It’s news to no one that the prevalence of mental health conditions rose during the pandemic and has remained high. In 2022, there were an estimated 59.3 million adults aged 18 or older in the United States with a mental illness. This number represented 23.1% of all U.S. adults (see ‘Mental Illness Statistics’).

Not surprisingly, the percentage of all U.S. adults receiving psychotherapy rose from 6.5% in 2018 to 8.5% in 2021. Psychotherapy use was highest among young adults (12%), followed by middle-aged adults (8.3%), and lowest among older adults (4.6%) (see ‘Trends In Outpatient Psychotherapy Among Adults In The U.S.’).

These increases in psychotherapy utilization followed notable patterns. Utilization was higher among younger adults, women, college-educated individuals, and those with higher family incomes. People with private insurance were also more likely to use psychotherapy.

The authors of the study attributed the differences in utilization to the use of telehealth, higher mental health literacy among more educated populations, lack of insurance coverage, and high consumer cost and cost-sharing. Issues around telehealth were primary—with nearly 4 in 10 adults receiving psychotherapy via telehealth. Technological challenges, lack of broadband access, social isolation, and lower digital literacy were cited as contributing factors.

A lack of insurance coverage and high costs were also identified as barriers to seeking mental health care. Adults with higher income levels and private insurance were more likely to access psychotherapy than individuals with lower family income levels and without private health insurance were less likely to use teletherapy. “Public insurance programs may not be sufficient to counter adverse associations of low-income levels with psychotherapy access. Low psychotherapy reimbursements by Medicaid and commercial insurance can deter psychotherapists from participating in insurance networks [and] contribute to local shortages…” This is complicated by the increase in teletherapy, where “…psychotherapists can select and accept individuals from a larger pool of potential patients. Some psychotherapists may use this flexibility to select more highly educated people or those who are younger, have less than serious psychological distress, or have other readily ascertainable characteristics that therapists may associate with responsiveness to psychotherapy.”

In an era of focus on performance, these gaps in the utilization of mental health treatment are both a challenge and an opportunity. The challenge is the shifting definitions of performance in the market. With more competition for consumers and health plan contracts, provider organization executive teams need to focus on improving access among underserved consumer cohorts. In performance-based contracts, where metrics like total cost of care, emergency room utilization, and follow-up after hospitalization are the measures of success, connecting consumers to mental health services is critical. This is because almost 35% of total health care resources are used by the 5% of the population with a behavioral health disorder (see ‘How Do Individuals With Behavioral Health Conditions Contribute To Physical And Total Healthcare Spending?’ and ‘Concentration Of Healthcare Expenditures And Selected Characteristics Of Persons With High Expenses’). And lack of access drives increased costs. For consumers diagnosed with a behavioral health condition, those who receive outpatient behavioral health care have a significantly lower total cost of care—due to fewer emergency department visits and inpatient hospitalizations (see ‘Outpatient Behavioral Health Treatment Reduces Total Cost of Care; Savings Effect Magnified For Consumers With Co-Morbid Conditions’). And a 69% reduction in emergency department (ED) visits has been documented among consumers with medically unexplained symptoms after receiving the psychotherapy intervention (see ‘Reduction Of Mental Health–Related Emergency Department Admissions For Youth And Young Adults Following A Remote Intensive Outpatient Program: Quality Improvement Analysis’).

The opportunity for community-based provider organizations is both improving performance and driving more revenue by creating a better ‘consumer experience’ for underserved population cohorts—older adults, rural consumers, adults with limited literacy, and consumers with no access to broadband. One opportunity is creating time-limited, disorder-specific psychotherapies with demonstrated outcomes for specific underserved populations. Another is creating solutions specific to the 54% of adults who read below a sixth-grade reading level (see ‘Literacy Statistics 2024- 2025 (Where We Are Now)’). And with a growing 65+ population, mental health services tailored to that population present opportunities for growth. 

Meeting people where they are in the health and human service system is not only good for population health but also good for business. Specifically, expanding access to mental health services among underserved groups can reduce overall health care costs and provide the opportunity for service line expansion.