The Crisis of Mental Health in the US

Well before COVID-19, our nation faced a growing mental health care crisis. In 2019, 21 percent of adults experienced mental illness. Our rate of death by suicide has risen by 35 percent since 1999, and is now the second leading cause of death for young people. Seventy thousand Americans died from drug overdoses in 2019, a 57 percent increase from 2013.

But by the summer of 2020, the level of unmet need had grown totally out of control: The percentage of adults experiencing mental illness nearly doubled. Rates of anxiety and depression were three times higher, and the number of fatal drug overdoses spiked by 21 percent.

In 2020, 57.2 percent of adults with a mental illness received no treatment.

In 2019, 89.7 percent of Americans 12 and older, with a substance use disorder, were unable to get treatment. Among youth with severe depression, 72.7 percent did not receive consistent treatment.

Almost a quarter (22.3 percent) of all adults with a mental illness, who actively sought treatment – including 47.7 percent of those with serious mental illness – said they were not able to receive the care they needed. This percentage has not changed since the implementation of the Affordable Care Act (ACA).

The gap in care is particularly apparent among those with the highest need.

A recent study in JAMA looked at caregivers reported to Child Protective Services who had a psychiatric disorder. Only 38 percent received counseling and 67 percent received psychiatric medication. Among caregivers with a substance use disorder, 40 percent received counseling and 38 percent received a substance use disorder medication.

Americans with untreated mental illness – including children – often end up on the streets, in the emergency room, or in jail. Locally, a Sonoma County Grand Jury found that the sheriff’s office was mismanaging care for people in lockup, in large part because of the high concentration of inmates with mental health issues. Yet a nearly 10-year-old funded plan to build a Sonoma County jail mental health wing remains in limbo.

Why can’t Americans get the mental health care we need?
Barriers to care included a lack of insurance coverage for mental health, a shortage of mental health providers, lack of available treatment types and high out-of-pocket costs – such as deductibles, copays and fees paid to providers not covered by a patient’s insurance network.

A 2024 report by the US Department of Health and Human Services Office of Inspector General found that Medicare and Medicaid have a dire shortage of mental health care providers, causing significant problems in finding care.

On Medicare, one in 4 enrollees are living with a mental illness, and yet less than half of those people are receiving treatment. There is evidence that those enrolled in Medicare Advantage plans face even greater barriers to care.

Among people on Medicaid, one in three has a mental illness, and one in five have a substance use disorder. The need is tremendous, yet treatment remains elusive.

Commercial insurers discriminate against mental health care

1. Despite laws requiring parity for mental health and physical health services, commercial insurers pay mental health providers 24 percent less than primary care providers for similar services, causing mental health providers to opt out of insurance “networks.” Eighty percent of counties outside core metro areas have no psychiatrists. Sixty one percent had no psychologists.
2. Insurers limit our choice of providers. A visit to a mental health provider is six to 10 times more likely to be “out-of-network,” forcing patients to wait weeks or months for appointments, to travel long distances, or to seek costly care from “out-of-network” providers. Many simply give up.
3. Insurers limit or deny common treatments such a s medication, therapy and hospitalization. The nation’s largest insurer, United Behavioral Health, was recently found guilty of denying 67,000 claims for mental health care based on financial – not medical – reasons.

Don’t other countries have similar mental health problems?
The US had the highest suicide rate among the 11 high-income countries, a trend that has been worsening for nearly 20 years.

Compared with these other countries, both white and Black US adults reported the highest rates of mental health needs. Here we compare the percentage of adults age 18-plus who reported a mental health need: Source: 2020 Commonwealth Fund International Health Policy Survey.

How did they define mental health need? Respondents who reported they had been told they had depression, anxiety or other mental health conditions, or said there was a time in the past 12 months they wanted to talk with a health care professional about their mental health.

Approaches to expanding mental health services in other countries offer the US important lessons on prioritizing mental health, making care more convenient, and scaling treatment approaches  to help more people.

What can and must be done?
While many complex factors contribute to mental illness, we cannot address our nation’s mental health crisis without first providing universal, comprehensive and patient-centered health coverage.

Only a single-payer healthcare system would eliminate the greed and waste of commercial insurance and cover  everybody in the US for all medically necessary care – including medications and services for behavioral and mental health and substance use disorder – with no copays, deductibles, or gaps in coverage. And unlike commercial insurance, single-payer provides free choice of hospital and provider, including psychiatrists, psychologists and licensed counselors.

We are one of many groups continually advocating, educating and agitating for this drastically needed change in our health, including mental health care.

Contact the Healthcare for All Working Group, 707-480-2271 or [email protected]

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Terry Winter is a retired nurse and Chair of the Healthcare for All Working Group, So.Co.

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