Q: What methods were used to rank states?
A: MHA used data that was: publicly available and as current as possible to provide up-to-date results; available for all 50 states and the District of Columbia; available for both adults and youth; and able to capture information regardless of varying utilization of the private and public mental health system.
The rankings are based on the percentages, or rates, for each state collected from the most recently available data, mostly up through 2020 (see below for more specifics on time period). 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 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: “Youth with Severe Major Depressive Episode Who Received Some Consistent Treatment” and “Students Identified with Emotional Disturbance for an Individualized Education Program.”
Q: What are the 15 measures used?
A: The measures we use are:
- Adults with Any Mental Illness (AMI)
- Adults with Substance Use Disorder in the Past Year
- Adults with Serious Thoughts of Suicide
- Youth with at Least One Major Depressive Episode (MDE) in the Past Year
- Youth with Substance Use Disorder in the Past Year
- Youth with Severe MDE
- Adults with AMI Who Did Not Receive Treatment
- Adults with AMI Reporting Unmet Need
- Adults with AMI Who Are Uninsured
- Adults Reporting 14+ Mentally Unhealthy Days a Month Who Could Not See a Doctor Due to Costs
- Youth with MDE Who Did Not Receive Mental Health Services
- Youth with Severe MDE Who Received Some Consistent Treatment
- Youth with Private Insurance That Did Not Cover Mental or Emotional Problems
- Students Identified with Emotional Disturbance for an Individualized Education Program
- Mental Health Workforce Availability
While the 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.
Q: How was the data weighted to calculate the Overall, Adult, Youth, Need/Prevalence, and Access Rankings?
A: All measures included in each of these rankings were considered equally important in calculating the aggregate rankings, and no weights were given to any measure. However, there are more measures of Access (9) than Prevalence of Mental Illness (6), so the Overall Ranking is slightly more representative of access than prevalence.
Q: Why can’t this year’s results be compared to previous years?
A: 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, the indicators in this year’s report cannot be compared to previous years.
Data collection, after being suspended in March 2020, for the Substance Abuse and Mental Health Services Administration’s (SAMHSA) “National Survey of Drug Use and Health” (NSDUH) resumed for a small sample in July 2020. However, 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, and online interviews were added. As a result of the lack of complete data and changes to data collection from in-person to online, SAMHSA determined that the results of the 2020 NSDUH cannot be compared to those of previous years.
The rankings presented in this year’s State of Mental Health in America report cannot be reliably compared to the rankings of previous years’ reports. Instead, the report should be interpreted as a snapshot-in-time ranking rather than a reflection of trends over time.
You can, however, compare states within this year’s rankings (2023) to each other.
Q: What time period is reflected in this year’s report?
A: Most of the indicators in this year’s report are calculated from 2019-2020 data, but it may vary by indicator based on methodological differences. The indicators Adults with Any Mental Illness (AMI), Adults with AMI Reporting Unmet Need, Adults with AMI Who Are Uninsured, Adults with Serious Thoughts of Suicide, Adults with AMI Who Did Not Receive Mental Health Treatment, Youth with At Least One Past Year Major Depressive Episode (MDE), Youth with MDE Who Did Not Receive Mental Helath Services, Youth with Severe MDE, Youth with Severe MDE Who Received Some Consistent Treatment, and Youth with Private Insurance That Did Not Cover Mental or Emotional Problems were calculated using 2019-2020 data. The indicators Adults with Substance Use Disorder and Youth with Substance Use Disorder were both calculated using only 2020 data, as SAMHSA updated the criteria for substance use disorder from the DSM-IV to DSM-V criteria in 2020. Students (K+) Identified with Emotional Disturbance for an Individualized Education Program is based on Department of Education data from 2020-2021. Workforce Availability is based on 2021 County Health Rankings data. For more information on each of the indicators, visit the Indicator Glossary here.
Q: How do I interpret ranking vs. rate? Why did my ranking change if the rate did not change?
A: Rankings are determined from Z scores, which compare a state’s rate against other states. If the rates in other states drastically improve or worsen, this can cause a change in other states’ rankings, even if their rates did not change. The ranking provides context for how a state is performing on each indicator in the context of other states. However, it is important to look at the rate for each indicator to know whether your state is improving or worsening.
Q: What does it mean to “not receive mental health treatment”?
A: The indicator “Adults with AMI Who Did Not Receive Treatment” is calculated using a recoded variable that divides people into did and did not receive care in the past year. The SAMHSA National Survey on Drug Use and Health “NSDUH” asks adults what types of mental health services they received in the past year. There were seven categories under those who did receive care: inpatient treatment only, outpatient treatment only, prescription medication treatment only, both inpatient and outpatient treatment only, inpatient and prescription medication treatment only, outpatient and prescription medication treatment only, or inpatient, outpatient, and prescription medication treatment. Individuals who reported they did not receive any inpatient/outpatient care or medication for their mental health were determined not to have received mental health treatment in the past year.
Q: What’s the difference between “unmet need” and “not receiving treatment”?
A: “Not receiving treatment” is calculated from the SAMHSA NSDUH variable representing what type of mental health services an individual received in the last year (see above). Either by choice or not, “not receiving treatment” means that an individual reported they did not receive inpatient/outpatient care or medication for their mental health in the past year. An “unmet need” is defined within the SAMHSA NSDUH as “feeling a perceived need for mental health treatment/counseling that was not received.” Individuals who report experiencing an “unmet need” for mental health treatment in the past year are asked why they felt they did not receive treatment. Those responses include: Not knowing where they could go to get services; thinking they could handle their mental health without treatment; not having the time to get treatment; and health insurance not paying enough for mental health treatment.
Q: Will we be able to compare future State of Mental Health in America reports to previous years?
A: We use data from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) “National Survey of Drug Use and Health” (NSDUH) to calculate most indicators within the State of Mental Health in America report. Currently SAMHSA is cautioning against comparing the data from 2020 to data from previous years due to methodological changes during the COVID-19 pandemic. However, SAMHSA said this does not mean the data are not comparable, it means the comparability is unknown. Find the full SAMHSA FAQ on this data here.