild SUD category if they met two or three applicable SUD criteria for that substance.
• People were classified in the moderate SUD category if they met four or five applicable SUD criteria for that substance.
• People were classified in the severe SUD category if they met six or more applicable SUD criteria for that substance.

In addition to the three levels of SUD severity for individual substances, measures of severity were created for aggregate SUD categories listed in Table 3.7. SUD severity measures for these aggregate SUD categories were defined from the maximum severity level (i.e., mild, moderate, or severe) across the multiple SUDs that were included in the category. For example, if people had a moderate alcohol use disorder and a mild marijuana (cannabis) use disorder as their only SUDs in the past year, then they were classified as having moderate SUD.

3.4.3.2.2 Imputation Issues for Substance Use Disorder Measures

Missing values in the DSM‑5 SUD data for drugs and alcohol were replaced using statistical imputation (see Section 2.3.3). Consequently, the variables for specific SUDs (e.g., marijuana use disorder; Table 3.6) as well as the composite SUD variables (e.g., drug use disorder; Table 3.7) were not subject to the kinds of potential biases due to missing data described in Section 3.3.2.

If measures for SUD and SUD severity needed to be imputed for a given substance, only the final SUD and severity outcomes were imputed; individual SUD criterion variables for a given substance were not. Details on the imputation procedures for SUD and SUD severity in the 2023 NSDUH will appear in the 2023 Editing and Imputation Report (CBHSQ, forthcoming b). Until that report becomes available, refer to the 2022 Editing and Imputation Report (CBHSQ, 2024b) for the most recent documentation procedures for imputing these SUD measures.

3.4.3.2.3 Miscellaneous Data Issues for Substance Use Disorder Measures

For alcohol and marijuana, respondents were asked the SUD questions if they reported substance use on 6 or more days in the past year or if they reported any substance use in the past year but had missing data for the frequency of use in the past year. Therefore, inconsistencies could occur where respondents were classified as having an alcohol or marijuana use disorder but their statistically imputed frequency of use was fewer than 6 days in the past year. However, this situation was uncommon. For example, about 39,000 respondents (unweighted) reported past year alcohol use in 2023.⁵² Of these, fewer than 100 respondents had missing frequency data and were asked the alcohol use disorder questions, but their final statistically imputed frequency of use indicated they used alcohol on 5 or fewer days in the past year.

For methamphetamine, cocaine, and heroin, respondents were asked the respective SUD questions if they reported past year use in the corresponding substance use sections or if they reported use in the past year in the special drugs section (i.e., use of methamphetamine, cocaine, or heroin with a needle in the past year or smoking or sniffing of heroin in the past year). Thus, the questionnaire logic allowed some respondents to be asked the SUD questions for these drugs even if they did not report past year use when they were asked previously about their most recent use of methamphetamine, cocaine, crack cocaine, or heroin in the respective main drug sections. For example, about 540 respondents in 2023 were asked the questions about methamphetamine use disorder because they reported past year use when asked directly about their most recent use of methamphetamine. Fewer than 10 additional respondents were asked these questions because they reported past year use of methamphetamine with a needle in the special drugs section despite not having previously reported past year use of methamphetamine.

Missing or incomplete responses were not statistically imputed in the special drugs section for the use of cocaine, heroin, or methamphetamine with a needle or for smoking or sniffing heroin. Therefore, if respondents were statistically imputed to have last used cocaine, heroin, or methamphetamine more than 12 months ago and there was nothing from the special drugs section to indicate use of these substances in the past year, then the final statistically imputed recency was used to infer that SUD questions did not apply.

3.4.4 Substance Use Treatment

The substance use treatment questions underwent considerable revisions for the 2022 NSDUH; these questions remained the same for 2023. Revisions for 2022 were intended to reflect contemporary changes in the delivery of substance use treatment services. The following is a summary of key changes to these questions:

• Respondents who reported any lifetime use of prescription drugs (pain relievers, tranquilizers, stimulants, or sedatives) were eligible to be asked questions about the receipt of substance use treatment. Before 2022, respondents who reported lifetime use but not misuse of prescription drugs were not asked about the receipt of substance use treatment unless they reported lifetime use of alcohol or other drugs (marijuana, cocaine, heroin, hallucinogens, inhalants, or methamphetamine).
• All lifetime users of alcohol or drugs were asked whether they received specific types of treatment services in the past 12 months. Before 2022, respondents who reported the use of alcohol or illicit drugs were not asked about the specific types of treatment they received in the past 12 months unless they first reported that they received any substance use treatment in their lifetime and, if so, whether they received substance use treatment in the past 12 months. These changes meant that more respondents beginning in 2022 were eligible to be asked the questions about the types of treatment they received in the past 12 months.
• Additional inpatient and outpatient locations were provided for respondents to report where they received treatment in the past 12 months.
• The question about the receipt of treatment over the phone or through video (i.e., telehealth treatment) was revised to emphasize that the treatment was from a therapist or other healthcare professional.
• Questions about medication-assisted treatment (MAT) for alcohol or opioid use were added to the section.

Because of these changes, the definition for the receipt of substance use treatment changed beginning in 2022. Estimates from 2022 and later years based on these outcomes should not be compared with estimates from 2021 because of these changes.⁵³ However, it would be appropriate to compare the 2023 substance use treatment estimates with those from 2022.

Questions for whether respondents perceived an unmet need for substance use treatment and the reasons for respondents not receiving treatment were also revised for the 2022 NSDUH; these questions did not change for 2023. Specific changes are discussed in Section 3.4.4.5 in the context of measurement of these outcomes.

3.4.4.1 Locations and Types of Services for Substance Use Treatment

Receipt of substance use treatment includes the receipt of treatment in the past year for the use of alcohol or drugs in an inpatient location, in an outpatient location, via telehealth, or in a prison, jail, or juvenile detention center. The definition also includes the receipt of MAT for alcohol use or opioid use.

Inpatient treatment was defined as treatment in locations where people stayed overnight or longer and included the following locations:

• a hospital,
• a residential drug or alcohol rehab or treatment center,
• a residential mental health treatment center, or
• some other place the respondent stayed overnight or longer.

Outpatient treatment was defined as treatment people received in locations that did not require them to stay overnight or longer. These measures included the following locations:

• a drug or alcohol rehab or treatment center as an outpatient;
• a mental health treatment center as an outpatient;
• the office of a therapist, psychologist, psychiatrist, or other substance use treatment professional;
• a general medical clinic or doctor’s office;
• a hospital as an outpatient;
• a school health or counseling center; or
• some other place as an outpatient.

Questions on MAT were asked in the emerging issues section of the questionnaire in 2021. MAT questions were asked in the alcohol or drug treatment section beginning in 2022 in the context of questions about other substance use treatment in the past 12 months. The skip logic also changed for these questions in the alcohol and drug treatment section. Therefore, estimates for MAT since 2022 are not comparable with MAT estimates from the 2021 NSDUH. However, the 2023 estimates are comparable with the 2022 estimates.

Variables for the receipt of substance use treatment in the past year in inpatient locations, in outpatient locations, via telehealth, or in a prison, jail, or juvenile detention center were statistically imputed. Variables also were statistically imputed for the receipt of MAT in the past year for alcohol use or opioid use. Consequently, variables since 2022 for the receipt of substance use treatment in the past year do not have missing data.

3.4.4.2 Receipt of Other Services for Substance Use

The 2023 NSDUH also collected information on the receipt of other services in the past year for the use of alcohol or drugs, including the following:

• services from a support group,
• services from a peer support specialist or recovery coach,
• services in an emergency room or emergency department, or
• detoxification or withdrawal support services.

NSDUH did not classify these other services as “substance use treatment.” However, they were included in a separate aggregate measure created to cover the receipt of substance use treatment or other services. Variables for the receipt of other services also were statistically imputed, so these variables do not have missing data.

3.4.4.3 Substances for Which People Received Treatment or Other Services

If respondents in the 2023 NSDUH reported the use of alcohol or drugs in their lifetime and reported that they received substance use treatment in the past year, then they were asked to report the substances for which they received treatment. Questions varied depending on the locations in which people received treatment or whether people received treatment via telehealth. Respondents who received other services in the past year also were asked to report the substances for which they received these services.

For MAT, the questions applied specifically to the use of alcohol or opioids. Respondents who reported lifetime use of alcohol were asked whether they received MAT specifically for their use of alcohol. Although respondents were asked about MAT for their use of “drugs,” respondents were asked this MAT question only if they reported lifetime use of opioids (i.e., heroin or prescription pain relievers).

3.4.4.3.1 Substances for Which People Received Treatment as Inpatients or Outpatients

Respondents who reported receiving treatment in inpatient or outpatient locations in the past year were asked to report whether they received treatment for the specific substances that they used in their lifetime; respondents were asked about treatment only for the specific substances they reported using in their lifetime. Respondents could be asked about the receipt of inpatient or outpatient treatment for the following substances:

• alcohol,
• marijuana,
• cocaine,
• heroin,
• hallucinogens,
• inhalants,
• methamphetamine,
• prescription pain relievers,
• prescription tranquilizers,
• prescription stimulants, and
• prescription sedatives.

For example, if respondents reported the use of alcohol, marijuana, cocaine, heroin, and prescription pain relievers in their lifetime, and they reported the receipt of treatment in one or more outpatient locations in the past year, then they were asked whether they received treatment as an outpatient for their use of these five specific substances. These respondents were not asked whether they received treatment as an outpatient for their use of hallucinogens, inhalants, methamphetamine, prescription tranquilizers, prescription stimulants, or prescription sedatives. The same logic applied to questions for the receipt of treatment as an inpatient in the past year for the use of specific substances respondents used in their lifetime.

In addition to these substances, respondents who reported substance use treatment as an inpatient or an outpatient were asked whether they received treatment in the respective setting for their use of “some other drug.” Respondents were asked to specify the other drug or drugs for which they received treatment. However, respondents might not report that they received treatment as an inpatient or an outpatient for their use of a particular substance (e.g., heroin), but they could specify it as “some other drug” for which they received treatment. In this situation, respondents were logically inferred to have received treatment in the respective setting for their use of that substance.

In 2023, relatively large proportions of people who reported that they received inpatient or outpatient treatment in the past 12 months did not indicate the specific substance(s) for which they received treatment in these locations, including treatment for the use of some other drug. Stated another way, these reports of inpatient or outpatient treatment were not substantiated by reports of treatment for the use of specific substances. Specifically, about one quarter of respondents who reported inpatient treatment in the past year did not report the specific substances for which they received treatment as inpatients. Among respondents who reported outpatient treatment in the past year, about one third did not report the specific substances for which they received treatment as outpatients. A “substance unspecified” category was created for these respondents. If respondents in this “substance unspecified” group did not actually receive substance use treatment, then estimates for any substance use treatment and for inpatient or outpatient substance use treatment could be overestimates.

3.4.4.3.2 Substances for Which People Received Treatment via Telehealth or in a Prison, Jail, or Juvenile Detention Center

Respondents who reported treatment via telehealth or treatment in a prison, jail, or juvenile detention center and who reported lifetime use of alcohol and drugs were asked for these types of treatment whether they received treatment for their use of alcohol only, drugs only, or both alcohol and drugs. Respondents were not asked these follow-up questions if they reported lifetime use of only alcohol or only drugs.

If respondents reported the lifetime use of alcohol, and they answered “no” to all questions about their use of drugs in their lifetime, then they were logically inferred to have received these types of treatment for their use of alcohol only. Similarly, if respondents reported the lifetime use of one or more drugs, and they answered “no” for their lifetime use of alcohol, then they were logically inferred to have received these types of treatment for their use of drugs only.

Edited variables for the receipt of these types of treatment for the use of alcohol only, drugs only, or both alcohol and drugs retained missing values if respondents reported the lifetime use of only alcohol or only drugs but they had missing data for the lifetime use of some substances. The recoded variables for the receipt of these types of treatment for the use of alcohol or the use of drugs reduced the amount of missing data by incorporating data from statistically imputed variables for the lifetime use of alcohol and drugs. Respondents with missing data were excluded from the analyses to produce published estimates for the 2023 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

3.4.4.3.3 Substances for Which People Received Other Substance Use Services

For the other substance use services described in Section 3.4.4.2, respondents who reported lifetime use of alcohol and drugs were asked for these other services whether they received these other services for their use of alcohol only, drugs only, or both alcohol and drugs. Respondents were not asked these follow-up questions if they reported lifetime use of only alcohol or only drugs.

If respondents reported the lifetime use of alcohol, and they answered “no” to all questions about their use of drugs in their lifetime, then they were logically inferred to have received these other services for their use of alcohol only. Similarly, if respondents reported the lifetime use of one or more drugs, and they answered “no” for their lifetime use of alcohol, then they were logically inferred to have received these other services for their use of drugs only.

These variables for the receipt of specific other services for the use of alcohol only, drugs only, or both alcohol and drugs were not statistically imputed and retained missing values if respondents reported the lifetime use of only alcohol or only drugs but they had missing data for the lifetime use of some substances. For example, if respondents reported the lifetime use of only alcohol, but they did not know or refused to report whether they had ever used some drugs, then it could not be determined unambiguously that these respondents were lifetime users of only alcohol.

3.4.4.4 Need for Substance Use Treatment

Historically, NSDUH data products have included substance use treatment at a “specialty facility” in the past year as part of the definition for whether people needed substance use treatment. With the changes to the questionnaire in 2022, the term “specialty facility” was dropped from the 2022 and future NSDUH data products, including for 2023.

Consequently, the definition of the need for substance use treatment was revised beginning with the 2022 NSDUH. Respondents were classified as needing substance use treatment if they had an SUD in the past year, as defined in Section 3.4.3, or they received substance use treatment in the past year, as defined in Section 3.4.4.1. As noted previously, the “other services” described in Section 3.4.4.2 were not counted as substance use treatment. Because the variables for SUD and receipt of substance use treatment in the past year were statistically imputed, the variable for the need for substance use treatment does not have missing data.

3.4.4.5 Perceived Unmet Need for Substance Use Treatment and Reasons for Not Receiving Treatment

Questions about whether respondents perceived an unmet need for substance use treatment and the reasons for not receiving treatment were also revised for the 2022 NSDUH. As noted previously, the questions did not change for 2023.

• These questions were asked only if respondents did not report any substance use treatment in the past year (i.e., inpatient or outpatient treatment, MAT, telehealth treatment, or treatment in a prison, jail, or juvenile detention center).
• Respondents were asked whether they sought treatment rather than being asked whether they made an effort to get treatment.
• Respondents who did not report seeking treatment were asked whether they thought they should get treatment rather than being asked whether they thought they needed treatment.

NSDUH respondents were classified as having a perceived unmet need for substance use treatment if they did not receive substance use treatment in the past year and reported either of the following:

• They did not receive other services (i.e., from a support group, from a peer support specialist or recovery coach, in an emergency room, or detoxification or withdrawal support services), but they sought or thought they should get treatment in the past 12 months for their use of alcohol or drugs.
• They received other services, described in the preceding bullet, but they sought or thought they should get additional professional counseling, medication, or other treatment in the past 12 months for their use of alcohol or drugs.

Questions about reasons for people not receiving substance use treatment (i.e., barriers to treatment) were asked of respondents who reported a perceived unmet need for substance use treatment. The questionnaire changes for 2022 also included an expanded list of possible barriers to the receipt of treatment. For each reason for not receiving treatment, respondents were asked whether that reason was “one of the reasons” or “not one of the reasons” they did not seek or get professional counseling, medication, or other treatment for their use of alcohol or drugs.

Variables for the perceived unmet need for substance use treatment and reasons for not receiving substance use treatment were not statistically imputed and had missing data. Respondents with missing data were excluded from the analyses used to produce published estimates beginning with the 2022 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

3.4.5 Mental Health Treatment

The mental health treatment questions underwent considerable revisions for the 2022 NSDUH; these questions remained the same for 2023. Revisions for 2022 were intended to reflect contemporary changes in the delivery of mental health treatment services. The changes also made the content more similar between the alcohol and drug treatment and the mental health services utilization sections of the questionnaire. The following is a summary of key changes to these questions:

• Adolescents aged 12 to 17 and adults aged 18 or older received the same questions about mental health treatment. Before 2022, adolescents and adults received different sets of questions, such that measures differed for adolescents and adults.
• The instruction was dropped for respondents not to report mental health treatment associated with their use of alcohol or drugs.
• Terminology was updated, and questions were included about newer treatment options.
• Additional inpatient and outpatient locations were provided for adult respondents to report where they received treatment in the past 12 months. As noted previously, adolescents were asked about the receipt of treatment in these same inpatient and outpatient locations.
• The question about the use of medication that was prescribed to help with people’s mental health applied to all respondents, regardless of age. Before 2022, only adults were asked whether they took prescribed medication to help with their mental health.
• The question about treatment received in prison, jail, or a juvenile detention center applied to all respondents, regardless of age. Before 2022, only adolescents were asked whether they received services in a juvenile detention center, prison, or jail.
• The question about the receipt of treatment over the phone or through video (i.e., telehealth treatment) was revised to emphasize that the treatment was from a therapist or other healthcare professional.

Because of these changes, the definition for the receipt of mental health treatment changed beginning in 2022. Estimates from 2022 and later years based on these outcomes should not be compared with estimates from 2021 because of these changes.⁵⁴ However, it would be appropriate to compare the 2023 mental health treatment estimates with those from 2022.

Questions for whether respondents perceived an unmet need for mental health treatment and the reasons for respondents not receiving treatment were also revised for the 2022 NSDUH; these questions did not change for 2023. Specific changes are discussed in Section 3.4.5.3 in the context of measurement of these outcomes.

3.4.5.1 Locations and Types of Services for Mental Health Treatment

Receipt of mental health treatment includes the receipt of treatment in the past year to help people with their mental health, emotions, or behavior that was received in an inpatient location, in an outpatient location, via telehealth, or in a prison, jail, or juvenile detention center. The definition also includes the receipt of prescription medication to help with mental health, emotions, or behavior.

Inpatient treatment was defined as treatment in locations where people stayed overnight or longer and included the following locations:

• a hospital,
• a residential mental health treatment center,
• a residential drug or alcohol rehab or treatment center, or
• some other place the respondent stayed overnight or longer.

Outpatient treatment was defined as treatment people received in locations that did not require them to stay overnight or longer. These measures included the following locations:

• a mental health treatment center as an outpatient;
• a drug or alcohol treatment or rehab center as an outpatient;
• the office of a therapist, psychologist, psychiatrist, or mental health professional;
• a general medical clinic or doctor’s office;
• a hospital as an outpatient;
• a school health or counseling center; or
• some other place as an outpatient.

Variables for the receipt of mental health treatment in the past year in inpatient locations, in outpatient locations, via telehealth, or in a prison, jail, or juvenile detention center were statistically imputed. The variable for the receipt of prescription medication to treat mental health, emotions, or behavior in the past year was also statistically imputed. Consequently, variables since 2022 for the receipt of mental health treatment in the past year do not have missing data.

3.4.5.2 Receipt of Other Services for Mental Health Treatment

The 2023 NSDUH also collected information on the receipt of other services in the past year to help people with their mental health, emotions, or behavior. These other services include the following:

• services from a support group,
• services from a peer support specialist or recovery coach, or
• services in an emergency room or emergency department.

NSDUH did not classify these other services as “mental health treatment.” However, they were included in a separate aggregate measure created to cover the receipt of mental health treatment or other services. Variables for the receipt of other services also were statistically imputed, so these variables do not have missing data.

3.4.5.3 Perceived Unmet Need for Mental Health Treatment and Reasons for Not Receiving Treatment

Questions about whether respondents perceived an unmet need for mental health treatment and the reasons for not receiving treatment were also revised for the 2022 NSDUH. As noted previously, the questions did not change for 2023.

• These questions were asked of respondents of all ages, including those aged 12 to 17, not just adults aged 18 or older.
• These questions were asked only if respondents did not report mental health treatment (i.e., inpatient or outpatient treatment, prescription medication, telehealth treatment, or treatment in prison or jail).
• Respondents were asked whether they sought treatment.
• Respondents who did not report seeking treatment were asked whether they thought they should get treatment.

NSDUH respondents were classified as having a perceived unmet need for mental health treatment if they did not receive mental health treatment in the past year and reported either of the following:

• They did not receive other services (i.e., from a support group, from a peer support specialist or recovery coach, or in an emergency room), but they sought or thought they should get treatment in the past 12 months for their mental health, emotions, or behavior.
• They received other services, described in the preceding bullet, but they sought or thought they should get additional professional counseling, medication, or other treatment in the past 12 months for their mental health, emotions, or behavior.

Questions about reasons for people not receiving mental health treatment (i.e., barriers to treatment) were asked of respondents who reported a perceived unmet need for mental health treatment. The questionnaire changes for 2022 also included an expanded list of possible barriers to treatment for adults aged 18 or older. Beginning in 2022, adolescents aged 12 to 17 were asked about these same barriers. For each reason for not receiving mental health treatment, respondents were asked whether that reason was “one of the reasons” or “not one of the reasons” they did not seek or get professional counseling, medication, or other treatment for their mental health, emotions, or behavior.

Variables for the perceived unmet need for mental health treatment and reasons for not receiving mental health treatment were not statistically imputed and had missing data. Respondents with missing data were excluded from the analyses to produce published estimates beginning with the 2022 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

3.4.6 Definition of County Type

County type is based on the “Rural-Urban Continuum Codes”⁵⁵ developed by the U.S. Department of Agriculture. The county type measure used in 2023 was based on the 2013 Rural-Urban Continuum Codes. Because counties are defined for all NSDUH respondents, the county type measures did not have missing data.

To create the 2013 Rural-Urban Continuum Codes, all U.S. counties and county equivalents were first grouped according to their official metropolitan-nonmetropolitan status (i.e., statistical area definitions), as determined by the OMB in February 2013. This grouping distinguished metropolitan counties by the population size of their metropolitan area and nonmetropolitan counties by their degree of urbanization and adjacency to a metropolitan area. The OMB determined current metropolitan status by applying population and worker commuting criteria to the results of the 2010 census and the 2006‑2010 ACS. No major changes were made in either the metropolitan-nonmetropolitan or urban-rural criteria between 2000 and 2010. However, the decennial census long form was eliminated in 2010, and the OMB used 5‑year average commuting flow data from the 2006‑2010 ACS rather than a point-in-time estimate to delineate metropolitan and micropolitan areas.

Nonmetropolitan counties in the three urban-sized categories were further subdivided by whether the county was adjacent to one or more metropolitan areas. A nonmetropolitan county was defined as adjacent if it physically adjoined one or more metropolitan areas and had at least 2 percent of its employed labor force commuting to central metropolitan counties. Nonmetropolitan counties not meeting these criteria were classed as nonadjacent. The 2006‑2010 ACS commuting flow data were also used to compute adjacency for the 2013 Rural‑Urban Continuum Codes.

Metropolitan and nonmetropolitan categories were subdivided into three metropolitan and six nonmetropolitan categories, resulting in a nine-part county codification.

• Large metropolitan statistical areas (MSAs) (large metropolitan) have a total population of 1 million or more.
• Small MSAs (small metropolitan) have a total population of fewer than 1 million. Small MSAs are further subdivided into two categories:
  • 250,000 to 1 million population; and
  • less than 250,000 population.
• Nonmetropolitan counties were classified according to the aggregate size of their urban population and whether they were adjacent to a metropolitan area. Nonmetropolitan areas include counties in micropolitan statistical areas and counties outside of both metropolitan and micropolitan statistical areas and are classified as follows:
  • urban population of 20,000 or more, adjacent to a metropolitan area (“urbanized adjacent”);
  • urban population of 20,000 or more, not adjacent to a metropolitan area (“urbanized nonadjacent”);
  • urban population of 2,500 to 19,999, adjacent to a metropolitan area (“less urbanized adjacent”);
  • urban population of 2,500 to 19,999, not adjacent to a metropolitan area (“less urbanized nonadjacent”);
  • completely rural or less than 2,500 urban population, adjacent to a metropolitan area (“completely rural adjacent”); and
  • completely rural or less than 2,500 urban population, not adjacent to a metropolitan area (“completely rural nonadjacent”).

For NSDUH, nonmetropolitan counties were categorized as “urbanized,” “less urbanized,” and “completely rural.” 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 are based 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 percentage represented fewer than 20,000 people in the county.

3.4.7 Estimation of Serious and Other Levels of Mental Illness

3.4.7.1 Background

The 1992 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act created SAMHSA and required the new organization to develop a definition and methodology for estimating SMI among adults for use by states in developing their plans for use of block grant funds distributed by SAMHSA. A technical advisory group convened by SAMHSA was tasked with developing a definition of SMI, which was published in the Federal Register in 1993 (SAMHSA, 1993):

Pursuant to Section 1912(c) of the Public Health Service Act, as amended by Public Law 102‑321, “adults with serious mental illness” are defined as the following:

• Individuals aged 18 and over, who currently or at any time during the past year, have had diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM‑III‑R that has resulted in functional impairment, which substantially interferes with or limits one or more major life activities.
• These disorders include any mental disorder (including those of biological etiology) listed in DSM‑III‑R or their ICD‑9‑CM equivalent (and subsequent revisions), with the exception of DSM‑III‑R “V” codes, substance use disorders, and developmental disorders, which are excluded unless they co‑occur with other diagnosable serious mental illness.
• All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity or disabling effects. Functional impairment is defined as difficulties that substantially interfere with or limit role functioning in one or more major life activities including basic daily living skills (e.g., eating, bathing, dressing); instrumental living skills (e.g., maintaining a household, managing money, getting around the community, taking prescribed medication); and functioning in social, family, and vocational/educational contexts.
• Adults who would have met functional impairment criteria during the referenced year without benefit of treatment or other support services are considered to have serious mental illness.

In December 2006, a new technical advisory group was convened by SAMHSA’s Office of Applied Studies (which later became CBHSQ) and the Center for Mental Health Services to solicit recommendations for data collection strategies to address SAMHSA’s legislative requirements. Although the technical advisory group recognized the ideal way to estimate SMI in NSDUH would be to administer a clinical diagnostic interview annually to all adult respondents, this approach was not feasible because of constraints on the interview time and the need for trained mental health clinicians to conduct the interviews. Therefore, the approach recommended by the technical advisory group and adopted by SAMHSA for NSDUH was to utilize short scales in the NSDUH interview to separately measure psychological distress and functional impairment. NSDUH used the resulting data collected from these short scales in a statistical model to predict whether a respondent had mental illness.

To create the model, SAMHSA’s CBHSQ initiated a Mental Health Surveillance Study (MHSS) in 2007 as part of NSDUH to develop and implement methods to estimate SMI. Models using the short scales for psychological distress and impairment to predict mental illness status were developed from a subsample of adult respondents who had completed the NSDUH interview and were administered a clinical psychological diagnostic interview soon afterward. For the clinical interview data, people were classified as having SMI if they had a diagnosable mental, behavioral, or emotional disorder in the past 12 months according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‑IV; American Psychiatric Association, 1994), other than a developmental disorder or SUD, that resulted in substantial functional impairment. This estimation methodology was implemented in the 2008 NSDUH.

To recalibrate estimate(s) of mental illness using DSM‑5 criteria in the future, the Mental Illness Calibration Study (MICS) is being conducted as part of the 2023 and 2024 NSDUHs. At the end of the NSDUH interview, adult respondents are randomly selected and asked to participate in a follow-up clinical interview conducted using DSM‑5 diagnostic criteria. The goal of MICS is to fit a prediction model for SMI among adults aged 18 or older that can be used to create updated model-based estimates of SMI and other mental illness categories at the national and domain levels, such as by age group and race/ethnicity. Instrumentation from the clinical interviews will provide the “gold standard” for the presence of a diagnosable mental disorder and level of functional impairment that will be used in an updated prediction model to estimate mental illness in NSDUH based on the DSM‑5 criteria. For more information on the MICS sample design, see the 2023 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 2: Sample Design Report (CBHSQ, 2024f).

3.4.7.2 Historical Summary of the 2012 Model

The model used for 2023 to predict mental illness was developed for the 2012 NSDUH (subsequently referred to as the “2012 model”). This 2012 model was previously updated from a model developed in 2008 (subsequently referred to as the “2008 model”).

The 2008 model was created from a randomly selected subsample of approximately 1,500 adults in 2008 who had completed the NSDUH interview. Respondents were recruited for a follow-up clinical interview consisting of a diagnostic assessment for mental disorders.⁵⁶ In order to determine the optimal scale for measuring functional impairment in NSDUH, roughly half of the adult respondents were assigned to receive an abbreviated eight-item version of the World Health Organization Disability Assessment Schedule (WHODAS; Novak et al., 2010), and the other half were assigned to receive the Sheehan Disability Scale (SDS; Leon et al., 1997). The WHODAS was chosen as the impairment scale to be administered in the 2009 and subsequent NSDUHs (Office of Applied Studies, 2009), although the SDS is included in NSDUH for measurement of impairment during the most severe depressive episode in the past 12 months. For more information on the 2008 MHSS design and analysis, see Colpe et al. (2009) and Office of Applied Studies (2009). Information about the 2008 model is available in Appendix B of the Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings (CBHSQ, 2013b) and in Section 3.4.7 of the 2020 Methodological Summary and Definitions report (CBHSQ, 2021).

Based on the accumulated MHSS clinical data collected from 2008 to 2012, however, SAMHSA determined the 2008 model had some important shortcomings not detected in the original model fitting because of the small sample of clinical interview respondents in 2008. Specifically, estimates of SMI and AMI among young adults based on the 2008 model were higher than the estimates for this age group based on the clinical interview data. In addition, improvements were needed in the weighting procedures for the MHSS clinical data to account better for undercoverage and nonresponse. Only NSDUH respondents in 2008 who answered their surveys in English were eligible for the clinical follow‑up, and people with mental illness appeared to be more likely to participate in the follow‑up.

Because of these concerns, SAMHSA fit a more accurate model using combined 2008‑2012 clinical data for the 2012 model. To reduce bias and improve prediction, additional mental health-related variables and an age variable were included in the model. In addition, to protect against potential coverage and nonresponse error, alternatives for the weights were applied to the clinical sample data for the model development.

The next sections describe the instruments and items used to measure the variables employed in the 2012 model. Specifically, sections include descriptions of the instrument used to measure mental illness in the clinical interviews, followed by the scales and items in the main NSDUH interviews used as predictor variables in the model (i.e., the Kessler‑6 [K6] and WHODAS total scores, age, MDE, and suicidal thoughts); see Sections 3.4.8 and 3.4.12 for more information on the measurement of MDE and serious thoughts of suicide among adults, respectively. Next, procedures for the MHSS clinical interview sampling and weighting and for developing the 2012 model are described. Section 3.4.7.9 discusses SEs for the mental illness estimates based on the 2012 model. Remaining sections discuss miscellaneous issues for the mental illness variables.

3.4.7.3 Clinical Measurement of Mental Illness

Mental illness was measured in the MHSS clinical interviews using an adapted version of the Structured Clinical Interview for the DSM‑IV‑TR Axis I Disorders, Research Version, Non-patient Edition (SCID‑I/NP) (First et al., 2002) and was differentiated by the level of functional impairment based on the Global Assessment of Functioning (GAF) scale (Endicott et al., 1976).⁵⁷ Past year disorders assessed through the SCID included mood disorders (e.g., MDE, manic episode), anxiety disorders (e.g., panic disorder, generalized anxiety disorder, posttraumatic stress disorder), eating disorders (e.g., anorexia nervosa), intermittent explosive disorder, and adjustment disorder. In addition, the presence of psychotic symptoms was assessed. SUDs were also assessed, although these disorders were not used to produce estimates of mental illness.

• Respondents were classified as having any mental illness (AMI) if they were determined to have any of the mental disorders assessed in the SCID (not including SUDs), regardless of the level of functional impairment.
• Respondents were classified as having low (mild) mental illness if they had any of the mental disorders assessed in the SCID (not including SUDs), but these disorders resulted in no more than mild impairment, based on GAF scores of greater than 59.
• Respondents were classified as having moderate mental illness if they had any of the mental disorders assessed in the SCID (not including SUDs), and these disorders resulted in moderate impairment, based on GAF scores of 51 to 59.
• Respondents were classified as having serious mental illness (SMI) if they had any of the mental disorders assessed in the SCID (not including SUDs), and these disorders resulted in substantial impairment in carrying out major life activities, based on GAF scores of 50 or below. The SMI diagnosis was used as the response variable in both the 2008 and 2012 prediction models.

The SCID and the GAF in combination from the MHSS were considered to be the “gold standard” for measuring mental illness.

3.4.7.4 K6

The K6 in the main NSDUH interview consists of two sets of six questions in the mental health section for adult respondents. These questions ask adult respondents how frequently they experienced symptoms of psychological distress during two different time periods: (1) during the past 30 days, and (2) if applicable, the 1 month in the past year when they were at their worst emotionally. Respondents were asked about the second time period only if they indicated there was a month in the past 12 months when they felt more depressed, anxious, or emotionally stressed than they felt during the past 30 days. All questions had the same response categories:

1All of the time
2Most of the time
3Some of the time
4A little of the time
5None of the time
Don’t know/Refused

The six questions in the K6 scale for the past month are as follows:

NERVE30

During the past 30 days, how often did you feel nervous?

HOPE30

During the past 30 days, how often did you feel hopeless?

FIDG30

During the past 30 days, how often did you feel restless or fidgety?

NOCHR30

During the past 30 days, how often did you feel so sad or depressed that nothing could cheer you up?

EFFORT30

During the past 30 days, how often did you feel that everything was an effort?

DOWN30

During the past 30 days, how often did you feel down on yourself, no good or worthless?

In the 2023 NSDUH, all adult respondents with item nonresponse for these psychological distress items had their scores statistically imputed (see Section 2.3.3). Thus, there were no missing values in the 2023 survey for measures of psychological distress (based on the K6 distress scale) used in the mental illness prediction model. Imputation also mitigated potential effects of nonresponse from adult respondents who broke off the interview before or during the mental health section of the interview.

To create the score corresponding to the past month, the imputation-revised values for the six items for the past 30 days (NERVE30, HOPE30, FIDG30, NOCHR30, EFFORT30, and DOWN30) on the K6 scale were recoded from 0 to 4 so that “all of the time” was coded as 4, “most of the time” as 3, “some of the time” as 2, “a little of the time” as 1, and “none of the time” as 0. Summing across the transformed values for responses in these six items resulted in a score with a range from 0 to 24.

If respondents were asked about a month in the past 12 months when they felt more depressed, anxious, or emotionally stressed than they felt during the past 30 days, they were asked comparable K6 items for that particular month in the past 12 months. The imputation and scoring procedures for these K6 items corresponding to the worst month in the past 12 months were the same as those described previously for the past 30 days.

The maximum of the two K6 total scores for the past 30 days or past 12 months was used for MHSS analysis purposes and in the adult respondents’ final data. If respondents were asked K6 items for both the past 30 days and past 12 months, two K6 total scores were calculated for these periods, and the maximum of the two scores was identified. For respondents who were asked the K6 questions only for the past 30 days, the maximum score was the score for the past 30 days.

An alternative K6 total score was also created from the maximum K6 score. Maximum K6 scores less than 8 were recoded as 0. A maximum score of 8 was recoded as 1, a maximum score of 9 was recoded as 2, and so on, until a score of 24 was recoded as 17 in the alternative score variable. This alternative K6 score was used in the 2012 SMI prediction model because SMI prevalence typically was extremely low for respondents with past year K6 scores of less than 8. The prevalence started increasing only when scores were 8 or greater.

3.4.7.5 WHODAS

The WHODAS was modified for use in a general population survey such as NSDUH by making minor changes to question wording and reducing its length (Novak, 2007). A subset of eight items was found to capture the information represented in the full 16‑item scale with no significant loss of information.

Respondents were asked the WHODAS questions if they reported having at least some symptoms of psychological distress in the past 30 days or in their worst period in the past 12 months at least a little of the time (i.e., their answers yielded a K6 score greater than zero). Similar to the K6 variables, statistical imputation was used to replace missing data in the WHODAS variables (see Section 2.3.3). Thus, there were no missing values in the 2023 survey for measures of adult SMI and other mental illness measures created from a model using the WHODAS scores. Imputation also mitigated potential effects of nonresponse from adult respondents who broke off the interview before or during the mental health section of the interview.

Respondents were not asked the WHODAS questions if their maximum reported K6 score was zero. Respondents had a maximum unimputed K6 score of zero if their response was “none of the time,” “don’t know,” or “refused” in the past 30 days and in their worst period in the past 12 months (if applicable) for all six symptoms of psychological distress. The K6 score was zero if all K6 questions had missing data because respondents answered all questions as “don’t know” or “refused” or if they broke off the interview before being asked the K6 questions. If respondents were not asked the WHODAS questions because of missing data in the K6 questions, but the K6 scores were imputed to a value greater than zero, then missing data in the skipped WHODAS variables also were statistically imputed.

The imputation-revised values for the eight WHODAS items included in the main NSDUH mental health section of the interview were coded on a 0 to 3 scale, with imputed responses of “no difficulty” coded as 0; “mild difficulty” coded as 1; “moderate difficulty” coded as 2; and “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 whether they did not do so because of emotions, nerves, or mental health. Respondents with an imputation-revised value of “yes” to these follow-up questions were subsequently assigned to the “severe difficulty” category. Respondents with an imputation-revised value of “no” to these follow-up questions were assigned to the “no difficulty” category. Summing across these codes for the eight responses resulted in a total score with a range from 0 to 24.

An alternative WHODAS total score was used in the 2012 SMI prediction model starting from the imputation-revised WHODAS items. Individual item scores of less than 2 were recoded as 0 and item scores of 2 to 3 were recoded as 1. The individual alternative item scores then were summed to yield a total alternative score ranging from 0 to 8. Creation of an alternative version of the WHODAS score assumed a dichotomous measure dividing respondents into two groups (i.e., severely impaired vs. less severely impaired) would fit better than a linear continuous measure in models predicting SMI.

3.4.7.6 Suicidal Thoughts, MDE, and Age

In addition to the K6 and WHODAS scales, the 2012 model included the following measures as predictors of SMI: (1) serious thoughts of suicide in the past year, (2) having a past year MDE, and (3) adjusted age, as defined later in this section. The first two variables were added to the model to decrease the error rate in the predictions (i.e., the sum of the false-negative and false-positive rates relative to the clinical interview results). A recoded age variable reduced the bias in estimates for particular age groups, especially for 18- to 25‑year‑olds.

All adult respondents in NSDUH were asked the following question in the mental health section about serious thoughts of suicide: “At any time in the past 12 months, that is from [DATEFILL] up to and including today, did you seriously think about trying to kill yourself?”⁵⁸ Definitions for MDE in the lifetime and past year periods were based on questions in the adult depression section and are discussed in Section 3.4.8. For the modeling, beginning in 2021, missing data from adult respondents for whether they had serious thoughts of suicide or for having a past year MDE were statistically imputed. See the 2022 Editing and Imputation Report (CBHSQ, 2024b) for specifics on how the adult suicidality and MDE measures were imputed for the 2022 NSDUH; these procedures did not change for the 2023 NSDUH.

For respondents aged 18 to 30, an adjusted age was created by subtracting 18 from the respondent’s current age, resulting in values ranging from 0 to 12. For a respondent aged 18, for example, the adjusted age was 0 (i.e., 18 minus 18), and for a respondent aged 30, the adjusted age was 12 (i.e., 30 minus 18). For respondents aged 31 or older, the adjusted age was assigned a value of 12.

3.4.7.7 Sampling and Weighting of the 2012 Model

The target annual respondent sample sizes for the MHSS clinical interviews were 1,500 in 2008 (750 of which received the WHODAS and were used in developing the 2008 model), 500 in 2009 and 2010, and 1,500 in 2011 and 2012. Respondent sample sizes were roughly equal across quarters.

A stratified Bernoulli selection process was used in which all eligible NSDUH respondents were given an independent probability of selection into the MHSS based on their strata. In 2008 and the first two quarters in 2009, stratification was based on K6 scores in an attempt to minimize the variance of the estimate for SMI prevalence. In the last two quarters in 2009, stratification attempted to minimize the variance of the AMI prevalence estimate rather than the variance of the SMI estimate. This change reduced the probability a respondent with an extremely large weight would be selected. Starting from 2010, stratification for the MHSS sample incorporated information on functional impairment levels (WHODAS scores) and age in addition to K6 scores. Younger age groups were undersampled for the MHSS clinical sample to reverse the impact of the oversampling of young adults aged 18 to 25 in the main survey (see Section A.1 in Appendix A in the 2012 NSDUH Mental Health Findings report [CBHSQ, 2013b]). This undersampling of younger age groups resulted in a more equally allocated clinical sample by age. More details about the sample design for the MHSS clinical study can be found in the 2012 Sample Design Report (CBHSQ, 2013a).

Special clinical sample analysis weights were created. Each was the product of the following seven weight components: (1) the NSDUH analysis weight; (2) a coverage adjustment for Hispanics completing the main NSDUH interview in English to account for Hispanics who completed it in Spanish and thus were not eligible for the English-language clinical follow-up interview; (3) the inverse of the selection probability for clinical follow‑up; (4) a refusal adjustment to account for NSDUH respondents who were selected for the MHSS but declined to be contacted for the clinical interview; (5) another nonresponse adjustment to account for MHSS nonresponse among NSDUH respondents who had originally agreed to be recontacted for the clinical interview but did not complete the interview; (6) poststratification adjustments to reduce the variance of the resulting estimates by matching the weighted main NSDUH interview sample by age, gender, race/ethnicity, alternative K6 score, alternative WHODAS score, having had serious thoughts of suicide in the past year, and having had an MDE;⁵⁹ and (7) a yearly scaling factor. The first six weight components were created separately for each year.

The 2012 model was fit by assuming the relationship between SMI and the covariates of the model stayed the same from 2008 through 2012. Because the sample size, sampling allocation, and weight adjustments for the MHSS clinical samples differed across years, gains in statistical efficiency were realized by scaling the weights in each year using the following scaling factors: 12 percent for 2008, 4 percent for 2009, 14 percent for 2010, 35 percent for 2011, and 35 percent for 2012. The scaling factors were determined based on the relative sizes of the estimated variances for estimates of SMI, AMI, and past year MDE made directly from SCID diagnoses.⁶⁰

3.4.7.8 2012 SMI Model

The 2012 SMI prediction model was fit with data from 4,912 WHODAS MHSS respondents from 2008 through 2012. The response variable Y equaled 1 when an SMI diagnosis was positive based on the clinical interview; otherwise, Y was 0. Letting X be a vector of the characteristics attached to a NSDUH respondent and letting the probability this respondent had SMI be , the 2012 SMI prediction model was as follows:

where refers to the estimate of the SMI response probability .

The beta values for equation (1) are displayed in Table 3.8. The following covariates in equation (1) came from the main NSDUH interview data and were statistically imputed:

• = Alternative Past Year K6 Score: Past year maximum K6 score of less than 8 recoded as 0; past year maximum K6 score of 8 to 24 recoded as 1 to 17.
• = Alternative WHODAS Score: WHODAS item score of less than 2 recoded as 0; WHODAS item score of 2 to 3 recoded as 1, then summed for a score ranging from 0 to 8.
• = Serious Thoughts of Suicide in the Past Year: Coded as 1 if “yes”; coded as 0 otherwise.
• = Past Year MDE: Coded as 1 if the criteria for past year MDE were met (see Section 3.4.8);⁶¹ coded as 0 otherwise.
• = Adjusted Age: Coded as age minus 18 if aged 18 to 30; coded as 12 otherwise.

A cut point probability was determined so that if for a particular respondent, then the respondent was predicted to be SMI positive; otherwise, the respondent was predicted to be SMI negative. The cut point (0.260573529) was chosen so that the weighted numbers of false positives and false negatives in the MHSS dataset were as close to equal as possible. The predicted SMI status for all adult NSDUH respondents was used to compute prevalence estimates of SMI. The model is directly related to the probability of being diagnosed with SMI in the MHSS.

A second cut point probability (0.0192519810) was determined so that any respondent with an SMI probability greater than or equal to the cut point was predicted to be positive for AMI, and the remainder were predicted to be negative for AMI. The second cut point was chosen so that the weighted numbers of AMI false positives and false negatives were as close to equal as possible. The model is not directly related to the probability of being diagnosed with AMI in the MHSS.

The 2023 national reports and tables show estimates for AMI, SMI, and “AMI excluding SMI.” Adults with AMI excluding SMI currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder resulting in less than substantial impairment in carrying out major life activities.

3.4.7.9 Standard Errors for Mental Illness Estimates

For the national reports and tables, SEs for mental illness estimates (SMI, AMI, and AMI excluding SMI) were computed using the NSDUH dichotomous variable values without taking into account any variance introduced through using a model based on the clinical subsample data. This ignores the added error resulting from fitting the 2012 SMI model, which can be very large (see the 2012 National Survey on Drug Use and Health: Methodological Resource Book [Section 16a, 2012 Mental Health Surveillance Study: Design and Estimation Report]; CBHSQ, 2014a). These conditional SEs (conditional on the model predictions being correct) are useful when making comparisons across years and across subpopulations (except those involved in modeling) within years because the errors due to model fitting are nearly the same across the estimates being compared.

3.4.7.10 Limitations in Using the Mental Illness Variables in Analyses

There are many advantages to using the cut point methodology described in this section to predict the SMI and AMI status for every adult responding to the NSDUH main survey interview. For some analyses, however, these predicted values should not be used. In particular, these predicted values should not be employed in analyses using the mental illness variables in conjunction with variables used or closely related to variables used in the prediction model. Because variables used in the prediction models would be expected to be correlated with the SMI or AMI probabilities, SMI or AMI should not be estimated for the following groups of adults: among people with past year or lifetime MDE; among people with past year suicidal thoughts, suicide plans, or suicide attempts; or among people with particular K6 or WHODAS scores. For details, see the Estimating Mental Illness among Adults in the United States: Revisions to the 2008 Estimation Procedures report (CBHSQ, 2015).

3.4.8 Major Depressive Episode (Depression)

Two sections related to MDE were included in the 2023 questionnaire: an adult depression section and an adolescent depression section. These sections were originally derived from DSM‑IV criteria for MDE and remained applicable to the more recent DSM‑5 criteria. Consistent with the DSM‑5 criteria, NSDUH does not exclude MDEs occurring exclusively in the context of bereavement. In addition, no exclusions were made for MDEs caused by medication, alcohol, illicit drugs, or any medical illness.

Questions on depression permit estimates to be calculated for the occurrence of MDE in the population and receipt of treatment for MDE. Separate sections were administered to adults aged 18 or older and youths aged 12 to 17. The adult questions were adapted from the depression section of the National Comorbidity Survey Replication (NCS‑R), and the questions for youths were adapted from the depression section of the National Comorbidity Survey Replication Adolescent Supplement (NCS‑A).⁶² To make the sections developmentally appropriate for youths, there are minor wording differences in a few questions between the adult and youth sections. Revisions to the questions in both sections were made primarily to reduce their length and to modify the NCS questions, which were interviewer-administered, for self-administration in NSDUH.

According to DSM‑5, people are classified as having had an MDE⁶³ in their lifetime if they had at least five or more of nine symptoms nearly every day (except where noted) in the same 2‑week period, where at least one of the symptoms is a depressed mood or loss of interest or pleasure in daily activities. These symptoms are as follows:

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 sick or dieting, or weight gain when not pregnant or growing,⁶⁴ or decrease or increase in appetite;
4. insomnia or hypersomnia;
5. psychomotor agitation or retardation at a level observable by others;
6. fatigue or loss of energy;
7. feelings of worthlessness or excessive or inappropriate guilt;
8. diminished ability to think or concentrate or indecisiveness; and
9. recurrent thoughts of death or suicidality (i.e., recurrent suicidal ideation without a specific plan, making a specific plan, or making an attempt).

Unlike the other symptoms, recurrent thoughts of death or suicidality did not need to have occurred nearly every day.

Respondents who have had an MDE in their lifetime are asked whether, during the past 12 months, they had a period of depression lasting 2 weeks or longer while also having some of the other symptoms mentioned previously for the lifetime period. Respondents reporting experiences consistent with their having had an MDE in the past year are asked questions from the SDS to measure the level of functional impairment in major life activities reported to be caused by the MDE in the past 12 months (Leon et al., 1997).

NSDUH measures the nine symptoms associated with MDE as defined in DSM‑5 with the following questions. The questions shown are taken from the adult depression section of the 2023 NSDUH questionnaire. A few of the questions in the youth section were modified slightly to use wording more appropriate for youths aged 12 to 17.

1. Depressed mood most of the day
   
   The following questions refer to the worst or most recent period of time when the respondent experienced any or all of the following: sadness, discouragement, or lack of interest in most things.
   
   During that [worst/most recent] period of time …
   1. … did you feel sad, empty, or depressed most of the day nearly every day?
   2. … did you feel discouraged about how things were going in your life most of the day nearly every day?
2. Markedly diminished interest or pleasure in all or almost all activities most of the day
   1. … did you lose interest in almost all things like work and hobbies and things you like to do for fun?
   2. … did you lose the ability to take pleasure in having good things happen to you, like winning something or being praised or complimented?
3. Weight
   
   In answering the next questions, think about the [worst/most recent] period of time.
   1. Did you have a much smaller appetite than usual nearly every day during that time?
   2. Did you have a much larger appetite than usual nearly every day?
   3. Did you gain weight without trying to during that [worst/most recent] period of time?
      1. … because you were growing?
      2. … because you were pregnant?
      3. How many pounds did you gain?
   4. Did you lose weight without trying to?
      1. … because you were sick or on a diet?
      2. How many pounds did you lose?
4. Insomnia or hypersomnia
   1. Did you have a lot more trouble than usual falling asleep, staying asleep, or waking too early nearly every night during that [worst/most recent] period of time?
   2. During that [worst/most recent] period of time, did you sleep a lot more than usual nearly every night?
5. Psychomotor agitation or retardation
   1. Did you talk or move more slowly than is normal for you nearly every day?
      1. Did anyone else notice that you were talking or moving slowly?
   2. Were you so restless or jittery nearly every day that you paced up and down or couldn't sit still?
      1. Did anyone else notice that you were restless?
6. Fatigue or loss of energy
   1. During that [worst/most recent] period of time, did you feel tired or low in energy nearly every day, even when you had not been working very hard?
7. Feelings of worthlessness
   1. Did you feel that you were not as good as other people nearly every day?
   2. Did you feel totally worthless nearly every day?
8. Diminished ability to think or concentrate or indecisiveness
   1. During that [worst/most recent] time period, did your thoughts come much more slowly than usual or seem confused nearly every day?
   2. Did you have a lot more trouble concentrating than usual nearly every day?
   3. Were you unable to make decisions about things you ordinarily have no trouble deciding about?
9. Recurrent thoughts of death or recurrent suicidal ideation
   1. Did you often think about death, either your own, someone else’s, or death in general?
   2. During that period, did you ever think it would be better if you were dead?
   3. Did you think about committing suicide?

Beginning in 2021, missing data were statistically imputed in variables for whether adult respondents had an MDE in their lifetime and whether adult respondents had an MDE in the past 12 months. MDE variables were not statistically imputed for youths aged 12 to 17. Respondents aged 12 to 17 who had missing data for whether they had an MDE in the past 12 months were excluded from the analyses to produce published estimates for the 2023 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

NSDUH also collects data on impairment using the SDS, which is a measure of impairment due to mental health issues in four major life activities or role domains. These four domains are defined separately for adults aged 18 or older and youths aged 12 to 17 to reflect the different roles associated with the two age groups. See Section 3.4.8.1 for details about the questions for adults and Section 3.4.8.2 for details about the questions for youths. Each role domain consists of four questions, and each item uses an 11‑point scale ranging from 0 (no interference for adults and no problems for adolescents) to 10 (very severe interference for adults and very severe problems for adolescents). The impairment score is defined as the single highest severity level of role impairment across the four SDS role domains. Ratings greater than or equal to 7 on the scale were considered severe impairment.

In addition to past year MDE, NSDUH shows estimates for past year MDE with severe impairment. Estimates for severe impairment are calculated separately for youths and adults because the four domains are slightly different for the two groups. Missing data for MDE with severe impairment were statistically imputed for adults but not for youths aged 12 to 17. Respondents aged 12 to 17 who had missing data for impairment were excluded from the analyses to produce published estimates for MDE with severe impairment in the 2023 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

Because variables for lifetime and past year MDE among adults and MDE with severe impairment in the past year were statistically imputed, the main analysis weight described in Section 2.3.4 was used to produce estimates in national reports and tables for the 2023 NSDUH. For youths aged 12 to 17, the main person-level analysis weight was used to produce estimates of MDE and MDE with severe impairment in the past year because the number of break-offs among youths was minimal.

3.4.8.1 Adult Depression Section: Functional Impairment

The questions pertaining to the four domains of functional impairment for adults aged 18 or older are listed below. The scale is shown below for the first domain but applies to all four domains.

ASDSHOME

Think about the time in the past 12 months when these problems with your mood were most severe.

Using the 0 to 10 scale shown below, where 0 means no interference and 10 means very severe interference, select the number that describes how much these problems interfered with your ability to do each of the following activities during that period. You can use any number between 0 and 10 to answer.

     D

How much did your [depression symptoms] interfere with your ability to do home management tasks, like cleaning, shopping, and working around the house, apartment, or yard?

ASDSWORK

During that time in the past 12 months when your [depression symptoms] were most severe, how much did this interfere with your ability to work?

ASDSREL

How much did your [depression symptoms] interfere with your ability to form and maintain close relationships with other people during that period of time?

ASDSSOC

How much did [depression symptoms] interfere with your ability to have a social life during that period of time?

3.4.8.2 Youth Depression Section: Functional Impairment

The questions pertaining to the four domains of functional impairment for adolescents aged 12 to 17 are listed below. The scale is also shown below for the first domain but applies to all four domains.

YSDSHOME

Think about the time in the past 12 months when these problems with your mood were the worst.

Using the 0 to 10 scale shown below, where 0 means no problems and 10 means very severe problems, select the number that describes how much your [depression symptoms] caused problems with your ability to do each of the following activities during that time. You can use any number between 0 and 10 to answer.

     D

How much did your [depression symptoms] cause problems with your chores at home?

YSDSWORK

During that time in the past 12 months when your [depression symptoms] were worst, how much did this cause problems with your ability to do well at school or work?

YSDSREL

How much did your [depression symptoms] cause problems with your ability to get along with your family during that time?

YSDSSOC

How much did your [depression symptoms] cause problems with your ability to have a social life during that time?

3.4.9 Recovery

Adult respondents aged 18 or older in 2023 were asked up to four questions about their recovery from substance use problems or mental health issues. These questions were in the emerging issues section of the questionnaire. Respondents first were asked whether they thought that they ever have had a problem with their own drug or alcohol use. If adult respondents answered “yes,” they were asked whether they considered themselves to be in recovery or to have recovered from their own problem with drug or alcohol use. These first two questions on recovery from a substance use problem were followed by a set of two similar questions asking adult respondents whether they have ever had a problem with their own mental health and, if so, whether they considered themselves to be in recovery or to have recovered from their own mental health problem.

Adult recovery estimates were included in national reports and tables for the 2023 NSDUH. Estimates of recovery were reported among (1) adults who reported ever having a substance use problem or mental health issue and (2) all adults, regardless of whether they perceived themselves ever to have had a problem. To generate estimates among the total adult population, adults who reported not having a problem were classified as not being in recovery or having recovered from a problem. Respondents were excluded from substance use or mental health analyses if they had unknown information for whether they ever had a substance use problem or mental health issue, respectively. Respondents were also excluded from analyses if they had unknown information for whether they perceived themselves to be in recovery or to have recovered from their respective problem (e.g., if respondents reported ever having had a substance use problem but did not know or refused to report whether they perceived themselves to be in recovery or to have recovered from their substance use problem). For a discussion on how procedures for handling missing data may bias estimates, see Section 3.3.2.

Consistent with the discussion in Section 3.3.3, data users are reminded that these estimates are based on self-reports. Specifically, these estimates reflect adults’ perceptions of whether they had substance use or mental health problems, but not necessarily the clinical assessments of medical or mental health professionals or the internal consistency of respondents’ answers. It is important to note that the terms “problem” and “recovery” were not defined for respondents. Therefore, how respondents subjectively defined these terms may have varied. In addition, data on adults’ perceptions of whether they had a problem with their substance use or mental health and whether they perceived themselves to have recovered or to be in recovery from these problems were not edited relative to data in other sections of the interview for substance use, SUDs, substance use treatment, mental health issues, or the receipt of mental health treatment (see Section 2.3.2). Therefore, perceptions may seem to be inconsistent with substance use and mental health data from earlier sections of the interview.

The emerging issues section occurred in the 2023 NSDUH interview after the mental health and adult depression sections. Also, the recovery variables were not statistically imputed for 2023. Therefore, 2023 estimates for recovery were created using the break-off analysis weight described in Section 2.3.4.

3.4.10 Nicotine Vaping

Questions on vaping of nicotine were included in the nicotine section of the 2023 questionnaire. Respondents aged 12 or older were asked whether they ever vaped nicotine with an e‑cigarette or other vaping device, including devices that may also be called vapes, vape pens, or mods. Respondents were asked to consider any device that heats a liquid containing nicotine into a vapor.

Follow-up questions if respondents reported nicotine vaping in their lifetime were patterned after similar questions for tobacco products and included questions for the first time respondents vaped nicotine (age at first use, and if applicable, the year and month of first use), when respondents last vaped nicotine, and the number of days that respondents vaped nicotine in the past 30 days, if they last vaped nicotine in that period. Associated measures for initiation of nicotine vaping, most recent nicotine vaping, and the frequency of nicotine vaping in the past 30 days were all statistically imputed for 2023 and do not contain missing data. Nicotine vaping measures are comparable between 2022 and 2023.⁶⁵

3.4.11 CNS Stimulant Misuse

CNS stimulants are a group of drugs that include cocaine, methamphetamine, and prescription stimulants. These drugs act in similar ways to stimulate the brain. They produce stimulant effects, such as increased alertness, wakefulness, or energy. They can also produce physical side effects of rapid or irregular heartbeat or increased blood pressure and body temperature (NIDA, 2023a, 2023c, 2024).

An aggregate measure for CNS stimulant misuse was created for inclusion of estimates in national reports and tables for the 2023 NSDUH. Because this aggregate measure includes the misuse of prescription stimulants in addition to the use of cocaine or methamphetamine, it was defined as CNS stimulant misuse.

CNS stimulant misuse data for 2023 were available for the past year and past month, and data for any use of CNS stimulants were available for the past year. Because of potential measurement issues for the lifetime misuse of prescription drugs (see Section 3.3.3.2), lifetime estimates for CNS stimulant misuse and any use were not presented in national reports and tables for the 2023 NSDUH. Measures for CNS stimulant misuse in the past year or past month periods and any use of CNS stimulants in the past year were created according to the most recent time when respondents used or misused these substances. Because the measures were statistically imputed for cocaine use, methamphetamine use, and prescription stimulant misuse for the past year and past month, the aggregate measures for CNS stimulant misuse in those periods had no missing data for 2023. Similarly, the aggregate measure for any CNS stimulant use in the past year had no missing data because the measure for any past year use of prescription stimulants was statistically imputed. Section 3.4.3.2 also describes the creation of measures for CNS stimulant use disorder.

3.4.12 Suicidal Thoughts and Behavior

The 2023 NSDUH included separate sets of questions asking adults aged 18 or older and adolescents aged 12 to 17 whether they had serious thoughts of suicide, made a suicide plan, or attempted suicide in the past 12 months. All adult and adolescent respondents were asked whether they made a suicide plan or attempted suicide regardless of whether they reported that they had serious thoughts of suicide in the past 12 months. Respondents who reported that they made a suicide attempt were asked whether they received medical attention or stayed overnight in the hospital because of their suicide attempt.

3.4.12.1 Suicidal Thoughts and Behavior among Adults

The mental health section of the NSDUH questionnaire included questions about suicidal thoughts and behavior among adults. Beginning in 2021, the variables for suicidal thoughts and behavior among adults were statistically imputed, so these variables had no missing data for 2023. Estimates for suicidal thoughts and behavior among adults in the past year were created for 2023 using the standard analysis weight described in Section 2.3.4.

3.4.12.2 Suicidal Thoughts and Behavior among Adolescents

Questions about adolescents’ suicidal thoughts and behaviors in the past 12 months have been included in the youth experiences section of the questionnaire since the 2022 NSDUH. Unlike the questions for adults, 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 standard response choices for “yes” and “no.” Adolescent respondents also could choose these response choices for “I’m not sure” and “I don’t want to answer” instead of using function keys (as is the practice elsewhere in the interview) for answers of “don’t know” or “refused,” respectively.

Estimates for suicidal thoughts and behavior among adolescents in national reports and tables for 2023 included estimates for “I’m not sure,” and “I don’t want to answer,” in addition to estimates for “yes” and “no.” Responses of “don’t know” were grouped with “I’m not sure,” and refusals were grouped with “I don’t want to answer.” Thus, measures for suicidal thoughts and behavior among adolescents were not statistically imputed for 2023, but adolescent respondents who did not know or refused to report whether they had suicidal thoughts or behavior in the past year were not excluded from analyses. However, adolescents who broke off the interview before reaching these questions were excluded from the analyses.

The 2023 estimates for suicidal thoughts and behavior among adolescents were created using the main analysis weights, with no adjustment because of break-offs. As discussed in Section 2.3.4, review of the 2023 NSDUH data indicated that a small number of adolescents aged 12 to 17 broke off the interview before they reached the youth experiences section where the questions were located for suicidal thoughts and behavior among adolescents.

3.4.13 Modes of Marijuana Use

The marijuana section of the 2023 NSDUH questionnaire included questions to assess the ways that people used marijuana in the past year or past month.⁶⁶ Respondents who reported using marijuana in these periods were asked to report whether they used marijuana in any of the following ways:

• smoking;
• vaping;
• dabbing waxes, shatter, or concentrates;
• eating or drinking;
• putting drops, strips, lozenges, or sprays in their mouth or under their tongue;
• applying lotion, cream, or patches to their skin;
• taking pills; or
• using it in some other way.

Respondents could report that they used marijuana in more than one way in the past year or past month. For example, respondents could report that they smoked marijuana and vaped it in the past year.

3.4.13.1 Data Inconsistencies

The following patterns of inconsistent data could occur for modes of marijuana use:

• Respondents did not report a particular mode of use (e.g., vaping) in the past year or past month but reported “some other way” and specified that mode for using marijuana in that period.
• Respondents did not report a particular mode of use in the past year but reported it as a mode of use for the past month.
• Respondents had missing data for the mode of marijuana use in the past month (i.e., they did not know or refused to report how they used it). However, they reported using marijuana in only one way in the past year.

These inconsistencies were resolved through logical editing procedures. See the 2022 Editing and Imputation Report (CBHSQ, 2024b) for further details; these editing procedures did not change for the 2023 NSDUH.

In addition to mode questions in the marijuana section, questions about marijuana vaping remained in the emerging issues section of the 2023 questionnaire. However, data for marijuana vaping from the emerging issues section were not used in creating the published 2023 estimates for marijuana use in the lifetime, past year, or past month periods or for marijuana vaping in the past year or past month. Consequently, although inconsistencies may remain in the 2023 data for marijuana use and marijuana vaping between the marijuana and emerging issues sections, they will not be reflected in published estimates for 2023.

3.4.13.2 Measures for Modes of Marijuana Use

The 2023 Detailed Tables (CBHSQ, 2024k) and the 2023 Key Substance Use and Mental Health Indicators report (CBHSQ, 2024j) presented past year estimates for all eight specific modes of marijuana use that were described at the beginning of this section, including use in some other way. The 2023 Detailed Tables also present an aggregate “other” category that includes modes for applying lotion, cream, or patches to the skin; putting drops, strips, lozenges, or sprays in the mouth or under the tongue; taking pills; and using marijuana in some other way.

For the 2023 NSDUH, all variables for modes of marijuana use were statistically imputed and do not have missing data. See the 2023 Editing and Imputation Report (CBHSQ, forthcoming b) for further details on the imputation process. This situation differed from 2022 when the variables were imputed only for vaping marijuana in the past year and past month. Because the entire set of variables for modes of marijuana use was imputed, the imputation methods were changed for 2023. These revised methods were also applied to produce imputed variables for all modes of marijuana use for 2022, including revised marijuana vaping variables. Therefore, the past month and past year marijuana vaping estimates for 2022 in the 2023 Detailed Tables may differ from previously published estimates. In addition, 2022 estimates for other modes of marijuana use in the 2023 Detailed Tables may differ from previously published estimates because the variables no longer had missing data.