Serious psychological distress is measured by asking respondents how often they experienced each of six symptoms of psychological distress in the past 30 days. The question reads, “During the past 30 days, how often did you feel…..So sad that nothing could cheer you up? Nervous? Restless or fidgety? Hopeless? That everything was an effort? Worthless?” Possible answers are “All of the time” (4 points), “Most of the time” (3 points), “Some of the time” (2 points), “A little of the time” (1 point”), and “None of the time” (0 points). The points are added together, yielding a total of 0 to 24 points. A threshold of 13 points or more is used to define serious psychological distress.