The following information provides a guideline about: 1) how we chose our data, 2) how we ranked our data, and 3) important information about the national surveys where we acquired and analyzed our data.

This data and accompanying chartbook present a collection of data that provides a baseline for answering some questions about how many people in America need and have access to mental health services. The full report includes state and national data and shareable infographics.

MHA Guidelines

Given the variability of data, MHA developed guidelines to identify mental health measures that are most appropriate for inclusion in our ranking. Chosen indicators met the following guidelines:

• Data that are publicly available and as current as possible to provide up-to-date results.
• Data that are available for all 50 states and the District of Columbia. 
• Data for both adults and youth. 
• Data that captures information regardless of varying utilization of the private and public mental health system.
• Data that could be collected over time to allow for analysis of future changes and trends.

Our 2023 Measures

1. Adults with Any Mental Illness (AMI)
2. Adults with Substance Use Disorder in the Past Year
3. Adults with Serious Thoughts of Suicide
4. Youth with at Least One Major Depressive Episode (MDE) in the Past Year
5. Youth with Substance Use Disorder in the Past Year
6. Youth with Severe MDE
7. Adults with AMI Who Did Not Receive Treatment
8. Adults with AMI Reporting Unmet Need
9. Adults with AMI Who Are Uninsured
10. Adults Reporting 14+ Mentally Unhealthy Days a Month Who Could Not See a Doctor Due to Costs
11. Youth with MDE Who Did Not Receive Mental Health Services
12. Youth with Severe MDE Who Received Some Consistent Treatment
13. Youth with Private Insurance That Did Not Cover Mental or Emotional Problems
14. Students Identified with Emotional Disturbance for an Individualized Education Program
15. Mental Health Workforce Availability

A Complete Picture

While the above 15 measures are not a complete picture of the mental health system, they do provide a strong foundation for understanding the prevalence of mental health concerns, as well as issues of access to insurance and treatment, particularly as that access varies among the states. MHA will continue to explore new measures that allow us to capture more accurately and comprehensively the needs of those with mental illness and their access to care.

Ranking

To better understand the rankings, it is 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. They are less comparable to less populous states like South Dakota, North Dakota, Alabama, or Wyoming. Keep in mind that the size of states and populations matter, both New York City and Los Angeles alone have more residents than North Dakota, South Dakota, Alabama, and Wyoming combined.

The rankings are based on the percentages, or rates, for each state collected from the most recently available data. The majority of indicators represent data collected up to 2020. States with positive outcomes are ranked higher (closer to one) than states with poorer outcomes (closer to 51). The overall, adult, youth, prevalence, and access rankings were analyzed by calculating a standardized score (Z score) for each measure and ranking the sum of the standardized scores. For most measures, lower percentages equated to more positive outcomes (e.g., lower rates of substance use or those who are uninsured).

There are two measures where high percentages equate to better outcomes. These include “Youth with Severe MDE (Major Depressive Episode) Who Received Some Consistent Treatment” and “Students Identified with Emotional Disturbance for an Individualized Education Program.” Here, the calculated standardized score was multiplied by -1 to obtain a reverse Z score that was used in the sum. All measures were considered equally important, and no weights were given to any measure in the rankings.

Along with calculated rankings, each measure is ranked individually with an accompanying chart and table. The table provides the percentage and estimated population for each ranking. The estimated population number is weighted and calculated by the agency conducting the applicable federal survey. The ranking is based on the Z scores. Data are presented with two decimal places when available. 

Major Changes to This Year’s Report Indicators

The COVID-19 pandemic had a serious impact on the ability to collect data for national surveillance in 2020. As a result of both measure and methodological changes below, the indicators in this year’s report cannot be compared to previous years.

The measure “Adults with Cognitive Disability Who Could Not See a Doctor Due to Costs” was used as an indicator for the Adult Ranking, the Access to Care Ranking, and the Overall Ranking in the 2020, 2021, and 2022 State of Mental Health in America reports. The measure, “Adults with Cognitive Disability Who Could Not See a Doctor Due to Costs” was calculated using the Behavioral Risk Factor Surveillance System (BRFSS) question: "Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?” (DECIDE). For this report, the indicator was amended to “Adults Reporting 14+ Mentally Unhealthy Days a Month Who Could Not See a Doctor Due to Costs” using a calculated variable derived from the BRFSS question: “Now thinking about mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” (MENTHLTH). The calculated variable, _MENT14D, contains four values: Zero days when mental health was not good, 1-13 days when mental health was not good, 14+ days when mental health was not good, and Don’t Know/Refused/Missing. The DECIDE measure includes those who may be experiencing cognitive challenges due to a physical health condition, and is specific to difficulties with concentrating, remembering, or making decisions. The _MENT14D indicator likely serves as a better measure for individuals who are experiencing any significant mental distress and is therefore a more sensitive measure for the population we are attempting to count.

The measure “Students Identified with Emotional Disturbance for an Individualized Education Program,” is calculated as the percent of “school age” children identified as having an emotional disturbance among enrolled students. The number of children identified as having an emotional disturbance is reported in the IDEA Part B Child Count and Educational Environments data collected by the Office of Special Education Programs (OSEP). In previous years, OSEP defined “school age” as youth ages 6-21. Therefore, the measure “Students Identified with Emotional Disturbance for an Individualized Education Program” was previously calculated as the percentage of youth ages 6-21 identified as having an emotional disturbance of those enrolled in grades 1-12 and ungraded. In the 2020-2021 data, OSEP expanded the range to include kindergarten, and therefore defined “school age” as youth ages 5-21. To reflect that change, this year the measure “Students Identified with Emotional Disturbance for an Individualized Education Program” was calculated as the percentage of youth ages 5-21 identified as having an emotional disturbance of those enrolled in kindergarten, grades 1-12, and ungraded. Due to data quality concerns, the 2020 disability data figure for Louisiana and the 2019 and 2020 figures for Iowa were not available. This report notes the 2019 figure for Louisiana and the 2018 figure for Iowa.

The measures “Adults with Substance Use Disorder” and “Youth with Substance Use Disorder” are both collected through the Substance Abuse and Mental Health Services Administration’s (SAMHSA) “National Survey of Drug Use and Health” (NSDUH). Prior to the 2020 NSDUH, substance use disorders were assessed using criteria from the DSM-IV. However, in the 2020 NSDUH, these criteria were updated to the DSM-V criteria for substance use disorders. As a result, the rates of substance use for both youth and adults within this report cannot be compared to previous years.  

Survey Limitations

Twelve of the 15 indicators used in this report are collected from SAMHSA’s national survey, the NSDUH. Historically, the NSDUH was collected through in-person interviews in the respondent’s residence. However, due to the COVID-19 pandemic, data collection was suspended in March 2020. Collection of data for the NSDUH resumed for a small sample in July 2020, but because of continued high rates of COVID-19, it was determined that a sample large enough to be representative of the country could not be collected solely through in-person interviews. As a result, 2020 NSDUH data collection did not fully resume until October 2020. At this time, survey data were collected both in-person and online. In summary, 2020 NSDUH data was only collected at full scale in the first and fourth quarters of the year. As a result of the lack of complete data and changes to data collection from in-person to online, SAMHSA has determined that the results of the 2020 NSDUH cannot be compared to those of previous years. This means that the rankings presented throughout this year’s State of Mental Health in America report cannot be reliably compared to the rankings of previous years’ reports, and therefore should be interpreted as a snapshot in time ranking rather than a reflection of trends over time.

Additionally, each survey has its own strengths and limitations. For example, strengths of both SAMHSA’s NSDUH and the CDC’s BRFSS are that they include national survey data with large sample sizes and utilize statistical modeling to provide weighted estimates of each state population. This means that the data is more representative of the general population. An example limitation of particular importance to the mental health community is that the NSDUH does not collect information from persons who are experiencing homelessness and who do not stay at shelters, are active-duty military personnel, or are institutionalized (i.e., in jails or hospitals). This limitation means that those individuals who have a mental illness who are also experiencing homelessness or are incarcerated are not represented in the data presented by the NSDUH. As a result, these data likely represent the minimum number of individuals experiencing behavioral health conditions and/or lacking access to care in each state. If the data did include individuals who were experiencing homelessness and/or incarcerated, we would possibly see prevalence of behavioral health issues increase and access to treatment rates worsen. It is MHA’s goal to continue to search for the best possible data in future reports. Additional information on the methodology and limitations of the surveys can be found online as outlined in the glossary.

Finally, most of these data were gathered through 2020. This means that they are the most current data reported by the states and available to the public. They are most useful in providing a snapshot of the needs and systems that were in place in each state in the first year of the COVID-19 pandemic.