US State Policy Contexts and Mental Health Among Working-Age Adults.

Policy Points States' overarching policy contexts are a meaningful yet overlooked predictor of adults' mental health, with more conservative contexts associated with worse mental health outcomes over a 30-year period. Counterfactual analyses suggest that widespread policy shifts could meaningfully alter the national prevalence of mental distress, positioning state policy contexts as important yet underutilized levers for improving population mental health. These associations are strongest among adults without a college degree, underscoring that state policy contexts may exacerbate existing educational disparities in mental health. CONTEXT: Mental health among US working-age adults notably worsened during the COVID-19 pandemic, following a steady decades-long decline. The impact of states' COVID-19 policies on mental health has received much attention; however, less is known about the impact of a broader set of long-standing and overarching state policy contexts. This study examines how working-age adults' mental health was associated with states' policy contexts over 30 years. It also assesses whether the pandemic disrupted the association and whether the association is more pronounced among adults without a college degree.

methodsWe use nationally representative data on adults ages 25-64 in the 1993-2022 waves of the Behavioral Risk Factor Surveillance System (N = 5,891,073), merged with measures of three state policy indices. The outcomes are self-rated poor mental health days in the last 30 days and extreme distress (poor mental health in all 30 days). The main independent variable is an index that summarizes states' overarching policy contexts, on a liberal-to-conservative continuum, annually from 1993-2020. Two additional indices summarize states' COVID-19 policies, one on in-person restrictions and a second on economic supports, monthly from March 2020 to December 2022. We estimate the association between states' overarching policy contexts and mental health, net of covariates, fixed differences between states, and COVID-19 policies.

findingsDuring the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree.

conclusionsStates' overarching policy contexts are an important yet understudied predictor of mental health. Current and proposed changes in state policies may have important consequences for mental health among working-age adults, their families, and communities.