Behavioral Health

Last Updated Mar 10, 2023

This guide is intended to help donors gain a deeper understanding of the issues related to the U.S. healthcare system and outlines opportunities to address the root causes of inequitable outcomes. See the entire seriesBy Lucy Brennan-Levine

Did you know?

What is Behavioral Health?

Behavioral health describes the individual behaviors that impact a person’s health. The term encompasses various health experiences and conditions like mental health, substance abuse, addiction, smoking, sleep issues, and diabetes management, among others.  

These health conditions are extremely prevalent today: One in five U.S. adults has experienced a mental, behavioral, or emotional disorder in the past year.

For every 10 people in a doctor’s office, seven are there seeking care for reasons related to behavioral health.

Mental health conditions such as depression and anxiety impact demographic groups differently. For instance, 17.3% of non-Hispanic Black or African-American adults in the U.S. experience mental illnesses compared to 13.9% of non-Hispanic Asian adults and 22% non-Hispanic white adults. There is also a growing youth mental health crisis in the United States, in the wake of the pandemic. Emergency room visits by teen girls for mental health conditions have increased significantly since 2020. Compared to other countries, the United States has higher death rates from mental and substance use disorders.

Substance Abuse and Addiction

Substance abuse disorders can exist simultaneously with other mental health conditions, exacerbating health problems and access to treatment services. Treatment for ongoing substance abuse issues can be long term and hard to access for many people: 

Racial-based Trauma and Mental Health

Racial trauma can mirror the symptoms of PTSD and cause negative health outcomes. Black Americans have long experienced racism, bias, discrimination, and race-based violence by living under a system of white supremacy that significantly impacts people of color and their mental health. Black transgender and gender non-conforming individuals experience the highest levels of discrimination of all trans populations. Moreover, Asian Americans reported nearly 1,500 acts of Anti-Asian violence following the COVID-19 outbreak in the United States. 

White supremacy has also contributed to what is known as historical trauma, which refers to “cumulative emotional and psychological harm, as a result of group traumatic experiences, transmitted across generations within communities and families. Racial and ethnic population groups that have suffered major losses and assaults on their culture and wellbeing experience historical trauma.” Native Americans have experienced historical trauma from years of mass genocide, oppression, assimilation schools, and broken treaties, leading to PTSD in Native communities in the United States, which has severely impacted their mental health.

Another form of racial trauma that is prevalent in the U.S. is xenophobia. Xenophobia can fuel racism and discrimination against immigrant communities, especially Latinx/Hispanic immigrant communities. This population experiences decreased access to employment, medical sterilization on Hispanic/Latino women – leading to medical distrust – and anti-immigrant sentiment in the public discourse, which all contribute to declining mental health.

Why Donors Should Care

 

Behavioral Health infographic

Investment in a robust mental healthcare system can help change these trends and address mental health as a serious issue and potentially reduce hospitalizations as well as provide care for those that need it. 

Limited access to mental healthcare services has extreme effects on the workforce.

For instance, depression accounted for $44 billion in losses to workforce productivity. Untreated mental illness could cost the workforce up to $100 billion each year in the U.S. and can lead to unemployment, disability, homelessness, incarceration, and suicide.

A Gallup poll found that nearly one in five people say their mental health is “fair” or “poor” and those employees take an average of 12 unplanned days off annually compared with 2.5 days for all other workers. 

Access to behavioral services can be expensive, with patients spending $10,836 a year on average for mental healthcare. Even with insurance, mental health services are five times more likely to be charged as out-of-network. Poverty and mental illness are cyclically linked. For instance, mental healthcare costs are very high and can exacerbate existing financial challenges for individuals and families, while at the same time, poverty is a contributing factor to a higher risk of developing mental illness. Mental healthcare costs for the United States are also exorbitant.

Mental Healthcare Spending infographic

Investing in strong behavioral health systems can help alleviate the cycle of poverty and mental illness. With more access to resources like high-quality food, education, and employment opportunities, communities will have improved mental health and healthier livelihoods. 

Mental health treatment is by far the largest subsector of the broader mental health, sexual assault support and crisis intervention segment, attracting more than ⅓ ($12.1 billion) of the total segment dollars ($33.6 billion). The mental health treatment segment alone is almost the same size as the more than $13.9B total of the next three largest subsectors combined (community mental health centers, $7.3B; residential mental health treatment, $4.3B; psychiatric hospitals, $2.3B).

Behavioral Health Donor Funding infographic

Donor investment in fighting mental health stigma by amplifying mental health storytelling and spreading awareness and education about mental illness can help strengthen behavioral health systems.

Who Is Affected?

Low-income People of Color

There are significant behavioral health disparities among Black and white adults that impact long-term health outcomes and demonstrate the need for care. 

Patients who experience racial trauma, systemic racism, and oppression continue to be disenfranchised or kept in cycles of poverty and face barriers to receiving services. 

Behavioral Health Services by Race infographic

Black individuals also have  limited access to culturally competent mental health providers and are less likely to be offered either evidence-based medication therapy or psychotherapy.

Additionally, “individuals with the lowest level of socioeconomic status are estimated to be about 2 to 3 times more likely to have a mental disorder than are those with the highest level of such status.” Approximately 1 in 4 Americans reported having to choose between mental health services and basic daily necessities due to high costs and unaffordable care. An estimated 45% of psychiatrists don’t accept any form of insurance, making care extremely hard to afford out-of-pocket. Communities that have been exposed to natural disasters, are now facing both the financial and mental costs of climate change. Approximately 25% to 50% of people exposed to extreme weather are at risk of developing conditions like anxiety, depression, and suicide.

Children: Youth Mental Health Crisis

More than a third of high school students experienced poor mental health during the COVID-19 pandemic, and 44% reported feeling consistently sad or down for the past year. However, young people were already reporting poor mental health in the years leading up to 2020. In 2018, suicide was the second leading cause of death for young people ages 10 to 34. These rates have been rising since 2000. For children of color, mental health support is much more difficult to find. One reason for this disparity is that children of color are overrepresented in both welfare and the juvenile justice systems and have higher rates of mental health needs, but a shortage of mental health providers as well as shortages in mental health community centers, and child psychiatrists make access to care challenging.  

Additionally, young people of color experience more stressors than white children, which can lead to poor mental health outcomes. 

Adverse Childhood Experiences (ACEs) 

Adverse childhood experiences are traumatic events that can occur during childhood (before 18 years old) and can have long-term effects on mental, physical, and emotional health. Examples of these include (but are not limited to) violence and abuse in the home, family members dying, or suicide attempts. ACES can be linked to chronic health issues, mental health problems, and substance abuse illnesses. Studies indicate that 61% of surveyed adults have had at least one type of ACE before age 18, and women and racial minority groups are at greater risk of experiencing ACEs. ACEs are also connected to the social determinants of health, such as living in a food desert or experiencing homelessness or racial trauma. The greater number of adverse childhood experiences, the greater risk for negative health outcomes.

What Causes These Disparities?

Structural Racism

Research found that Black adults report experiencing stigmatization and the minimization of their mental health issues while in treatment. There are compounding mental health disparities and issues for the Black community: 

“The increased incidence of psychological difficulties in the Black community is related to the lack of access to appropriate and culturally responsive mental health care, prejudice and racism inherent in the daily environment of Black individuals, and historical trauma enacted on the Black community by the medical field. Moreover, given that the Black community exists at the intersection of racism, classism, and health inequity, their mental health needs are often exacerbated and mostly unfulfilled.” -Columbia University Department of Psychiatry

Additionally, people of color are more likely to be uninsured and face access barriers due to high costs. Racial disparities in healthcare affordability are driven by racial inequity in healthcare coverage. For instance, Black and Latinx/Hispanic adults are uninsured at higher rates than their white counterparts and Black and Latinx/Hispanic populations disproportionately live in states that are not expanding Medicaid coverage. Other factors such as medical distrust, generational poverty, and inequity along the social determinants of health all have racist roots that have disenfranchised communities of color and made it more difficult to receive access to behavioral healthcare.

Healthcare Fragmentation and Workforce Gaps

Healthcare fragmentation occurs when healthcare works in different “subsystems” that provide healthcare for different groups of one population, which limits the quality of care. One report cites the United States’ “lack of universal health coverage, high out-of-pocket spending, and “disjointed services” for patients with complex medical issues as barriers to improving coordination.”  

Collaborative care models are one way to provide high-quality care for populations that need specialized behavioral healthcare such as therapy, access to psychiatrists or substance abuse services. Since many people often go to their primary care physicians (PCPs) for mental health problems, PCPs can screen for behavioral health conditions and refer patients to behavioral care managers who can help with specialized issues and then consult and coordinate back with primary care physicians on how best to move forward. This coordination and integration of behavioral services into primary care can help decrease fragmentation in patient care. 

For people of color trying to find a mental health counselor or professional of the same race and ethnicity, the options are extremely limited. Close to 70% of U.S. social workers and 76% of mental health counselors are white. Research finds that the lack of diversity in the mental health workforce likely contributes to “underdiagnosis and/or misdiagnosis of mental illness in BIPOC communities.” For AAPI communities, the number of AAPI mental health providers is extremely low and the field lacks diverse linguistic and culturally appropriate mental health services.

The U.S. healthcare system is also facing a shortage of psychologists and psychiatrists. Currently, it’s projected that the United States has a shortage of between 14,280 and 31,091 psychiatrists. There are 150 million people living in areas that have shortages of mental health professionals. 

Behavioral health nonprofits across the country are working to solve the many causes of disparities within the healthcare system. Below, public data demonstrate how many organizations are serving state populations (compiled by X4Impact based on forms 990 filed with the IRS and U.S. Census data).

 

Geography: Rural and Urban Mental Healthcare Systems

Behavioral Health and Rural Communities infographic

Even more troubling are the existing gaps for children in rural areas trying to access mental health services.

One in five children in the U.S. lives in a county with no child psychiatrists.

While rural areas suffer from a lack of services and limited treatment options, urban cities pose higher risks for residents to develop major mental illnesses such as anxiety, psychotic, mood, or addictive disorders. Many mental healthcare systems are not built to respond to the growing impact of urbanization on our collective mental health. (I.e. increases in homelessness, violence, hate crimes, etc). 

 

Stigma

Stigma is a barrier for receiving mental healthcare because individuals with mental illness do not feel comfortable seeking mental health services.

Nearly one-third of Americans, or 31%, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population, or 21%, have even lied to avoid telling people they were seeking mental health services.

Research indicates that mental health stigma is strong in Black communities, and mental health illnesses or disorders are sometimes perceived as a personal weakness rather than a legitimate health concern. This stigma creates significant barriers for communities to seek treatment and receive sustained mental healthcare.

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