2024 National Survey on Drug Use and Health (NSDUH):
Methodological Summary and Definitions

1.1 Background on the 2024 NSDUH

Conducted by the federal government since 1971, the 2024 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., people experiencing homelessness and not in shelters), military personnel on active duty, and residents of institutional group quarters, such as jails or 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 2024 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 2024 estimates are comparable with the 2021‑2023 estimates that are calculated with an adjusted weight (see Section 2.3.4.2).

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 2024 NSDUH are presented in five key products:

1. The Key Substance Use and Mental Health Indicators in the United States: Results from the 2024 National Survey on Drug Use and Health report (CBHSQ, 2025g) is a national‐level report focusing on estimates among people aged 12 years or older among the civilian, noninstitutionalized population in the United States. This report presents trends in estimates from 2021 to 2024.
2. The 2024 Companion Infographic Report: Results from the 2021 to 2024 National Surveys on Drug Use and Health (CBHSQ, 2025f) shows selected estimates from 2021 to 2024 among the population aged 12 or older.
3. SAMHSA will produce a series of reports using pooled data from the 2022‑2024 NSDUHs that will examine associations in greater depth between selected demographic characteristics and substance use and mental health indicators. Reports in this series will be available on the NSDUH Data Collection web page.
4. The Results from the 2024 National Survey on Drug Use and Health: Detailed Tables (CBHSQ, 2025h) 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 2023 and 2024 and whether there was a statistically significant change between 2023 and 2024 when applicable. Multiyear tables are also included that show selected estimates for 2021‑2024 and whether there are significant changes between estimates in 2024 and corresponding estimates in 2021‑2023.

Additional 2024 national reports and products can be found on the NSDUH Data Collection web page. State‐level estimates and substate estimates for substance use and mental health outcomes² are also available on SAMHSA’s website.

As in previous years, CBHSQ will construct a public use data file for the 2024 NSDUH that will be available in late 2025 on the NSDUH Data Collection web page. 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 includes the following:

• 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).

The survey excludes the following:

• individuals with no fixed household address (e.g., people experiencing homelessness and not in shelters);
• active‐duty military personnel; and
• residents of institutional group quarters, such as jails or hospitals.

People who are unable to take the survey in either English or Spanish are part of the eligible population but are also excluded.

2.1.1 Coordinated Sample Design for 2014‑2024

A coordinated sample design was developed for the 2014‑2024 NSDUHs. It 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. The 2014‑2024 NSDUH sample design provides a sufficient number of completed interviews to support both state and national estimates.

For the NSDUH 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 within each SSR 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). However, for the 2024 NSDUH, the selection of smaller area segments within census block groups (Stage 3) was eliminated. Selecting the DU samples from larger geographic areas was expected to increase precision.

The coordinated sample design for 2014‑2024 includes a 50 percent overlap in sampled areas within each successive 2‑year period for 2014‑2024 (e.g., 2014‑2015, 2015‑2016, 2016‑2017). 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.

For the 2024 NSDUH, a hybrid field enumeration and address‐based sampling (ABS) approach was used to construct DU frames within sampled areas. Census block groups, or “segments,” 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.⁴ To improve efficiencies and data quality, an electronic listing (eListing) application has been used since 2023 to enumerate DUs in field enumeration segments and to locate sampled DUs during data collection.

Table 2.1 provides the target and achieved sample allocations for the 2024 NSDUH. Adolescents aged 12 to 17 years and young adults aged 18 to 25 years were oversampled. See the 2024 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 2: Sample Design and Experience Report (Center for Behavioral Health Statistics and Quality [CBHSQ], forthcoming b) 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 (DUs²⁹) 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 (SRR³⁰) is defined as the weighted number of successfully screened DUs³¹ divided by the weighted number of eligible DUs (as defined in Table 3.4). Of the 927,672 eligible sampled DUs in 2024, 203,743 were screened successfully, for a weighted SRR of 21.91 percent (Table 3.4).

For the 2024 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 3.5). In the screened DUs, a total of 137,170 people were selected, and completed interviews were obtained from 70,241 of these sampled people, for a weighted IRR of 51.54 percent. In an effort to maximize the IRR, all respondents were offered a $30 incentive to encourage them to complete the 2024 NSDUH interview. To be considered a completed interview, a respondent for the 2024 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 (23.6 percent) and (2) did not participate because the residents were not available, never at home, or did not respond to the web survey (20.3 percent) (Table 3.5). Among demographic subgroups, the weighted IRR was higher among people aged 26 or older (52.8 percent), females (54.0 percent), Black people (54.2 percent), people in the South (52.8 percent), and residents of nonmetropolitan areas (53.2 percent) than among their corresponding counterparts (Table 3.6).

The overall weighted response rate (ORR) of 11.3 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 3.6); 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 in the United States: Results from the 2023 National Survey on Drug Use and Health report (CBHSQ, 2024e) 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 Differences in Past Year Mental Health among Young Adults Aged 18 to 25 (CBHSQ, 2024/2025) 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 2024, 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.³² In 2024, 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.³³

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, not all mental health variables were statistically imputed for 2024 (see Section 3.4.10).

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 2024. 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.³⁴ Among adult web respondents, the majority of the missing data was from interview break‐offs. Break‐offs contributed less to item nonresponse for adolescents aged 12 to 17 than for adults. Unlike adults, item nonresponse was generally lower for adolescents who completed the survey via the web than it was for those who were interviewed in person.

The questions about 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.³⁵ 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 2024 (see Section 3.4.8), 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 having enough knowledge about these topics. Some questions in the NSDUH interview also gave respondents the option of choosing responses such as “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. See Section 3.4.13 for more information on these response choices for suicidal thoughts and behavior among adolescents and the reporting of associated estimates.

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 in the mental health and later sections of the interview for the 2024 NSDUH. However, some mental health or other variables in later sections of the 2024 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 adolescents between the ages of 12 and 17 who were exposed to school‐based substance use prevention messages. This analysis includes a domain variable for adolescents who attended school in the past 12 months (including those who were homeschooled) and multiple outcome variables, which consist of whether adolescents 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 adolescents. Assuming that some of these adolescents 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 2023 Statistical Inference Report (CBHSQ, 2025d).

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.

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 issue discussed in this section is the reporting of sensitive topics in web surveys.

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 adolescents and young adults reported their recent drug use accurately in self‐reports (Harrison et al., 2007).³⁶

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 since the 2020 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 if they feel assured that the privacy of their answers will be protected. 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.

Some research suggests that web surveys can provide respondents with a greater sense of anonymity and privacy for reporting on sensitive topics such as substance use (Lygidakis et al., 2010; Miller & Sønderlund, 2010). Beckalova and Drapalova (2022) noted the following limitations of web surveys for collecting data on substance use:

• To reach populations of substance users who may not be commonly found in general population surveys, web surveys are often based on nonprobability samples, such that inferences cannot be made about substance use in the broader population.
• Web surveys may have higher rates of item nonresponse and break‐offs because an interviewer is not present to answer respondents’ questions or keep respondents motivated to complete the interview.
  • NSDUH requires respondents to have answered a minimum set of substance use questions in order for their interviews to be considered usable (see Section 2.3.1).
  • Nevertheless, a higher rate of break‐offs has been noted among adult NSDUH respondents who completed their interviews via the web (see Section 2.3.4). A special break‐off analysis weight has been used to create estimates for specific measures that were not statistically imputed.
• Web survey respondents could be prone to “satisficing,” in which they answer questions in a manner to reduce the amount of time to complete the survey. However, a study in four northern European countries with high Internet coverage that compared survey administration via the web or a paper questionnaire did not support the assumption that web survey respondents are more prone to satisficing behavior (Clement et al., 2023).

The Monitoring the Future (MTF) study for 2023 uses a probability sample and since 2021 has used a web‐based questionnaire to collect data from 8th, 10th, and 12th graders. Students since 2021 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 adolescent substance use estimates across national surveys (CBHSQ, 2012).

For the 2024 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—recent 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 2024 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 2024 national reports and tables.

The prescription drug questions in 2024 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, 2024 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.³⁷

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 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.³⁸ See Section 2.2.2 in the 2022 Methodological Summary and Definitions report (CBHSQ, 2023).

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. The race questions were placed in a self‐administered demographic section because some questions that were added for 2023 were considered sensitive and better suited for self‐administration. The 2022‑2024 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

The change from interviewer administration to self‐administration for the race question in the 2023 in‑person questionnaire 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). This change was driven by the increase in missing data among respondents who completed the interview in person; the missing data percentages were consistent between years for those who completed the survey via the web because these questions were always self‐administered for web respondents. In 2024, the percentage of respondents who did not know or refused to answer the race question continued to be higher than the percentage from 2022. Specifically, the numbers and percentages of respondents with missing data for race in 2024 were about 1,250 (1.8 percent) regardless of mode; about 250 (0.9 percent) for web; and about 950 (2.3 percent) for in person. More information on item nonresponse can be found in Section 3.3.2.1. For additional information on changes to the race question for the 2022 NSDUH questionnaire that also increased the percentage of respondents who did not know or refused to answer the race question, see the 2022 Methodological Summary and Definitions report (CBHSQ, 2023).

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 questionnaire and change of the in‑person questions to being self‐administered in 2023, the unweighted number of in‑person non‐Hispanic American Indian or Alaska Native respondents more than doubled from 2021 to 2023 (around 460 to 1,130), and the corresponding unweighted percentage increased over this period (from 1.5 to 2.6 percent of in‑person respondents). In 2024, the number and percentage of in‑person respondents who reported that they were American Indian or Alaska Native were similar to those in 2023 (1,000 people and 2.4 percent). As for item nonresponse, there was little change for web respondents between 2022 and 2024.

NSDUH data that are published in the 2024 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 2022‑2024 did not change compared with the procedures for 2021. The NSDUH weighted population counts were consistent with those from prior years. Despite the weighted population size for non‑Hispanic American Indian or Alaska Native people being consistent between years, caution is nevertheless advised in comparing outcomes for this group from 2021 with outcomes from 2022 and later years due to the change since 2022 in the unweighted number of respondents for this group.

3.4 Measurement Issues

Several measurement issues that are presented in the 2024 NSDUH data products are discussed in this section. Issues addressed include the methods for measuring the use of inhalants, central nervous system (CNS) stimulant use, use and misuse of fentanyl (including illegally made fentanyl [IMF]), nicotine vaping, experiences among adolescents aged 12 to 17, the initiation of substance use or misuse of prescription drugs, SUDs, and substance use treatment. Additionally, this section discusses the mental health measures for AMI, SMI, receipt of mental health treatment, symptoms of generalized anxiety disorder (GAD), MDE, and suicidality. Starting with Section 3.4.14, topics are discussed for modes of marijuana use, recovery, and the definition of county type.

This section also discusses how missing data were handled analytically to produce the estimates found in the national reports and tables for the 2024 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 Inhalant Use

Questions for inhalant use were revised for the 2024 NSDUH. The introductory language for the inhalants section was revised for brevity, and the individual inhalant question wordings were revised from asking about use of inhalants “for kicks or to get high” to “for fun or to get high.” The wording update was intended to make the questions more relatable and understandable, especially for younger respondents. Review of the final data from all 12 months of 2024 indicated that this change in questionnaire wording affected the reporting of the use of inhalants, especially among adolescent respondents aged 12 to 17.

Consequently, estimates in 2024 data products based on questions from the inhalants section of the interview were considered not to be comparable with those in data products from prior years for the following:

• lifetime, past year, and past month use of any inhalant;
• lifetime use of all specific inhalants (e.g., amyl nitrite, poppers, locker room odorizers, or Rush; correction fluid, degreaser, or cleaning fluid; gasoline or lighter fluid);
• past year initiation of inhalant use, including risk for initiation, age at first use, and the date of first use (see Section 3.4.6); and
• past year and past month frequency of use (i.e., number of days used).

Estimates in 2024 data products also were considered not to be comparable with those in data products from prior years for the use of illicit drugs other than marijuana in the lifetime, past year, and past month because a relatively large proportion of people who used illicit drugs other than marijuana used inhalants.

The change in question wording for inhalants did not appear to affect the comparability of estimates between 2024 and prior years for the overall use of any illicit drug in the lifetime, past year, and past month and for inhalant use disorder in the past year. However, investigations into comparability were limited and may not cover other comparisons that data users want to make.

The variables for the measure of inhalant use, initiation of inhalant use, and frequency of use were statistically imputed and have no missing data. Variables for specific lifetime inhalants (e.g., amyl nitrite, poppers, locker room odorizers) were not imputed and contain missing data.

3.4.2 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, 2023, 2024a, 2024c).

An aggregate measure for CNS stimulant misuse was created for inclusion of estimates in national reports and tables for the 2024 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 2024 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 2024 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 2024. 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 3.4.7.2 also describes the creation of measures for CNS stimulant use disorder.

3.4.3 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., 2025). 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). Although the age‐adjusted death rates for drug overdose deaths involving any opioid or synthetic opioids other than methadone decreased between 2022 and 2023 (Garnett & Miniño, 2025), age‐adjusted rates of drug overdose deaths from 2016 to 2021 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).³⁹

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 2024 Detailed Tables (CBHSQ, 2025h) 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.

3.4.4 Nicotine Vaping

Questions on vaping of nicotine were included in the nicotine section of the 2024 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 and do not contain missing data. Nicotine vaping measures are comparable for 2022‑2024.⁴⁰

3.4.5 Youth Experiences

This section focuses on changes to existing questions in the youth experiences section for the 2024 NSDUH (see Section 2.2.2) and implications for analyses. Section 2.2.2 also lists questions from this section that were dropped from the 2024 questionnaire. Analyses were conducted using data from the first 6 months of 2024 to verify that deletion of these questions did not affect how respondents answered subsequent questions.

Starting with the 2024 NSDUH, response options were revised for questions corresponding to how respondents aged 12 to 17 think their parents would feel about them using substances. Response options also were revised for questions corresponding to how respondents would feel about their peers using substances. Two new response options were added for “strongly approve” and “somewhat approve.” The response option order was also reversed to begin with “strongly disapprove” as a first option and “strongly approve” as the last option. Prior to 2024, response options for these questions were limited to “neither approve nor disapprove,” “somewhat disapprove,” and “strongly disapprove.” The following behaviors were asked about in these questions:

• smoking cigarettes every day,
• trying marijuana or any cannabis product,
• using marijuana or any cannabis product once a month or more, and
• having one or two alcoholic beverages nearly every day.

Also beginning in 2024, the question measuring screen time was revised to ask respondents aged 12 to 17 how often their parents limited the amount of time spent with television, tablets, smartphones, computer, or video games. Prior to 2024, respondents were asked specifically how often their parents limited the amount of time they watched television in the past 12 months.

Because of these changes for 2024, these measures are not considered comparable with those from prior years.

Respondents with missing data for these measures were excluded from the analyses to produce published estimates for the 2024 NSDUH. For a discussion on how procedures for handling missing data may bias estimates, see Section 3.3.2.

In addition, some questions in the youth experiences section of the survey ask for an opinion or a perception. As mentioned previously, for example, respondents aged 12 to 17 were asked what they thought their parents would think about them using or trying cigarettes, marijuana, or alcohol. If respondents do not know what their parents would think, a response of “don’t know” can be an informative and valid response.⁴¹ Also, analyses of data from these types of questions that exclude responses of “don’t know” could include bias. See Section 3.3.2 for more information on bias.

3.4.6 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.⁴² All of the initiation variables used to create published estimates for the 2024 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 of a substance 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 first use of a substance (or misuse for psychotherapeutic drugs) was within the 12 months prior to their interview date.⁴³ 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 3.1, 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.⁴⁴ 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).⁴⁵ Section 4.6.3 discusses additional issues for the measurement of initiation of benzodiazepine misuse. For these reasons, the 2024 national reports and tables do not show past year initiation estimates for the aggregate categories of illicit drugs,⁴⁶ prescription psychotherapeutic drugs, opioids, benzodiazepines, the aggregate category for tranquilizers or sedatives, or CNS stimulants.

NSDUH does not collect initiation data for pipe tobacco. In addition, NSDUH does not collect initiation data on marijuana vaping or vaping of flavoring. Thus, the 2024 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 percentage and number of people initiating use of a substance in the past year, 2024 NSDUH estimates were created for the following:

• risk for initiation, and
• mean age at first use or misuse among people who initiated use or misuse of a substance in the past year.

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

NSDUH cannot identify people at risk for initiation of use for the aggregate categories of either tobacco products or tobacco products or nicotine vaping because respondents were not asked when they first used pipe tobacco. NSDUH also cannot identify people at risk for initiation of illicit drug use, use of illicit drugs other than marijuana, misuse of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives), benzodiazepines, misuse of opioids, misuse for the aggregate category for tranquilizers or sedatives, and misuse of CNS stimulants.

Estimates were computed for the mean age at first use or misuse among people who initiated use or misuse of a given substance in the past year. 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 2024 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).

For the 2024 NSDUH, questions for inhalant use were revised from asking about use of inhalants “for kicks or to get high” to “for fun or to get high” (see Section 2.2.2). This change in the questionnaire wording appeared to have affected how respondents answered questions about the use of inhalants, especially among adolescent respondents aged 12 to 17. Consequently, estimates in 2024 data products for past year initiation of inhalant use, including risk for initiation and the mean age at first use among past year initiates, were considered not to be comparable with those in data products from prior years. See Section 3.4.1 for more details on this change to the inhalant use questions.

3.4.6.1 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 2024 and the statistically imputed month, day, and year of first use of the relevant substance. (If respondents reported first use in calendar year 2023, 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 2024 Detailed Tables (CBHSQ, 2025h) show all three of these percentages.

3.4.6.2 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 3.2 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). See the 2023 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 10: Editing and Imputation Report (CBHSQ, 2025c) for more information.

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 2024 national reports and tables present estimates for 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 2024 Detailed Tables (CBHSQ, 2025h) 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 2024 Detailed Tables (CBHSQ, 2025h).

3.4.7 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 2024 Detailed Tables. Estimates for SUD and SUD severity for alcohol and drugs are included in national reports and tables for the 2024 NSDUH.

3.4.7.1 Nicotine Dependence

For nicotine, questions pertaining to dependence were based on the Nicotine Dependence Syndrome Scale (NDSS; Shiffman et al., 1995, 2004) and the Fagerström Test of Nicotine Dependence (FTND; Fagerström, 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 2024 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 2024 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 2024 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.

3.4.7.2 Substance Use Disorder for Drugs and Alcohol

SUD estimates for drugs and alcohol in the 2024 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, 2021b).

Users of NSDUH reports and tables also should be aware that questions about the use of IMF appear after SUD questions (see Section 3.4.3 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 2024 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 3.7 shows how these 11 DSM‑5 SUD criteria apply to substances in NSDUH. For prescription opioids, tranquilizers, stimulants, and sedatives, Table 3.7 also shows how these criteria apply if respondents misused these prescription drugs, or if they simply used but did not misuse them 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 the 12‑month period before the interview.

For alcohol, marijuana, cocaine, heroin, and methamphetamine, all 11 criteria applied (see Table 3.7). 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 3.7, the applicable DSM‑5 criteria for classifying respondents as having an SUD 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 3.7 applied. However, if respondents used but did not misuse prescription drugs in the past year, only the first 9 criteria shown in Table 3.7 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 3.8 lists the substances that were included in aggregate SUD measures in the 2024 NSDUH. Questions are asked about SUD symptoms that respondents specifically attributed to their use in the past year of cocaine, heroin, methamphetamine, prescription pain relievers, prescription tranquilizers, prescription stimulants, and prescription sedatives. However, DSM‑5 groups these substances into a smaller set of categories for classifying people as having SUDs.

• Cocaine, methamphetamine, and prescription stimulants are included in an overall category for stimulants (referred to in NSDUH as CNS stimulants to differentiate between stimulants that are available by prescription and those that are not).
• Heroin and prescription pain relievers that are opioids are included in an overall category for opioids.
• Prescription tranquilizers and sedatives are included in an overall category for sedatives, hypnotics, and anxiolytics (referred to in NSDUH as prescription tranquilizer or sedative use disorder).

The 2024 Key Substance Use and Mental Health Indicators report (CBHSQ, 2025g) focused on aggregate SUD measures for consistency with the substance categories in the DSM‑5 criteria. The 2024 Detailed Tables (CBHSQ, 2025h) and appendix tables in the 2024 Key Substance Use and Mental Health Indicators report continue to show estimates for SUDs that people attributed to the use of these specific substances.

3.4.7.2.1 Prescription Pain Reliever and Opioid Use Disorder Changes

As discussed in Section 2.2.2, new “OTHER, Specify” questions for any use of other prescription pain relievers were added to the 2024 NSDUH questionnaire to capture details on whether respondents used opioid or nonopioid pain relievers. Section 4.4 contains more information on how these new questions were used to create measures for the use and misuse of prescription opioids for 2024. Section 4.4 also discusses how measures for the use and misuse of prescription opioids were created for 2021‑2023 without the availability of these “OTHER, Specify” questions for any use of other prescription pain relievers.

Using this information for the use and misuse of prescription opioids, a new measure for prescription opioid use disorder was created and reported in 2024 data products. Beginning with the 2024 NSDUH, respondents were not counted as having an opioid use disorder in the past year if they used prescription pain relievers but not prescription opioids in the past year and they did not use heroin in the past year.⁵² Respondents also were not counted as having an opioid use disorder if they did not meet the full SUD criteria individually for heroin or prescription opioids. To allow trends in opioid use disorder to be presented for 2021‑2024 in NSDUH data products, similar measures of opioid use disorder were created for 2021‑2023. Because “OTHER, Specify” data for any use of other pain relievers were not available for these prior years, respondents were assumed not to have used prescription opioids in the past year if they reported the use of only “other” pain relievers (see Section 4.4.5 and Figure 4.7). A measure of prescription pain reliever use disorder in the past year continued to be created for 2024 for use in creating measures for any SUD, drug use disorder, and prescription drug use disorder, but this measure was not used to estimate opioid use disorder (Table 3.8).

3.4.7.2.2 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 3.8. 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. SUD severity measures for prescription pain reliever use disorder and prescription opioid use disorder were also updated based on the changes described in Section 3.4.7.2.1 to be consistent with their respective SUD variables. SUD severity measures for CNS stimulant use disorder, opioid use disorder, and tranquilizer or sedative use disorder in the 2024 Key Substance Use and Mental Health Indicators report (CBHSQ, 2025g) focused on whether people had an SUD that they attributed to illicit drug use within that category (e.g., heroin use or the misuse of prescription opioids), or they had an SUD that they attributed only to the use but not misuse of prescription drugs (e.g., use but not misuse of prescription opioids).

3.4.7.2.3 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 [cannabis] use disorder; Table 3.7) as well as the composite SUD variables (e.g., drug use disorder; Table 3.8) 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. Further documentation of imputation procedures for SUD measures other than the SUD measures with changes for 2024 can be found in the 2023 Editing and Imputation Report (CBHSQ, 2025c). Information on changes to imputation procedures for SUD measures for 2024 is expected to appear in the 2024 Editing and Imputation Report (CBHSQ, forthcoming c).

3.4.7.2.4 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 41,000 respondents (unweighted) reported past year alcohol use in 2024.⁵³ Of these, fewer than 50 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 600 respondents in 2024 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 15 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.

3.4.8 Substance Use Treatment

The substance use treatment questions underwent considerable revisions for the 2022 NSDUH. 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 medications for alcohol use disorder (MAUD) or medications for opioid use disorder (MOUD) were added to the section.

New follow‑up questions were added to the 2024 NSDUH for respondents who reported that they received treatment in an inpatient or outpatient location but they did not report any substances for which they received treatment (see Section 2.2.2). These respondents were given a second opportunity to specify the substances for which they received inpatient or outpatient treatment or to enter “None” if they did not receive treatment.

Starting in June 2024, additional changes were included in the questionnaire to improve respondent understanding of whether they received treatment for their use of alcohol or drugs at specific inpatient or outpatient locations (see Section 2.2.2). The following changes were made:

• Introductory text for questions about inpatient and outpatient treatment was revised to mention “any of the locations below” for response choices for specific locations.
• For each inpatient and outpatient location that was presented to respondents, text was added to indicate that the treatment was “for alcohol or drug treatment.” For example, the response option for a mental health treatment center as an outpatient was revised to mention a mental health center as an outpatient “for alcohol or drug treatment.”
• In the grid format for respondents to report the locations where they received inpatient treatment, the heading “Stayed overnight or longer for alcohol or drug treatment in…” was replaced with “LOCATION.”
• In the grid format for respondents to report the locations where they received outpatient treatment, the heading “Received outpatient alcohol or drug treatment at…” was replaced with “LOCATION.”

Because of the changes in 2022, the definition for the receipt of substance use treatment changed. Therefore, estimates from 2022 based on these outcomes should not be compared with estimates from 2021.

Analysis of the data from June to December 2024 indicated that the changes implemented in June 2024 not only reduced the number of respondents who did not report the specific substances for which they received inpatient or outpatient treatment (see Section 3.4.8.3) but also affected reporting of the receipt of treatment in inpatient and outpatient locations. As a consequence of these changes, substance use treatment estimates overall and for inpatient or outpatient locations from 2024 are not comparable with those from 2022 and 2023. The substance use treatment estimates from 2024 for the receipt of MAUD or MOUD, treatment via telehealth, and treatment in a prison, jail, or juvenile detention center (see Section 3.4.8.1) are still comparable with estimates from 2022 and 2023. For measures of the receipt of specific other services described in Section 3.4.8.2 that were available for 2021‑2024, estimates also remain comparable with estimates from 2022 and 2023.⁵⁴ Work will be performed for the 2025 NSDUH to allow trends to be presented for the receipt of substance use treatment from 2022 to 2025.

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. Due to the additional changes for 2024 that were described previously, estimates from 2024 for the perceived unmet need for substance use treatment and reasons for not receiving treatment also are not considered comparable with corresponding estimates from prior years. Specific changes are discussed in Section 3.4.8.5 in the context of the measurement of these outcomes.

3.4.8.1 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 MAUD or MOUD.

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.

MAUD and MOUD questions were revised and asked in the alcohol or drug treatment section for 2022 in the context of questions about other substance use treatment in the past 12 months. Therefore, estimates for MAUD and MOUD since 2022 are not comparable with MAUD and MOUD estimates from the 2021 NSDUH that were based on questions in the emerging issues section of the questionnaire. However, the 2024 MAUD and MOUD estimates are comparable with the 2022 and 2023 estimates.

As mentioned previously, however, estimates from 2024 based on variables for any receipt of substance use treatment in the past year and receipt of treatment in inpatient and outpatient locations are not comparable with estimates from 2022 and 2023. Estimates from 2024 for the receipt of treatment via telehealth and treatment in a prison, jail, or juvenile detention center remain comparable with estimates from 2022 and 2023.

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 MAUD and MOUD in the past year. Consequently, variables since 2022 for the receipt of substance use treatment in the past year do not have missing data.

3.4.8.2 Receipt of Other Services for Substance Use

The 2024 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,
• withdrawal management services, or
• receipt of overdose reversal medicine such as Narcan^® or naloxone.

NSDUH did not classify these other services as “substance use treatment.” For example, the subject matter experts who worked with SAMHSA to develop the revised substance use treatment questions for 2022 thought that services in an emergency room or emergency department and withdrawal management services were primarily intended to treat acute medical conditions, such as an overdose or withdrawal symptoms, rather than to engage patients in a longer term process of change to promote recovery from SUDs. Experts also did not consider services from a support group or recovery coach to be substance use treatment because of issues related to licensure or reimbursement for services.

However, these other services were included in a separate aggregate measure presented in the 2024 Detailed Tables (CBHSQ, 2025h) that was created to cover the receipt of substance use treatment or other services. A question about the receipt of overdose reversal medicine was added to the questionnaire, and the associated measure for the receipt of overdose reversal medicine was included in this aggregate measure beginning in 2024.

Because of the changes to the inpatient and outpatient questions in June 2024 and the addition of this new question on receipt of overdose reversal medicine in 2024, the estimates from 2024 for the aggregate measure of the receipt of substance use treatment or other services are not comparable with those from prior years. However, estimates from 2024 for specific services from a support group through withdrawal management services that were mentioned previously remained comparable with estimates from 2022 and 2023. Variables for the receipt of other services also were statistically imputed, so these variables do not have missing data.

3.4.8.3 Substances for Which People Received Treatment or Other Services

If respondents in the 2024 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. Except for the receipt of overdose reversal medicine, respondents who received other services in the past year, as described in Section 3.4.8.2, also were asked to report whether they received these services for alcohol use only, drug use only, or both alcohol and drug use.

For MAUD and MOUD, the questions applied specifically to the use of alcohol or opioids. Respondents who reported lifetime use of alcohol were asked whether they received medication in the past 12 months that was prescribed to them to help them cut back on or stop their use of alcohol. Examples of medications shown to respondents that are prescribed as a part of MAUD included the following:

• acamprosate (also known as Campral^®),
• disulfiram (also known as Antabuse^®),
• naltrexone pills (also known as ReVia^® or Trexan^®), and
• injectable naltrexone (also known as Vivitrol^®).

Respondents who reported the lifetime use of heroin or prescription pain relievers were asked whether they received medication in the past 12 months to help them cut back on or stop their “drug use,” but this question was asked only if respondents reported lifetime use of the drugs mentioned previously. Examples of medications shown to respondents that are prescribed as a part of MOUD included the following:

• methadone,
• buprenorphine or buprenorphine‐naloxone pills or film taken by mouth (also known as Suboxone^®, Zubsolv^®, Bunavail^®, or Subutex^®),
• injectable buprenorphine (also known as Sublocade^®),
• buprenorphine implants (also known as Probuphine^®),
• naltrexone pills (also known as ReVia^® or Trexan^®), and
• injectable naltrexone (also known as Vivitrol^®).

Because of this list of drugs in the questionnaire, respondents who used prescription pain relievers but not heroin in their lifetime and who reported receiving prescription medication in the past year to help reduce or stop their use of drugs were assumed to have received MOUD.

3.4.8.3.1 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 2024, 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.

As mentioned previously, new follow‑up questions were added to the 2024 NSDUH for respondents who reported that they received treatment in an inpatient or outpatient location but they did not report any substances for which they received treatment. These respondents were given a second opportunity to specify the substances for which they received inpatient or outpatient treatment or to enter “None” if they did not receive treatment. For example, respondents could enter “None” if they made a mistake in their previous reports of inpatient or outpatient treatment. If respondents entered “None” on follow‑up, it logically would follow that they did not receive treatment. Consequently, data from these respondents could overestimate the percentages of people who received any substance use treatment, inpatient treatment, or outpatient treatment if these respondents had not received treatment for their use of alcohol or drugs. For the 2024 NSDUH reports and tables, substance use treatment estimates from 2024 do not incorporate information from these new follow‑up questions.

As was mentioned in Section 3.4.8, additional questionnaire changes were included in June 2024 to improve respondent understanding of whether they received treatment for their use of alcohol or drugs at specific inpatient or outpatient locations. Analysis of the data from June to December 2024 indicated that these changes reduced the number of respondents in the “substance unspecified” categories. As a consequence of these changes, however, estimates from 2024 for any treatment for the use of specific substances and estimates for inpatient and outpatient treatment for the use of specific substances are not comparable with those from prior years. Work will be performed for the 2025 NSDUH to allow trends to be presented for the receipt of substance use treatment from 2022 to 2025.

3.4.8.3.2 Substances for Which People Received Treatment via Telehealth; in a Prison, Jail, or Juvenile Detention Center; or through Other Services

Respondents who reported (1) substance use treatment via telehealth; treatment in a prison, jail, or juvenile detention center; or the receipt of other substance use services (see Section 3.4.8.2), except for the receipt of overdose reversal medicine; and (2) 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. Whether respondents received other services for the use of alcohol only, drugs only, or both alcohol and drugs did not apply to the question about overdose reversal medicine because this question was specific to drug use.

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. 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.

Variables for the substances for which respondents received treatment in these locations were not statistically imputed. However, the procedures for creating recoded variables for the receipt of telehealth treatment for the use of alcohol or the use of drugs that were reported in 2024 NSDUH data products reduced the amount of missing data by incorporating data from statistically imputed variables for the lifetime use of alcohol and drugs. Any remaining respondents with missing data were excluded from the analyses to produce published estimates for the 2024 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

Estimates for the substances for which people received treatment via telehealth or in a prison, jail, or juvenile detention center remain comparable with estimates from 2022 and 2023. Estimates for the substances for which people received other services also remain comparable with estimates from 2022 and 2023.

3.4.8.4 Need for Substance Use Treatment

Before 2022, NSDUH data products 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.

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 3.4.7, or they received substance use treatment in the past year, as defined in Section 3.4.8.1. As noted previously, the “other services” described in Section 3.4.8.2 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.

People who received substance use treatment in the past year were classified as needing substance use treatment. The changes to the questions for inpatient and outpatient treatment in June 2024 that were described previously also affected the need for substance use treatment measure. Consequently, estimates from 2024 for the need for substance use treatment are considered not to be comparable with estimates from 2022 and 2023.

3.4.8.5 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. The questions did not change for 2024.

• These questions were asked only if respondents did not report any substance use treatment in the past year (i.e., inpatient or outpatient treatment, MAUD or MOUD, 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 services from a support group, from a peer support specialist or recovery coach, in an emergency room, or from withdrawal management services, but they sought or thought they should get treatment in the past 12 months for their use of alcohol or drugs.
• They received the other services described in the preceding bullet (see Section 3.4.8.2), 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.⁵⁵

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.

Although questions for the perceived unmet need for substance use treatment and reasons for people not receiving treatment did not change for 2024, the questions for inpatient and outpatient treatment changed in June 2024, as described previously. These changes affected who was eligible to receive questions about unmet need. Consequently, estimates from 2024 for the perceived unmet need for substance use treatment and reasons for not receiving treatment are considered not to be comparable with estimates from 2022 and 2023.

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 for these measures. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

3.4.9 Estimation of Serious and Other Levels of Mental Illness

3.4.9.1 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 within SAMHSA 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, a Mental Health Surveillance Study (MHSS) was initiated 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 subgroup 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 for use 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, 2024a) or the 2024 National Survey on Drug Use and Health (NSDUH) Methodological Resource Book, Section 2: Sample Design and Experience Report (CBHSQ, forthcoming b).

3.4.9.2 Historical Summary of the 2012 Model

The model used for 2024 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, 2021b).

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 3.4.12 and 3.4.13 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 3.4.9.9 discusses SEs for the mental illness estimates based on the 2012 model. Remaining sections discuss miscellaneous issues for the mental illness variables.

3.4.9.3 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.

3.4.9.4 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 2024 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 2024 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.

3.4.9.5 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 2024 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.

3.4.9.6 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 3.4.12. 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 2023 Editing and Imputation Report (CBHSQ, 2025c) for more information on how the adult suicidality and MDE measures were imputed for the 2023 NSDUH; these procedures did not change for the 2024 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.

3.4.9.7 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 Hispanic people who completed the main NSDUH interview in English to account for Hispanic people 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, sex, 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

3.4.9.8 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 3.9. 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 3.4.12);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 2024 national reports and tables show estimates for AMI and SMI. The 2024 Detailed Tables (CBHSQ, 2025h) also show estimates for “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.

3.4.9.9 Standard Errors for Mental Illness Estimates

For the national reports and tables, SEs for mental illness estimates (SMI, AMI, and AMI excluding SMI⁶²) 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.

3.4.9.10 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).

3.4.10 Mental Health Treatment

The mental health treatment questions underwent considerable revisions for the 2022 NSDUH. 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 a prison, jail, or juvenile detention center applied to all respondents, regardless of age. Before 2022, only adolescents were asked whether they received services in a prison, jail, or juvenile detention center.
• 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.

Starting in June 2024, additional changes were included in the questionnaire to improve respondent understanding of whether they received treatment for their mental health, emotions, or behavior at specific inpatient or outpatient locations (see Section 2.2.2). The following changes were made:

• Introductory text for questions about inpatient and outpatient treatment was revised to mention “any of the locations below” for response choices for specific locations.
• For each inpatient and outpatient location that was presented to respondents, text was added to indicate that the treatment was “for mental health, emotions, or behavior.” For example, the response option for receiving treatment at a general medical clinic or doctor’s office as an outpatient was revised to mention receiving treatment at a general medical clinic or doctor’s office as an outpatient “for mental health, emotions, or behavior.”
• In the grid format for respondents to report the locations where they received inpatient treatment, the heading “Stayed overnight or longer for treatment in…” was replaced with “LOCATION.”
• In the grid format for respondents to report the locations where they received outpatient treatment, the heading “Received outpatient treatment at…” was replaced with “LOCATION.”

Because of the changes in 2022, the definition for the receipt of mental health treatment changed. Therefore, estimates from 2022 based on these outcomes should not be compared with estimates from 2021.

Analysis of the data from June to December 2024 indicated that the changes to the mental health treatment questions in June 2024 affected estimates of the receipt of any mental health treatment, inpatient mental health treatment, and outpatient mental health treatment in the past year. As a consequence of these changes, mental health treatment estimates overall and for inpatient or outpatient locations from 2024 are not comparable with those from 2022 and 2023. Estimates from 2024 for mental health treatment via telehealth or in a prison, jail, or juvenile detention center and for the receipt of prescription medication to treat mental health, emotions, or behavior (see Section 3.4.10.1) are still comparable with estimates from 2022 and 2023. Estimates for measures of the receipt of specific other services described in Section 3.4.10.2 also remain comparable with estimates from 2022 and 2023.

In addition, questions for whether respondents perceived an unmet need for mental health treatment and the reasons for respondents not receiving treatment were revised for the 2022 NSDUH. Due to the additional changes for 2024 that were described previously, estimates from 2024 for the perceived unmet need for mental health treatment and reasons for not receiving treatment also are not considered comparable with corresponding estimates from prior years. Specific changes are discussed in Section 3.4.10.3 in the context of measurement of these outcomes.

3.4.10.1 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.

As mentioned previously, however, estimates from 2024 based on variables for any receipt of mental health treatment in the past year and receipt of treatment in inpatient and outpatient locations are not comparable with estimates from 2022 and 2023. Estimates from 2024 for mental health treatment via telehealth or in a prison, jail, or juvenile detention center and for the receipt of prescription medication to treat mental health, emotions, or behavior remain comparable with estimates from 2022 and 2023.

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.

3.4.10.2 Receipt of Other Services to Help with Mental Health

The 2024 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.” For example, the subject matter experts who worked with SAMHSA to develop the revised mental health treatment questions for 2022 thought that services in an emergency room or emergency department were primarily intended to treat acute medical conditions, such as from a suicide attempt, rather than to engage patients in a longer term process of change to promote recovery from mental disorders. Experts also did not consider services from a support group or recovery coach to be mental health treatment because of issues related to licensure or reimbursement for services.

However, these other services were included in a separate aggregate measure presented in the 2024 Detailed Tables (CBHSQ, 2025h) that was created to cover the receipt of mental health treatment or other services. Because of the changes to the inpatient and outpatient questions in June 2024, the estimates from 2024 for the aggregate measure of the receipt of mental health treatment or other services are not comparable with those from prior years. However, estimates from 2024 for specific services from a support group through services in an emergency room mentioned previously remain comparable with estimates from 2022 and 2023. Variables for the receipt of other services were statistically imputed, so these variables do not have missing data.

3.4.10.3 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. The questions did not change for 2024.

• 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 a prison, jail, or juvenile detention center).
• 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 (see Section 3.4.10.2), 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.

Although questions for the perceived unmet need for mental health treatment and reasons for people not receiving treatment did not change for 2024, the questions for inpatient and outpatient treatment changed in June 2024, as described previously. These changes affected who was eligible to receive questions about unmet need. Consequently, estimates from 2024 for the perceived unmet need for mental health treatment and reasons for not receiving treatment are considered not to be comparable with estimates from 2022 and 2023.

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 for these measures. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

3.4.11 Symptoms of Generalized Anxiety Disorder

The seven‐item generalized anxiety disorder (GAD‑7) screener was added to the 2024 NSDUH questionnaire in the youth experiences section for adolescents aged 12 to 17 and to the mental health section for adults aged 18 or older. The GAD‑7 is a validated self‐report measure to screen for GAD and assess symptoms of GAD in the past 2 weeks in adolescents and adults (Mossman et al., 2017; Spitzer et al., 2006). Symptoms of GAD include feeling nervous or on edge, excessively worrying about different things, having difficulty controlling thoughts of worry, having trouble relaxing, being restless, feeling irritable, and feeling that something awful might happen.

The GAD‑7 questions had the same response categories for adolescents and adults:

1Not at all
2Several days
3More than half the days
4Nearly every day
Don’t know/Refused

The GAD‑7 questions are as follows:⁶³

YGAD1

Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?

YGAD2

Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?

YGAD3

Over the last 2 weeks, how often have you been bothered by worrying too much about different things?

YGAD4

Over the last 2 weeks, how often have you been bothered by having trouble relaxing?

YGAD5

Over the last 2 weeks, how often have you been bothered by being so restless that it is hard to sit still?

YGAD6

Over the last 2 weeks, how often have you been bothered by becoming easily annoyed or irritable?

YGAD7

Over the last 2 weeks, how often have you been bothered by feeling afraid as if something awful might happen?

In the 2024 NSDUH, all respondents with item nonresponse for these anxiety symptom questions had their responses statistically imputed (see Section 2.3.3). Thus, there were no missing values for the variables associated with the GAD‑7 questions that were used in analyses. Imputation also mitigated potential effects of nonresponse from respondents who broke off the interview before or during the sections of the interview where the GAD‑7 questions appeared.

To create respondents’ GAD‑7 scores, the imputation‐revised values for the seven individual items were recoded from 0 to 3 so that “nearly every day” was coded as 3, “more than half the days” as 2, “several days” as 1, and “not at all” as 0. Summing across the transformed values for responses in these seven items resulted in a score with a range from 0 to 21.

GAD‑7 scores were classified as follows, with higher scores indicating greater symptom severity (Spitzer et al., 2006; Terlizzi & Villaroel, 2020):

• 0 to 4 = no or minimal symptoms of GAD,
• 5 to 9 = mild symptoms,
• 10 to 14 = moderate symptoms, and
• 15 to 21 = severe symptoms.

3.4.12 Major Depressive Episode (Depression)

Two sections related to MDE were included in the 2024 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 an MDE in the population and receipt of treatment for an MDE. Separate sections were administered to adults aged 18 or older and adolescents 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 adolescents were adapted from the depression section of the National Comorbidity Survey Replication Adolescent Supplement  (NCS‑A). To make the sections developmentally appropriate for adolescents, there are minor wording differences in a few questions between the adult and adolescent sections. Revisions to the questions in both sections were made primarily to reduce their length and to modify the interviewer‐administered NCS questions for self‐administration in NSDUH.

According to DSM‑5, people are classified as having had an MDE⁶⁴ 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,⁶⁵ 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 had an MDE in their lifetime are asked whether they had a period of depression during the past 12 months 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 an MDE in the past year are asked questions from the SDS to measure the level of functional impairment in major life activities that were caused by their 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 2024 NSDUH questionnaire. A few of the questions in the adolescent section were modified slightly to use wording more appropriate for adolescents 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 adolescents 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 2024 NSDUH. See Section 3.3.2 for a discussion of the potential bias in estimates because of missing data.

NSDUH also collects data on functional impairment using the SDS, which is a measure of impairment due to mental health conditions in four major life activities or role domains. These four domains are defined separately for adults aged 18 or older and adolescents aged 12 to 17 to reflect the different roles associated with the two age groups. See Section 3.4.12.1 for details about the questions for adults and Section 3.4.12.2 for details about the questions for adolescents. There is one question for each of the four domains, and each question 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 adolescents 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 adolescents 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 2024 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 2024 NSDUH. For adolescents 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 adolescents was minimal.

3.4.12.1 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.

View Linear Scale 1 long description

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?

3.4.12.2 Adolescent 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.

View Linear Scale 2 long description

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?

3.4.13 Suicidal Thoughts and Behavior

The 2024 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.

3.4.13.1 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 2024. Estimates for suicidal thoughts and behavior among adults in the past year were created for 2024 using the standard analysis weight described in Section 2.3.4.

3.4.13.2 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 2024 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 2024, 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 2024 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 2024 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.

3.4.14 Modes of Marijuana Use

The marijuana section of the 2024 NSDUH questionnaire included questions to assess the ways that people used marijuana in the past year or past month. 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.

In 2024, the question on lifetime vaping of marijuana was moved from the emerging issues section to the earlier marijuana section of the interview. Respondents were asked whether they ever vaped marijuana if they used marijuana in their lifetime and they did not report that marijuana vaping was one of the ways they used marijuana in the past year or past month. The focus of the remainder of this section is on the modes of marijuana use in the past year or past month because lifetime estimates for marijuana vaping were not presented in reports and tables for the 2024 NSDUH.

3.4.14.1 Measures for Modes of Marijuana Use

The 2024 Detailed Tables (CBHSQ, 2025h) and the 2024 Key Substance Use and Mental Health Indicators report (CBHSQ, 2025g) 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 2024 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.

Since the 2023 NSDUH, all variables for modes of marijuana use have been statistically imputed and do not have missing data. See the 2023 Editing and Imputation Report (CBHSQ, 2025c) for further details on the imputation processes that were implemented beginning with the 2023 survey; these procedures did not change for 2024. These revised methods were also applied to produce imputed variables for all modes of marijuana use for 2022, including revised marijuana vaping variables.

3.4.14.2 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 2023 Editing and Imputation Report (CBHSQ, 2025c) for further details; these editing procedures did not change for the 2024 NSDUH.

As noted previously, the question on lifetime vaping of marijuana was moved from the emerging issues section to the marijuana section of the interview for 2024. Because respondents were asked about lifetime vaping of marijuana only if they did not report that they vaped marijuana in the past year or past month, inconsistencies did not exist between lifetime vaping of marijuana and vaping in the past year or past month.

Before the 2024 NSDUH, 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 could have remained in the 2023 data for marijuana use and marijuana vaping between the marijuana and emerging issues sections, they were not reflected in published estimates for 2023.

3.4.15 Recovery

Adult respondents aged 18 or older in 2024 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. Adult respondents first were asked whether they thought that they ever have had a problem with their own drug or alcohol use. If 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 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 2024 NSDUH among adults who reported ever having a substance use problem or mental health issue. The 2024 Detailed Tables (CBHSQ, 2025h) also presented recovery estimates among 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 the respective analyses if they had unknown information for whether they ever had a substance use problem or mental health issues. 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 problems with their substance use or mental health issues, but not necessarily the clinical assessments by 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 conditions, 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 that contained these questions on recovery occurred in the 2024 NSDUH interview after the mental health and adult depression sections. Also, the recovery variables were not statistically imputed for 2024. Therefore, 2024 estimates for recovery were created using the break‐off analysis weight described in Section 2.3.4.

3.4.16 Definition of County Type

County type is based on the Rural‐Urban Continuum Codes⁶⁶ developed by the U.S. Department of Agriculture. The county type measure used in 2024 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.