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Mental Health Conditions and Substance Use: Comparing U.S. Needs and Treatment Capacity with Those in Other High-Income Countries

Highlights

  • About one-quarter of U.S. adults report having a mental health diagnosis such as anxiety or depression or experiencing emotional distress. This is one of the highest rates among 11 high-income countries.
  • While U.S. adults are among the most willing to seek professional help for emotional distress, they are among the most likely to report access or affordability issues.
  • Emotional distress is associated with social and economic needs in all countries. Nearly half of U.S. adults who experience emotional distress report such worries, a higher share than seen in other countries.
  • The United States has some of the worst mental health–related outcomes, including the highest suicide rate and second-highest drug-related death rate.
  • The U.S. has a relatively low supply of mental health workers, particularly psychologists and psychiatrists. Just one-third of U.S. primary care practices have mental health professionals on their team, compared to more than 90 percent in the Netherlands and Sweden.

Mental health is an important indicator of a society’s overall well-being. Mental health interacts closely with physical health: people with chronic physical conditions often also have mental health issues.1

This data brief examines the mental health burden in the United States compared with 10 other high-income countries that participate in the Commonwealth Fund’s annual international health policy survey. We also look at the relationship between mental health burden and social determinants of health, differences in seeking care, access and affordability of care, mental health and substance use disorder outcomes, and health system capacity. Such cross-country comparisons can provide valuable insights into how the provision of mental health and substance use care can be strengthened in the U.S. This analysis also can serve as a baseline measurement of underlying mental health needs across countries before the COVID-19 pandemic, which is likely to exacerbate mental health conditions in several countries experiencing social distancing measures.2

More U.S. adults have received mental health diagnoses than adults in other high-income countries.

Among adults in high-income countries, those in the U.S. were most likely to have been diagnosed with depression, anxiety, or other mental health conditions by a doctor. In 2016, nearly one-quarter (23%) of U.S. adults reported a mental health diagnosis, compared to fewer than 10 percent of adults in France, the Netherlands, and Germany.

The incidence of mental health conditions may reflect differences in physician diagnostic patterns, in part because of different clinical guidelines or cultural factors in the 11 countries. Also, not everyone who experiences mental health symptoms goes to see a doctor. As a result, many psychiatric conditions may go undiagnosed and untreated. Self-reports of emotional distress may, therefore, provide a better understanding of actual mental health burden among the general population.

In 2016, slightly more than one-quarter (26%) of U.S. adults reported that in the past two years they had experienced emotional distress, such as anxiety or great sadness, that was difficult to cope with alone. The U.S. rate is similar to Canada’s (27%) and Sweden’s (24%), while only 7 percent and 12 percent of German and French adults reported emotional distress.

Emotional distress rates are higher among people worried about neighborhood safety issues or having enough money for food or housing. U.S. adults with emotional distress are the most likely among the countries to have these social and economic concerns.

Nearly half (45%) of U.S. adults who reported experiencing emotional distress also reported being concerned about neighborhood safety or having enough money for housing or food. In contrast, only 16 percent to 19 percent of adults reporting emotional distress in the United Kingdom, France, and Germany reported unmet social and economic needs. This suggests that unmet social needs in the U.S. may be more prevalent than in other high-income countries, potentially contributing to the experience of emotional distress.

U.S. adults are among the most likely to want to see a professional when experiencing emotional distress.

Cultural norms and stigma associated with psychological illness may contribute to differences in the likelihood of people seeking mental health care during a time of need.3 While a considerable share of British, Swiss, and Dutch adults (41%–45%) reported not wanting to see a professional when experiencing emotional distress, only 23 percent of U.S. adults reported the same. This suggests that there may be less stigma associated with seeking mental health treatment in the U.S. than in some other high-income countries.

One in six U.S. adults is unable to get or afford professional help when experiencing emotional distress.

Access to professional mental health care can be lifesaving in a time of crisis. Among U.S. adults who had experienced emotional distress in the past two years, approximately one in six (15%) said that they could not get or afford professional help. However, rates were higher in France (21%) and similar in Norway (16%). In contrast, only 3 percent of Dutch and 7 percent of New Zealand adults experiencing emotional distress could not get or afford the help they needed.

The U.S. has the highest suicide rate among 11 high-income countries, and the rate has increased every year since 2000.

Barriers to accessing care may help explain why the U.S. has one of the highest suicide rates in the industrialized world.4 At 13.9 suicides per 100,000 people, the 2016 rate is the highest among the 11 countries studied. While France also has a high rate, at 13.1 suicides per 100,000, the U.S. rate is nearly twice that of the country with the lowest number of suicides, the U.K. (7.3 per 100,000).

Looking at suicide trends over time reveals that the U.S. has historically had one the lowest rates among the 11 countries. However, since the early 2000s, the U.S. suicide rate has been steadily increasing. Deaths of despair, reflecting deaths from suicides, drug overdoses, and alcohol, also have increased in recent years.5

In most other countries, suicide rates have either remained stable or improved. A handful of other countries, including Australia, Canada, and the U.K., have also experienced increases in suicide rates in recent years, but these have been relatively small.

The U.S. has one of highest death rates from substance use disorders.

In 2016, nine of every million deaths in the U.S. was caused by a substance use disorder. In comparison, the majority of the countries studied had three or fewer deaths per million tied to substance use disorders. Along with the U.S., Switzerland and Germany had comparably high rates.

The relatively high unmet mental health needs among U.S. adults may reflect a limited health system capacity to meet those needs. Compared to most other high-income countries, the U.S. has a smaller total supply of mental health workers, with 105 professionals per 100,000 people. Canada, Switzerland, and Australia have approximately twice that number of mental health workers.

The United States is not the only country with capacity issues. New Zealand, Sweden, and Germany have an even lower supply of mental health workers than the United States.

In the U.S., social workers and nurses make up the majority of the mental health workforce, while the supply of psychologists and psychiatrists is far lower than in most other countries.

Including mental health providers on primary care teams is less common in the U.S. than in some other countries.

One-third of U.S. primary care practices have a mental health provider, such as a psychologist, on their patient care teams. This is comparable to the share of primary care practices in the U.K., France, and New Zealand. But some countries are more likely to integrate mental health into primary care. More than 90 percent of primary care practices in the Netherlands and Sweden reported having mental health providers.

U.S. primary care physicians are among the least likely to report that their practices have sufficient skills and experience to treat patients with mental health conditions. Specifically, less than half of U.S. practitioners report being well prepared to manage these patients. In comparison, the vast majority of primary care practices in the Netherlands, Australia, Norway, New Zealand, and Germany are well prepared to care for patients with mental illnesses.

In general, primary care physicians across all countries were less prepared to manage patients with substance use–related issues than mental health conditions, with fewer than one-quarter reporting being well prepared in the U.S. and most other countries.

Discussion

The United States has one of the highest mental health burdens among high-income countries studied. Structural capacity to meet mental health needs, in terms of workforce numbers and preparedness, is also relatively lower in the U.S. than in other high-income countries. Although the Affordable Care Act strengthened insurance coverage for, and access to, mental health care and substance use disorder treatment, considerable gaps remain.6 We can draw four key strategies from abroad:

  1. In many high-income countries, primary care serves as the first-level setting for mental health care, offering ongoing treatment for mild-to-moderate conditions, such as depression or anxiety. In France, ambulatory centers provide primary mental health care, including home visits. In Norway, local governments fund multidisciplinary mental health teams that do community outreach. In the U.S., team-based treatment models — such as assertive community treatment and coordinated specialty care — are available in some regions.7 Coverage and affordability barriers remain, however.
  2. Other countries have taken steps to remove cost-related access barriers to some mental health care and substance use treatment services. There is no cost-sharing toward primary care visits in Canada, Germany, Netherlands, or the United Kingdom, which helps eliminate financial barriers to first-level care. Some countries also have removed copayments for prescription drugs for individuals with mental health conditions. For example, France waives all copayments for care related to long-term chronic mental illnesses, such as bipolar disorder, schizophrenia, or severe forms of anxiety or depression. Many countries also have removed cost barriers to care for children and youth, recognizing that roughly half of mental illnesses start during teenage years.8 For example, in Norway, children and youth under age 18 do not have to pay for mental health care or treatments.
  3. Faced with a dearth of psychiatrists and psychologists, the U.S. could expand on alternative workforce models that might enable greater access to care. More than a decade ago, NHS England expanded access to talk therapies in primary care settings through the Increasing Access to Psychological Therapies program. Today, more than 1.4 million patients in the program are served by specialized, nonclinical mental health practitioners. The program has been described as “the world’s most ambitious effort to treat depression,” 9 and favorable outcomes have been reported.10
  4. Because mental health problems and substance use disorder are often tied to social determinants of health — reflecting the conditions in which people live and work — collaboration is needed across social policy areas. This is already happening in some regions of the U.S. For example, Los Angeles recently introduced a community-based mental health model known as the TRIESTE project. Imported from Trieste, Italy, the model addresses the social needs of individuals with mental health problems, including individuals experiencing homelessness.11

Some high-income countries have made mental health a national priority. For example, in 2018, the U.K. appointed its first-ever Minister of Suicide and, soon thereafter, a Minister of Loneliness was named. Similarly, the New Zealand government recently released its first Wellbeing Budget, which prioritizes mental health on par with physical health. U.S. leaders could learn from their counterparts abroad in terms of prioritizing mental health on the policy agenda, drawing attention to ways to reduce cost-related access barriers, and improving the availability of community-based care.

 

How We Conducted This Study

This analysis used data from the 2019 release of health statistics compiled by the Organisation for Economic Co-operation and Development (OECD), which tracks and reports on a wide range of health system measures across 36 high-income countries. Data were extracted between July and August 2019. While data collected by the OECD reflect the gold standard in international comparisons, one limitation is that data may mask differences in how countries collect their health data. Full details on how indicators were defined, as well as country-level differences in definitions, are available from the OECD.

We also used data from the 2016 Commonwealth Fund International Health Policy Survey and the 2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Further details on how these surveys were conducted are available on the Commonwealth Fund website including for the 2016 and 2019 surveys. Workforce data were derived from the World Health Organization’s Global Health Observatory data repository. The 10 comparator countries included in this comparison represent those high-income countries12 that take part in the Commonwealth Fund’s annual International Health Policy Survey: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

 

Acknowledgments

The authors wish to thank Gabriella N. Aboulafia for her careful review and helpful comments.

Notes

1. Cynthia Boyd et al., Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations (Center for Health Care Strategies, Dec. 2010).

2. Betty Pfefferbaum and Carol S. North, “Mental Health and the COVID-19 Pandemic” (Perspective), New England Journal of Medicine, published online Apr. 13, 2020.

3. Taraneh Mojaverian, Takeshi Hashimoto, and Heejung S. Kim, “Cultural Differences in Professional Help Seeking: A Comparison of Japan and the U.S.,” Frontiers in Psychology 3, no. 615, published online Jan. 11, 2013.

4. Stephanie Brooks Holliday, The Relationship Between Mental Health Care Access and Suicide (RAND Corporation, Mar. 2, 2018).

5. Steven H. Woolf and Heidi Schoomaker, “Life Expectancy and Mortality Rates in the United States, 1959–2017,” JAMA 322, no. 20 (Nov. 26, 2019): 1996–2016.

6. Jesse C. Baumgartner, Gabriella N. Aboulafia, and Audrey McIntosh, “The ACA at 10: How Has It Impacted Mental Health Care?,” To the Point (blog), Commonwealth Fund, Apr. 3, 2020; and Amanda J. Abraham et al., “The Affordable Care Act Transformation of Substance Use Disorder Treatment,” American Journal of Public Health 107, no. 1 (Jan. 2017): 31–32.

7. Heather O’Donnell, Kristin Davis, and Samantha Mestan, “Building the Community-Based Mental Health Workforce to Expand Access to Treatment,” Health Affairs Blog, Oct. 24, 2019.

8. Ronald C. Kessler et al., “Age of Onset of Mental Disorders: A Review of Recent Literature,” Current Opinion in Psychiatry 20, no. 4 (July 2007): 359–64.

9. Benedict Carey, “England’s Mental Health Experiment: No-Cost Talk Therapy,” New York Times, July 24, 2017.

10. NHS England, “NHS Welcomes Record High Recovery Rate for Common Mental Illness,” press release, Feb. 27, 2018.

11. Rob Waters, “A New Approach to Mental Health Care, Imported from Abroad,” Health Affairs 39, no. 3 (Mar. 2020): 362–66.

12. “High income” is defined as per the World Bank Country and Lending Groups, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.

Publication Details

Publication Date: May 21, 2020
Contact: Roosa Tikkanen, Senior Research Associate, International Program in Health Policy and Practice Innovations, The Commonwealth Fund
Citation:

Roosa Tikkanen et al., Mental Health Conditions and Substance Use: Comparing U.S. Needs and Treatment Capacity with Those in Other High-Income Countries (Commonwealth Fund, May 2020). https://doi.org/10.26099/09ht-rj07

Experts

Roosa Tikkanen
Senior Research Associate, International Program in Health Policy and Practice Innovations, The Commonwealth Fund
Katharine Fields
Program Assistant, International Program in Health Policy and Practice Innovations, The Commonwealth Fund
Reggie Williams
Vice President, International Health Policy and Practice Innovations , The Commonwealth Fund
Melinda K. Abrams
Senior Vice President, Delivery System Reform and International Innovations, The Commonwealth Fund