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 report 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 data and tables include state and national data.

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 annually over time to allow for analysis of future changes and trends.

Our 2024 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 Serious Thoughts of Suicide
7. Youth Flourishing
8. Adults with SUD Who Needed but Did Not Receive Treatment
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. Adults with AMI with Private Insurance That Did Not Cover Mental or Emotional Problems
12. Youth with MDE Who Did Not Receive Mental Health Services
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

Data is also presented for Youth with MDE Who Reported Treatment or Counseling Helped Them, but this indicator was not included in the rankings because data for South Carolina and South Dakota was suppressed in 2021-2022.

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.

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The rankings are based on the percentages for each state collected from the most recently available data. The majority of indicators represent data collected up to 2022. 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 three measures where high percentages equate to better outcomes. These include “Youth Flourishing,” “Students Identified with Emotional Disturbance for an Individualized Education Program,” and “Youth with MDE Who Reported Treatment or Counseling Helped Them.” 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 measures “Youth with Severe MDE,” “Youth with Severe MDE Who Received Some Consistent Treatment,” “Adults with AMI Who Did Not Receive Treatment,” and “Adults with AMI Reporting Unmet Need” were removed from this year’s report. Each of these measures were calculated using data from the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health (NSDUH). The indicator “Youth with Severe MDE” was removed because it did not differ significantly from the measure “Youth with at Least One Major Depressive Episode (MDE) in the Past Year.” In 2022, SAMHSA made changes to the mental health and substance use treatment questions. This report relies on state-level data, which is only available in a two-year pair. The changes to the 2022 mental health treatment measures meant that the dataset was not comparable to the 2021 measures and could not be combined into a two-year pair. These measures may return to the indicator list in next year’s report once the 2022-2023 NSDUH data are available.

The measures “Youth with Serious Thoughts of Suicide,” “Youth Flourishing,” “Adults with SUD Who Needed but Did Not Receive Treatment,” and “Adults with AMI with Private Insurance That Did Not Cover Mental or Emotional Problems” were added to the indicator list in this year’s report. The measure “Youth with Serious Thoughts of Suicide” was added because SAMHSA began gathering data on youth suicidality for the first time in 2020, and this is the first report published since that data has been made available. “Youth Flourishing” captures data on flourishing among children and adolescents ages 6-17, and was added as an upstream, protective measure for youth as part of the Prevalence ranking. “Adults with SUD Who Needed but Did Not Receive Treatment” and “Adults with AMI with Private Insurance That Did Not Cover Mental or Emotional Problems” were added to capture more nuanced information about access to behavioral health care in the U.S.

For the measure “Students Identified with Emotional Disturbance for an Individualized Education Program,” data for Iowa on the number of students with Emotional Disturbance was not available. Iowa does not collect disability category data and therefore was excluded from the ranking for that indicator.

Survey Limitations

Twelve of the 16 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, in 2020 data collection shifted to both in-person interviews and online questionnaires due to the COVID-19 pandemic. Since 2020, SAMHSA discovered that these changes to data collection created a mode effect such that estimates from the web and in-person interviews cannot be compared to estimates from in-person interviews alone. As a result, SAMHSA has determined that 2021 will represent a trend break from previous years, meaning the results of the NSDUH moving forward will not be comparable to data collected before 2021. 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 Behavioral Risk Factor Surveillance System (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 are 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 2022. This means that they are the most current data reported by the states and available to the public.