Demand for behavioral health services outstrips supply of providers, driving higher costs, analysis finds

It has been well established by studies and research that the COVID-19 pandemic exacerbated a growing mental health crisis in the U.S. and around the world.

In the first year of the pandemic, the global prevalence of anxiety and depression increased by a massive 25%, according to research from the World Health Organization. The pandemic also catalyzed investments in digital health capabilities, such as expanding virtual therapy and e-prescribing, in response to unprecedented demand.

Despite increased awareness and attention to behavioral health challenges, there continues to be a shortage of mental health providers. According to data from the Kaiser Family Foundation, 47% of the U.S. population in 2022 was living in a mental health workforce shortage area, with some states requiring up to 700 more practitioners to remove this designation. 

A recent analysis of the U.S. behavioral health market and massive shifts that have occurred in the past three years point to troubling trends. Demand for and prescription use for behavioral health care has dramatically increased since the onset of the COVID-19 pandemic. Though behavioral health visit volumes were relatively flat prior to 2020, by the second quarter of 2022, visit volumes were 18% above pre-pandemic levels, and demand grew faster than the national average in nine of the 10 largest metropolitan core-based statistical areas, according to market research and healthcare analytics company Trilliant Health. 

"There is a significant mismatch between demand continues to outpace available supply,” said Sanjula Jain, Ph.D., Trilliant Health's chief research officer and senior vice resident of market strategy.

This mismatch is already resulting in fewer patients receiving specialized behavioral health care, increased prescription use and comorbidity risk, while also growing the total cost of care, she noted.

"These distressing trends suggest that by the laws of economics, the post-pandemic behavioral health market will likely increase the economic burden facing the U.S. healthcare system, which is already fast approaching 20% of GDP," Jain said.

Anxiety and depressive disorders catalyzed the significant increase in visit volumes. In the first half of 2021, these conditions represented 40% of all behavioral health visits. Yet, when analyzing volumes over time, neither condition group had the highest growth rate. Since 2019, visit volume for eating disorders grew the most (52.6%), followed by anxiety (47.9%), alcohol and substance use disorders (27.4%), depression (24.4%) and bipolar disorder (12.2%), Trilliant Health's analysis shows.

There are still significant gaps in access to treatment for behavioral health conditions. In 2021, 22.8% of adults had a mental illness, or approximately 58.9 million people in the U.S. At the same time, only 18.8% of adults received any form of treatment.

More specifically, while 21.4% of Black Americans have a mental illness, only 13.5% of Black Americans received any treatment and 8.6% received a prescription medication as part of treatment, Trilliant Health's data show.

Untreated behavioral health conditions will exacerbate other comorbidities, both in terms of acuity and cost of care, according to researchers.

During the past three years, there has been increased adoption and investment in virtual behavioral health but these digital services still don't address the "supply" problem, Jain noted. 

"We all have the same foundational problem, which is that we just don't have enough behavioral health professionals. Regardless of whether you're a health system or you're a digital health therapy provider, we're all competing for this finite resource," she said. "We have psychiatrists who are aging and retiring, we don't have enough graduate programs and residency positions to replace them."

Of the roughly 2,000 U.S. psychiatric residency positions, 50.8% are concentrated among six states. Without an expansion in the number of residency positions, the gap in supply and demand for psychiatrists will continue to widen, according to the research.

For the analysis, Trilliant Health researchers used the company's national all-payer claims data set that combines commercial, Medicare Advantage, traditional Medicare and Medicaid claims, which provides a nationally representative and statistically significant sample accounting for more than 300 million lives.

Researchers leveraged the data and applied the laws of economics to provide a longitudinal analysis of the ways in which patients accessed care and were treated for behavioral health conditions from 2019 to 2022.

With the expiration of the public health emergency back in May, it's important for providers and payers to understand the ways in which the pandemic changed the behavioral health market, she noted.

The COVID-19 pandemic exacerbated the behavioral health crisis, but the extent to what is temporary versus sustained is not yet clear.

New policy initiatives, such as the U.S. Preventive Services Task Force’s fall 2022 recommendations to screen children and a proposal to screen all adults for anxiety and depression, has significant implications for the future of the U.S. healthcare system. At the same time, any future decisions from the Drug Enforcement Administration about the online prescribing of controlled substances will have an impact as well.

Behavioral health demand forecasts indicate that by 2026, 25.2% of Americans will require behavioral health services, which is 1.2 percentage points above observed 2021 levels.

"This proportion could be even greater when factoring in the effects of policies such as new screening recommendations from the U.S. Preventive Services Task Force," researchers wrote.

Healthcare stakeholders, including health systems, payers, employers and policymakers, need to think about the demand, supply and yield trends influencing the future of the behavioral health economy, Jain noted.

Trilliant Health's analysis indicates that a behavioral health morbidity like depression results in even higher total cost of care. After analyzing a cohort of patients being treated for diabetes, hypertension and depression, the total cost of care was 20% higher compared to patients with diabetes and hypertension alone.

As mental health screenings for certain patient populations become increasingly recommended as part of routine care, the total costs of care for all patients will also likely rise, constraining the existing limited supply of clinician resources and potentially exacerbating access issues for underserved communities, according to the report.

The share of prescriptions for treating all mental health conditions—including for anxiety, depression, ADHD and more serious mental health conditions—has grown annually as a percentage of all prescriptions since 2017, rising to 21.5% in 2021.

One trend to watch: Americans under 18 are experiencing higher diagnosis rates of select behavioral health conditions. Between the first quarter of 2018 and the second quarter of 2022, diagnoses for eating disorders grew by more than 107.4% in the under-18 cohort, followed by depressive disorders at 44% and self-harm growing slightly at 2.35%.

Prescribing for mental health treatment now represents a larger percentage of all prescriptions given to people under 18 years old. Between 2017 and 2021, prescriptions for treating mental health grew from approximately 16.2% to 21.8% of all prescriptions for this age group, representing a 35% increase.

Notably, while prescriptions for Adderall and its generic to ADHD patients under 21 and over 45 remained relatively consistent with pre-pandemic levels, prescriptions skyrocketed by 58.2% in the 22 to 44 age cohort from the first quarter of 2018 to the second quarter of 2022, an area of potential concern given the known side effects of Adderall, researchers wrote in the report.

"We seeing are indications that younger patients will likely be on medication therapy for longer periods of time, what does that represent for the health economy as far as comorbidities?" Jain asked.

Trilliant Health’s analysis found that patients with a history of stimulant use experience higher rates of medical conditions like hypertension, sleep disorders and other issues. Thus, it is important to consider whether rising rates of stimulant prescriptions will lead to increasing demand for treatments for comorbidities over time, creating a higher cost of care per patient, the researchers wrote in the report.

"From a health system perspective, behavioral health is a service line and we are now seeing implications that more and more of behavioral health patients that are coming in for treatment, they're going to look different, they're going to be younger and they're going to come in with more chronic conditions," Jain said.

Building on its vast healthcare research that examines trends at the national level, Trilliant Health also launched a premium subscription research service that analyzes market-specific changes in demand and supply.  Market-level data can help stakeholders effectively quantify and forecast growth opportunities to maximize return on investment in a capital-constrained market, Jain noted.