An In-Depth Look at Behavioral Health Trends

Why Behavioral Health Trends are a Matter of Urgency

Across the United States, behavioral health symptoms and diagnoses – which encompass mental health and substance use disorders – are on the rise. Because they are common across both adult and pediatric populations, our team of researchers set out to better understand the societal impact of this increase. Our researchers found that behavioral health diagnoses are a matter of public health urgency, and lead to considerable morbidity, mortality, healthcare utilization, and treatment costs.

We wrote the following issue brief to uncover the epidemiology and socio-economic impact of four key diagnoses: anxiety, depression, substance use disorders, and suicidality. Throughout this brief, our research highlights the impact of these conditions on healthcare costs and clinical outcomes. Finally, we illustrate the urgent need for an ecosystem of stakeholders – consisting of community leaders, payers, government, and healthcare entities – to jointly provide evidence-based, scalable, equitable, and sustainable solutions.

Research Results: Key Takeaways at a Glance

• As we show in Figures 1 and 2, based on data from the National Survey on Drug Use and Health (NSDUH)¹ and the National Health Interview Survey (NHIS),² depression, anxiety, substance use disorders (SUDs), and suicidality are common nationwide.

• Notable trends in the prevalence of each condition are described below and summarized in Tables 1 and 2. Details surrounding the methods employed in this investigation are included in the Methodological Supplement.

The Impact of the COVID-19 Pandemic on Behavioral Health

Far and wide, research repeatedly showed that the COVID-19 pandemic negatively impacted behavioral health across the age spectrum. Data limitations prevent this issue brief from specifically assessing the impact of COVID-19 on all reported diagnoses and age groups. However, there is evidence in the available data to suggest the following:

• Adolescent depression was increasing in prevalence before the pandemic, and this trend accelerated between 2020-2021.

• Other conditions, such as adult and pediatric anxiety, increased predominately in the most severe years of the pandemic after 2020.

• Adult depression and adult suicidality, changed negligibly between 2018 and 2023.

• For adult and pediatric SUDs, comparable data using the same methodology were not available prior to 2020, so it is challenging to ascertain trends prior to that year, though prevalence for both age groups increased notably after 2020.

A Public Health Lens

From a public health standpoint, the generally high prevalence of behavioral health conditions is concerning. The uptick in negative behavioral health trends invariably leads to worse general health outcomes, reduced quality of life, lower functional status, and higher overall health costs. Moreover, impacts to individuals and society, and the cost of care, are prevalent across anxiety, depression, substance abuse disorders, and suicidality.

A Closer Look at the Epidemiology of Four Key Disease States

 Anxiety

• The impact on human health: High treatment costs have been noted for anxiety disorders, which are widely known to be underdiagnosed and under-treated, especially in primary care settings.⁴

• Generalized Anxiety Disorder (GAD) has been associated with impairments in psychosocial functioning, work productivity, and health-related quality-of-life, resulting in an average annual medical cost of almost $6,500 per person.⁵

Depression

• Co-morbidities on the rise: The National Institute of Mental Health (NIMH) notes that depression is associated with an increased likelihood of co-morbid chronic diseases such as heart disease, diabetes, stroke, and chronic pain.⁶ These adverse physical health conditions are driven by challenges completing health tasks (e.g., exercise), difficulties accessing medical care that could help prevent, detect, or treat chronic disease, and changes in the way the body functions due to depression (e.g., increased inflammation, abnormalities in stress hormones).

• The financial cost of major depressive disorder has increased over time, representing $236.6 billion in 2010 (2020 dollar values) and $326.2 billion in 2018 (2020 dollar values).⁷

Substance Use Disorders

• Mortality rates on the rise: SUDs, including alcohol and drug use disorders, are associated with immense morbidity and mortality nationwide, especially among working age adults, where the majority of direct treatment costs are incurred. Investigators from the Centers for Disease Control and Prevention (CDC) estimated that between 2001 and 2020, more than 90% of deaths caused by drug or alcohol poisoning and approximately 80% of non-fatal poisoning emergency department visits occurred among people between the ages of 20 and 64 years.⁸

• The financial burden: Annual treatment costs attributable to SUDs among employer-sponsored insurance plans have been estimated to be upwards of $15,000 per affected enrollee, totaling more than $35 billion overall.⁹ Similarly high treatment costs have been found for public insurance beneficiaries, with one study estimating that average Medicaid spending is twice as high for enrollees with a SUD diagnosis compared with other enrollees – costing upwards of $1,200 per month compared to less than $550 per month, respectively.⁹

• The impact to society: The broader societal cost of SUDs extends far beyond finances, as rates of drug overdose or accidental poisoning have increased markedly in recent decades. Starting at 6.2 per 100,000 in 2000, the rate surged to 31.4 per 100,000 by 2023, representing a 406% increase, while the total number of these deaths grew from 17,415 to 105,002, marking a 503% increase.

• The pandemic effect: The onset of the COVID-19 pandemic impacted overdose or accidental poisoning rates, which increased by 31% from 21.6 per 100,000 in 2019 to 28.3 in 2020. This trend continued through 2022, with the overdose rate reaching 32.6 per 100,000 in 2022 before slightly decreasing to 31.4 in 2023.^11,12 These trends highlight the urgent need for better solutions to address the ongoing challenge of drug overdoses or accidental poisonings in the United States.

Suicide

• A suicide prevention strategy is needed: Deaths from suicide have increased to unprecedented numbers in the United States. According to the CDC, approximately 50,000 people die from suicide annually, equating to one death every 11 minutes.¹³ Roughly 1.5 million people attempt suicide each year,¹⁴ and the age-adjusted suicide rate rose steadily from 10.4 per 100,000 in 2000 to 14.2 in 2023, with the total number of suicide deaths rising by 68% from 29,350 to 49,315.

• An ongoing challenge: Between 2022 and 2023, the age-adjusted suicide rate remained steady at 14.2 per 100,000, indicating a persistent public health challenge (Figure 3).^15,16 As of 2022, suicide is the second leading cause of death for people 44 years of age and younger.¹⁷

  
  

  “The uptick in negative behavioral health trends invariably leads to worse general health outcomes, reduced quality of life, lower functional status, and higher overall health costs.”

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The Need for Rigorous Research and Reporting

Based on our extensive research, we drew the following conclusion: behavioral health symptoms are often under-reported due to associated stigma or social and cultural conceptualizations of health.²¹ Without objective measures (e.g., laboratory tests, medical imaging) or standardized clinical interviews to assess behavioral health symptoms, diagnosis is often measured using patient-reported symptoms or observations. Given these challenges, estimated behavioral health prevalence rates often vary considerably.

In the case of depression and other common behavioral health conditions, the rates reported above from the NSDUH and NHIS may differ from those reported through other sources, as criteria for having the disorder often differ across assessments. For example, a widely cited study reported that 28% and 33% of adults in the United States had depression in 2020 and 2021, respectively, using depression operationalized as a Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher.²² Conversely, the NSDUH measures depression using the DSM-V criteria for major depressive episodes in the past year.

Another study demonstrated that symptoms of depressive disorders increased from 25% to 30% between August and December 2020, though findings in that evaluation were informed by the four-item Patient Health Questionnaire (PHQ-4) for depression and anxiety and not past-year major depressive episodes.²³ Similar findings have been noted for other conditions and populations, such as anxiety and substance use disorders in children and adolescents²⁴ and depression in older adults.²⁵ 

Looking Ahead: Committing Sustained Attention to Behavioral Health is Critical

The examples we have shared illustrate the importance of examining the underlying datasets used, methodologies, inclusion or exclusion criteria, and measures to avoid comparing fundamentally different sources when interpreting national psychiatric epidemiology data, especially for psychiatrically underserved and disenfranchised populations.²⁶ It is important to acknowledge additional disparities in care, and to note that marginalized individuals are more likely to experience barriers to effective treatment – barriers that must be addressed. Such barriers can also be seen across race and ethnicity, gender, age, and sexual/gender identity.

Ultimately, regardless of the methods or definitions chosen, the prevalence of common behavioral health conditions are substantial at population scale, leading to immense morbidity, mortality and cost. To mitigate the harm from these alarming trends, we believe that community leaders, payers, government, and healthcare entities must partner to promote evidence-based, scalable, equitable, and sustainable solutions.

Supplemental Material: Our Methodological Approach²⁷

Data presented in Figure 1 above were obtained from the National Survey on Drug Use and Health (NSDUH),²⁸ an annual survey administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Health Interview Survey (NHIS), an annual survey administered by the Centers for Disease Control and Prevention (CDC).²⁹ Both surveys use a complex sampling design to generate nationally representative estimates on SUDs, mental health, and receipt of treatment among adults, children, and adolescents in the United States.

Important NSDUH methodological considerations are briefly outlined below:

• All measures are self-reported and did not include structured clinical interviews or professional evaluation.

• Measures are limited to major depressive episodes, alcohol or drug use disorder symptoms (as defined by DSM-V criteria) that occurred over the prior 12 months.

• For adults only, the NSDUH asks about suicidal thoughts or behaviors using measures of past year “serious thoughts of suicide,” “made any suicide plans,” or “attempted suicide.” The NSDUH generates a composite variable from these three measures to report the prevalence of suicidality annually.

Anxiety is not directly assessed by the NSDUH. As a result, NHIS was employed for adult and pediatric anxiety prevalence estimates between 2019 and 2023. Of note, NHIS was not used to estimate anxiety prevalence in 2018, as the survey methodology was markedly changed in 2019, making comparisons to years prior to 2019 unfeasible. For adults, the authors employed a framework described by the National Center for Health Statistics³⁰ and two questions developed by the Washington Group on Disability Statistics (WG) that specifically inquire about anxiety frequency and intensity (WG-ANX).³¹ Using this framework, which links answers on the two WG-ANX questions to estimated anxiety severity, the authors coded respondents with “medium” or “high” levels of anxiety as “anxious” for the purposes of this evaluation. For children and adolescents in NHIS, only one WG-ANX question was publicly available – anxiety frequency. As a result, the authors coded participants who reported feeling “worried, nervous, or anxious” either daily or weekly as “anxious” for the purposes of this evaluation.