US Mental Health Services Ranked by State

Nancy A. Melville

January 13, 2015

Although it is too soon to get a big-picture assessment of the effect the Affordable Care Act (ACA) has had on US mental health services, a new report from Mental Health America (MHA, formerly the National Mental Health Association) offers a snapshot of the nation's mental health care status based on the most recent data, and it is not a pretty picture.

"[The report shows] there is tremendous variation across the states, which means that states are responsible for the mental health of their citizens and have the power to improve it if they invest in it," MHA president and CEO Paul Gionfriddo told Medscape Medical News.

"It [also] shows that political philosophy doesn't matter ― conservative and liberal states are both in the top tier," he added.

The report ranked states and the District of Columbia on measures reflecting mental health status and accessibility of care using the most recently available national data, mostly from 2012, before the ACA went into effect, but ranging from 2010 to 2013.

Measures included rates of mental illness in adults and children, drug abuse or thoughts of suicide, rates of the failure to receive treatment among adults and children who were uninsured, and state hospital readmission rates.

In the overall ranking, the top five states, reflecting the lowest prevalence of mental illness and the highest rates of access to care, were Delaware (5), North Dakota (4), Maine (3), Vermont (2), and Massachusetts, which was ranked number 1.

The five states with the highest prevalence of mental illness and the lowest rates of access to care were Louisiana (47), Washington (48), Nevada (49), Mississippi (50) and Arizona (51).

The report showed that overall, 42.5 million adults (18%) suffered from any kind of mental illness; 19.7 million (8.46%) of the population had a substance abuse problem; and 8.8 million (3.77%) reported serious thoughts of suicide.

Impact of ACA Not Clear Yet

With regard to youth, the report showed that 6.2 million (8.5%) in the nation suffered from an emotional, behavioral, or developmental issue, 1.6 million (6.48%) had a substance abuse problem, 2.1 million (8.66%) had at least one episode of major depression in the previous year, and 8.01% reported that they attempted suicide once in the previous year. Young females were twice as likely to attempt suicide (10.6%) than males (5.4%).

The highest rates of emotional, behavioral, or developmental problems were seen in states just to the west of the Appalachian Mountains in areas that also have high poverty levels. However, substance abuse in those areas was among the lowest for youth.

About 5 of 10 states with the highest rates of substance abuse and depression among youth were in the West.

As reflected in the most recent data on mental health care access, from 2012, 8.1 million Americans with a mental illness were uninsured, and only 41.4% of those with any mental illness reported receiving treatment.

One out of every 3 children with an ongoing emotional behavioral disorder had inadequate insurance, and costs prevented 1 out of every 3 adults with disability from seeing a doctor, according to the report.

Although the ACA is known to have significantly increased the number of insured Americans, the percentage of those who had a mental illness is not yet clear.

"It will be several more years before we can fully evaluate the effects of the ACA on individuals with mental illness," the report states.

Lost Opportunity

However, according to the MHA, what is becoming clear is that the 2012 Supreme Court ruling allowing states to choose whether or not to expand Medicaid for individuals earning up to 138% of the federal poverty line has left many who need mental health care coverage uninsured.

As of the release of the report, 27 states and the District of Columbia had expanded Medicaid, and 19 had opted not to expand, with four states expected to expand in the next year.

According to an assessment by the American Mental Health Counselors Association in February 2014, that left an estimated 3.47 million uninsured Americans with serious mental health and substance abuse conditions in need of coverage.

"While there is some relationship between states that did not expand Medicaid and states that do poorly in the rankings, the real problem is that the states that did not expand Medicaid lost an opportunity to improve care and treatment for many people ― especially adults ― with serious mental illnesses," Gionfriddo said.

"So [those states] are likely to fall further in the rankings in the coming years ― while, ironically, spending a lot more state dollars on this population."

Psychiatrist Shortage

A glimpse of figures from Massachusetts, a state that already had a health system similar to that established by the ACA, suggests that even with widespread insurance coverage, access to mental health treatment can still be a challenge.

According to the report, although only 1% of adults with any mental illness were uninsured in Massachusetts, an estimated 20.4% reported having an unmet need.

Among key barriers to mental health care across the country has been a significant shortage of psychiatrists. According to the report, there is only one mental health care provider for every 790 individuals.

And an even greater need is anticipated under the ACA, said Renee Binder, MD, president-elect of the American Psychiatric Association (APA) and a professor in the Department of Psychiatry at the University of California, San Francisco.

"The country will need an additional 30,000 child psychiatrists to meet the needs generated by the expanded coverage under the ACA, and we currently only have 8000, so we need to triple the number of child psychiatrists," she told Medscape Medical News.

The APA has been proactive in addressing the shortage through several avenues, including pushing for integrative programs to extend the reach of psychiatrists throughout the healthcare system and the community, she noted.

"The APA has been promoting new systems of collaborative care, with psychiatrists working together with other specialties, including primary care providers and pediatricians," she said.

Aiming for Early Intervention

Efforts have also included expanding the educational system, with a program offered through the America Psychiatric Foundation called Typical or Trouble, designed to help teachers identify behaviors that warrant intervention.

"Early intervention is very important in addressing mental health issues," Dr Binder said.

"Studies have shown that identifying people with potential problems early on can be very essential in improving outcomes, and since teachers can be the best ones to identify problems early, it makes sense to educate them on what to look for," she added.

Gionfriddo echoed the sentiment regarding the need to address mental illness as early as possible. In the report, he noted his own personal experience with a son with schizophrenia and how he could have benefited from the MHA's emphasis on an early intervention approach dubbed "B4Stage4."

"We have to stop waiting until mental illnesses reach Stage 4 to treat them," he writes.

"By Stage 4, problems are so far advanced that even with the best treatments available, recovery is often compromised."

Gionfriddo underscored the fact that half of all mental health concerns manifest by age 14 years.

"[We need to] give children the support they need to stay and succeed in school and young adults the support they need to live and work independently," he said. "And we need to change our thinking from crisis intervention to support and recovery."

"The best-ranked states remind us that recovery is not only possible, it's to be expected when intervention comes early."

The researchers received support from Eli Lilly and Company, Genentech, Otsuka America Pharmaceutical Inc, Sunovion Pharmaceuticals Inc, Takeda Pharmaceuticals USA, Inc, and Lundbeck US.

Parity or Disparity: The State of Mental Health in America 2015. Full text

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