A Closer Look at Mental/Behavioral Health
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Our July nSight demonstrated that, nationally, emotional or mental health (‘mental health’) reported by patients has been declining over the past decade. In parallel, the evolving understanding of – and willingness to talk about – mental and behavioral health has helped reduce longstanding stigmas, generating unprecedented demand for services. Despite progress in both in-person and digital treatment modalities, there are significant gaps in the availability, accessibility, and affordability of behavioral health services. As there is no magic wand to backfill the shortage of trained professionals, we suggested that one key to more successfully addressing mental and behavioral health is for health systems to better coordinate the services they offer while more tightly interfacing with services based in the workplace, school, community, or increasingly, home.
The September nSight takes a closer look, primarily by stratifying data on both mental health and perceptions about therapists by age, sex, and race/ethnicity. Of course, caution is in order when viewing demographic data, because there may be an inclination to ascribe group characteristics to individuals. The best path to individualized care is through Human Understanding® – treating each patient as a unique person, not as a type or group. Indeed, the patterns that emerge from our demographic analyses reinforce the importance of going even deeper in practice.
This nSight highlights 6 key points:
- The proportion of people in our HCAHPS sample who reported ‘excellent,’ or ‘very good’ mental health dipped from 65% in 2013 to 60% in 2023. A ZIP code-level analysis illustrates that the overall decline is not universal: In some parts of the country, self-reports have improved.
- While younger patients (ages 18-44) have reported substantial declines in mental health over the past decade, 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 (85+) has been consistently low; people in this age group have the highest rate of suicide in the United States.
- After several years of reporting higher mental health, females now report their mental health as slightly worse than do males. The crossover point coincides with the onset of the pandemic in 2020. However, younger males report markedly lower mental health than do females in the same age groups.
- Our analysis reveals a concerning downward trajectory for young males: Only 50% of 27-to-34-year-olds rate their own mental health as ‘excellent’ or ‘very good.’ This age group has the second highest rate of suicide in the United States.
- While this decline in self-reported mental health is evident across different racial/ethnic groups, the biggest differential over the past decade is amongst people identifying as Native Hawaiian/Pacific Islander and Native Alaskan/American Indian.
- Patients who are 18-26 years old, who are older than 85 years old, or who identify as Hispanic express markedly lower perceptions around therapist listening, trust in therapists, and consistency of therapists. Males reported slightly lower perceptions on each of these metrics than did females.
Self-Reported Mental Health
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.
Perceptions About Therapists
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.
Bottom Line
Health organizations – and the people who deliver healthcare – play a vitally important and central role in addressing the mental health crisis. But they cannot do it alone. Recognizing the importance of a coordinated approach, the American Hospital Association outlined behavioral health strategic priorities for 2023:
- Integration. Increase hospitals’ and health systems’ integration of physical and behavioral health services in acute inpatient, emergency department, and primary care settings.
- Community Partnerships. Pursue initiatives by hospitals and health systems, community partners, social service agencies, and others to expand access to a continuum of behavioral health services in a region.
- Stigma Reduction. Reduce stigmas and deaths of despair, while addressing the unique stigmas of specific age groups, cultures, and other demographics.
- Suicide Prevention. Prevent suicide through behavioral health initiatives, awareness, and intervention.
While this future-oriented agenda is valuable, it is equally important to consider what health organizations can do right now. A practical first step is to tune into the issues and patterns highlighted in this nSight, while never losing sight of the imperative to focus on each patient as a unique person. For instance, our analysis that shows a troubling trajectory for young males does not mean that every young male is struggling, or that everyone who is struggling has a common experience.
Our July nSight noted that the core elements of Human Understanding – Connect with me, Listen to me, Partner with me – are paramount for people who are struggling, as well as for those who care for them. Indeed, listening for cues about the challenges people face, such as loneliness and social isolation, can open the door to discussions about the kind of support that can change lives for the better. Better coordinating internal services and integrating with external resources will streamline mechanisms for connecting patients with appropriate support once issues are surfaced.
My visit there was very helpful for my mental health, it is one of the best things that has ever happened to me. Thanks to the wonderful staff!
My visit there was very helpful for my mental health, it is one of the best things that has ever happened to me. Thanks to the wonderful staff!
When I came to the hospital I was not in a good frame of mental health. Thanks to your care given, I have been referred to people who can help me. Thank you!
When I came to the hospital I was not in a good frame of mental health. Thanks to your care given, I have been referred to people who can help me. Thank you!
Explore additional nSight reports to get insider data and perspectives you need to drive strategic change. Discover More.
© NRC Health 2023
Explore additional nSight reports to get insider data and perspectives you need to drive strategic change. Discover More.
© NRC Health 2023