The State of Mental Health in America 2020: Youth Prevalence and Access to Care

The Patient Protection and Affordable Care Act, also known as the ACA, was enacted a decade ago. It has expanded access to healthcare, and made it more affordable for tens of millions of United States citizens. The Mental Health Parity and Addiction Equity Act (MHPAEA) is a part of the ACA , and it’s designed to ensure that mental health and substance use disorders are treated no differently than any other health condition.

Ten years later, how well are the laws working? What is the current state of mental health in America, and how much better is behavioral healthcare than it was prior to the ACA? Mental Health America (MHA), a nonprofit mental health advocacy group founded in 1909, brings us the answers. The State of Mental Health in America is a comprehensive survey that covers both youth and adult mental health. Because the project is so extensive, we’ve broken the results into two parts–youth and adults. Here’s a look at youth mental health in America. 

Key Takeaways

  • Youth mental health in the United States has actually worsened since the ACA was enacted, indicating that causes other than access to care must be addressed
  • Major depression in youth ages 12 to 17 is up by 4.35%, from 8.66% to 13.01%
  • The total number of youth experiencing major depression with severe impairment is a staggering 2 million patients
  • Substance use disorder has declined in youth, from 6.48% to 4.13%
  • Although the percentage of youth receiving consistent treatment is up, more than 70% of young people with major depression are not getting the ongoing care they need
  • Insurance is still insufficient, with the number of insured youth whose private insurance does not adequately cover mental health nearly doubling, and out of pocket costs soaring

Prevalence of Mental Illness

According to the study, 13.01% of US young people have experienced at least one major depressive episode in the past year, and this number continues to rise, while substance use disorder has dropped to 4.13%. More than 2 million adolescents, or just over 9% of the population, are living with severe depression.  Additionally, while the numbers were not addressed in this study, it’s important to keep in mind that there is often overlap between depression and substance use. Some percentage of young people are experiencing both at the same time. 

Access to Care

Despite the ACA and ongoing efforts by mental health advocates, more than half of young people with major depression do not receive any treatment at all, and less than 30% receive treatment consistently. Many insured youth do not have proper access to care, as some insurance companies have applied overly restrictive guidelines that do not achieve mental health parity. This percentage ranges from 2% to 18%, depending on state.

Schools have long been thought of as a place where youth with “emotional disturbances” (defined as mental illnesses that interfere with success at school) could be identified and receive interventions in the form of an Individualized Education Program (IEP). Shockingly, despite worsening adolescent mental health, just 0.73% of students have IEPs for emotional disturbances. Stepping up identification and intervention at school could perhaps help to improve youth mental health at earlier stages, when treatment is generally easier.

Additionally, there is an unequal distribution of behavioral health providers throughout counties in the United States. In 2016, more than half the counties across the country had ZERO psychiatrists. While integrating primary care (pediatricians) and behavioral health care is a necessary first step in reducing the impact of the shortage, primary care providers cannot solely fill the void created by a lack of psychiatrists. Expanding the use of telepsychiatry and employing peer support specialists and other paraprofessionals as providers of care are just some of the solutions that may help alleviate this shortage.

Variations by State

The COVID-19 pandemic has shown us very clearly that the United States does not operate in lockstep. Each state bases its public health responses on factors ranging from politics to local health officials’ opinions. Additionally, some states have more mental health providers than others. Youth prevalence of mental health or substance use disorders, as well as access to care, are largely based on where you live.

To better understand the rankings, it’s important to compare similar states. Factors to consider include geography and size. For example, California and New York are similar. Both are large states with densely populated cities and include cities that are larger than some smaller states. With that caveat in mind, here’s what the results show. Youth rates of at least one major depressive episode in the past year range from 10.49% in Washington, DC to 16.34% in Oregon. Substance use rates range from 3.18% in Georgia to 6.54% in Alaska. Rates of adolescents going without treatment also vary by state, ranging from 39.5% in Rhode Island to 74.3% in North Carolina. The percentage of insured young people without adequate mental health coverage is just 2% in New Hampshire, but 18.1% in Mississippi. In Massachusetts, there is one mental health professional per 180 people, but in Alabama there are 1100 people to every mental health provider.

Putting It All Together

Mental Health America has created a state ranking system to account for these disparities. Based on 15 factors for adults as well as children, Overall Ranking indicates both lower prevalence of mental health issues and better access to care. Pennsylvania, New York, and Vermont, in that order, are ranked highest overall. When ranking solely for youth, Washington, DC, Pennsylvania, and North Dakota take the top three spots.

According to the results of this study, there is much more work to be done in identifying and properly treating young people with mental illnesses and/or substance use disorders. In youth, earlier identification is often associated with better treatment outcomes, so implementing strategies to proactively identify at-risk young people should be a core strategy. Like so much in public health, though, this is largely up to the states. Those living in states that are taking active steps to enforce mental health parity tend to have better outcomes than those whose states are ignoring the problem. Those who live in states that have expanded Medicaid and have taken active steps to ensure mental health parity tend to have better access and better mental health outcomes than those living in states with other priorities.

This national data should be used to increase dialogue that helps to improve outcomes for individuals and families with mental health needs.


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