As shown in the July nSight, NRC Health HCAHPS data collected over the past decade reveals that self-reported ratings of ‘excellent’ or ‘very good’ mental health have been declining since 2016; the current proportion is 60%. When looking only at people who rated their mental health as ‘excellent,’ the current number drops to 26%. We ran a deeper level of analysis to determine the extent to which the picture changes with location, age, sex, and race/ethnicity.

Location

Our ZIP code-level analysis illustrates that the national decline in self-reported mental health is not universal: In some parts of the country, the percentage of ‘excellent’/’very good’ responses has improved. While there is a limited supply of therapists, there is real opportunity to bring an increased level of service where decline is evident (shown in orange). This could be in the form of group care, blended care (i.e., in-person + online), and/or digital treatment modalities.

Age

As compared to 2013, mental health ratings have declined markedly for younger patients (ages 18-44) – with the biggest drop among the 18-26 age group – but their ratings are still higher than those reported by patients in older age groups. Self-reported mental health for patients in the oldest age group (age 85+) has been consistently low, and this age group has been associated with the highest suicide rate in the country since 2019. While attention to mental health is important across all age groups, it is most important to tailor care at the individual level.

Sex

This analysis is based on sex, not gender identity. After several years of reporting higher mental health, females (blue line) now report slightly lower mental health than do males. The crossover point coincides with the onset of the pandemic in 2020.

But exploring the relationship between age and sex reveals a different pattern for younger patients. Younger males (orange lines) report markedly lower mental health than do females in the same age groups. There is a concerning downward trajectory over time for younger patients; the decline is particularly steep for males aged 18-26, as well as for those aged 27-34, only 50% of whom rate their own mental health as ‘excellent’ or ‘very good.’ This age group has been associated with the second highest suicide rate in the country since 2020. For reference, males in the three age groups shown within this graph report mental health on par with or lower than that reported by males age 85+. Health organizations will be an important part of the solution – in concert with families and communities – but the first step to addressing this crisis is taking a clear-eyed, data-driven approach to acknowledging that it exists.

Race/Ethnicity

While the decline in self-reported mental health is evident across different racial/ethnic groups, the biggest differential over the past decade is among people identifying as Native Hawaiian/Pacific Islander and Native Alaskan/American Indian. Relative to other groups, Asian and White patients have rated their mental health consistently higher; Black and Hispanic patients have rated their mental health on the low side. Not everyone in any of these groups is struggling; the key is to identify and intervene with those who are.

Myriad personal and social factors contribute to the mental health crisis in the United States, yet each person is unique. Some who need help do not seek it, others seek help but cannot access it, and still others are actively engaged in care. While mental health intersects with care in any setting, organizations offering behavioral health services are at the forefront of helping many people who are struggling. Using top-box percentages, our July nSight showed that patients tend to have a favorable impression of therapists in terms of listening and trust. However, only about two-thirds report consistency in care (i.e., report that therapists are consistent with each other), underscoring the burden on patients, therapists, and healthcare organizations.

Our demographic analyses provide a more nuanced picture of experience data, again focusing on patient responses to three questions: Did you trust the therapists? Did the therapists listen to you carefully? Were therapists consistent with each other when providing care?

Age

While patients aged 65-74 are the most sanguine about their relationship with therapists, those aged 18-26 or older than 85 years old express markedly lower perceptions of therapist listening, trust in therapists, and consistency between therapists. Given the self-reported mental health data noted above, it is essential that therapists associated with health organizations make every effort to make stronger connections with all patients, especially those in the youngest and oldest age groups.

Sex

The analysis shown here is based on sex, not gender identity. While females and males report similar perceptions about their experience with therapists, males slightly downgraded each of these metrics.

Race/Ethnicity

There is a tangible, logical connection between listening, consistency, and trust, and a very clear pattern of results: Patients who identify as Hispanic are less likely to report that therapists listened, were consistent, or earned their trust. While the picture is not quite as stark for Asian and Black patients, these patients report less consistency and lower trust; people in groups that experience more consistency (Hawaiian/Pacific Islander, Native American, and White) express higher trust.