Ranking Guidelines 2022

Ranking Guidelines 2022

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 were 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 data and table include state and national data and sharable 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. Indicators were chosen that 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 2022 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 with Disability 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. Children 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 fifteen 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 more accurately and comprehensively capture the needs of those with mental illness and their access to care.

Ranking

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. 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. For most indicators, the data represent data collected up to 2019. States with positive outcomes are ranked higher (closer to one) than states with poorer outcomes. 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.  

The measure “Adults With Disability Who Could Not See a Doctor Due to Costs” was previously calculated using the Behavioral Risk Factor Surveillance System (BRFSS) question: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” (QLACTLM2). The QLACTLM2 question was removed from the BRFSS questionnaire after 2016, and therefore could not be calculated using 2019 BRFSS data. For this report, the indicator was amended to “Adults With Cognitive Disability Who Could Not See a Doctor Due to Costs,” using the BRFSS question: "Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?” (DECIDE). This indicator likely serves as a better measure for individuals who experience disability tied to mental, cognitive, or emotional problems, as it is less likely to include people who experience limitations due to a physical disability and is therefore a more sensitive measure for the population we are attempting to count. 

For the measure “Students Identified With Emotional Disturbance for an Individualized Education Program,” due to data suppression because of quality, the 2016-2019 figures for Wisconsin were not available. This report notes the 2015 figure for Wisconsin. The 2019 figure for Iowa was also not available because Iowa no longer captures disability category data, and therefore the number of students identified with emotional disturbance could not be determined. This report notes the 2018 figure for Iowa.  

Survey Limitations

Each survey has its own strengths and limitations.  For example, strengths of both SAMHSA’s National Survey of Drug Use and Health (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 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. 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. 

In addition, these data were gathered through 2019. This means that they are the most current data reported by the states and available to the public. They are most useful in providing some comparative baselines in the states for the needs and systems that were in place prior to the COVID-19 pandemic, as data reflective of the COVID-19 pandemic will not be made available until next year. MHA regularly reports on its real-time data gathered from more than 11 million completed mental health screenings (through September 2021). Based on these screening results from a help-seeking population, and both U.S. Census Bureau 2020-2021 Pulse Survey data, which included brief depression and anxiety screening questions, and survey data reported by the Centers for Disease Control and Prevention (CDC), it appears that (1) the data in this report likely under-reports the current prevalence of mental illnesses in the population, both among children and adults, (2) higher-ranked states may have been better prepared to deal with the mental health effects of the pandemic at its start, and (3) because of its nationwide effect, nothing in the pandemic by itself would suggest that the relative rankings of the states would have changed solely because of the pandemic.