2Behavioral Health Needs in the United States

Mental Health

SAMHSA defines mental health as including emotional, psychological, and social well-being (SAMHSA, 2023c). A person’s mental health affects how he or she thinks, feels, acts, and develops. It also plays a role in determining how a person handles stress, relates to others, and makes health choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood, and a person’s mental health can change.

Many factors contribute to mental health conditions, including:

• Biological factors such as genetics, brain chemistry, physical health, and age;
• Health behaviors such as sleep, diet, and substance use/misuse;
• Life experiences such as trauma and abuse;
• Psychological factors such as beliefs, perceptions, and emotions;
• The environment in which a person lives, works, and plays;
• Social factors such as relationships, family, culture, work, financial status, and housing; and
• Family history of mental health problems.

Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities. Being mentally healthy as an adult implies a state of well-being in which “individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities” (Srivastava, 2011, p.75). Resilience, which the American Psychological Association defines as “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands,” is an important characteristic of being mentally healthy (VandenBos and APA, 2015).

Mental Illness

SAMHSA defines any mental illness (AMI) as “any mental, behavior, or emotional disorder in the past year that met [Diagnostic and Statistical Manual]-VTR criteria (excluding developmental and substance use disorders” and defines serious mental illness (SMI) as “any mental, behavior, or emotional disorder that substantially interfered with or limited one or more major life activities” (SAMHSA, 2023c). In 2022, an estimated 15.4 million U.S. adults aged 18 and older had an SMI in the past year, representing 6.0 percent of all U.S. adults (SAMHSA, 2023a). Some 4.0 million, or 11.6 percent, of young adults aged 18 to 25 had an SMI, while 7.8 million, or 7.6 percent, of adults aged 26 to 49 and 3.5 million, or 3.0 percent, of adults aged 50 and older had an SMI in the past year (SAMHSA, 2023a). The Centers for Disease Control and Prevention describes mental disorders among children as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day (CDC, 2023).

Mental illnesses (Boxes 2-1 and 2-2) can vary in the way they affect a person and range from no impairment to mild, moderate, and even severe impairment. SMIs result in significant functional impairment that interferes substantially with or limits one or more major life activities. SAMHSA states that, “Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just ‘passes’ or can be ‘snapped out of’ with willpower” (SAMHSA, 2023c). Though mental illness and SMI are relatively common, as noted above, research shows that medical and other therapeutic treatments for mental illness and SMI are effective.

BOX 2-1

Mental Illnesses in Adults.

BOX 2-2

Mental Illnesses in Children and Adolescents.

Data from the 2022 National Survey on Drug Use and Health (NSDUH) found that 21.8 percent of all adults aged 18 or older received some mental health treatment in the previous year. The percentage of adults aged 18 or older with AMI in the previous year was highest among young adults aged 18 to 25, at 36.2 percent, followed by adults aged 26 to 49 at 29.4 percent, and adults aged 50 or older at 13.9 percent. Among the 59.3 million adults with AMI in the previous year, 50.6 percent had received mental health treatment in the previous year (SAMHSA, 2023a).

In 2022, 6.0 percent of adults aged 18 or older had had SMI in the past year (SAMHSA, 2023a). The percentage of adults with SMI was highest among young adults aged 18 to 25, at 11.6 percent, followed by adults aged 26–49 at 7.6 percent and adults aged 50 or older at 3.0 percent. Among the 15.4 million adults with SMI, 66.7 percent had received mental health treatment in the previous year (SAMHSA, 2023a).

Anxiety disorders are generally the earliest mental illness to appear, with first appearances usually around age 11. An estimated 19.1 percent of U.S. adults experience an anxiety disorder every year, with an estimated 31.1 percent of U.S. adults having experienced an anxiety disorder at some point during in their lives (ADAA, 2022; NIMH, n.d.). An estimated 9.7 percent of U.S. adults experience a mood disorder such as bipolar disorder or major depression in a given year, with an estimated lifetime prevalence of 21.4 percent (NIMH, n.d.). Among those aged 18 to 44, impulse control disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder appear relatively early, around age 11, and are more prevalent among adults aged 18 to 29 (27 percent) than among adults aged 30 to 44 (23 percent) (SAMHSA, 2013).

In 2022, 29.8 percent of adolescents aged 12 to 17 had received mental health treatment within the previous year. Though NSDUH does not report data on SMI in adolescents, it does report specifically on major depressive disorder, and among the 4.8 million adolescents who experienced major depressive disorder, 56.8 percent had received mental health treatment in the previous year. NSDUH identifies people with major depressive disorder through structured interviews based on Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, regardless of whether they have received treatment or a formal diagnosis. However, more than 40 percent of adolescents who experienced major depressive disorder in the preceding 12 months did not receive mental health treatment (SAMHSA, 2023a).

Substance Use Disorders

SUD is a condition that affects a person’s brain and behavior, leading to the person’s inability to control the use of substances, such as legal or illegal drugs, alcohol, or medications. Symptoms can be mild to severe, with addiction being the most severe form of SUD. People with SUD may also have other mental health disorders, and people with mental health disorders may also struggle with substance use (Ross and Peselow, 2012). Research suggests that adolescents with SUD also have high rates of co-occurring mental illness, with over 60 percent of adolescents enrolled in treatment programs also meeting the diagnostic criteria for another mental illness (Hser et al., 2001).

Experimentation with alcohol peaks during adolescence, while young adults are likely to experiment with other substances, such as marijuana, cocaine, and prescription medications such as Adderall. Adults who have used alcohol and illicit substances may have an undiagnosed alcohol use disorder, and others will develop late-onset SUD (Schulte and Hser, 2013; Stewart et al., 2023). Research has shown that early initiation of substance use increases the risk for subsequent development of SUD (Behrendt et al., 2009). The severity of alcohol and drug use during adolescence increases the risk of developing SUD as an adult (McCabe et al., 2022; Volkow and Wargo, 2022).

According to NSDUH data, in 2022, SUD had affected 17.3 percent of people aged 12 or older, or 48.7 million people, in the previous year, including 29.5 million who had an alcohol use disorder (AUD), 27.2 million who had a drug use disorder, and 8.0 million people who had both an AUD and drug use disorder (SAMHSA, 2023a). In 2022, the percentage of people aged 12 or older with an SUD in the past year was highest among young adults aged 18 to 25, at 27.8 percent or 9.7 million people, followed by 16.6 percent or 36.8 million adults aged 26 or older and 8.7 percent or 2.2 million adolescents aged 12 to 17 (SAMHSA, 2023a).

Among the 29.5 million people aged 12 or older in 2022 with a past-year AUD, 59.1 percent had what NSDUH characterized as a mild disorder, compared with 20.7 percent who had a severe disorder. Among the 19.0 million people aged 12 or older in 2022 with a past-year marijuana use disorder, 55.1 percent had a mild disorder, compared with 17.3 percent who had a severe disorder (SAMHSA, 2023a).

Life Stressors and Crises

Stressful experiences are a normal part of life, and the stress response is a survival mechanism that primes the body to respond to threats. However, an extensive body of research has shown that life stressors, particularly toxic stress during childhood and adverse childhood experiences (ACEs), can lead to the development, maintenance, or exacerbation of several mental health conditions, including anxiety disorders, depression, bipolar disorder, post-traumatic stress disorder (PTSD), personality disorders, and suicidality (Bourvis et al., 2017; Green et al., 2010; Johnson et al., 1999; Kendler et al., 1999). One study, for example, found a dose–response relationship between Adverse Childhood Experiences (ACEs), a considerable source of stress during childhood, and the likelihood of developing mild to moderate SUD, heavy drinking, depression, and suicide attempts in adulthood (Merrick et al., 2017). Severe stress can trigger a range of physiological consequences affecting the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous, and reproductive systems (APA, 2023; Yaribeygi et al., 2017). In terms of life stressors from a health equity standpoint, an extensive body of research has demonstrated an association between experiences of racism and poorer mental health outcomes among racial and ethnic minority populations (Paradies et al., 2015).

Co-Occurring Disorders

Despite the historic separation of behavioral health and physical health, the two are intertwined, and the co-occurrence of behavioral health and physical health conditions is not uncommon (Han et al., 2019). For example, the prevalence of depression and anxiety ranged from 6 percent to as high as 80 percent among patients with chronic obstructive pulmonary disease (COPD) and from 10 percent to as high as 60 percent among patients with heart failure (Yohannes et al., 2010). SUD, HIV/AIDS, and hepatitis C are common co-occurring illnesses (Granados-García et al., 2019; Hartzler et al., 2017). One study found that 25 percent of adults with obesity and chronic physical illness such as asthma, diabetes, heart disease, hypertension, or osteoarthritis had an SMI (Shen et al., 2008), while another study identified clusters of clinically meaningful co-occurrence of mental illness, AUD, and physical health that included hypertension, arthritis, digestive and bowel problems, emerging multimorbidity, and complex multimorbidity (Gomez et al., 2023). A 2021 scoping review emphasized the co-occurrence of anxiety, mood, and attention disorders among children with epilepsy, asthma, and allergies (Romano et al., 2021).

When physical health conditions and behavioral health disorders (Horvitz-Lennon et al., 2006) occur together, they can shorten a person’s lifespan by as much as 10 to 20 years (Chesney et al., 2014). Co-occurring behavioral and physical health problems can complicate diagnosis, treatment, and disease progression so that conditions often go undiagnosed among patients with co-occurring physical and mental illnesses (Owens et al., 2018). For example, COPD and heart failure may mask or mirror symptoms of depression, anxiety, and PTSD, making their recognition and diagnosis less likely (Ratcliff et al., 2017). In addition, physical health conditions can increase the risk of psychological distress, exacerbate mental disorders, and compound functional impairment (Horvitz-Lennon et al., 2006; Whooley et al., 2008). Similarly, individuals with an SMI have higher rates of chronic conditions, including hypertension and diabetes (Zolezzi et al., 2017).

People with an SUD are at elevated risk of developing a co-occurring mental health problem and vice versa. According to SAMHSA’s 2022 NSDUH, approximately 21.5 million U.S. adults have a co-occurring mental health problem and SUD (SAMHSA, 2023b). One study found that approximately 3.3 percent of the U.S. population had had a co-occurring SUD and SMI in the preceding 12 months, with 52.5 percent receiving neither mental health care nor SUD treatment (Han et al., 2017).

Unique Issues that Apply to Children and Adolescents

Common mental health issues in children (Box 2-2) include anxiety; depression; oppositional defiant disorder, characterized by constant disobedience and hostility; conduct disorder, characterized by aggression and law-breaking tendencies; and ADHD, characterized by inattention, impulsivity, and overactivity (CDC, 2023). Children with ADHD often have difficulty concentrating and are easily distracted. Many children with ADHD say they do not understand why they sometimes feel out of control or lonely. Early life adversity in the form of psychosocial and material neglect; exposure to intimate partner violence; and physical, sexual, and emotional abuse are strongly correlated with higher rates of almost all commonly occurring mental health issues, including mood, anxiety, and SUD (Kim and Cicchetti, 2010; McLaughlin et al., 2010). Mental health issues associated with early life adversity are more severe, persistent, and treatment resistant than mental health issues not associated with early life adversity (McLaughlin et al., 2010).

For many individuals, adolescence is a time of experimentation and becoming involved in risk-taking behaviors such as using alcohol, tobacco, and other drugs that can have a major effect on a person’s mental health. Adolescence is a time of identity formation, particularly regarding sexual orientation and gender identification. There is strong evidence that when adolescents who identify as LGBTQ+ cannot express their true selves, they either hide or deny their attractions and identity (Rafferty et al., 2018). Because of the stigma and bullying they face, LGBTQ+-identifying adolescents are at higher risk of mental health problems, including depression, suicidality, altered body image, and substance use (Levine et al., 2013; Parsons et al., 2007). Adolescents experiencing gender dysphoria are at increased risk of emotional health problems, including depression and suicidality, victimization and violence, eating disorders, and substance use (Rafferty et al., 2018).

Stigma often deters individuals from seeking care despite experiencing symptoms or discomfort. Suicide is the second leading cause of death in adolescents. According to a 2017 survey of high school students, 7.4 percent of high school students had attempted suicide within the previous 12 months, and 13.6 percent had made a suicide plan (CDC, 2018). In 2021, 45 percent of LGBTQ+ adolescents considered attempting suicide (The Trevor Project, 2022). A 2023 systematic review and meta-analysis found that 36 percent of adolescents had received treatment for depressive episodes and 20 percent had received treatment for anxiety disorders (Wang et al., 2023). Eating disorders most commonly develop during adolescence and are often accompanied by other mental health problems (NIMH, 2024). After researching this topic and given the multitude of news stories highlighting the mental health crisis affecting children and adolescents, the committee concurs with the Surgeon General that there is a need to “improve mental health data collection and integration to understand youth mental health needs, trends, services, and evidence-based interventions” (U.S. Surgeon General, 2021).

Disparities in Unmet Behavioral Health Needs and Mental Health Outcomes

Studies show an increased disparity in mental health care services in terms of the quality of care, availability, and service usage across different races, cultures, ethnicities, age groups, and economic strata in society (American Psychiatric Association, 2023). Racial, ethnic, gender, and sexual minoritized individuals often suffer from poor mental health outcomes resulting from multiple factors, including inaccessibility of high-quality mental health care services, cultural stigma surrounding mental health care, and discrimination.

According to NSDUH data, among individuals aged 18 or older in 2022, 35.2 percent of multiracial adults had AMI in the previous year, compared with 24.6 percent of White adults, 21.4 percent of Hispanic adults, 19.7 percent of Black adults, 19.6 percent of American Indian or Alaska Native adults, and 16.8 percent of Asian adults (SAMHSA, 2022a). Among adults aged 18 or older in 2022, 11.8 percent of multiracial adults had SMI, compared with 6.5 percent of White adults, 5.3 percent of Hispanic adults, 4.7 percent of Black adults, 4.1 percent of Asian adults, and 3.5 percent of Native Hawaiian or Other Pacific Islander adults (SAMHSA, 2022a). The percentages of people aged 12 or older with a past-year SUD ranged from 9.0 percent of Asian Americans to 24.0 percent of American Indian or Alaska Native people. Except for Asian people, percentages did not differ significantly by race or ethnicity (SAMHSA, 2022a).

Compared with non-Hispanic White Americans, Black Americans with AMI have lower rates of any mental health service use, including prescription medications and outpatient services, but higher use of inpatient services (Center for Behavioral Health Statistics and Quality, 2021). Only one-third of Black Americans who need mental health services receive it, and compared with White Americans, Black Americans are less likely to receive guideline-consistent care. In addition, Black Americans are more frequently diagnosed with schizophrenia and less frequently diagnosed with mood disorders than their White counterparts (Bell et al., 2015).

In 2021 only 36 percent of Hispanic and Latino Americans who had AMI received mental health services, compared with 52.4 percent of non-Hispanic White Americans with AMI (SAMHSA, 2022b). Latino youth have higher rates of unmet needs than White youth, leading to greater suicidal thoughts and attempts, depression, anxiety, and rates of dropping out of high school than White youth (Kataoka et al., 2002). Hispanic and Latino Americans experience barriers to receiving mental health services which include experiences of racism and discrimination stemming from structural and systemic factors, stigma based in culture, language access issues, and a lack of ethnically and linguistically competent care providers.

Asian Americans and Pacific Islander (AAPI) adults are least likely among all racial and ethnic groups to seek behavioral health services, and they are three times less likely to access behavioral health services than non-Hispanic White Americans (Bloom and Black, 2016; SAMHSA, 2022b). There is, however, wide variation among AAPI ethnic subgroups, with Vietnamese Americans, Native Hawaiians, and Pacific Islanders reporting mental health issues at rates closer to the U.S. average than to their AAPI counterparts.

The high rates of alcohol, substance use and mental health disorders, suicide, and behavior-related morbidity and mortality in American Indian and Alaska Native communities continue to be disproportionately higher than the rest of the U.S. population (Gone and Trimble, 2012). Studies show Indigenous people have disproportionately higher rates of mental health problems such as suicide, PTSD, and substance use disorders. These high rates result in American Indian and Alaska Native people reporting serious psychological distress 2.5 times more often than the general population over a month’s time (IHS, 2015; NCHS, 2023).

LGBTQ+ individuals are more than twice as likely as heterosexual men and women to have a mental health disorder in their lifetime and 2.5 times more likely to experience depression, anxiety, and substance use compared with heterosexual individuals (American Psychiatric Association, 2017). Some 42 percent of LGBTQ+ youth seriously considered attempting suicide in the past year, including more than half of transgender and nonbinary youth, while 48 percent of LGBTQ+ youth reported they wanted care from a mental health profession but could not receive it in the past year. Over 70 percent of LGBTQ+ youth reported symptoms of generalized anxiety disorder in the past 2 weeks, including more than three-quarters of transgender and nonbinary youth; 62 percent of LGBTQ+ youth reported symptoms of major depressive disorder in the past 2 weeks, including more than two-thirds of transgender and nonbinary youth; and 70 percent of LGBTQ+ youth reported that their mental health was poor during the COVID-19 pandemic (The Trevor Project, 2021).

Child and Adolescent Behavioral Health Care Services and Access

Two of the populations with prevalent critical deficits for mental health care who are undiagnosed and undertreated are children and adolescents. There are approximately 10,500 practicing child and adolescent psychiatrists in the United States and the national average age of practicing child and adolescent psychiatrists is 52 years (AACAP, 2022). Medicaid is the largest insurer of children and the single-largest payer of behavioral health services. Studies have documented that numerous Medicaid-insured children with mental health and behavioral disorders do not receive any psychosocial treatment, including psychotherapy. Medicaid-insured children and adolescents have been overlooked in the current supply of behavioral health services (Harati et al., 2020).

One clear example for the committee that stands out was learned through our webinar for child and adolescent access and ease of obtaining behavioral health care. In Michigan the mother of an early age teen sought care for his disruptive, dangerous mental health issues. After months and many promises for care, he was placed in a juvenile correction locked facility in Montana. The geographic distance alone does not support family involvement, much less rehabilitative opportunities. Thus, this exemplifies the critically poor supply of reasonable treatment for children and adolescents.

This clearly points to the workforce issues of the committee’s statement of task. Without increased professionals practicing with these populations, the dire situation will not change. Training for psychiatrists, psychologists, advance practice nurses, and clinical social workers to increase the provider pool specializing in children and adolescents is an important issue for health care leaders to address.

Behavioral health care services for children and adolescents are concentrated in few locations, which also reduces geographic access to services for the Medicaid-insured population. Confounding the access factor is the issue that adolescents may often come for health care with physical symptoms that are the result of their mental turmoil and confidentiality is a huge issue. Many articles cite the load of adolescent cases in a pediatrician’s office as being a quarter of the total caseload. For instance, one publication reflects on the various domains whereby this age group requires attention (Trent, 2020).

Studies also suggest that, in general, the treatment rates for mental health disorders among children and adolescents were low, especially for depression and anxiety. Targeted intervention policies and effective measures should be designed and implemented to improve treatment rates of psychiatric disorders among youth (Harati et al., 2020). In one study to support the underserviced children, researchers identified 63,314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per- year caseload was less than 25 children and more than 250 visits across all provider types. Providers with a mental health center–related taxonomy accounted for more than 40% of visits for more than 30% of patients. Fewer than 10% of providers and locations accounted for more than 50% of patients and visits (Harati et al., 2020).

Likewise in a meta-analysis of 40 studies including 310,584 children and adolescents, the combined treatment rate was 38% (95% CI, 30%–45%) for any mental disorder, 36% (95% CI, 29%–43%) for depressive disorders, 31% (95% CI, 21%–42%) for anxiety disorders, 58% (95% CI, 42%–73%) for attention-deficit/hyperactivity disorder, and 49% for behavior disorders (95% CI, 35%–64%) (Wang et al., 2023). Age, income level, and region were significantly associated with treatment rates for mental disorders among youth. The data highlights a significant problem for the mental health of children and adolescents and the impact on future generations if remedies are not immediately sought by organizations, agencies, and payers (Wang et al., 2023). More professional providers should be trained and incentivized to offer care in more locations and to accept increased numbers of Medicaid-insured patients of this age group.