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Mental Health and Substance Use Challenges (Volume 103)
Quarterly Article
Noa Krawczyk
Hillary Samples
Jul 30, 2026
May 6, 2026
June 2026
Back to The Milbank Quarterly
Policy Points:
See all articles in the special issue, Mental Health and Substance Use Challenges Facing the United States: What Can State Policymakers Do?
The United States is facing an ongoing mental health and substance use crisis. In 2023, 58.7 million US adults had a past-year mental illness, 46.3 million had a substance use disorder (SUD), and 20.4 million had both.1 Overdose and suicide deaths have risen substantially over the past decades,2-6 contributing to declining life expectancy that is unevenly distributed across sociodemographic subgroups.7 In addition to their impact on premature mortality, mental illness and SUD are primary contributors to acute and chronic morbidity and disability.8 Still, only half of people with a mental illness and a quarter with SUD in the United States received any treatment for these conditions in 2023.1
Despite gaps in access to behavioral health treatment, people with mental illness and SUD interact with general health care settings for a range of needs. Two critical points of care are primary and emergency care settings. Primary care is often the first or sole point of contact for most of the population, playing an increasingly significant role in identification, treatment, and referral to other specialties or levels of care for behavioral health conditions.9, 10 Indeed, over a third of visits for any mental illness in the United States occur in primary care settings.11 At the other end of the spectrum, emergency departments (EDs) and hospitals bear the charge of addressing severe behavioral health needs, particularly in the aftermath of the COVID-19 pandemic.12-16 Of all ED encounters between 2018 and 2020, 12% were for behavioral health conditions.15
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2023 National Survey on Drug Use and Health. SAMHSA. July 2024. Accessed December 30, 2024. samhsa.gov/data/report/2023-nsduh-annual-national-report
Garnett MF, Curtin SC, Stone DM. Suicide mortality in the United States, 2000–2020: NCHS data brief 433. Centers for Disease Control and Prevention. March 2022. Accessed May 15, 2022. cdc.gov/nchs/products/databriefs/db433.htm
Garnett MF, Curtin SC. Suicide mortality in the United States, 2001–2021: NCHS data brief 464. Centers for Disease Control and Prevention. April 13, 2023. Accessed December 28, 2024. doi:10.15620/cdc:125705
Garnett MF, Curtin SC. Suicide mortality in the United States, 2002–2022: NCHS data brief 509. Centers for Disease Control and Prevention. September 2024. Accessed December 28, 2024. www.cdc.gov/nchs/products/databriefs/db509.htm
Hedegaard H, Miniño AM, Spencer MR, Warner M. Drug overdose deaths in the United States, 1999–2020: NCHS data brief 428. Centers for Disease Control and Prevention. December 30, 2021. Accessed December 8, 2024. doi:10.15620/cdc:112340
Spencer MR, Miniño AM, Warner M. Drug overdose deaths in the United States, 2001–2021: NCHS data brief 457. Centers for Disease Control and Prevention. December 2022. Accessed February 14, 2023. cdc.gov/nchs/products/databriefs/db457.htm
Harper S, Riddell CA, King NB. Declining life expectancy in the United States: missing the trees for the forest. Annu Rev Public Health. 2021; 42: 381–403.
Vigo D, Jones L, Thornicroft G, Atun R. Burden of mental, neurological, substance use disorders and self-harm in North America: a comparative epidemiology of Canada, Mexico, and the United States. Can J Psychiatry. 2020: 65(2): 97–98.
Burke SP, Frank RG, Kennedy PJ, et al. Tackling America’s mental health and addiction crisis through primary care integration. Bipartisan Policy Center. March 2021. Accessed December 31, 2024. bipartisanpolicy.org/download/?file=/wp-content/uploads/2021/03/BPC_Behavioral-Health-Integration-report_R03.pdf
Kates N, Arroll B, Currie E, et al. Improving collaboration between primary care and mental health services. World J Biol Psychiatry. 2019; 20(10): 748–765.
Jetty A, Petterson S, Westfall JM, Jabbarpour Y. Assessing primary care contributions to behavioral health: a cross-sectional study using medical expenditure panel survey. J Prim Care Community Health. 2021; 12.
Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health-related emergency department visits among youth, 2011–2020. JAMA. 2023; 329(17): 1469–1477.
Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2021; 78(4): 372–379.
Gutiérrez-Sacristán A, Serret-Larmande A, Hutch MR, et al. Hospitalizations associated with mental health conditions among adolescents in the US and France during the COVID-19 pandemic. JAMA Netw Open. 2022; 5(12):e2246548.
Peters ZJ, Santo L, Davis D, DeFrances CJ. Emergency department visits related to mental health disorders among adults, by race and Hispanic ethnicity: United States, 2018–2020: NCHS report 181. Centers for Disease Control and Prevention. March 1, 2018. Accessed December 30, 2024. doi:10.15620/cdc:123507
Santillanes G, Axeen S, Lam CN, Menchine M. National trends in mental health-related emergency department visits by children and adults, 2009–2015. Am J Emerg Med. 2020; 38(12): 2536–2544.