Key Substance Use and Mental Health Indicators in the United States:
Results from the 2021 National Survey on Drug Use and Health

Executive Summary

The Substance Abuse and Mental Health Services Administration (SAMHSA) presents Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by SAMHSA, within the U.S. Department of Health and Human Services. The 2021 NSDUH used multimode data collection, in which 69,850 respondents aged 12 or older completed the survey in person or via the web. Estimates based on multimode data collection in 2021 are not comparable with estimates from 2020 or prior years. Therefore, this report presents NSDUH estimates from 2021 only.

SAMHSA is pleased to announce that the 2021 report includes selected estimates by race and ethnicity, in addition to estimates by age group. SAMHSA is committed to using data and evidence to fulfill the mission and vision of promoting mental health, preventing substance misuse, and providing treatments and supports to foster recovery while ensuring equitable access and positive outcomes. NSDUH is a vital data tool that supports SAMHSA's mission and aligns with SAMHSA's vision to guide stakeholders in developing policies and programs so that people in the United States who have, are affected by, or are at risk for mental health or substance use conditions receive care, thrive, and achieve wellbeing.

Key findings from the 2021 NSDUH are highlighted as follows:

Alcohol Use in the Past Month

• Among the 133.1 million current alcohol users aged 12 or older in 2021, 60.0 million people (or 45.1 percent) were past month binge drinkers. Among past month binge drinkers, 16.3 million people were past month heavy drinkers.
• Among people aged 12 or older in 2021, Asian people (10.7 percent) were less likely to be binge drinkers in the past month compared with people in other racial or ethnic groups.

Illicit Drug Use in the Past Year

• Among people aged 12 or older in 2021, 3.3 percent (or 9.2 million people) misused opioids (heroin or prescription pain relievers) in the past year.
• Opioid misuse in the past year among people aged 12 or older in 2021 did not differ among racial or ethnic groups.

Substance Use Disorders in the Past Year

• In 2021, 46.3 million people aged 12 or older (or 16.5 percent) had a substance use disorder (SUD) in the past year, including 29.5 million who had an alcohol use disorder, 24.0 million who had a drug use disorder, and 7.3 million people who had both an alcohol use disorder and a drug use disorder.
• The percentage of people aged 12 or older in 2021 with a past year SUD was higher among American Indian or Alaska Native (27.6 percent) or Multiracial people (25.9 percent) than among Black (17.2 percent), White (17.0 percent), Hispanic (15.7 percent), or Asian people (8.0 percent). The percentage was lower among Asian people than among people in all other racial or ethnic groups.

Substance Use Treatment

• Among the 40.7 million people aged 12 or older in 2021 with an illicit drug or alcohol use disorder in the past year who did not receive treatment at a specialty facility, 96.8 percent (or 39.5 million people) felt they did not need treatment, 2.1 percent (or 837,000 people) felt that they needed treatment but did not make an effort to get treatment, and 1.1 percent (or 447,000 people) felt that they needed treatment and made an effort to get treatment.
• Among people aged 12 or older in 2021 who had an illicit drug or alcohol use disorder in the past year and did not receive substance use treatment at a specialty facility, similar percentages of people across racial or ethnic groups felt they did not need substance use treatment.

Tobacco Product Use or Nicotine Vaping in the Past Month

• In 2021, about 3 in 5 adolescents aged 12 to 17 who used nicotine products in the past month (60.5 percent) vaped nicotine but did not use tobacco products.

Mental Illness among Adults

• In 2021, 5.5 percent of adults aged 18 or older (or 14.1 million people) had serious mental illness (SMI) in the past year. The percentage of adults aged 18 or older with SMI was highest among young adults aged 18 to 25 (11.4 percent or 3.8 million people), followed by adults aged 26 to 49 (7.1 percent or 7.3 million people), then by adults aged 50 or older (2.5 percent or 3.0 million people).
• Among adults aged 18 or older in 2021, Multiracial adults (8.2 percent) were more likely to have had SMI in the past year compared with Hispanic (5.1 percent), Black (4.3 percent), or Asian adults (2.8 percent). The percentage of adults with SMI in the past year was lower among Black adults than among White adults (6.1 percent). The percentage was also lower among Asian adults than among White or Hispanic adults.

Major Depressive Episode among Adolescents

• Among adolescents aged 12 to 17 in 2021, 20.1 percent (or 5.0 million people) had a past year major depressive episode (MDE), and 14.7 percent (or 3.7 million people) had a past year MDE with severe impairment.
• The percentages of Asian or Black adolescents aged 12 to 17 in 2021 who had a past year MDE (13.8 and 14.0 percent, respectively) were lower than the corresponding percentages of Multiracial (27.2 percent), Hispanic (22.2 percent), or White adolescents (20.7 percent).

Suicidal Thoughts and Behavior

• Among adolescents aged 12 to 17 in 2021, 12.7 percent (or 3.3 million people) had serious thoughts of suicide, 5.9 percent (or 1.5 million people) made a suicide plan, and 3.4 percent (or 892,000 people) attempted suicide in the past year. However, these estimates are likely to be conservative because the questions for respondents aged 12 to 17 included the response options “I'm not sure” and “I don't want to answer,” which were not included in the corresponding questions for adults.
• Among adults aged 18 or older in 2021, 4.8 percent (or 12.3 million people) had serious thoughts of suicide, 1.4 percent (or 3.5 million people) made a suicide plan, and 0.7 percent (or 1.7 million people) attempted suicide in the past year.
• Few racial/ethnic differences in suicidal thoughts and behavior in 2021 were found among youth and adults.

Mental Health Services

• In 2021, 18.8 percent of adults aged 18 or older (or 46.5 million people) received any of the following mental health services in the past year: inpatient or outpatient mental health services, prescription medication for a mental health issue, or virtual (i.e., telehealth) services. Among the 57.8 million adults with any mental illness (AMI) in the past year, 47.2 percent (or 26.5 million people) received any of these mental health services in the past year. Among the 14.1 million adults with SMI in the past year, 65.4 percent (or 9.1 million people) received any of these mental health services in the past year.
• Among adults aged 18 or older in 2021 who had AMI in the past year, White (52.4 percent) or Multiracial adults (52.2 percent) were more likely than Black (39.4 percent), Hispanic (36.1 percent), or Asian adults (25.4 percent) to have received any of these mental health services in the past year. Asian adults with AMI also were less likely to have received mental health services in the past year compared with Black or Hispanic adults with AMI.

Mental Health and Substance Use Conditions

• Nearly half of young adults aged 18 to 25 in 2021 (45.8 percent or 15.3 million people) had either an SUD or AMI in the past year. This percentage was higher than corresponding percentages among adults aged 26 to 49 (39.5 percent or 40.4 million people) and adults aged 50 or older (22.6 percent or 26.7 million people).
• The percentage of adults aged 18 or older in 2021 who had either an SUD or AMI in the past year was higher among Multiracial adults (48.0 percent) than among White (33.6 percent), Black (32.3 percent), Hispanic (30.3 percent), or Asian adults (21.4 percent). Asian adults were less likely to have had either AMI or an SUD in the past year compared with adults in most other racial or ethnic groups. Similar patterns among racial or ethnic groups were observed for the percentages of adults who had both an SUD and AMI in past year.

Perceived Recovery

• Among the 29.0 million adults aged 18 or older in 2021 who perceived that they ever had a substance use problem, 72.2 percent (or 20.9 million people) considered themselves to be in recovery or to have recovered from their drug or alcohol use problem.
• Among adults aged 18 or older in 2021 who perceived that they ever had a substance use problem, there were no differences among White (73.5 percent), Black (69.2 percent), or Hispanic adults (67.6 percent) who considered themselves to be in recovery or to have recovered from their drug or alcohol use problem.
• Among the 58.7 million adults aged 18 or older in 2021 who perceived that they ever had a problem with their mental health, 66.5 percent (or 38.8 million people) considered themselves to be in recovery or to have recovered from their mental health issues.
• Among adults aged 18 or older in 2021 who perceived that they ever had a problem with their mental health, percentages of those who considered themselves to be in recovery or to have recovered from their mental health issues did not differ among racial or ethnic groups.

NSDUH supports SAMHSA's mission to promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery by providing data on key mental health and substance use outcomes that inform policy and practice. By leveraging data to inform the public health response, SAMHSA will better achieve its vision that people with, affected by, or at risk for mental health and substance use conditions receive care, thrive, and achieve wellbeing. Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health summarizes the most recent data on substance use, mental health, and treatment in the United States.

Introduction

Substance use and mental health issues have significant impacts on people, families, communities, and societies.^1,2,3,4 The National Survey on Drug Use and Health (NSDUH), conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides nationally representative data on use of tobacco, alcohol, and illicit drugs; substance use disorders (SUDs); receipt of substance use treatment; mental health issues; and use of mental health services among the civilian, noninstitutionalized population aged 12 or older in the United States. NSDUH estimates allow researchers, clinicians, policymakers, and the general public to better understand and improve the nation's behavioral health. SAMHSA is steadfast in its efforts to advance the health of the nation while also promoting equity. Therefore, this report, based on 2021 NSDUH data, contains findings on key substance use and mental health indicators in the United States by race/ethnicity.

Results from the 2021 National Survey on Drug Use and Health: Detailed Tables show comprehensive substance use and mental health-related estimates and are available separately at https://www.samhsa.gov/data/report/2021-nsduh-detailed-tables.⁵

The 2021 NSDUH used multimode data collection, in which respondents completed the survey in person or via the web. As discussed in the 2021 National Survey on Drug Use and Health (NSDUH): Methodological Summary and Definitions report, methodological investigations led to the conclusion that estimates based on multimode data collection in 2021 are not comparable with estimates from 2020 or prior years.⁶ Therefore, this report presents NSDUH estimates from 2021 only.

Survey Background

NSDUH is an annual survey sponsored by SAMHSA within the U.S. Department of Health and Human Services (HHS). NSDUH covers residents of households and people in noninstitutional group settings (e.g., shelters, boarding houses, college dormitories, migratory workers' camps, halfway houses). The survey excludes people with no fixed address (e.g., people who are homeless and not in shelters), military personnel on active duty, and residents of institutional group settings, such as jails, nursing homes, mental health institutions, and long-term care hospitals.

Overview of Data Collection in 2021

NSDUH employs a probability sample designed to be representative of both the nation as a whole and for each of the 50 states and the District of Columbia.⁷ The 2021 NSDUH used multimode data collection throughout the year. Eligibility of areas for in-person data collection in 2021 was determined by state- and county-level coronavirus disease 2019 (COVID-19) metrics.⁸ In-person data collection commenced in eligible areas after potential respondents first were given the opportunity to complete the survey via the web. Throughout 2021 data collection, sampled individuals residing in areas approved for in-person data collection also retained the option to participate via the web. Therefore, respondents could choose whether to complete screenings or interviews via the web or in person. Respondents also could transition between data collection modes for screening and interviewing (e.g., completing household screening via the web and the main interview in person) if in-person interviewing was available where respondents lived.⁹

Data Collection in Each Quarter of 2021

A full sample was available from all 4 quarters in 2021. (See the next paragraph for definitions of the individual quarters.) Screening was completed for 220,743 addresses, and the final sample consisted of 69,850 completed interviews. Based on information from the household screenings, there were 13,270 interviews from adolescents aged 12 to 17 and 56,580 interviews from adults aged 18 or older.¹⁰ Overall, 54.6 percent of interviews were completed via the web, and 45.4 percent were completed in person. Weighted response rates for household screening and for interviewing were 22.2 and 46.2 percent, respectively, for an overall response rate of 10.3 percent for people aged 12 or older. The weighted interview response rates were 38.4 percent for adolescents aged 12 to 17 and 47.0 percent for adults aged 18 or older.¹¹

The percentages of interviews that were completed via the web or in person varied by quarter in 2021. The percentage of interviews that were completed via the web decreased by quarter as 2021 progressed. About three fourths of interviews in Quarter 1 of 2021 (i.e., January to March) were completed via the web (76.6 percent). In Quarter 2 of 2021 (i.e., April to June), the majority of the interviews (56.8 percent) also were completed via the web. Fewer than half of interviews in Quarter 3 (i.e., July to September) and Quarter 4 of 2021 (i.e., October to December) were completed via the web (47.9 and 41.5 percent, respectively).

Further information about the 2021 NSDUH design and methods can be found on the web at https://www.samhsa.gov/data/report/2021-methodological-summary-and-definitions.¹²

Data Presentation and Interpretation

Presentation of Estimates and Statistical Testing

This report focuses on substance use and mental health indicators in the United States based on NSDUH data from 2021. All estimates (e.g., percentages and numbers) presented in the report are derived from survey data that are subject to sampling errors and have met the criteria for statistical precision.¹³

Estimates of substance use and related treatment are presented for people aged 12 or older, including adolescents and adults.¹⁴ However, estimates of mental health issues and mental health service use are presented separately for adolescents aged 12 to 17 and adults aged 18 or older because the two groups answered different questions regarding mental health and mental health service utilization.

New for 2021, estimates are presented by racial or ethnic group for selected outcomes. Estimates that are presented for racial or ethnic groups are based on federal standards for reporting these data.¹⁵ Definitions for racial and ethnic groups are provided in Appendix A of the 2021 Methodological Summary and Definitions report.¹² The racial and ethnic groups discussed in this report are mutually exclusive. People who were of Hispanic or Latino ethnicity could be of any race but are not included in the estimates for any of the racial categories. Estimates for people who were not of Hispanic or Latino ethnicity are reported by race. People reporting two or more races and who were not of Hispanic or Latino ethnicity are noted as “Two or More Races” in the 2021 Detailed Tables and as “Multiracial” in this report; the two terms are used interchangeably. People reporting their race as Black or African American are subsequently referred to as Black. People reporting their ethnicity as Hispanic or Latino are subsequently referred to as Hispanic.

Statistical testing was performed for comparisons of estimates across age groups and among racial or ethnic groups according to procedures described in the 2021 Methodological Summary and Definitions report.¹⁶ For consistency with the typical criteria for statistical testing in NSDUH, age group differences were considered statistically significant at the .05 level of significance. For testing among racial or ethnic groups, a more conservative level of .01 was used for considering differences to be statistically significant. Statistically significant differences resulting from these testing procedures are described using terms such as “higher,” “lower,” “more likely,” or “less likely.” Statements use terms such as “similar” or “the same” when a difference was not statistically significant. When estimates are presented without reference to differences across groups, statistical significance is not implied.

Implications of the COVID-19 Pandemic for the 2021 NSDUH

The COVID-19 pandemic continued to affect data collection for the 2021 NSDUH. Because multimode data collection was used in 2021, data processing accounted for the potential effects of survey mode¹⁷ on responses.¹² As noted previously, the percentage of interviews that were completed via the different data collection modes varied by quarter in 2021. In addition, the 2021 NSDUH marked the first year in which population projections from the 2020 decennial census were used to develop analysis weights for making estimates.

Presentation of NSDUH estimates from prior years can be misleading because apparent differences in estimates between 2021 and prior years may be attributable to multimode data collection in 2021 rather than actual changes in the civilian, noninstitutionalized population of the United States during the COVID-19 pandemic. For this reason, this report presents NSDUH estimates from 2021 only, as indicated in the Introduction.

However, this report does present people's perceptions of how the COVID-19 pandemic in 2021 affected their substance use, mental health, and other parts of their lives in the section on Substance Use, Mental Health Issues, and the COVID-19 Pandemic. Sections on suicidal thoughts and behaviors among adults and adolescents also include estimates of whether these thoughts and behaviors were because of COVID-19.

Moreover, this report does compare estimates among members of different age groups in 2021. This report also presents estimates by racial or ethnic group for selected outcomes. Differences in estimates by age group or by racial or ethnic group are useful for identifying age groups or racial or ethnic groups that appear to be at greater or lower risk for negative substance use and mental health outcomes or that are less likely to receive needed services. In addition, the 2021 Detailed Tables present estimates by gender and by racial or ethnic group that can be used to identify other disparities in behavioral health outcomes during the COVID-19 pandemic. Because some estimates in supplemental tables in the appendices of this report may not be found in the 2021 Detailed Tables, the appendices include standard errors for the associated estimates.¹⁸ Appendices A and B contain tables of estimates by age group and by racial or ethnic group, respectively.

Although it is not appropriate for data users to compare estimates from this report with estimates from prior years, estimates from 2021 remain important to inform efforts across multiple behavioral health programming and policy areas. These efforts include preventing substance use and the onset of mental disorders, identifying substance use and mental health issues before they progress to SUDs or mental disorders, ensuring equitable access to appropriate substance use treatment and mental health services, and promoting long-term recovery from SUDs or mental disorders.

NSDUH also was not the only national survey that was affected by the COVID-19 pandemic. For example, the 2021 National Youth Tobacco Survey (NYTS) did not compare nicotine product use estimates from 2021 with those from prior years because of methodological changes to the 2021 NYTS in response to the COVID-19 pandemic.¹⁹ The 2021 Methodological Summary and Definitions report discusses how the COVID-19 pandemic has affected data collection for other national surveys.²⁰

As COVID-19 infections in the United States wax and wane over time, the proportions of web and in-person NSDUH interviews may continue to fluctuate somewhat by quarter in the short term. However, these proportions are expected to stabilize at some future point. SAMHSA is investigating approaches to ensure that estimates from the 2021 NSDUH can be compared with estimates from future years.

General Substance Use in the Past Month

This section provides an overview of estimates according to whether respondents aged 12 or older reported using tobacco products, alcohol, or illicit drugs, or vaping nicotine or tobacco in the 30 days before the NSDUH interview (i.e., in the past month, also referred to as “current use”). Additional information on the use of tobacco products, alcohol, and illicit drugs is provided in other sections of this report.¹⁸

Past month tobacco use includes any use of these four tobacco products: cigarettes, smokeless tobacco (such as snuff, dip, chewing tobacco, or snus), cigars, and pipe tobacco. Past month alcohol use refers to having more than a sip or two of any type of alcoholic drink (e.g., a can or a bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it). Past month illicit drug use includes any use of marijuana (including use of marijuana with a vaping device), cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine, as well as misuse of prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), or pain relievers. (See the section on the Misuse of Psychotherapeutic Drugs for the definition of “misuse.”) Past month nicotine vaping refers to the use of an e-cigarette or other vaping device to vaporize (i.e., vape) nicotine or tobacco. Any vaping in the past month includes the use of a vaping device to vape any substance, including (but not limited to) nicotine, marijuana, or flavoring.

Tables in Appendix A also include estimates of past month use for the following other substances: gamma hydroxybutyrate (GHB), the misuse of nonprescription cold and cough medicine, kratom, synthetic marijuana (fake weed, K2, or Spice), and synthetic stimulants (“bath salts” or flakka). Estimates for the use or misuse of these other substances are discussed later in the report for the past year (rather than the past month) because of low prevalence estimates in the past month for many of these substances.

Among people aged 12 or older in 2021, 57.8 percent (or 161.8 million people) used tobacco, alcohol, or an illicit drug in the past month; 47.5 percent (or 133.1 million people) drank alcohol in the past month; 19.5 percent (or 54.7 million people) used a tobacco product in the past month; and 14.3 percent (or 40.0 million people) used an illicit drug in the past month (Figure 1 and Table A.1B). Estimates for tobacco, alcohol, or illicit drugs are not mutually exclusive because respondents could have used more than one type of substance (e.g., tobacco products and alcohol) in the past month.

Tobacco Use or Nicotine Vaping in the Past Month

Before 2020, NSDUH assessed tobacco use but did not include questions on nicotine vaping. However, findings from the 2019 National Youth Tobacco Survey (NYTS) and the 2019 Monitoring the Future (MTF) study indicated increases in nicotine vaping.^21,22,23 NYTS data indicate that e-cigarettes have been the most commonly used nicotine product among youths since 2014, including in 2021,¹⁹ and that e-cigarette use in 2019 had reached epidemic proportions among youths.²³ In addition, vaping of nicotine products among adolescents has been identified as a risk factor for future cigarette use.²² However, combined data for 8th, 10th, and 12th graders in the 2021 MTF study indicated a significant decrease between 2020 and 2021 in nicotine vaping in the past month.²⁴ The prevalence of nicotine vaping among adults aged 19 to 30 did not differ significantly between 2019 and 2020.²⁵

The 2021 NYTS indicated that 11.3 percent of high school students used e-cigarettes in the past month and that e-cigarettes were the most common form of nicotine products used among adolescents. Because of methodological changes to the 2021 NYTS in response to the COVID-19 pandemic, the NYTS did not compare nicotine product use estimates from 2021 with those from prior years. Nevertheless, NYTS researchers stressed the need for continued efforts to reduce all forms of nicotine product use among adolescents.¹⁹ Therefore, the 2021 NSDUH included questions to assess the use of nicotine vaping in both adolescents and adults.

As noted in the section on General Substance Use in the Past Month, past month tobacco use in NSDUH includes any use of these four tobacco products: cigarettes, smokeless tobacco (such as snuff, dip, chewing tobacco, or snus), cigars, and pipe tobacco. Past month nicotine vaping refers to the use of an e-cigarette or other vaping device to vape nicotine or tobacco. Aggregate estimates for the past month use of tobacco or nicotine vaping (also referred to as current use of nicotine products) are presented for people who used any of these tobacco products or vaped nicotine in the past month (or both).

The following sections present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for selected measures.¹³

Among people aged 12 or older in 2021, 22.0 percent (or 61.6 million people) used tobacco products or vaped nicotine in the past month (Figure 2 and Table A.1B). The percentage of people who used tobacco products or vaped nicotine in the past month was lowest among adolescents aged 12 to 17 (6.7 percent or 1.7 million people). Estimates among young adults aged 18 to 25 and adults aged 26 or older were 24.7 percent (or 8.3 million people) and 23.4 percent (or 51.6 million people), respectively.

Among current nicotine product users, the use of specific nicotine products varied by age group. An estimated 60.5 percent of adolescents aged 12 to 17 who used nicotine products in the past month vaped only nicotine products compared with 32.2 percent of young adults aged 18 to 25 and only 6.2 percent of adults aged 26 or older who used nicotine products in the past month (Figure 3 and Table A.2B). In contrast, 86.2 percent of adults aged 26 or older who used nicotine products in the past month used only tobacco products compared with 21.2 percent of adolescents aged 12 to 17 and 42.8 percent of young adults aged 18 to 25 who used nicotine products in the past month.

By Race/Ethnicity

Among people aged 12 or older in 2021, 36.1 percent of American Indian or Alaska Native people used tobacco products or vaped nicotine in the past month (Figure 4 and Table B.1B). This percentage was higher than the corresponding percentages of White (24.6 percent), Black (23.6 percent), Hispanic (14.9 percent), or Asian people (9.3 percent). The percentage of people who used tobacco products or vaped nicotine in the past month was lowest among Asian people compared with people in all other racial or ethnic groups.

Among current nicotine product users aged 12 or older in 2021, the use of specific nicotine products varied by racial or ethnic group. Black people who used nicotine products in the past month were less likely to vape only nicotine (5.1 percent) compared with past month users of nicotine products who were Multiracial (17.7 percent), White (12.3 percent), or Hispanic (11.2 percent) (Table B.2B). In contrast, Black people who were current nicotine product users were more likely to use only tobacco products in the past month (90.5 percent) compared with current nicotine product users who were Hispanic (79.4 percent), White (76.5 percent), Asian (76.5 percent), or Multiracial (70.0 percent).

Tobacco Product Use

In 2021, of the 54.7 million current (i.e., past month) tobacco users aged 12 or older (Figure 1), the majority were current cigarette smokers (43.6 million; Figure 2). This pattern matches historical usage patterns.²⁶ Additionally, 10.3 million people aged 12 or older were current cigar smokers, 7.3 million people were current smokeless tobacco users, and 1.8 million people were current pipe tobacco smokers.

Among people aged 12 or older in 2021 who used any tobacco product in the past month (regardless of whether or not they vaped nicotine), 67.5 percent smoked cigarettes but did not use other tobacco products, 12.3 percent smoked cigarettes and used some other type of tobacco product, and 20.3 percent used only noncigarette tobacco products (i.e., other tobacco products but not cigarettes) (Table A.3B). The percentage for the use of only cigarettes was highest among adults aged 26 or older who used tobacco products in the past month (69.6 percent). Among adolescents aged 12 to 17 and young adults aged 18 to 25 who used tobacco products in the past month, 48.0 percent and 51.2 percent, respectively, used only cigarettes in the past month. Overall, 57.5 percent of adolescents aged 12 to 17 and 68.4 percent of young adults aged 18 to 25 who were past month tobacco users smoked cigarettes, either as the only tobacco product they used or in addition to other tobacco products.²⁷

The remainder of this section on tobacco use focuses on cigarette smoking because most current tobacco users aged 12 or older were cigarette smokers. Information on the use of smokeless tobacco, cigars, and pipe tobacco in the past month among people aged 12 or older and by age group can be found in Table A.1B.

Cigarette Use

Among people aged 12 or older in 2021, 15.6 percent (or 43.6 million people) smoked cigarettes in the past month (Figure 5 and Table A.1B). The percentage of people who smoked cigarettes in the past month was highest among adults aged 26 or older (17.9 percent or 39.4 million people), followed by young adults aged 18 to 25 (11.5 percent or 3.8 million people), then by adolescents aged 12 to 17 (1.5 percent or 392,000 people).

By Race/Ethnicity

Among people aged 12 or older in 2021, the percentage of people who were past month cigarette smokers was lower among Asian (7.4 percent) or Hispanic people (11.2 percent) than among those who were American Indian or Alaska Native (26.5 percent), Multiracial (20.4 percent), Black (17.3 percent), or White (17.1 percent) (Table B.1B). Asian people were also less likely than Hispanic people to smoke cigarettes in the past month.

Daily Cigarette Use

Among the 43.6 million current cigarette smokers aged 12 or older in 2021 (see the section on Cigarette Use), 27.0 million people (or 61.9 percent) were daily cigarette smokers (Figure 6). Among current cigarette smokers, adults aged 26 or older were more likely than young adults aged 18 to 25 to be daily smokers (65.8 vs. 27.6 percent) (Table A.1B). Estimates for daily cigarette smoking among adolescents aged 12 to 17 could not be calculated with sufficient precision.

Among the 27.0 million daily cigarette smokers aged 12 or older in 2021, 11.3 million people (or 41.9 percent) smoked one or more packs of cigarettes per day (Figure 6 and Table A.1B). Among daily cigarette smokers, adults aged 26 or older were more likely than young adults aged 18 to 25 to smoke one or more packs of cigarettes per day (42.7 vs. 24.2 percent).

Nicotine Vaping

In 2021, 13.2 million people aged 12 or older (or 4.7 percent) used an e-cigarette or other vaping device to vape nicotine in the past month (Figures 2 and 7 and Table A.1B). The percentage of people who vaped nicotine was highest among young adults aged 18 to 25 (14.1 percent or 4.7 million people), followed by adolescents aged 12 to 17 (5.2 percent or 1.4 million people), then by adults aged 26 or older (3.2 percent or 7.1 million people).

By Race/Ethnicity

Among people aged 12 or older in 2021, Multiracial (8.9 percent), American Indian or Alaska Native (7.5 percent), or White people (5.8 percent) were more likely to have used an e-cigarette or other vaping device to vape nicotine in the past month compared with Black (2.2 percent) or Asian people (2.2 percent) (Table B.1B). Multiracial or White people were also more likely than Hispanic people (3.1 percent) to have vaped nicotine in the past month.

Underage Tobacco Use or Nicotine Vaping

Legislation in December 2019 raised the federal minimum age for sale of tobacco products (along with e-cigarettes) from 18 to 21 years.²⁸ All 50 states and the District of Columbia now prohibit the sale of tobacco products to people younger than 21.

Among people aged 12 to 20 in 2021, 11.0 percent (or 4.3 million people) used tobacco products or used an e-cigarette or other vaping device to vape nicotine in the past month (Table A.1B). Among people in this age group, 8.1 percent (or 3.1 million people) vaped nicotine, 5.4 percent (or 2.1 million people) used tobacco products, and 3.4 percent (or 1.3 million people) smoked cigarettes in the past month.

By Race/Ethnicity

Among people aged 12 to 20 in 2021, White (14.5 percent) or Multiracial people (12.2 percent) were more likely to have used tobacco products or to have used an e-cigarette or other vaping device to vape nicotine in the past month compared with people in most other racial or ethnic groups (Table B.3B). Asian people were less likely to have used tobacco products or vaped nicotine in the past month (2.9 percent) compared with people in most other racial or ethnic groups. White or Multiracial people aged 12 to 20 in 2021 were more likely to have vaped nicotine in the past month (11.1 and 9.5 percent, respectively) compared with underage Hispanic (5.0 percent), Black (3.9 percent), or Asian people (2.7 percent).

White people aged 12 to 20 in 2021 were more likely to have used tobacco products or to have smoked cigarettes in the past month compared with underage Black, Hispanic, or Asian people (Table B.3B). For example, 7.0 percent of underage White people used tobacco products in the past month compared with 4.0 percent of those who were Black, 3.6 percent of those who were Hispanic, and 1.8 percent of those who were Asian. The percentage of underage Multiracial people who used tobacco products in the past month (4.9 percent) also was higher than the corresponding percentage of underage Asian people.

Alcohol Use in the Past Month

As noted in the section on General Substance Use in the Past Month, the 2021 NSDUH asked respondents aged 12 or older about their alcohol use in the 30 days before the interview. In addition to asking about any alcohol use, NSDUH collected information on past month binge alcohol use and heavy alcohol use. In the 2021 NSDUH, binge drinking for males was defined as drinking five or more drinks²⁹ on the same occasion on at least 1 day in the past 30 days. Binge drinking for females was defined as drinking four or more drinks on the same occasion on at least 1 day in the past 30 days. This definition of binge alcohol use is consistent with federal definitions.³⁰ Heavy alcohol use was defined as binge drinking on 5 or more days in the past 30 days based on the thresholds previously described for males and females.

The following sections present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for the measures in this section.¹³

Among the 133.1 million current alcohol users aged 12 or older in 2021, 60.0 million people (or 45.1 percent) were past month binge drinkers (Figure 8). Among past month binge drinkers, 16.3 million people were past month heavy drinkers. The 16.3 million heavy drinkers represent 27.2 percent of current binge drinkers and 12.3 percent of current alcohol users.²⁷

Any Alcohol Use

Among people aged 12 or older in 2021, 47.5 percent (or 133.1 million people) drank alcohol in the past month (Figure 9 and Table A.1B). The percentage was highest among adults aged 26 or older (51.9 percent or 114.5 million people), followed by young adults aged 18 to 25 (50.1 percent or 16.8 million people). The percentage was lowest among adolescents aged 12 to 17 (7.0 percent or 1.8 million people).

By Race/Ethnicity

Among people aged 12 or older in 2021, 52.2 percent of White people drank alcohol in the past month (Table B.4B). This percentage was higher than the percentages of people in all other racial or ethnic groups. Asian people had a lower estimate of past month alcohol use (32.0 percent) compared with White, Multiracial (43.2 percent), Hispanic (41.9 percent), or Black people (41.6 percent).

Binge Alcohol Use

Among people aged 12 or older in 2021, 21.5 percent (or 60.0 million people) were binge drinkers in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (29.2 percent or 9.8 million people), followed by adults aged 26 or older (22.4 percent or 49.3 million people). The percentage was lowest among adolescents aged 12 to 17 (3.8 percent or 995,000 people).

By Race/Ethnicity

Among people aged 12 or older in 2021, Asian people (10.7 percent) were less likely to be binge drinkers in the past month compared with people in other racial or ethnic groups (Figure 10 and Table B.4B). The estimate of binge drinking in the past month could not be calculated with sufficient precision for people in the Native Hawaiian or Other Pacific Islander group.¹³ Estimates of binge drinking in the past month did not differ among people in the other racial or ethnic groups.

Heavy Alcohol Use

Among people aged 12 or older in 2021, 5.8 percent (or 16.3 million people) were heavy alcohol users in the past month (Figures 8 and 9 and Table A.1B). The percentage was highest among young adults aged 18 to 25 (7.1 percent or 2.4 million people), followed by adults aged 26 or older (6.3 percent or 13.9 million people). The percentage was lowest among adolescents aged 12 to 17 (0.4 percent or 103,000 people).

By Race/Ethnicity

Among people aged 12 or older in 2021, White people were more likely to be heavy alcohol users in the past month (6.7 percent) compared with Black (5.2 percent), Hispanic (4.7 percent), or Asian people (1.9 percent) (Figure 11 and Table B.4B). Asian people were less likely to be heavy alcohol users in the past month than American Indian or Alaska Native (7.2 percent), Multiracial (5.7 percent), Black, or Hispanic people.

Underage Alcohol Use

In 2021, all 50 states and the District of Columbia prohibited the possession of alcoholic beverages by people younger than 21 (although some states may have had exceptions).³¹ Most states also prohibited underage consumption (i.e., consumption of alcoholic beverages prior to the age of 21).³² Among people aged 12 to 20 in 2021, 15.1 percent (or 5.9 million people) were past month alcohol users (Table A.1B). Estimates of binge alcohol use and heavy alcohol use in the past month among underage people were 8.3 percent (or 3.2 million people) and 1.6 percent (or 613,000 people), respectively.

By Race/Ethnicity

Among people aged 12 to 20 in 2021, White people were more likely than people in many other racial or ethnic groups to be past month alcohol users, binge drinkers, or heavy alcohol users. Underage Asian people tended to have lower estimates of past month alcohol use, binge drinking, or heavy alcohol use than underage people in many other racial or ethnic groups.

For example, 18.1 percent of underage White people in 2021 drank alcohol in the past month compared with 14.5 percent of underage people who were Hispanic, 13.2 percent of those who were Multiracial, 9.4 percent of those who were Black, and 6.4 percent of those who were Asian (Table B.5B). Underage Asian people were less likely than underage Hispanic or Multiracial people to be past month alcohol users.

In addition, 10.1 percent of White people aged 12 to 20 in 2021 were past month binge drinkers compared with 7.3 percent of underage people who were Hispanic, 5.5 percent of those who were Black, and 2.5 percent of those who were Asian (Table B.5B). Underage Asian people were less likely to be past month binge drinkers compared with underage Multiracial (7.5 percent), Hispanic, or Black people.

In 2021, 2.1 percent of White people aged 12 to 20 were past month heavy alcohol users (Table B.5B). This percentage was higher than the percentages of underage Hispanic (1.0 percent) or Asian people (0.2 percent). Underage Asian people were less likely than underage Hispanic people to be heavy alcohol users in the past month.

Marijuana Use and Marijuana Vaping in the Past Month

The 2021 NSDUH questionnaire included new questions to assess the use of vaping devices to vape marijuana. Questions about marijuana vaping appeared in a later section of the questionnaire, after respondents had answered questions about any marijuana use. Consequently, some respondents reported that they last vaped marijuana more recently than when they reported last using any marijuana. As part of the procedures for logically editing 2021 NSDUH data, respondents who reported that they vaped marijuana more recently than they previously reported using marijuana were inferred to be more recent users of any marijuana.³³

In 2021, 13.0 percent of people aged 12 or older (or 36.4 million people) used marijuana in the past month, including 2.7 percent (or 7.4 million people) who vaped marijuana in that period (Table A.1B). The percentage of people who used marijuana in the past month was highest among young adults aged 18 to 25 (24.1 percent or 8.1 million people), followed by adults aged 26 or older (12.2 percent or 26.8 million people), then by adolescents aged 12 to 17 (5.8 percent or 1.5 million people). The percentage of people who vaped marijuana in the past month was also highest among young adults aged 18 to 25 (6.5 percent or 2.2 million people). Percentages of adolescents aged 12 to 17 and adults aged 26 or older who vaped marijuana in the past month were similar (2.3 and 2.1 percent, respectively). These percentages correspond to 600,000 adolescents aged 12 to 17 and 4.7 million adults aged 26 or older who vaped marijuana in the past month.

About 1 in 5 current marijuana users aged 12 or older (20.5 percent) vaped marijuana in the past month (Figure 12 and Table A.4B). The percentage for marijuana vaping in the past month among current marijuana users was highest among adolescents aged 12 to 17 (40.0 percent), followed by young adults aged 18 to 25 (27.0 percent), then by adults aged 26 or older (17.4 percent).

By Race/Ethnicity

Among people aged 12 or older in 2021, American Indian or Alaska Native (27.0 percent) or Multiracial people (21.1 percent) were more likely to have used marijuana in the past month compared with people in most other racial or ethnic groups (Table B.6B). Asian people (5.4 percent) were less likely to use marijuana in the past month compared with people in all other racial or ethnic groups.

Among people aged 12 or older in 2021, similar percentages of Multiracial or White people vaped marijuana in the past month (4.9 and 3.1 percent, respectively) (Table B.6B). Percentages for these two groups were higher than the percentages among Hispanic (2.0 percent), Black (1.5 percent), or Asian people (1.5 percent).

Among current marijuana users aged 12 or older in 2021, 9.9 percent of Black people vaped marijuana in the past month (Table B.6B). This percentage was lower than the corresponding percentages among current marijuana users who were Multiracial (23.0 percent), White (23.0 percent), or Hispanic (19.1 percent).

Any Vaping in the Past Month

The 2021 NSDUH added new questions to assess the use of vaping devices to vape flavoring. Along with questions on nicotine vaping and marijuana vaping, these questions on vaping of flavoring allow for more in-depth examination of the types of substances that people vaped in the past month. This section does not present findings by race or ethnicity because of the complexity of the associated measures for any vaping.

Among people aged 12 or older in 2021, 6.6 percent (or 18.6 million people) used a vaporizing device to vape any substance in the past month (Table A.1B). As indicated previously, 4.7 percent of people aged 12 or older (or 13.2 million people) vaped nicotine, and 2.7 percent (or 7.4 million people) vaped marijuana in the past month. In addition, 1.3 percent (or 3.6 million people) vaped flavoring in that period, including 3.3 percent of young adults aged 18 to 25 (or 1.1 million people), 1.8 percent of adolescents aged 12 to 17 (or 462,000 people), and 0.9 percent of adults aged 26 or older (or 2.0 million people).

Among people in 2021 who vaped any substance in the past month, use of a vaporizing device to vape nicotine was the predominant form of vaping for people aged 12 or older and in each age group, followed by marijuana vaping, then by vaping of flavoring (Table A.5B). Among people aged 12 or older who vaped any substance, 71.1 percent vaped nicotine, 40.1 percent vaped marijuana, and 19.2 percent vaped flavoring. Among adolescents aged 12 to 17 and young adults aged 18 to 25 who vaped any substance in the past month, about four fifths vaped nicotine (80.6 percent of adolescents aged 12 to 17 and 81.9 percent of young adults aged 18 to 25), and about one third vaped marijuana (35.5 percent of adolescents aged 12 to 17 and 37.7 percent of young adults aged 18 to 25). Among adults aged 26 or older who vaped any substance, 64.1 percent vaped nicotine, 42.0 percent vaped marijuana, and 18.0 percent vaped flavoring. Note that these estimates for nicotine vaping, marijuana vaping, and vaping of flavoring are not mutually exclusive. Therefore, the individual estimates for vaping these substances sum to more than 100 percent.

Because people who vaped any substance could have vaped more than one substance in the past month, Table A.5B also presents estimates for the number of substances (i.e., nicotine, marijuana, or flavoring) that people vaped in the past month. Estimates for vaping of only one of these substances, two of these substances, or all three substances sum to less than 100 percent because people who vaped any substance in the past month could have vaped substances other than nicotine, marijuana, or flavoring.

Among people aged 12 or older in 2021 who vaped any substance in the past month, 65.0 percent vaped only one of three substances (i.e., nicotine, marijuana, or flavoring), 25.0 percent vaped two of these three substances, and 5.1 percent vaped all three substances (Figure 13 and Table A.5B). An additional 4.8 percent of people who vaped any substance in the past month did not vape nicotine, marijuana, or flavoring; the other substance(s) that these people vaped in the past month is unknown.

Among people who vaped any substance in the past month, there were age group differences in the number of substances that people vaped. About half of adolescents aged 12 to 17 and young adults aged 18 to 25 who vaped any substance in the past month vaped only one substance among nicotine, marijuana, or flavoring (52.5 and 57.3 percent, respectively) (Table A.5B). In comparison, 70.9 percent of adults aged 26 or older who vaped any substance vaped only one of these substances. About one third of adolescents aged 12 to 17 and young adults aged 18 to 25 who vaped any substance in the past month vaped two of these three substances (32.6 and 32.5 percent, respectively) compared with 1 in 5 adults aged 26 or older who vaped any substance (20.0 percent).

Illicit Drug Use in the Past Year

The 2021 NSDUH obtained illicit drug use information for the use of marijuana (including use of marijuana with a vaping device), cocaine (including crack), heroin, hallucinogens, inhalants, and methamphetamine, as well as for the misuse of prescription stimulants, tranquilizers, sedatives,³⁴ and pain relievers (see the section on the Misuse of Psychotherapeutic Drugs for the definition of “misuse”). This report presents estimates of past year (rather than past month) illicit drug use because of low prevalence estimates for some illicit drugs (e.g., heroin). Moreover, the 2021 NSDUH collected only past year (rather than past month) data on the misuse of benzodiazepines and specific subtypes of prescription pain relievers (e.g., fentanyl products).

The following sections present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for selected measures.¹³

Among people aged 12 or older in 2021, 61.2 million people used illicit drugs in the past year (Figure 14). The most commonly used illicit drug in the past year was marijuana, which was used by 52.5 million people. The second most common type of illicit drug use in the past year was the misuse of prescription pain relievers, which were misused by 8.7 million people. Smaller numbers of people were past year users of the other illicit drugs shown in Figure 14.³⁵

Any Illicit Drug Use

Among people aged 12 or older in 2021, 21.9 percent (or 61.2 million people) used illicit drugs in the past year (Figures 14 and 15 and Table A.6B). The percentage was highest among young adults aged 18 to 25 (38.0 percent or 12.7 million people), followed by adults aged 26 or older (20.3 percent or 44.8 million people), then by adolescents aged 12 to 17 (14.1 percent or 3.7 million people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who used illicit drugs in the past year was higher among American Indian or Alaska Native (36.1 percent) or Multiracial people (34.6 percent) than among Black (24.3 percent), White (22.5 percent), Hispanic (19.4 percent), or Asian people (11.1 percent) (Figure 16 and Table B.7B). The estimate of illicit drug use in the past year could not be calculated with sufficient precision for people in the Native Hawaiian or Other Pacific Islander group.¹³ Asian people were less likely to use illicit drugs in the past year compared with people in all other racial or ethnic groups. Black or White people were more likely to use illicit drugs in the past year compared with Hispanic people. Estimates for illicit drug use in the past year did not differ among Black or White people.

Marijuana Use

In 2021, 18.7 percent of people aged 12 or older (or 52.5 million people) used marijuana in the past year (Figures 14 and 15 and Table A.7B). The percentage was highest among young adults aged 18 to 25 (35.4 percent or 11.8 million people), followed by adults aged 26 or older (17.2 percent or 37.9 million people), then by adolescents aged 12 to 17 (10.5 percent or 2.7 million people).

By Race/Ethnicity

In 2021, the percentage of people aged 12 or older who used marijuana in the past year was higher among American Indian or Alaska Native (35.0 percent) or Multiracial people (30.7 percent) than among Black (21.3 percent), White (19.5 percent), Hispanic (15.8 percent), or Asian people (8.6 percent) (Figure 17 and Table B.7B). The estimate of marijuana use in the past year could not be calculated with sufficient precision for people in the Native Hawaiian or Other Pacific Islander group.¹³ Asian people were less likely to use marijuana in the past year compared with people in all other racial or ethnic groups. Black or White people were more likely to use marijuana in the past year compared with Hispanic people. Estimates for marijuana use in the past year did not differ among Black or White people.

Cocaine Use

Cocaine use includes the use of crack cocaine. Estimates of crack use are presented separately as well. Among people aged 12 or older in 2021, 1.7 percent (or 4.8 million people) used cocaine in the past year (Figures 14 and 18 and Table A.7B). The percentage was highest among young adults aged 18 to 25 (3.5 percent or 1.2 million people), followed by adults aged 26 or older (1.6 percent or 3.6 million people), then by adolescents aged 12 to 17 (0.2 percent or 40,000 people).

In 2021, an estimated 0.4 percent of people aged 12 or older (or 996,000 people) used crack in the past year (Table A.7B). The percentage was lowest among adolescents aged 12 to 17 (less than 0.1 percent or 3,000 people). An estimated 0.2 percent of young adults aged 18 to 25 (or 74,000 people) and 0.4 percent of adults aged 26 or older (or 919,000 people) used crack in the past year.

By Race/Ethnicity

In 2021, cocaine use in the past year among people aged 12 or older did not differ among racial or ethnic groups (Table B.7B). Percentages ranged from 1.0 percent among Asian people to 3.2 percent among Multiracial people. However, Black people (0.9 percent) were more likely to use crack in the past year compared with Hispanic or Asian people (both 0.1 percent).

Heroin Use

Among people aged 12 or older in 2021, 0.4 percent (or 1.1 million people) used heroin in the past year (Figures 14 and 18 and Table A.7B). The percentage was higher among adults aged 26 or older (0.5 percent or 1.0 million people) than among young adults aged 18 to 25 (0.2 percent or 66,000 people). Estimates of past year heroin use among adolescents aged 12 to 17 could not be calculated with sufficient precision.

Methamphetamine Use

Although methamphetamine is legally available by prescription (Desoxyn^®), most methamphetamine used in the United States is produced and distributed illicitly rather than through the pharmaceutical industry. Therefore, the 2021 NSDUH includes separate sections for methamphetamine use and the use and misuse of prescription stimulants.

Among people aged 12 or older in 2021, 0.9 percent (or 2.5 million people) used methamphetamine in the past year (Figures 14 and 19 and Table A.7B). Adolescents aged 12 to 17 had the lowest estimate of past year methamphetamine use (0.1 percent or 37,000 people). Percentages increased with age (0.5 percent of young adults aged 18 to 25 or 166,000 people; 1.1 percent of adults aged 26 or older or 2.3 million people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who used methamphetamine in the past year was higher among Multiracial (1.6 percent) or White people (1.1 percent) than among Black (0.4 percent) or Asian people (0.3 percent) (Table B.8B).

Hallucinogen Use

Several drugs are grouped under the category of hallucinogens, including LSD, PCP, peyote, mescaline, psilocybin mushrooms, “Ecstasy” (MDMA or “Molly”), ketamine, DMT/AMT/“Foxy,” and Salvia divinorum.³⁶ In 2021, 2.6 percent of people aged 12 or older (or 7.4 million people) used hallucinogens in the past year (Figures 14 and 19 and Table A.7B). The percentage was highest among young adults aged 18 to 25 (7.1 percent or 2.4 million people), followed by adults aged 26 or older (2.1 percent or 4.7 million people), then by adolescents aged 12 to 17 (1.3 percent or 347,000 people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who used hallucinogens in the past year was higher among Multiracial people (5.5 percent) than among White (2.9 percent), Hispanic (2.4 percent), Black (1.7 percent), or Asian people (1.4 percent) (Table B.8B). White people also were more likely to use hallucinogens in the past year compared with Black or Asian people.

Inhalant Use

Inhalants include volatile solvents (e.g., paint thinners and removers, dry cleaning fluids, degreasers, gasoline, glues, shoe polish, correction fluids, felt-tip markers), aerosols (e.g., spray paints, deodorant and hair sprays, fabric protector sprays, computer keyboard cleaner), gases (e.g., ether, halothane, nitrous oxide, butane, propane), and nitrites (e.g., amyl nitrite, “poppers,” locker room deodorizers, “rush”). NSDUH respondents were asked to report the use of inhalants to get high but not to include accidental inhalation of a substance.

Among people aged 12 or older in 2021, 0.8 percent (or 2.2 million people) used inhalants in the past year (Figures 14 and 19 and Table A.7B). Unlike other illicit drug use estimates, the percentage was highest among adolescents aged 12 to 17 (2.4 percent or 626,000 people). Percentages decreased with age (1.5 percent of young adults aged 18 to 25 or 497,000 people; 0.5 percent of adults aged 26 or older or 1.1 million people).

By Race/Ethnicity

Inhalant use in the past year among people aged 12 or older in 2021 did not differ among racial or ethnic groups. Percentages ranged from 0.3 percent among Native Hawaiian or Other Pacific Islander people to 1.1 percent among Multiracial people (Table B.8B).

Misuse of Psychotherapeutic Drugs

The 2021 NSDUH assessed the use and misuse of psychotherapeutic drugs currently or recently available by prescription in the United States, including prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers. In NSDUH, misuse of prescription drugs was defined as use in any way not directed by a doctor, including use without a prescription of one's own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Misuse of over-the-counter (OTC) drugs was not included.

Among people aged 12 or older in 2021, 5.1 percent (or 14.3 million people) misused prescription psychotherapeutic drugs in the past year (Table A.7B). The percentage was highest among young adults aged 18 to 25 (7.4 percent or 2.5 million people), followed by adults aged 26 or older (5.0 percent or 10.9 million people), then by adolescents aged 12 to 17 (3.3 percent or 851,000 people).

Of the prescription drugs presented in this report, prescription pain relievers were the most commonly misused prescription drug by people aged 12 or older. The 14.3 million people in 2021 who misused prescription psychotherapeutic drugs in the past year included 8.7 million people who misused prescription pain relievers, 4.9 million people who misused prescription tranquilizers or sedatives (including 3.9 million past year misusers of benzodiazepines), and 3.7 million people who misused prescription stimulants (Figure 14).

Stimulant Misuse

The 2021 NSDUH assessed the misuse of prescription stimulants in the following categories: amphetamine products, methylphenidate products, anorectic (weight-loss) stimulants, Provigil^®, or any other prescription stimulant. The amphetamine and methylphenidate products included in the NSDUH questionnaire are primarily prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD). Methamphetamine is not included as a prescription stimulant, unless respondents specified the prescription form of methamphetamine (Desoxyn^®) as some other stimulant they had misused in the past year.³⁷

Among people aged 12 or older in 2021, 1.3 percent (or 3.7 million people) misused prescription stimulants in the past year (Figures 14 and 20 and Table A.7B). The percentage was higher among young adults aged 18 to 25 (3.7 percent or 1.2 million people) than among adolescents aged 12 to 17 (1.2 percent or 304,000 people) or adults aged 26 or older (1.0 percent or 2.2 million people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who misused prescription stimulants in the past year was higher among Multiracial (3.1 percent) or White people (1.6 percent) than among Hispanic (1.0 percent), Black (0.6 percent), or Asian people (0.6 percent) (Table B.9B).

Tranquilizer or Sedative Misuse

Estimates of the misuse of prescription tranquilizers or sedatives are presented together because prescription drugs in both categories have a common effect on specific activity in the brain. Prescription tranquilizers include benzodiazepine tranquilizers (e.g., as alprazolam, lorazepam, clonazepam, or diazepam products), muscle relaxants, or any other prescription tranquilizer. Prescription sedatives include zolpidem products, eszopiclone products, zaleplon products, benzodiazepine sedatives (e.g., as flurazepam and temazepam products or triazolam products), barbiturates, or any other prescription sedative.

Among people aged 12 or older in 2021, 1.7 percent (or 4.9 million people) misused tranquilizers or sedatives in the past year (Figures 14 and 20 and Table A.7B). The percentage was highest among young adults aged 18 to 25 (2.6 percent or 874,000 people), followed by adults aged 26 or older (1.7 percent or 3.8 million people), then by adolescents aged 12 to 17 (0.9 percent or 225,000 people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who misused prescription tranquilizers or sedatives in the past year was higher among White people (2.1 percent) than among Hispanic (1.3 percent), Black (1.3 percent), or Asian people (0.5 percent) (Table B.9B). The percentage of people who misused prescription tranquilizers or sedatives in the past year was lower among Asian people than among Multiracial (2.5 percent), Hispanic, or Black people.

Benzodiazepine Misuse

Prescription benzodiazepines are a subcategory of drugs that may be prescribed either as tranquilizers for the relief of anxiety or as sedatives for the relief of insomnia. Benzodiazepines prescribed as tranquilizers are typically metabolized more slowly than benzodiazepines prescribed as sedatives.³⁸ Nevertheless, benzodiazepines are chemically similar, regardless of whether they are prescribed as tranquilizers or sedatives.

Among people aged 12 or older in 2021, 1.4 percent (or 3.9 million people) misused prescription benzodiazepines in the past year (Table A.7B). The percentage was highest among young adults aged 18 to 25 (2.4 percent or 787,000 people), followed by adults aged 26 or older (1.3 percent or 3.0 million people), then by adolescents aged 12 to 17 (0.7 percent or 181,000 people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who misused prescription benzodiazepines in the past year was higher among White people (1.7 percent) than among Hispanic (1.0 percent), Black (0.9 percent), or Asian people (0.4 percent) (Table B.9B). The percentage also was higher among Multiracial people (2.3 percent) than among Asian people.

Pain Reliever Misuse

The 2021 NSDUH assessed the misuse of prescription pain relievers in the following categories: products containing hydrocodone, oxycodone, tramadol, codeine, morphine, prescription fentanyl,³⁹ buprenorphine, oxymorphone, and hydromorphone, as well as Demerol^®, methadone, or any other prescription pain reliever. This section provides estimates of the misuse of any prescription pain reliever and specific subtypes of prescription pain relievers, the main reason for the most recent misuse of prescription pain relievers, and where people obtained the prescription pain relievers that they most recently misused in the past year.

Among people aged 12 or older in 2021, 3.1 percent (or 8.7 million people) misused prescription pain relievers in the past year (Figures 14 and 20 and Table A.7B). The percentage was lower among adolescents aged 12 to 17 (1.9 percent or 497,000 people) than among young adults aged 18 to 25 (3.0 percent or 1.0 million people) or adults aged 26 or older (3.3 percent or 7.2 million people).

By Race/Ethnicity

Prescription pain reliever misuse in the past year among people aged 12 or older in 2021 did not differ among racial or ethnic groups. Percentages ranged from 2.2 percent among Asian people to 6.3 percent among Multiracial people (Table B.10B).

Misuse of Subtypes of Pain Relievers

The 2021 NSDUH asked respondents to identify specific prescription pain relievers they used in the past year, then asked whether they misused those pain relievers in the past year. The specific pain relievers people misused in the past year were categorized into subtypes, such as hydrocodone products. For example, respondents who reported misusing the pain relievers Vicodin^® or hydrocodone were classified as misusers of hydrocodone products.

This section presents two ways of examining the misuse of subtypes of pain relievers. First, it presents estimates of the misuse of subtypes among people aged 12 or older who misused any pain reliever in the past year. Then it presents estimates of the misuse of subtypes of pain relievers among people who used that subtype for any reason in the past year (i.e., not necessarily misuse). See the Misuse of Psychotherapeutic Drugs section for the definition of misuse.

Among the 8.7 million people aged 12 or older in 2021 who misused prescription pain relievers in the past year, 46.9 percent (or 4.0 million people) misused hydrocodone products in the past year (Figure 21 and Table A.8B). Hydrocodone products were the most commonly misused subtype of prescription pain relievers for 2021, including Vicodin^®, Lortab^®, Norco^®, Zohydro^® ER, and generic hydrocodone. In addition, 30.4 percent of past year misusers of pain relievers (or 2.6 million people) misused oxycodone products in the past year, including OxyContin^®, Percocet^®, Percodan^®, Roxicodone^®, and generic oxycodone. About 1 in 4 people aged 12 or older who misused pain relievers in the past year were misusers of codeine products in the past year (26.4 percent or 2.3 million people).

An estimated 6.2 percent of people aged 12 or older who misused prescription pain relievers in the past year (or 539,000 people) were misusers of prescription fentanyl products. Because NSDUH respondents were asked only about the misuse of prescription forms of fentanyl, estimates of fentanyl misuse for 2021 may underrepresent people who used illicitly manufactured fentanyl (IMF) from clandestine laboratories (i.e., as opposed to the misuse of diverted prescription fentanyl produced by the pharmaceutical industry) and may not include those who used IMF mixed with heroin or sold as heroin (but contained only IMF).

However, most people aged 12 or older in 2021 who used prescription pain relievers for any reason in the past year did not misuse them in that period (Figure 22 and Table A.8B). Although hydrocodone products were the most commonly misused prescription pain reliever subtype in the past year, only 11.4 percent of people who used hydrocodone products for any reason in the past year misused them in that period. Among people who used buprenorphine products for any reason in the past year, 22.2 percent misused them, and 77.8 percent did not. Among people who used prescription fentanyl products for any reason in the past year, 20.9 percent misused them, and 79.1 percent did not. Stated another way, more than three fourths of past year users of buprenorphine products and about four fifths of past year users of prescription fentanyl products did not misuse them in that period.

Main Reasons for the Last Misuse of Pain Relievers

Respondents in the 2021 NSDUH who reported prescription pain reliever misuse in the past year were asked to report the reasons for misusing the last prescription pain reliever they misused. Respondents who reported more than one reason for misusing the last prescription pain reliever were asked to report their main reason for misusing it.

Among people aged 12 or older in 2021 who misused prescription pain relievers in the past year, the most common main reason for their last misuse of a pain reliever was to relieve physical pain (64.3 percent) (Table A.9B). Based on the NSDUH definition, use without a prescription of one's own or overuse of prescribed medication (e.g., use at a higher dosage or more often than prescribed) are both classified as misuse even if the use was for the purpose of pain relief.

In addition, 10.7 percent of people aged 12 or older who misused prescription pain relievers in the past year misused a pain reliever the last time to feel good or get high, and 7.3 percent misused a pain reliever the last time to relax or relieve tension. Other main reasons for the last misuse were to help with sleep (4.8 percent), because people were “hooked” or needed to have the drug (4.7 percent), to experiment or see what the drug was like (2.8 percent), to help with feelings or emotions (2.6 percent), and to increase or decrease the effects of other drugs (1.2 percent).

Source of the Last Pain Reliever That Was Misused

Among people aged 12 or older in 2021 who misused prescription pain relievers in the past year, 44.9 percent obtained the pain relievers the last time from a friend or relative in some way (i.e., being given them, buying them, or taking them without asking), and 43.2 percent obtained pain relievers the last time through prescription(s) or stole pain relievers from a health care provider, typically getting the pain relievers through a prescription from one doctor (39.3 percent) (Figure 23 and Table A.10B). An estimated 33.9 percent of people who misused pain relievers in the past year obtained pain relievers the last time by getting them from a friend or relative for free, 7.3 percent bought their last pain reliever from a friend or relative, and 3.7 percent took their last pain reliever from a friend or relative without asking. About 1 in 13 people who misused pain relievers in the past year (7.9 percent) bought the last pain reliever they misused from a drug dealer or other stranger.

Opioid Misuse

Opioids are a group of chemically similar drugs that include heroin and prescription opioids, such as hydrocodone (e.g., Vicodin^®), oxycodone (e.g., OxyContin^®), and morphine. In this report, opioid misuse includes the misuse of prescription pain relievers or the use of heroin. Prescription pain relievers could include some nonopioids because respondents could occasionally specify the misuse of other prescription pain relievers that are not opioids.

Among people aged 12 or older in 2021, 3.3 percent (or 9.2 million people) misused opioids in the past year (Figure 24 and Table A.7B). Similar to the misuse of prescription pain relievers in the past year, the percentage of people who misused opioids in the past year was lowest among adolescents aged 12 to 17 (1.9 percent or 497,000 people). Percentages were similar among young adults aged 18 to 25 (3.1 percent or 1.0 million people) and adults aged 26 or older (3.5 percent or 7.7 million people).

The vast majority of people who misused opioids in the past year misused prescription pain relievers (Figure 24). Specifically, 8.7 million people aged 12 or older misused prescription pain relievers in the past year compared with 1.1 million people who used heroin. In 2021, the majority of the 8.7 million misusers of prescription pain relievers misused only prescription pain relievers in the past year (8.1 million people), but they had not used heroin. An estimated 574,000 people misused prescription pain relievers and used heroin in the past year, and 525,000 people used heroin in the past year but had not misused prescription pain relievers.²⁷

By Race/Ethnicity

Opioid misuse in the past year among people aged 12 or older in 2021 did not differ among racial or ethnic groups. Percentages ranged from 2.3 percent among Asian people to 6.3 percent among Multiracial people (Table B.10B).

Central Nervous System Stimulant Misuse

Central nervous system (CNS) stimulants are a group of drugs that include cocaine, methamphetamine, and prescription stimulants. These drugs act in similar ways to stimulate the brain. They produce stimulant effects, such as increased alertness, wakefulness, or energy. They also can produce physical side effects of rapid or irregular heartbeat or increased blood pressure and body temperature.^40,41,42 In this report, CNS stimulant misuse includes the use of cocaine or methamphetamine or the misuse of prescription stimulants.

Among people aged 12 or older in 2021, 3.3 percent (or 9.2 million people) misused CNS stimulants in the past year (Figure 25 and Table A.7B). The percentage was highest among young adults aged 18 to 25 (6.3 percent or 2.1 million people), followed by adults aged 26 or older (3.1 percent or 6.7 million people), then by adolescents aged 12 to 17 (1.3 percent or 339,000 people).

Of the 9.2 million people in 2021 who misused CNS stimulants in the past year, 230,000 used or misused all three CNS stimulants in the past year (2.5 percent of people who misused CNS stimulants) (Figure 25). About one third of people who misused CNS stimulants in the past year used only cocaine (36.9 percent of CNS stimulant misusers or 3.4 million people), about one fourth misused only prescription stimulants (27.7 percent of CNS stimulant misusers or 2.5 million people), and about 1 in 6 used only methamphetamine (17.5 percent of CNS stimulant misusers or 1.6 million people). In addition to the 230,000 people who used or misused all three CNS stimulants in the past year, 701,000 people used cocaine and misused prescription stimulants but did not use methamphetamine (7.6 percent of CNS stimulant misusers), 452,000 used cocaine and methamphetamine but did not misuse prescription stimulants (4.9 percent of CNS stimulant misusers), and 257,000 used methamphetamine and misused prescription stimulants but did not use cocaine (2.8 percent of CNS stimulant misusers).²⁷

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who misused CNS stimulants in the past year was higher among Multiracial people (6.4 percent) than among White (3.5 percent), Hispanic (3.1 percent), Black (2.5 percent), Native Hawaiian or Other Pacific Islander (2.3 percent), or Asian people (1.5 percent) (Table B.10B). White people also were more likely than Black people to misuse CNS stimulants in the past year. In addition to the difference between Asian and Multiracial people, Asian people were less likely to misuse CNS stimulants in the past year compared with American Indian or Alaska Native (5.8 percent), White, or Hispanic people.

Other Substance Use in the Past Year

The 2021 NSDUH obtained information for the use and misuse of additional substances that can produce mind-altering effects. These substances include GHB, the misuse of nonprescription cold and cough medicine, kratom, synthetic marijuana (fake weed, K2, or Spice), and synthetic stimulants (“bath salts” or flakka).

GHB Use

Gamma hydroxybutyrate (GHB, also called “G,” “Georgia Home Boy,” “Grievous Bodily Harm,” or “Liquid G”) is a CNS depressant. GHB can produce hallucinations, euphoria, drowsiness, decreased anxiety, and excited and aggressive behavior. It also is addictive. GHB that is not produced as a pharmaceutical product with U.S. Food and Drug Administration (FDA) approval is classified as a Schedule I controlled substance in the United States.^43,44

Among people aged 12 or older in 2021, 0.1 percent (or 311,000 people) used GHB in the past year (Table A.6B). Less than 0.1 percent each of adolescents aged 12 to 17 and young adults aged 18 to 25 and 0.1 percent of adults aged 26 or older used GHB in the past year. Corresponding estimated numbers of people who used GHB in the past year were 5,000 adolescents aged 12 to 17, 14,000 young adults aged 18 to 25, and 292,000 adults aged 26 or older.

Nonprescription Cough and Cold Medicine Misuse

The cough suppressant dextromethorphan (DXM) is found in many cough and cold medicines. These medicines are available without a prescription (i.e., OTC) in the United States and are generally considered safe when used appropriately. When taken in large amounts, however, DXM can produce hallucinations or dissociative, “out-of-body” experiences. These effects are similar to those caused by the hallucinogens PCP and ketamine. Other drugs found in OTC cough and cold medicines also can have psychoactive effects. For example, the OTC antihistamine diphenhydramine (found in the brand-name drug Benadryl^®) can produce sedative side effects, such as drowsiness.⁴⁵ The OTC decongestant phenylephrine (found in the brand-name drug Sudafed PE^®) can produce stimulant side effects, such as nervousness and sleeplessness.⁴⁶ The 2021 NSDUH questionnaire asked respondents aged 12 or older about their use of nonprescription cough or cold medicines in the past 12 months for the purpose of getting high (i.e., “misuse”).

Among people aged 12 or older in 2021, 0.6 percent (or 1.6 million people) misused nonprescription cough and cold medicines in the past year (Table A.6B). Similar percentages of people in each age group misused cough and cold medicines in the past year (0.7 percent each of adolescents aged 12 to 17 and young adults aged 18 to 25 and 0.5 percent of adults aged 26 or older). Corresponding estimated numbers of people who misused cough and cold medicines in the past year were 173,000 adolescents aged 12 to 17, 243,000 young adults aged 18 to 25, and 1.2 million adults aged 26 or older.

Kratom Use

Kratom is an herbal extract from the leaves of the Mitragyna speciosa tree that is native to Southeast Asia. The leaves contain chemicals with mind-altering effects. Kratom can come in forms such as powders, pills, or leaves.^47,48 The 2021 NSDUH asked respondents aged 12 or older about their use of kratom in the 12 months before the interview.

Among people aged 12 or older in 2021, 0.6 percent (or 1.7 million people) used kratom in the past year (Table A.6B). The percentage was lower among adolescents aged 12 to 17 (0.2 percent or 45,000 people) than among young adults aged 18 to 25 (0.8 percent or 284,000 people) or adults aged 26 or older (0.6 percent or 1.4 million people).

Synthetic Marijuana Use

Synthetic cannabinoids are human-made chemicals that are similar to chemicals found in the marijuana plant. For this reason, these drugs are sometimes called “synthetic marijuana” or “fake weed.” They can be contained in plant material that is later smoked. They are also sold as liquids to be vaporized (i.e., vaped) and inhaled in e-cigarettes and other devices.^43,49 Several synthetic cannabinoids have been categorized as Schedule I controlled substances.⁴⁴

For simplicity, the 2021 NSDUH questionnaire asked respondents about their use of “synthetic marijuana” and included the slang terms “fake weed,” “K2,” and “Spice.” The 2021 NSDUH asked respondents aged 12 or older about their use of synthetic marijuana or fake weed in the 12 months before the interview.

Among people aged 12 or older in 2021, 0.2 percent (or 483,000 people) used synthetic marijuana in the past year (Table A.6B). The percentage was lower among adults aged 26 or older (0.1 percent or 212,000 people) than among adolescents aged 12 to 17 (0.4 percent or 112,000 people) or young adults aged 18 to 25 (0.5 percent or 159,000 people).

Synthetic Stimulant Use

Synthetic cathinones are human-made CNS stimulants that are chemically related to cathinone, a substance found in the khat plant. These substances can be marketed as “bath salts” or “flakka.”^43,50 Several synthetic cathinones have been categorized as Schedule I controlled substances.⁴⁴

For simplicity, the 2021 NSDUH questionnaire asked respondents about their use of “synthetic stimulants” and included the slang terms “bath salts” and “flakka.” The 2021 NSDUH asked respondents aged 12 or older about their use of synthetic stimulants, also called “bath salts” or flakka, in the 12 months before the interview.

Among people aged 12 or older in 2021, less than 0.1 percent (or 107,000 people) used synthetic stimulants in the past year (Table A.6B). Similar percentages of people in each age group used synthetic stimulants: 0.1 percent each of adolescents aged 12 to 17 and young adults aged 18 to 25 and less than 0.1 percent of adults aged 26 or older. In each age group, fewer than 50,000 people used synthetic stimulants.

Initiation of Substance Use

The 2021 NSDUH included questions to measure the initiation of substance use, that is, the first use of particular substances during a person's lifetime.⁵¹ This report presents the estimated number of recent substance use initiates or prescription drug misuse initiates.⁵² Recent initiates were substance users or prescription drug misusers who reported first using or misusing, respectively, a particular substance in the 12 months before the NSDUH interview.^18,53,54 See the section on the Misuse of Psychotherapeutic Drugs for the definition of “misuse” of prescription drugs.

In particular, this report presents estimates for past year initiation of heroin use, prescription pain reliever misuse, prescription tranquilizer misuse, and prescription sedative misuse, separately. The report does not present estimates for past year initiation of any opioid misuse (heroin or prescription pain reliever), any illicit drug use (including prescription drug misuse), and any prescription tranquilizer or sedative misuse because respondents who underreported lifetime (but not past year) misuse of prescription drugs might not truly be past year initiates of the use or misuse of any drug in these aggregate categories.⁵⁵ Estimates for the past year initiation of benzodiazepine misuse are not presented because some benzodiazepines in NSDUH were included as tranquilizers, and others were included as sedatives.⁵⁶

In addition, NSDUH respondents are asked how old they were when they first used or misused a substance. Respondents who first used a substance in the past year would need to recall only whether they first used the substance at their current age or at the age that was 1 year less than their current age. Information on the age when past year initiates first used a substance is useful for estimating whether past year initiates of the use of cigarettes, alcohol, or marijuana first used these substances before age 21 or after age 21.

Figure 26 and Table A.11A provide an overview of the numbers of people aged 12 or older in 2021 who were past year initiates of the use or misuse of the substances discussed in this section. In the past 12 months, 4.1 million people initiated alcohol use, and 1.2 million people tried a cigarette for the first time in their lifetime.⁵⁷ There were also 2.6 million new marijuana users, 1.8 million new misusers of prescription pain relievers, 1.3 million new hallucinogen users, 881,000 new misusers of prescription tranquilizers, and 773,000 new misusers of prescription stimulants. Other substances had smaller numbers of past year initiates.

Initiation of Cigarette Use

Among people aged 12 or older in 2021, 1.2 million people initiated cigarette smoking in the past year, meaning they had never smoked cigarettes before the past 12 months (Figures 26 and 27 and Table A.11A). Relatively few people (approximately 10 percent of past year initiates) tried cigarettes for the first time after age 25. In 2021, 362,000 adolescents aged 12 to 17, 705,000 young adults aged 18 to 25, and 120,000 adults aged 26 or older initiated cigarette smoking in the past year. Nearly three fourths of the 1.2 million people in 2021 who initiated cigarette smoking in the past year did so before age 21 (73.7 percent or 875,000 people) (Figure 28 and Table A.12AB).

Initiation of Alcohol Use

Among people aged 12 or older in 2021, 4.1 million people initiated alcohol use in the past year, not counting a sip or two from a drink (Figures 26 and 27 and Table A.11A). Among young adults aged 18 to 25 in 2021, 2.1 million people initiated alcohol use in the past year. In addition, 1.8 million adolescents aged 12 to 17 and 228,000 adults aged 26 or older initiated alcohol use in the past year. Consistent with the pattern of cigarette smoking initiation, relatively few people in 2021 started to use alcohol after age 25. Also, nearly three fourths of the 4.1 million people in 2021 who initiated alcohol use in the past year did so before age 21 (72.8 percent or 3.0 million people) (Figure 28 and Table A.12AB).

Initiation of Marijuana Use

Among people aged 12 or older in 2021, 2.6 million people initiated marijuana use in the past year (Figures 26 and 27 and Table A.11A). Among young adults aged 18 to 25 in 2021, 1.1 million people initiated marijuana use in the past year. In addition, 869,000 adolescents aged 12 to 17 and 620,000 adults aged 26 or older initiated marijuana use in the past year. Unlike people who initiated cigarette or alcohol use, almost 25 percent of people in 2021 who initiated marijuana use in the past year were aged 26 or older. About three fifths of the 2.6 million people in 2021 who initiated marijuana use in the past year did so before age 21 (60.3 percent or 1.6 million people) (Figure 28 and Table A.12AB).

Initiation of Cocaine Use

Among people aged 12 or older in 2021, 478,000 people initiated cocaine use in the past year (Figure 26 and Table A.11A).⁵⁸ Nearly 60 percent of people who used cocaine for the first time in the past year were between ages 18 and 25. Among young adults aged 18 to 25, 277,000 people initiated cocaine use in the past year. In addition, 20,000 adolescents aged 12 to 17 and 181,000 adults aged 26 or older initiated cocaine use in the past year.

Initiation of Heroin Use

Among people aged 12 or older in 2021, 26,000 people initiated heroin use in the past year (Figure 26 and Table A.11A). The number of adolescents aged 12 to 17 who initiated heroin use in the past year was not reported due to low statistical precision. Among young adults aged 18 to 25, 11,000 people initiated heroin use in the past year. Among adults aged 26 or older, 16,000 people initiated heroin use in the past year.

Initiation of Methamphetamine Use

Among people aged 12 or older in 2021, 101,000 people initiated methamphetamine use in the past year (Figure 26 and Table A.11A). Approximately 50 percent of people who used methamphetamine for the first time in the past year were older than age 25. Numbers of past year initiates of methamphetamine use by age group were 24,000 adolescents aged 12 to 17, 25,000 young adults aged 18 to 25, and 52,000 adults aged 26 or older.

Initiation of Hallucinogen Use

Among people aged 12 or older in 2021, 1.3 million people initiated hallucinogen use in the past year (Figure 26 and Table A.11A).⁵⁸ This number includes 176,000 adolescents aged 12 to 17, 687,000 young adults aged 18 to 25, and 427,000 adults aged 26 or older.

Initiation of Inhalant Use

Among people aged 12 or older in 2021, 385,000 people initiated inhalant use in the past year (Figure 26 and Table A.11A). Initiation of inhalant use was less common for adults older than age 25. Numbers of past year initiates of inhalant use by age group were 160,000 adolescents aged 12 to 17, 157,000 young adults aged 18 to 25, and 68,000 adults aged 26 or older.

Initiation of Prescription Stimulant Misuse

Among people aged 12 or older in 2021, 773,000 initiated prescription stimulant misuse in the past year (Figure 26 and Table A.11A). Among adults aged 26 or older, 309,000 people initiated prescription stimulant misuse in the past year. Corresponding numbers for young adults aged 18 to 25 and adolescents aged 12 to 17 were 310,000 people and 154,000 people, respectively.

Initiation of Prescription Tranquilizer or Sedative Misuse

Although this report includes combined estimates for the past year misuse of prescription tranquilizers or sedatives, estimates for the initiation of misuse of these substances are presented separately in this section. As noted previously, it cannot be determined unambiguously whether respondents were past year initiates for the aggregate category of any tranquilizer or sedative misuse because of the potential for respondents to underreport the misuse of prescription drugs that occurred more than 12 months ago.

Initiation of Prescription Tranquilizer Misuse

Among people aged 12 or older in 2021, 881,000 people initiated prescription tranquilizer misuse in the past year (Figure 26 and Table A.11A). Approximately two thirds of people who misused prescription tranquilizers for the first time in the past year were older than age 25. Among adults aged 26 or older, 595,000 people initiated prescription tranquilizer misuse in the past year. Among young adults aged 18 to 25 and adolescents aged 12 to 17, 225,000 people and 61,000 people initiated prescription tranquilizer misuse in the past year, respectively.

Initiation of Prescription Sedative Misuse

Among people aged 12 or older in 2021, 188,000 people initiated prescription sedative misuse (Figure 26 and Table A.11A). Nearly 70 percent of people who misused prescription sedatives for the first time in the past year were older than age 25. The numbers of past year initiates of prescription sedative misuse by age group were 14,000 adolescents aged 12 to 17, 46,000 young adults aged 18 to 25, and 128,000 adults aged 26 or older.

Initiation of Prescription Pain Reliever Misuse

Among people aged 12 or older in 2021, 1.8 million people initiated prescription pain reliever misuse in the past year (Figures 26 and 29 and Table A.11A). Nearly 80 percent of people who misused prescription pain relievers for the first time in the past year were older than age 25. Among adults aged 26 or older, 1.4 million people initiated prescription pain reliever misuse in the past year. The numbers of people who initiated prescription pain reliever misuse in the past year were 269,000 among young adults aged 18 to 25 and 130,000 among adolescents aged 12 to 17. Among young adults aged 18 to 25 and adolescents aged 12 to 17, the numbers of people who initiated prescription pain reliever misuse in the past year were 269,000 people and 130,000 people, respectively.

Perceived Risk from Substance Use

One factor that can influence whether people will use tobacco, alcohol, or illicit drugs is the extent to which they believe that using these substances might cause harm. In 2021, NSDUH respondents were asked how much they thought people risk harming themselves physically and in other ways when they use various substances in certain amounts or frequencies. Response choices for these items were “great risk,” “moderate risk,” “slight risk,” or “no risk.” Depending on the substance, respondents were asked about their perceived risk of harm from using a substance daily or using a substance once or twice a week (i.e., weekly use).

Figure 30 and Table A.13B present the percentages of people aged 12 or older in 2021 who perceived great risk of harm from the use of various substances. Risk perceptions across substances are not compared because of variations in the quantity and frequency of use across these substances.⁵⁹ The 2021 Detailed Tables include additional measures of risk perceptions from substance use.⁶⁰

Among people aged 12 or older in 2021, 69.2 percent of people perceived great risk of harm from smoking one or more packs of cigarettes a day, and 68.4 percent perceived great risk from having four or five alcoholic drinks nearly every day. Percentages of people who perceived great risk from cocaine or heroin use once or twice a week were 83.7 and 92.3 percent, respectively. In contrast, about one fourth of people (26.5 percent) perceived great risk from smoking marijuana once or twice a week.

In 2021, perceptions of great risk of harm from substance use varied by substance and age. For example, young adults aged 18 to 25 in 2021 were less likely than adolescents aged 12 to 17 or adults aged 26 or older to perceive great risk of harm from smoking marijuana weekly. In addition, adults aged 26 or older were more likely than adolescents aged 12 to 17 or young adults aged 18 to 25 to perceive great risk of harm from smoking one or more packs of cigarettes per day or to perceive great risk of harm from having four or five alcoholic drinks nearly every day (Table A.13B).

Finally, adolescents aged 12 to 17 in 2021 were less likely than young adults aged 18 to 25 or adults aged 26 or older to perceive great risk from using heroin or cocaine weekly. Additional data on finer age group categories that can be found in the 2021 Detailed Tables⁶⁰ indicate that the lower likelihood of adolescents than adults to perceive great risk of harm from cocaine and heroin use may be attributable to a general lack of knowledge about these substances among adolescents because younger adolescents aged 12 or 13 tended to have lower perceptions of the risk of harm compared with older adolescents or adults. Thus, age-specific communications are imperative from a public health perspective to help people fully understand important harms associated with the use of specific substances.

By Race/Ethnicity

Perceptions of great risk of harm from substance use among people aged 12 or older in 2021 varied by racial or ethnic group. The percentage of people who perceived great risk of harm from smoking one or more packs of cigarettes per day was higher among Asian (73.6 percent) or Hispanic people (71.9 percent) than among White people (68.1 percent) (Table B.11B). The percentage of people who perceived great risk of harm from having four or five alcoholic drinks nearly every day was higher among Asian people (77.8 percent) than among people in most other racial or ethnic groups. This percentage was also higher among Black (71.1 percent) or Hispanic people (70.0 percent) than among White people (66.6 percent).

The percentage of people aged 12 or older in 2021 who perceived great risk from smoking marijuana once or twice a week was higher among Asian people (46.1 percent) than among Hispanic (36.2 percent), American Indian or Alaska Native (26.8 percent), Black (25.8 percent), White (22.3 percent), or Multiracial people (18.0 percent) (Table B.11B). The percentage was also higher among Hispanic people than among Black, White, or Multiracial people.

White people aged 12 or older in 2021 were more likely than Hispanic, Black, or Asian people to perceive great risk of harm from heroin use once or twice a week. However, percentages in all racial or ethnic groups were high, ranging from 88.7 percent of Asian people to 93.7 percent of White people (Table B.11B). Perceptions of great risk of harm from cocaine use once or twice a week did not differ among racial or ethnic groups.

Among adolescents aged 12 to 17 in 2021, perceptions of great risk of harm did not differ among racial or ethnic groups for smoking one or more packs of cigarettes per day or for using cocaine once or twice a week. The percentage of adolescents aged 12 to 17 who perceived great risk of harm from having four or five alcoholic drinks nearly every day was higher among Asian adolescents (81.8 percent) than among adolescents in most other racial or ethnic groups (Table B.12B). This percentage was also higher among Black (67.6 percent) or White adolescents (66.5 percent) than among Hispanic adolescents (61.9 percent).

In 2021, fewer than half of adolescents aged 12 to 17 in each racial or ethnic group perceived great risk of harm from smoking marijuana once or twice a week. The percentage of adolescents who perceived great risk of harm from smoking marijuana once or twice a week was higher among Asian adolescents (44.4 percent) than among adolescents in most other racial or ethnic groups (Table B.12B).

White adolescents aged 12 to 17 in 2021 were more likely than Hispanic, Black, or Asian adolescents to perceive great risk of harm from heroin use once or twice a week. However, percentages in all racial or ethnic groups were high, ranging from 73.7 percent of Asian adolescents to 81.7 percent of White adolescents (Table B.12B).

Substance Use Disorders in the Past Year

Substance use disorders (SUDs) are characterized by impairment caused by the recurrent use of alcohol or other drugs (or both), including health problems, disability, and failure to meet major responsibilities at work, school, or home. The 2021 NSDUH included a series of questions to estimate the percentage of the population aged 12 or older who had at least one SUD in the past 12 months (subsequently referred to as “an SUD” or “a past year SUD”). The SUD questions assess the presence of an SUD in the past 12 months based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).^61,62 Respondents were asked SUD questions for any alcohol or drugs they used in the 12 months prior to the survey. Drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, and any use of prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers.¹⁸ Unlike in the section on Illicit Drug Use in the Past Year, the DSM-5 SUD criteria for prescription drugs apply to people who used but did not misuse prescription drugs in the past year, in addition to people who misused them.

A Clinical Validation Study (CVS) was conducted in early 2020 to assess NSDUH SUD questions that were revised to be consistent with the DSM-5 criteria discussed as follows.⁶³ For the 2021 NSDUH, the SUD questions from the CVS replaced the SUD questions in the 2020 questionnaire. Also beginning in 2021, NSDUH respondents who reported any use of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives) in the past year (i.e., not just misuse of prescription drugs) were asked the respective SUD questions for that category of prescription drugs.

DSM-5 includes the following SUD criteria (as measured in the 2021 NSDUH):

1. The substance is often taken in larger amounts or over a longer period than intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
4. There is a craving, or a strong desire or urge, to use the substance.
5. There is recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
6. There is continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of substance use.
8. There is recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. There is a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount of the substance (i.e., tolerance).
11. There are two components of withdrawal symptoms, either of which meet the overall criterion for withdrawal symptoms:
    1. There is a required number of withdrawal symptoms that occur when substance use is cut back or stopped following a period of prolonged use.⁶⁴
    2. The substance or a related substance is used to get over or avoid withdrawal symptoms.⁶⁵

Table 1 shows how these 11 DSM-5 SUD criteria apply to substances in NSDUH. For prescription pain relievers, tranquilizers, stimulants, and sedatives, Table 1 also shows how these criteria apply if respondents misused prescription drugs or if they simply used but did not misuse prescription drugs in the past year. For consistency with the DSM-5 criteria, NSDUH respondents were classified as having an SUD if they met two or more of the applicable criteria in a 12-month period.

For alcohol, marijuana, cocaine, heroin, and methamphetamine in Table 1, respondents were classified as having an SUD if they met 2 or more of the 11 criteria in a 12-month period. However, respondents were classified as having a hallucinogen use disorder or an inhalant use disorder if they met 2 or more of the first 10 criteria in the past 12 months; the withdrawal criterion does not apply to hallucinogens and inhalants.

For the use or misuse of prescription drugs in Table 1, the number of applicable DSM-5 criteria for classifying respondents as having a prescription drug use disorder depends on whether respondents misused prescription drugs, or they used prescription drugs in the past year, but they did not misuse them. If respondents misused prescription drugs in the past year, they were classified as having a prescription drug use disorder if they met 2 or more of the 11 criteria shown in Table 1. However, if respondents used prescription drugs in the past year but did not misuse them, they were classified as having a prescription drug use disorder if they met two or more of the first nine criteria shown in Table 1. Criteria 10 (tolerance) and 11 (withdrawal) do not apply to respondents who used but did not misuse these prescription drugs in the past year; tolerance and withdrawal can occur as normal physiological adaptations when people use these prescription drugs appropriately under medical supervision.⁶⁶

Table 2 shows the substances and types of use or misuse that are included in selected SUD measures in the 2021 NSDUH.

• Any SUD in the past year includes data from past year users of alcohol, marijuana,⁶⁷ cocaine (including crack), heroin, hallucinogens, inhalants, and methamphetamine, and any past year users of prescription psychotherapeutic drugs.
• Alcohol use disorder includes only data from past year users of alcohol.
• Drug use disorder includes data from past year users of marijuana, cocaine, heroin, hallucinogens, inhalants, and methamphetamine, and any past year users of prescription psychotherapeutic drugs. It does not include people who had an alcohol use disorder in the past year.
• Illicit drug or alcohol use disorder includes data from past year users of alcohol, marijuana, cocaine, heroin, hallucinogens, inhalants, and methamphetamine, and past year misusers of prescription psychotherapeutic drugs. This illicit drug or alcohol use disorder measure is relevant to the Substance Use Treatment in the Past Year section.

Major Depressive Episode in the Past Year

In the 2021 NSDUH, respondents were classified as having had a major depressive episode (MDE) in the past 12 months if (1) they had at least one period of 2 weeks or longer in the past year when for most of the day nearly every day, they felt depressed or lost interest or pleasure in daily activities; and (2) they also had problems with sleeping, eating, energy, concentration, self-worth, or having recurrent thoughts of death or recurrent suicidal ideation. The MDE questions are based on diagnostic criteria from DSM-5, which require the presence of five or more symptoms during the same 2-week period.⁶¹ The wording for some depression questions asked of adolescent respondents aged 12 to 17 differed from the wording for similar questions asked of adult respondents aged 18 or older. Therefore, the MDE estimates for adults aged 18 or older and adolescents aged 12 to 17 are not directly comparable and are presented separately.^18,68,69

The 2021 NSDUH also collected data on whether an MDE in the past year caused respondents to experience severe impairment in four major life activities or role domains. These domains were defined separately for adolescents aged 12 to 17 and adults aged 18 or older to reflect the different roles associated with the two age groups. Adolescents aged 12 to 17 were classified as having an MDE with severe impairment if their depression caused severe problems with their ability to do chores at home, do well at work or school, get along with their family, or have a social life. Adults aged 18 or older were classified as having an MDE with severe impairment if their depression caused severe problems with their ability to manage at home or work, have relationships with others, or have a social life.

Web-based interviewing affected the number of adult respondents aged 18 or older in 2021 who provided usable information on their substance use⁷⁰ but did not complete the mental health or later questions (i.e., “break-offs”). To reduce the potential for bias, missing data for measures of MDE and MDE with severe impairment among adults aged 18 or older were statistically imputed for 2021.⁷¹

In sections that present estimates for MDE in the past year among adolescents aged 12 to 17, estimates are first presented for all adolescents, followed by estimates among racial or ethnic groups. In sections that present estimates for MDE in the past year among adults aged 18 or older, estimates are first presented for all adults, followed by estimates by age group, then by racial or ethnic groups. Estimates among racial or ethnic groups of adolescents or adults are presented for selected measures.¹³

MDE and MDE with Severe Impairment among Adolescents

Among adolescents aged 12 to 17 in 2021, 20.1 percent (or 5.0 million people) had a past year MDE (Figure 38 and Table A.17B). An estimated 14.7 percent of adolescents aged 12 to 17 (or 3.7 million people) in 2021 had a past year MDE with severe impairment.

By Race/Ethnicity

Among adolescents aged 12 to 17 in 2021, 13.8 percent of Asian adolescents and 14.0 percent of Black adolescents had a past year MDE (Figure 39 and Table B.15B). These percentages were lower than the corresponding percentages of Multiracial (27.2 percent), Hispanic (22.2 percent), or White adolescents (20.7 percent). A similar pattern of differences among racial or ethnic groups was observed for past year MDE with severe impairment among adolescents.

MDE and MDE with Severe Impairment among Adults

Among adults aged 18 or older in 2021, 8.3 percent (or 21.0 million people) had a past year MDE (Figure 40 and Table A.18B). The percentage was highest among young adults aged 18 to 25 (18.6 percent or 6.2 million people), followed by adults aged 26 to 49 (9.3 percent or 9.5 million people), then by adults aged 50 or older (4.5 percent or 5.3 million people).

An estimated 5.7 percent of adults aged 18 or older (or 14.5 million people) in 2021 had a past year MDE with severe impairment. The percentage was highest among young adults aged 18 to 25 (13.3 percent or 4.4 million people), followed by adults aged 26 to 49 (6.5 percent or 6.6 million people), then by adults aged 50 or older (2.9 percent or 3.4 million people).

By Race/Ethnicity

Among adults aged 18 or older in 2021, Multiracial adults (13.9 percent) were more likely to have had an MDE in the past year compared with White (8.9 percent), Hispanic (7.9 percent), Black (6.7 percent), Native Hawaiian or Other Pacific Islander (5.1 percent), or Asian adults (4.8 percent) (Table B.16B). Black adults were less likely to have had a past year MDE compared with White adults, and Asian adults were less likely to have had a past year MDE compared with White or Hispanic adults. A similar pattern of differences among racial or ethnic groups was observed for past year MDE with severe impairment among adults.

Any Mental Illness among Adults in the Past Year

The 2021 NSDUH provided estimates of any mental illness (AMI) and serious mental illness (SMI) for adults aged 18 or older. Adults aged 18 or older were classified as having AMI if they had any mental, behavioral, or emotional disorder in the past year of sufficient duration to meet criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), excluding developmental disorders and SUDs.^72,73 Adults aged 18 or older who were classified as having AMI were classified as having SMI if they had any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities. Statistical prediction models that were developed using clinical interview data from a subset of NSDUH adult respondents aged 18 or older between 2008 and 2012 were used to classify whether respondents in the 2021 adult sample had AMI or SMI in the past year. For 2021, source variables were statistically imputed for the prediction models used to estimate AMI or SMI.⁷¹

In sections that present estimates for AMI or SMI in the past year among adults aged 18 or older, estimates are first presented for all adults, followed by estimates among age groups, then by racial or ethnic groups. Estimates among racial or ethnic groups are presented for selected measures.¹³

Among adults aged 18 or older in 2021, 22.8 percent (or 57.8 million people) had AMI in the past year (Figure 41 and Table A.19B). The percentage was highest among young adults aged 18 to 25 (33.7 percent or 11.3 million people), followed by adults aged 26 to 49 (28.1 percent or 28.8 million people), then by adults aged 50 or older (15.0 percent or 17.7 million people).

By Race/Ethnicity

Among adults aged 18 or older in 2021, Multiracial adults (34.9 percent) were more likely to have had AMI in the past year compared with White (23.9 percent), Black (21.4 percent), Hispanic (20.7 percent), Native Hawaiian or Other Pacific Islander (18.1 percent), or Asian adults (16.4 percent) (Figure 42 and Table B.17B). The percentage of adults with AMI in the past year was lower among Hispanic adults than among White adults. The percentage was lower among Asian adults than among White, Black, or Hispanic adults.

Serious Mental Illness among Adults in the Past Year

Among adults aged 18 or older in 2021, 5.5 percent (or 14.1 million people) had SMI in the past year (Figure 41 and Table A.19B). Consistent with the age group pattern for AMI, the percentage of adults aged 18 or older with SMI was highest among young adults aged 18 to 25 (11.4 percent or 3.8 million people), followed by adults aged 26 to 49 (7.1 percent or 7.3 million people), then by adults aged 50 or older (2.5 percent or 3.0 million people).

By Race/Ethnicity

Among adults aged 18 or older in 2021, Multiracial adults (8.2 percent) were more likely to have had SMI in the past year compared with Hispanic (5.1 percent), Black (4.3 percent), or Asian adults (2.8 percent) (Table B.17B). The percentage of adults with SMI in the past year was lower among Black adults than among White adults (6.1 percent). The percentage was also lower among Asian adults than among White or Hispanic adults.

Co-Occurring MDE and SUD among Adolescents

Adolescents aged 12 to 17 who had both a past year MDE and a past year SUD (i.e., drug use disorder, alcohol use disorder, or both) were classified as having co-occurring MDE and SUD. The order of the onset of an SUD relative to the onset of an MDE among adolescents aged 12 to 17 cannot be established based on the NSDUH data (i.e., whether the onset of an SUD preceded the onset of an MDE, or vice versa).

As noted previously, SUD estimates for 2021 included data from all past year users of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives). The Substance Use Treatment in the Past Year section discusses these changes in the measurement and estimation of SUDs in more detail.

Among adolescents aged 12 to 17 in 2021, 25.2 percent (or 6.3 million people) had either an SUD or an MDE in the past year, 16.4 percent (or 4.1 million people) had an MDE but not an SUD, 4.8 percent (or 1.2 million people) had an SUD but not an MDE, and 3.7 percent (or 935,000 people) had both an MDE and an SUD in the past year (Figure 43 and Table A.20AB).

Among adolescents aged 12 to 17 in 2021, 2.9 percent (or 724,000 people) had both an MDE with severe impairment and an SUD in the past year.

By Race/Ethnicity

Among adolescents aged 12 to 17 in 2021, Asian (15.4 percent) or Black adolescents (19.6 percent) were less likely to have either an SUD or an MDE in the past year compared with Multiracial (31.2 percent), Hispanic (27.7 percent), or White adolescents (25.8 percent) (Table B.18B). Black adolescents (1.6 percent) also were less likely to have a co-occurring MDE and an SUD in the past year compared with White (4.2 percent) or Hispanic adolescents (3.7 percent).

Substance Use among Adolescents with MDE

Adolescents aged 12 to 17 who had a past year MDE were more likely to use some substances in the past year or past month compared with their counterparts who did not have an MDE in the past year. In 2021, adolescents aged 12 to 17 with a past year MDE were more likely than adolescents aged 12 to 17 without a past year MDE to be past year illicit drug users (27.7 vs. 10.7 percent), including past year marijuana users (20.3 vs. 8.0 percent) (Figure 44 and Table A.21B). Adolescents aged 12 to 17 with a past year MDE also were more likely than those without a past year MDE to be past month binge alcohol users (6.7 vs. 3.1 percent). In addition, adolescents aged 12 to 17 with a past year MDE were more likely than those without a past year MDE to use tobacco products or to vape nicotine in the past month (14.3 vs. 4.7 percent). Except for cocaine and methamphetamine use in the past year and heavy alcohol use in the past month, adolescents aged 12 to 17 with a past year MDE also were more likely than those without a past year MDE to be past year or past month users of the other substances shown in Table A.21B.

Co-Occurring Mental Health Issues and SUD among Adults

Among adults aged 18 or older, having AMI and an SUD in the past year is referred to as having co-occurring AMI and SUD. Adults aged 18 or older having SMI and an SUD in the past year are referred to as having co-occurring SMI and SUD. However, the order of the onset of SUDs relative to the onset of mental disorders cannot be established based on the NSDUH data for adults aged 18 or older (i.e., whether the onset of SUDs preceded the onset of mental disorders, or vice versa).

As noted previously, SUD estimates for 2021 included data from all past year users of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives). The Substance Use Treatment in the Past Year section discusses the measurement and estimation of SUDs in more detail.

The following sections for adults aged 18 or older present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for selected measures.¹³

Co-Occurring AMI and SUD

Among adults aged 18 or older in 2021, 32.5 percent (or 82.5 million people) had either AMI or an SUD in the past year, 15.1 percent (or 38.4 million people) had AMI but not an SUD, 9.7 percent (or 24.7 million people) had an SUD but not AMI, and 7.6 percent (or 19.4 million people) had both AMI and an SUD (Figure 45 and Tables A.22A and A.22B).

Nearly half of young adults aged 18 to 25 in 2021 had either AMI or an SUD in the past year (45.8 percent or 15.3 million people) (Tables A.22A and A.22B). This percentage was higher than the percentages for AMI or an SUD in the past year among adults aged 26 to 49 (39.5 percent or 40.4 million people) and adults aged 50 or older (22.6 percent or 26.7 million people). Adults aged 26 to 49 also were more likely than adults aged 50 or older to have AMI or an SUD in the past year.

The percentage of adults aged 18 or older in 2021 who had both AMI and an SUD in the past year was lowest among adults aged 50 or older (3.7 percent or 4.4 million people) (Tables A.22A and A.22B). The percentage of adults aged 26 to 49 with both AMI and an SUD (10.2 percent or 10.5 million people) also was slightly lower than the percentage among young adults aged 18 to 25 (13.5 percent or 4.5 million people).

By Race/Ethnicity

The percentage of adults aged 18 or older in 2021 who had either AMI or an SUD in the past year was higher among Multiracial adults (48.0 percent) than among White (33.6 percent), Black (32.3 percent), Hispanic (30.3 percent), or Asian adults (21.4 percent) (Table B.19B). Asian adults were less likely to have had either AMI or an SUD in the past year compared with adults in most other racial or ethnic groups.

Similar patterns among racial or ethnic groups were observed for the percentages of adults aged 18 or older who had both AMI and an SUD in the past year. The percentage of adults aged 18 or older who had both AMI and an SUD in the past year was higher among Multiracial adults (16.3 percent) than among White (7.9 percent), Black (7.4 percent), Hispanic (7.2 percent), or Asian adults (3.5 percent) (Table B.19B). Asian adults were less likely to have had both AMI and an SUD in the past year compared with adults in most other racial or ethnic groups.

Co-Occurring SMI and SUD

Among adults aged 18 or older in 2021, 20.4 percent (or 51.7 million people) had either SMI or an SUD in the past year, 3.0 percent (or 7.7 million people) had SMI but not an SUD, 14.8 percent (or 37.7 million people) had an SUD but not SMI, and 2.5 percent (or 6.4 million people) had both SMI and an SUD (Figure 45 and Tables A.22A and A.22B).

Nearly one third of young adults aged 18 to 25 in 2021 had either SMI or an SUD in the past year (31.6 percent or 10.6 million people) (Tables A.22A and A.22B). This percentage was higher than the percentages for SMI or an SUD in the past year among adults aged 26 to 49 (25.4 percent or 26.0 million people) and adults aged 50 or older (12.8 percent or 15.2 million people). Adults aged 26 to 49 also were more likely than adults aged 50 or older to have SMI or an SUD in the past year.

By Race/Ethnicity

The percentage of adults aged 18 or older in 2021 who had either SMI or an SUD in the past year was higher among American Indian or Alaska Native (34.2 percent) or Multiracial adults (33.6 percent) than among White (21.1 percent), Black (20.4 percent), Hispanic (19.2 percent), or Asian adults (10.8 percent) (Table B.20B). Asian adults were less likely to have had either SMI or an SUD in the past year compared with adults in most other racial or ethnic groups.

Asian adults (0.5 percent) aged 18 or older in 2021 were also less likely to have had both SMI and an SUD in the past year compared with adults in most other racial or ethnic groups (Table B.20B). Estimates for having had both SMI and an SUD in the past year did not differ among other racial or ethnic groups of adults.

Substance Use among Adults, by Mental Illness Status

This section discusses how the prevalence of substance use among adults aged 18 or older differed based on past year mental illness status. Among adults aged 18 or older in 2021, those with SMI or AMI in the past year were more likely than those without mental illness in the past year to be past year users of illicit drugs (50.2 percent for SMI and 39.7 percent for AMI vs. 17.7 percent for adults aged 18 or older with no mental illness), past year users of marijuana (41.6 and 33.8 percent vs. 15.4 percent), or past year misusers of opioids (i.e., heroin users or misusers of prescription pain relievers) (10.3 and 7.7 percent vs. 2.2 percent) (Figure 46 and Table A.23B). In addition, adults aged 18 or older with SMI or AMI were more likely than adults aged 18 or older with no mental illness in the past year to be past month binge alcohol users (30.3 and 27.9 percent vs. 21.9 percent). Adults aged 18 or older with SMI or AMI were more likely to use tobacco products or to vape nicotine in the past month than adults aged 18 or older with no mental illness in the past year (37.3 and 32.6 percent vs. 20.9 percent). Except for alcohol use in the past month among adults aged 18 or older with SMI, adults aged 18 or older with AMI or SMI in the past year also were more likely than those without mental illness to be past year or past month users of the other substances shown in Table A.23B.

Suicidal Thoughts and Behaviors among Adults

Suicide is a leading cause of death and an important public health problem in the United States.⁷⁴ It is a tragedy for all involved—those who die by suicide and their families, friends, neighbors, colleagues, and communities. Provisional data from the National Vital Statistics System (NVSS) indicated that in 2020, 45,855 people in the United States died by suicide; this number was 3 percent less than the 47,511 deaths by suicide in 2019.^75,76 In 2020, suicide was the 12th leading cause of death among people of all ages in the United States. The age-adjusted rate of deaths by suicide declined between 2018 and 2020. Nevertheless, suicide was the second leading cause of death among people aged 10 to 34 and the fifth leading cause among people aged 35 to 54.⁷⁷ However, people who die by suicide represent a fraction of those who consider or attempt suicide.⁷⁸ Out of every 31 adults aged 18 or older in 2008 to 2011 in the United States who attempted suicide in the past 12 months, there was 1 death by suicide.⁷⁹

In 2021, NSDUH respondents aged 18 or older were asked if at any time during the past 12 months they had thought seriously about trying to kill themselves (serious thoughts of suicide). Adults aged 18 or older also were asked whether they made a plan to kill themselves (suicide plan) or tried to kill themselves (suicide attempt) in the past 12 months, regardless of whether they had serious thoughts of suicide in that period. This information helps guide suicide prevention programs and clinical intervention efforts.

The following sections for adults aged 18 or older present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for selected measures.¹³

In 2021, 12.3 million adults aged 18 or older (4.8 percent) had serious thoughts of suicide in the past year, 3.5 million (1.4 percent) made suicide plans, and 1.7 million (0.7 percent) attempted suicide (Figure 47 and Table A.24B). An estimated 1.3 million adults aged 18 or older (0.5 percent) had serious thoughts of suicide, made suicide plans, and also attempted suicide in the past year.²⁷ Additional highlights from Figure 47 include the following:

• Among the 12.3 million adults aged 18 or older who had serious thoughts of suicide in the past year, most (8.8 million) had serious thoughts of suicide only. An additional 1.9 million adults aged 18 or older had serious thoughts of suicide and made suicide plans, but they did not attempt suicide in the past year.
• Among the 3.5 million adults aged 18 or older who made suicide plans in the past year, 1.9 million adults aged 18 or older had serious thoughts of suicide but did not attempt suicide and 1.3 million adults aged 18 or older had serious thoughts of suicide and attempted suicide.
• Among the 1.7 million adults aged 18 or older who attempted suicide in the past year, most had serious thoughts of suicide, including 263,000 who had serious thoughts of suicide but did not make suicide plans and 1.3 million who had serious thoughts of suicide and made suicide plans. Only 67,000 adults aged 18 or older attempted suicide in the past year without having serious thoughts of suicide or making suicide plans.

Serious Thoughts of Suicide among Adults

Among adults aged 18 or older in 2021, 4.8 percent (or 12.3 million people) had serious thoughts of suicide in the past year (Figures 47 and 48 and Table A.24B). The percentage was highest among young adults aged 18 to 25 (13.0 percent or 4.4 million people), followed by adults aged 26 to 49 (5.4 percent or 5.5 million people), then by adults aged 50 or older (2.0 percent or 2.4 million people).

By Race/Ethnicity

The percentage of adults aged 18 or older in 2021 who had serious thoughts of suicide in the past year was higher among American Indian or Alaska Native adults (8.5 percent) than among Asian adults (2.6 percent) (Figure 49 and Table B.21B). Multiracial adults (8.2 percent) also were more likely to have had serious thoughts of suicide in the past year compared with Black (4.6 percent) or Asian adults. Asian adults were less likely to have had serious thoughts of suicide in the past year compared with adults in most other racial or ethnic groups.

Suicide Plans among Adults

Among adults aged 18 or older in 2021, 1.4 percent (or 3.5 million people) made a suicide plan in the past year (Figures 47 and 48 and Table A.24B). The percentage was highest among young adults aged 18 to 25 (4.9 percent or 1.6 million people), followed by adults aged 26 to 49 (1.5 percent or 1.5 million people), then by adults aged 50 or older (0.3 percent or 400,000 people).

By Race/Ethnicity

Percentages of adults aged 18 or older in 2021 who made a suicide plan in the past year did not differ among racial or ethnic groups. Percentages of adults who made a suicide plan in the past year ranged from 0.5 percent of Native Hawaiian or Other Pacific Islander adults to 2.4 percent of Multiracial adults (Table B.21B).

Suicide Attempts among Adults

Among adults aged 18 or older in 2021, 0.7 percent (or 1.7 million people) attempted suicide in the past year (Figures 47 and 48 and Table A.24B). The percentage was highest among young adults aged 18 to 25 (2.7 percent or 902,000 people), followed by adults aged 26 to 49 (0.7 percent or 672,000 people), then by adults aged 50 or older (0.1 percent or 173,000 people).

By Race/Ethnicity

The percentage of adults aged 18 or older in 2021 who attempted suicide in the past year was higher among Hispanic adults (1.1 percent) than among White (0.5 percent) or Asian adults (0.3 percent) (Table B.21B). Black adults (0.9 percent) also were more likely to have attempted suicide in the past year compared with Asian adults.

Suicidal Thoughts and Behaviors among Adults Because of COVID-19

During the COVID-19 pandemic, people with mental illness may experience worsening mental health problems and associated symptoms, such as thoughts of suicide. Other people may develop new mental health problems, such as depression, anxiety, or posttraumatic stress disorder, all of which are associated with increased suicide risk.⁸⁰ Indeed, levels of psychological distress among adults aged 18 or older have been elevated from April 2020 at the start of the COVID-19 pandemic into August 2021.⁸¹ Elevated symptoms of depression and anxiety have also persisted into later stages of the COVID-19 pandemic in the United States.^82,83,84

Questions were included in the 2021 NSDUH to better understand the potential impact of the COVID-19 pandemic on suicidal thoughts and behaviors among adults in the United States. If adult respondents aged 18 or older reported that they thought seriously about trying to kill themselves in the past 12 months, they were asked if they had these suicidal thoughts because of the COVID-19 pandemic. Adult respondents aged 18 or older who reported plans to kill themselves or who tried to kill themselves were also asked if they made these plans or tried to kill themselves because of the COVID-19 pandemic.

For the large majority of adults aged 18 or older in 2021 who had serious thoughts of suicide, made suicide plans, or attempted suicide in the past year, there was no evidence that they experienced these thoughts or behaviors because of the COVID-19 pandemic. Among adults aged 18 or older in 2021 who had serious thoughts of suicide in the past year, 15.8 percent (or 1.9 million people) were estimated to have had serious thoughts of suicide because of the COVID-19 pandemic (Figure 50 and Table A.25B). Among adults aged 18 or older who made a suicide plan in the past year, 13.7 percent (or 483,000 people) were estimated to have made a suicide plan because of the COVID-19 pandemic. Among adults aged 18 or older who attempted suicide in the past year, 16.0 percent (or 279,000 people) were estimated to have attempted suicide because of the COVID-19 pandemic. However, these estimates could be conservative if the COVID-19 pandemic indirectly contributed to suicidal thoughts or behavior among adult respondents aged 18 or older, but they did not attribute these thoughts or behaviors directly to the COVID-19 pandemic.

Among adults aged 18 or older in 2021 who had serious thoughts of suicide in the past year, the percentage whose thoughts of suicide were because of the COVID-19 pandemic was lowest among adults aged 50 or older (10.1 percent or 243,000 people) (Figure 50 and Table A.25B). Percentages for serious thoughts of suicide because of the COVID-19 pandemic were similar among young adults aged 18 to 25 and adults aged 26 to 49 who had serious thoughts of suicide in the past year (15.3 percent or 667,000 young adults aged 18 to 25; 18.6 percent or 1.0 million adults aged 26 to 49).

Among adults aged 18 or older in 2021 who made a suicide plan in the past year, similar percentages of young adults aged 18 to 25 and adults aged 26 to 49 made a suicide plan because of the COVID-19 pandemic (12.7 percent or 209,000 young adults aged 18 to 25; 16.5 percent or 245,000 adults aged 26 to 49) (Figure 50 and Table A.25B). Corresponding estimates for adults aged 50 or older who made a suicide plan because of the COVID-19 pandemic could not be calculated with sufficient precision.¹³

Among young adults aged 18 to 25 in 2021 who made a suicide attempt in the past year, about 1 in 10 (9.6 percent or 87,000 people) attempted suicide because of the COVID-19 pandemic (Figure 50 and Table A.25B). Corresponding estimates for adults in other age groups who attempted suicide because of the COVID-19 pandemic could not be calculated with sufficient precision.

Suicidal Thoughts and Behaviors among Adolescents

Trends in suicide attempts and deaths by suicide have been increasing among adolescents.^85,86,87 These trends in suicidal behaviors among adolescents are major public health concerns in the United States.^88,89 Vulnerable adolescent populations exposed to adverse childhood experiences (ACEs) are at particular risk of suicide and related behaviors.^90,91,92 In the midst of the COVID-19 pandemic, preliminary data suggest a rise in suicide-related emergency department (ED) visits, particularly among adolescents.⁹³ During March to October 2020, the proportion of all ED visits that were for mental health conditions increased among adolescents aged 12 to 17 compared with the proportion in 2019. Among adolescent females aged 12 to 17, the weekly average number of ED visits for mental health conditions increased between corresponding weeks in 2019 and 2021 for depression, eating disorders, tic disorders, and obsessive-compulsive disorder. In contrast, among adolescent males aged 12 to 17, the weekly average number of ED visits for mental health conditions decreased in 2020 and 2021. These gender differences could reflect differences in need, recognition, and help-seeking behavior.⁹⁴

Questions were included in the 2021 NSDUH to better understand suicidal thoughts and behaviors among adolescents aged 12 to 17. Adolescent respondents aged 12 to 17 were asked if they seriously thought about trying to kill themselves, if they made plans to kill themselves, and if they had tried to kill themselves in the past 12 months. Unlike the questions for adults, the questions for adolescent respondents aged 12 to 17 included the response options “I'm not sure” and “I don't want to answer.”

If adolescent respondents aged 12 to 17 reported that they thought seriously about trying to kill themselves in the past 12 months, they were asked if they had these suicidal thoughts because of the COVID-19 pandemic. Adolescent respondents aged 12 to 17 who reported plans to kill themselves or who tried to kill themselves were also asked if they had these plans or tried to kill themselves because of the COVID-19 pandemic.

The following sections present the overall estimates for adolescents aged 12 to 17. Estimates among racial or ethnic groups are presented for selected measures.¹³

In 2021, 3.3 million adolescents aged 12 to 17 (12.7 percent) had serious thoughts of suicide in the past year, 1.5 million (5.9 percent) made suicide plans, and 892,000 (3.4 percent) attempted suicide (Figure 51 and Table A.26B). An estimated 711,000 adolescents aged 12 to 17 (2.7 percent) had serious thoughts of suicide, made suicide plans, and also attempted suicide in the past year.²⁷ Additional highlights from Figure 51 include the following:

• A slight majority of the 3.3 million adolescents aged 12 to 17 who had serious thoughts of suicide in the past year had serious thoughts of suicide only (1.8 million adolescents aged 12 to 17). An estimated 714,000 adolescents aged 12 to 17 had serious thoughts of suicide and made suicide plans, but they did not attempt suicide in the past year.
• The majority of the 1.5 million adolescents aged 12 to 17 who made suicide plans in the past year either had serious thoughts of suicide but did not attempt suicide (714,000 adolescents aged 12 to 17) or had serious thoughts of suicide and attempted suicide (711,000 adolescents aged 12 to 17).
• Among the 892,000 adolescents aged 12 to 17 who attempted suicide in the past year, most had serious thoughts of suicide, including 89,000 who had serious thoughts of suicide but did not make suicide plans and 711,000 who had serious thoughts of suicide and made suicide plans. An estimated 58,000 adolescents aged 12 to 17 attempted suicide in the past year without having serious thoughts of suicide or making suicide plans.

Suicidal Thoughts and Behaviors among Adolescents for Any Reason

Among adolescents aged 12 to 17 in 2021, 12.7 percent (or 3.3 million people) had serious thoughts of suicide in the past year (Figures 51 and 52 and Table A.26B). In addition, adolescent respondents aged 12 to 17 who reported that they were not sure or did not know if they had serious thoughts of suicide correspond to a population estimate of 7.9 percent (or 2.0 million people). Adolescent respondents aged 12 to 17 who did not want to report whether they had serious thoughts of suicide correspond to a population estimate of 9.0 percent (or 2.3 million people). Therefore, the estimate of 12.7 percent of adolescents aged 12 to 17 who had serious thoughts of suicide in the past year is likely to be conservative. There were adolescents aged 12 to 17 who were unsure about whether they had serious thoughts of suicide or were unwilling to report whether they had these thoughts. This information suggests that some adolescents aged 12 to 17 could have had these thoughts but did not feel comfortable disclosing that information.

An estimated 5.9 percent of adolescents aged 12 to 17 in 2021 (or 1.5 million people) made a suicide plan in the past year (Figures 51 and 52 and Table A.26B). Adolescent respondents aged 12 to 17 who reported that they were not sure or did not know whether they made a suicide plan correspond to a population estimate of 3.6 percent (or 941,000 people). Adolescent respondents aged 12 to 17 who did not want to report whether they made a suicide plan correspond to a population estimate of 7.4 percent (or 1.9 million people). Therefore, the estimate of 5.9 percent of adolescents aged 12 to 17 who had made a suicide plan in the past year is likely to be conservative.

An estimated 3.4 percent of adolescents aged 12 to 17 in 2021 (or 892,000 people) attempted suicide in the past year (Figures 51 and 52 and Table A.26B). Adolescent respondents aged 12 to 17 who reported that they were not sure or did not know whether they attempted suicide correspond to a population estimate of 1.9 percent (or 492,000 people). Adolescent respondents aged 12 to 17 who did not want to report whether they attempted suicide correspond to a population estimate of 6.0 percent (or 1.6 million people). Therefore, the estimate of 3.4 percent of adolescents aged 12 to 17 who attempted suicide in the past year is likely to be conservative.

By Race/Ethnicity

Percentages of adolescents aged 12 to 17 in 2021 who had serious thoughts of suicide, made suicide plans, or attempted suicide in the past year did not differ among racial or ethnic groups of adolescents. Percentages of adolescents who had serious thoughts of suicide in the past year ranged from 11.2 percent of Asian adolescents to 16.8 percent of Multiracial adolescents (Table B.22B). Percentages of adolescents who made a suicide plan in the past year ranged from 4.2 percent of Multiracial adolescents to 7.0 percent of Hispanic adolescents. Percentages of adolescents who attempted suicide in the past year ranged from 2.7 percent of Multiracial adolescents to 4.2 percent of Hispanic adolescents.

Suicidal Thoughts and Behaviors among Adolescents Because of COVID-19

As for adolescents aged 12 to 17 in 2021, the large majority who had serious thoughts of suicide, made suicide plans, or attempted suicide in the past year did not connect these thoughts or behaviors to the COVID-19 pandemic. Among adolescents aged 12 to 17 in 2021 who had serious thoughts of suicide in the past year, 15.1 percent (or 484,000 people) had serious thoughts of suicide because of the COVID-19 pandemic (Figure 53 and Table A.27B). Among adolescents aged 12 to 17 who made a suicide plan in the past year, 12.0 percent (or 178,000 people) made a suicide plan because of the COVID-19 pandemic. Among adolescents aged 12 to 17 who attempted suicide in the past year, 8.4 percent (or 73,000 people) attempted suicide because of the COVID-19 pandemic.

Substance Use Treatment in the Past Year

Substance use treatment is intended to help people address problems associated with their use of alcohol or drugs not counting tobacco use, including medical problems associated with the use of alcohol or drugs.⁹⁵ The 2021 NSDUH provided two principal measures related to substance use treatment in the past year: (a) the need for substance use treatment and (b) the receipt of substance use treatment. The survey also collected information on the types of settings where people received treatment and barriers associated with people needing substance use treatment but not receiving it.¹⁸

As noted in the Substance Use Disorders in the Past Year section, respondents in 2021 who reported any past year use of prescription pain relievers, tranquilizers, stimulants, or sedatives in the past year (i.e., not just misuse) were asked SUD questions about the respective prescription drug category. However, respondents in 2021 who reported lifetime use (but not misuse) of prescription drugs were not asked questions about their receipt of substance use treatment unless they also reported lifetime use of alcohol, marijuana, cocaine, heroin, hallucinogens, inhalants, or methamphetamine.

In addition, SAMHSA historically has classified people as having a need for substance use treatment if they had an illicit drug or alcohol use disorder in the past year or if they received substance use treatment at a specialty facility⁹⁶ in the past year (regardless of whether they had either of these disorders).^97,98 Although respondents in 2021 who reported the past year use but not misuse of prescription drugs were asked the respective prescription drug use disorder questions, respondents who reported only the use but not misuse of prescription drugs (i.e., they did not report the lifetime use of alcohol or illicit drugs) did not have the opportunity to report whether they received substance use treatment at a specialty facility in the past year. Therefore, a measure of the need for substance use treatment was created for 2021 according to the definition mentioned previously. Specifically, respondents in 2021 were classified as needing substance use treatment in the past year if they had an illicit drug or alcohol use disorder in the past year or if they received substance use treatment at a specialty facility in the past year.

Before the COVID-19 pandemic, substance use treatment was typically delivered in person. The COVID-19 pandemic required changes in substance use treatment delivery to include expansion of virtual treatments. To support this need, regulations for opioid treatment have been relaxed for take-home medications and requirements for in-person treatment as long as the COVID-19 public health emergency (PHE) remains in effect.^99,100,101 Although reimbursement for some virtual behavioral health services was allowed before 2020, reimbursement for additional virtual services (including substance use treatment) was expanded during the COVID-19 pandemic, including reimbursement for services delivered over the phone (i.e., using only audio).¹⁰² However, the Centers for Medicare & Medicaid Services (CMS), which pays opioid treatment programs for opioid use disorder treatment services to people with Medicare Part B (medical insurance), announced that after the end of the COVID-19 PHE, CMS will allow audio-only interaction (e.g., telephone calls) in situations where audio/video communication is not available to opioid treatment patients.¹⁰³

Virtual substance use treatment has been shown to be effective^104,105,106 and has been proposed as an alternative to in-person services for some time, particularly in instances where access to such services is limited.¹⁰⁷ Data from SAMHSA's Behavioral Health Treatment Services Locator indicated that the availability of virtual substance use treatment services increased by 143 percent between January 2020 and January 2021. By January 2021, more than half of substance use treatment facilities were offering virtual services.¹⁰⁸

In light of these changes to substance use treatment delivery and reimbursement, the 2021 NSDUH questionnaire included questions on the receipt of virtual substance use treatment services. The Receipt of Virtual (Telehealth) Services for Substance Use Treatment section presents estimates on the receipt of virtual services for substance use treatment.

The following sections present the overall estimates first, then by age group. Estimates among racial or ethnic groups are presented for selected measures.¹³

Need for Substance Use Treatment

As noted previously, NSDUH respondents in 2021 were classified as needing substance use treatment in the past year if they had an illicit drug or alcohol use disorder or if they received substance use treatment at a specialty facility in the past year. Based on this definition, 15.6 percent of people aged 12 or older in 2021 (or 43.7 million people) needed substance use treatment in the past year (Figure 54 and Table A.28AB). Consistent with data on the presence of an illicit drug or alcohol use disorder in the past year, the percentage of people needing substance use treatment was highest among young adults aged 18 to 25 (25.1 percent or 8.4 million people), followed by adults aged 26 or older (15.1 percent or 33.3 million people), then by adolescents aged 12 to 17 (7.6 percent or 2.0 million people).

However, respondents who reported only the lifetime use (but not misuse) of prescription psychotherapeutic drugs were not asked questions to measure the receipt of substance use treatment at a specialty facility in the past year. Although some of these lifetime users (but not misusers) of only prescription psychotherapeutic drugs could have had prescription drug use disorders in the past year (so that they needed treatment for their use of prescription drugs), they did not have an opportunity to report whether they received services in response to their need. Consequently, respondents whose only SUDs were for the use (but not misuse) of prescription psychotherapeutic drugs were not counted in the 2021 estimates of the need for substance use treatment. Therefore, these 2021 estimates for the need for substance use treatment may be conservative.

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 needing substance use treatment in the past year was higher among American Indian or Alaska Native (28.7 percent) or Multiracial people (25.5 percent) than among Black (16.4 percent), White (15.9 percent), Hispanic (15.0 percent), or Asian people (7.7 percent) (Figure 55 and Table B.23B). Asian people were less likely to need substance use treatment in the past year compared with people in all other racial or ethnic groups including Native Hawaiian and Other Pacific Islander people (20.6 percent).

Receipt of Substance Use Treatment

NSDUH respondents who used alcohol or illicit drugs in their lifetime were asked whether they ever received substance use treatment, and those who received substance use treatment in their lifetime were asked whether they received treatment in the 12 months prior to the survey interview (i.e., in the past year). Of the respondents in 2021 who reported lifetime use of alcohol or drugs, 7.6 percent (unweighted) reported lifetime use of only prescription drugs but not misuse (and they did not report lifetime use of alcohol, marijuana, cocaine, heroin, hallucinogens, inhalants, or methamphetamine). Thus, 92.4 percent of respondents who were lifetime users of alcohol or drugs were also lifetime users of alcohol or illicit drugs.²⁷ For this reason, not including respondents who reported only the lifetime use (but not misuse) of prescription psychotherapeutic drugs in the group of respondents who were asked the substance use treatment questions is assumed to have a minimal effect on estimates for the receipt of substance use treatment in the past year.

Receipt of any substance use treatment includes substance use treatment received in the past year at any location, such as a hospital (inpatient), rehabilitation facility (outpatient or inpatient), mental health center, emergency room, private doctor's office, prison or jail, or self-help group (e.g., Alcoholics Anonymous or Narcotics Anonymous). In addition, respondents in 2021 who reported receiving substance use treatment in the past year were asked if they received professional counseling, medication, or treatment in the past 12 months for their alcohol or drug use over the phone, by email, or through video calling (i.e., virtual or telehealth services).

The 2021 NSDUH also collected information on the receipt of substance use treatment at a specialty facility. Substance use treatment at a specialty facility is included in the estimates of any substance use treatment because a subset of the treatment locations was categorized as specialty facilities. Receipt of substance use treatment at a specialty facility was defined as substance use treatment received by a respondent at a hospital (only as an inpatient), a drug or alcohol rehabilitation facility (as an inpatient or outpatient), or a mental health center. Substance use treatment at a specialty facility did not include virtual services or self-help groups.

Receipt of Any Substance Use Treatment

Among people aged 12 or older in 2021, 1.5 percent (or 4.1 million people) received any substance use treatment in the past year (Table A.28AB). An estimated 2.0 million people aged 12 or older received substance use treatment in the past year at a self-help group, 1.9 million received virtual services, 1.8 million received treatment at a rehabilitation facility as an outpatient, 1.5 million received treatment at a mental health center as an outpatient, 1.3 million received treatment at a rehabilitation facility as an inpatient, 1.1 million received treatment at a private doctor's office, and 1.1 million received treatment at a hospital as an inpatient (Figure 56 and Table A.29AB). Smaller numbers of people received treatment in an emergency room or in a prison or jail.

In 2021, 1.6 percent of adults aged 26 or older (or 3.6 million people) and 1.3 percent of young adults aged 18 to 25 (or 438,000 people) received any substance use treatment in the past year (Table A.28AB). These percentages were higher than the corresponding percentage among adolescents aged 12 to 17 (0.3 percent or 82,000 people).

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who received any substance use treatment in the past year was lower among Hispanic (1.0 percent) or Asian people (0.7 percent) than among American Indian or Alaska Native people (5.3 percent) (Table B.23B). Hispanic people also were less likely than White people (1.6 percent) to receive any substance use treatment in the past year.

Receipt of Any Substance Use Treatment among People with a Past Year Illicit Drug or Alcohol Use Disorder

Among people aged 12 or older in 2021 with a past year illicit drug or alcohol use disorder, 6.3 percent (or 2.7 million people) received any substance use treatment in the past year (Figure 57 and Table A.28AB). The percentage of people with a past year illicit drug or alcohol use disorder who received any substance use treatment in the past year was highest for adults aged 26 or older (7.1 percent or 2.3 million people). Percentages for the receipt of any substance use treatment in the past year were similar for adolescents aged 12 to 17 (3.5 percent) and for young adults aged 18 to 25 (4.1 percent). Corresponding numbers of adolescents aged 12 to 17 and young adults aged 18 to 25 with a past year illicit drug or alcohol use disorder who received any substance use treatment in the past year were 68,000 adolescents and 339,000 young adults.

By Race/Ethnicity

In 2021, there were no differences by racial or ethnic group in the percentage of people aged 12 or older with a past year illicit drug or alcohol use disorder who received any substance use treatment in the past year.

Receipt of Substance Use Treatment at a Specialty Facility

Among people aged 12 or older in 2021, 1.1 percent (or 3.0 million people) received substance use treatment at a specialty facility in the past year (Table A.28AB). Among people aged 12 or older in 2021 who received any substance use treatment in the past year, 71.8 percent received substance use treatment at a specialty facility. Among adults who received substance use treatment in the past year, percentages for the receipt of substance use treatment at a specialty facility did not differ by age group (71.5 percent of young adults aged 18 to 25 and 71.9 percent of adults aged 26 or older). Estimates for the receipt of substance use treatment at a specialty facility among adolescents aged 12 to 17 who received substance use treatment in the past year could not be calculated with sufficient precision.

By Race/Ethnicity

The percentage of people aged 12 or older in 2021 who received substance use treatment at a specialty facility in the past year was lower among Asian people (0.3 percent) than among Multiracial (2.1 percent), White (1.2 percent), or Black people (1.2 percent) (Figure 58 and Table B.23B). Hispanic people (0.6 percent) also were less likely than White people to receive substance use treatment at a specialty facility. Estimates for receipt of substance use treatment at a specialty facility in the past year among people aged 12 or older who received any substance use treatment are not presented by racial or ethnic group. This is because estimates for groups other than White could not be calculated with sufficient precision.¹³

Receipt of Substance Use Treatment at a Specialty Facility among People Who Needed Substance Use Treatment

Among the 43.7 million people aged 12 or older in 2021 who needed substance use treatment in the past year, 6.8 percent (or 3.0 million people) received substance use treatment at a specialty facility in the past year (Figure 59 and Table A.28AB).¹⁰⁹ Adults aged 26 or older who needed substance use treatment in the past year were more likely than adolescents aged 12 to 17 or young adults aged 18 to 25 to have received substance use treatment at a specialty facility in the past year. Among the 33.3 million adults aged 26 or older in 2021 who needed substance use treatment in the past year, 7.8 percent (or 2.6 million people) received substance use treatment at a specialty facility in the past year. In comparison, among the 2.0 million adolescents aged 12 to 17 in 2021 who needed substance use treatment in the past year, 2.8 percent (or 56,000 people) received substance use treatment at a specialty facility in the past year. Among the 8.4 million young adults aged 18 to 25 in 2021 who needed substance use treatment in the past year, 3.7 percent (or 314,000 people) received substance use treatment at a specialty facility in the past year.

By Race/Ethnicity

In 2021, there were no differences among racial or ethnic groups in the percentage of people aged 12 or older who received substance use treatment at a specialty facility among those who needed substance use treatment in the past year. Percentages for the receipt of substance use treatment at a specialty facility ranged from 3.9 percent of Asian people who needed substance use treatment in the past year to 8.3 percent of Multiracial people who needed substance use treatment in the past year (Table B.23B).

Receipt of Virtual (Telehealth) Services for Substance Use Treatment

Among people aged 12 or older in 2021 who received any substance use treatment in the past year, 46.2 percent (or 1.9 million people) received virtual (i.e., telehealth) services for substance use treatment (Table A.30AB). Among adults who received substance use treatment in the past year, 46.8 percent of those aged 26 or older (or 1.7 million people) and 44.3 percent of young adults aged 18 to 25 (or 194,000 people) received virtual substance use services. Estimates for the receipt of virtual services among adolescents aged 12 to 17 who received substance use treatment in the past year could not be calculated with sufficient precision.

By Race/Ethnicity

Estimates by racial or ethnic group among people aged 12 or older in 2021 are not presented for the receipt of virtual services among people who received substance use treatment in the past year because estimates for groups other than White could not be calculated with sufficient precision.¹³

Perceived Need for Substance Use Treatment

NSDUH respondents were classified as having a perceived need for substance use treatment (i.e., treatment for problems related to their use of alcohol or illicit drugs) if they indicated that they felt they needed substance use treatment in the past year. Respondents may have a perceived need for substance use treatment, regardless of whether they had an illicit drug or alcohol use disorder in the past year. In this report, estimates for the perceived need for substance use treatment are discussed only among people aged 12 or older who were classified as having an illicit drug or alcohol use disorder in the past year¹¹⁰ but did not receive substance use treatment at a specialty facility.^97,98

Among the 40.7 million people aged 12 or older in 2021 who had an illicit drug or alcohol use disorder in the past year and did not receive substance use treatment at a specialty facility, 96.8 percent (or 39.5 million people) did not feel they needed treatment, and 3.2 percent (or 1.3 million people) felt that they needed treatment (Figure 60 and Table A.31AB). An estimated 2.1 percent of people with an illicit drug or alcohol use disorder who did not receive treatment at a specialty facility (or 837,000 people) felt they needed treatment but did not make an effort to get treatment, and 1.1 percent (or 447,000 people) felt they needed treatment and made an effort to get treatment.¹¹¹ Among people in different age groups in 2021 with a past year illicit drug or alcohol use disorder who did not receive substance use treatment at a specialty facility, 98.6 percent of adolescents aged 12 to 17 (or 1.9 million people), 97.9 percent of young adults aged 18 to 25 (or 7.9 million people), and 96.5 percent of adults aged 26 or older (or 29.7 million people) did not feel they needed treatment.

By Race/Ethnicity

Among people aged 12 or older in 2021 who had an illicit drug or alcohol use disorder in the past year and did not receive substance use treatment at a specialty facility, similar percentages of people across racial or ethnic groups did not feel they needed substance use treatment. These percentages ranged from 96.7 percent of Black people to 99.4 percent of American Indian or Alaska Native people (Table B.24B).

Reasons for Not Receiving Substance Use Treatment

NSDUH respondents who did not receive substance use treatment in the past 12 months but felt they needed treatment were asked to report the reasons for not receiving treatment.¹¹² As noted in the previous section, among people aged 12 or older in 2021 who were classified as having an illicit drug or alcohol use disorder and did not receive substance use treatment at a specialty facility, only 3.2 percent perceived that they needed treatment.¹¹¹ For people who perceived a need for treatment, information on common reasons for not receiving substance use treatment is important for identifying and addressing barriers to treatment receipt.

Among people aged 12 or older in 2021 with a past year illicit drug or alcohol use disorder who did not receive treatment at a specialty facility and perceived a need for treatment, the following were common reasons for not receiving substance use treatment:

• not being ready to stop using (36.7 percent),
• having no health care coverage and not being able to afford the cost of treatment (24.9 percent),
• not knowing where to go for treatment (17.9 percent),
• not finding a program that offered the type of treatment they wanted (15.8 percent),
• thinking they could handle the problem without treatment (15.0 percent), and
• being concerned that getting treatment might have a negative effect on their job (14.7 percent) (Table A.32B).

Medication-Assisted Treatment for Alcohol Use or Opioid Misuse

The use of medications prescribed by a doctor to help people reduce or stop their use of alcohol or opioids is known as medication-assisted treatment (MAT). Specific drugs are approved for use as MAT. MAT does not include the use of medications that are prescribed to manage withdrawal symptoms or administered to stop a drug overdose.

In 2021, NSDUH respondents aged 12 or older who reported lifetime alcohol use and the receipt of substance use treatment at any location in the past year were asked to report whether a doctor or other health professional prescribed them medication in the past year to help reduce or stop their use of alcohol. Examples of medications shown to respondents that are prescribed as MAT for alcohol use included acamprosate (also known as Campral^®), disulfiram (also known as Antabuse^®), naltrexone pills (also known as ReVia^® or Trexan^®), and injectable naltrexone (also known as Vivitrol^®).

Questions on MAT for opioid misuse were asked of respondents aged 12 or older who reported ever using heroin or ever misusing prescription pain relievers and reported receiving substance use treatment at any location in the past year. These respondents were asked whether a doctor or other health professional prescribed them medication in the past year to help reduce or stop their use of heroin, misuse of prescription pain relievers, or both. Respondents also were informed that MAT for opioid misuse was different from medications given to stop a drug overdose. Examples of medications shown to respondents that are prescribed as MAT for opioid misuse included buprenorphine or buprenorphine-naloxone pills (also known as Suboxone^®, Zubsolv^®, Bunavail^®, or Subutex^®), injectable buprenorphine (also known as Sublocade^®), buprenorphine implants (also known as Probuphine^®), methadone, naltrexone pills (also known as ReVia^® or Trexan^®), and injectable naltrexone (also known as Vivitrol^®).

Medication-Assisted Treatment for Alcohol Use

In 2021, 2.6 million people aged 12 or older received treatment at any location in the past year for their alcohol use (regardless of whether they had a past year alcohol use disorder). Among these people who received treatment in the past year for their alcohol use, 15.1 percent (or 381,000 people) received MAT in the past year for their use of alcohol (Table A.33AB). Among the 29.5 million people aged 12 or older with a past year alcohol use disorder, 0.9 percent (or 265,000 people) received MAT in the past year for their alcohol use.

Medication-Assisted Treatment for Opioid Misuse

In 2021, 1.2 million people aged 12 or older received treatment at any location in the past year for their misuse of opioids (regardless of whether they had a past year opioid use disorder). Among these people who received treatment in the past year for their opioid misuse, 72.9 percent (or 887,000 people) received MAT in the past year for opioid misuse (Table A.34AB).

Estimates of opioid use disorder for 2021 were among people who used heroin in the past year or used prescription pain relievers for any reason in that period. A second estimate for opioid use disorder among people who used heroin or misused prescription pain relievers is shown in Table A.14B. This second estimate indicated that 0.9 percent of people aged 12 or older in 2021 had an opioid use disorder due to their use of heroin or misuse of prescription pain relievers in the past year.

This second measure for opioid use disorder for heroin use or prescription pain reliever misuse in the past year was used for estimates of the receipt of MAT in the past year among people with an opioid use disorder because the corresponding MAT estimates were among people who received substance use treatment in the past year and used heroin or misused prescription pain relievers in their lifetime. Among the 2.5 million people aged 12 or older with a past year opioid use disorder due to their use of heroin or misuse of prescription pain relievers, 22.1 percent (or 533,000 people) received MAT in the past year for opioid misuse (Table A.34AB).⁹⁷

Mental Health Service Use in the Past Year

The 2021 NSDUH included questions to estimate the use of mental health services in the United States among the adolescent and adult populations. In addition to estimating the use of mental health services among the overall adolescent and adult populations, these questions allowed for the estimation of mental health service utilization among adolescents aged 12 to 17 and adults aged 18 or older with mental health issues (i.e., MDE, AMI, and SMI).¹⁸

Similar to its effect on substance use treatment, the COVID-19 pandemic affected the availability of services as well as the modes of mental health service delivery. Even before the COVID-19 pandemic, virtual (i.e., telehealth) mental health care was proposed as an alternative to in-person mental health services as a means to increase availability and access, particularly in areas where services are limited or there are barriers to treatment (e.g., issues in transportation).^113,114 Mental health care delivered virtually has been shown to be effective.^115,116 Data from SAMHSA's Behavioral Health Treatment Services Locator indicated that the availability of virtual mental health services increased by 77 percent between January 2020 and January 2021. By January 2021, more than two thirds of outpatient mental health facilities were offering virtual services.¹⁰⁸

In light of these changes to the delivery of mental health services, questions were included in the 2021 NSDUH questionnaire to assess the use of virtual mental health services. The Receipt of Virtual (Telehealth) Mental Health Services among Adolescents and Mental Health Service Use among Adults subsections present estimates of the receipt of virtual mental health services.

In sections that present estimates for adolescents aged 12 to 17, estimates are presented for all adolescents. Estimates are not presented among racial or ethnic groups of adolescents because the relatively smaller sample of adolescents affects the conclusions that can be reached for the receipt of mental health services by racial or ethnic group. In sections that present estimates for adults aged 18 or older, estimates are first presented by age group, followed where applicable by estimates among racial or ethnic groups. For adults, estimates among racial or ethnic groups are presented for selected measures.¹³

Treatment for Depression among Adolescents

Adolescents aged 12 to 17 who met the criteria for having a past year MDE were asked whether they had received treatment for their depression in the past year. Adolescents aged 12 to 17 were classified as having received treatment for their depression in the past year if they reported seeing or talking to a health professional or taking prescription medication for their depression in that period.¹¹⁷

Among the 5.0 million adolescents aged 12 to 17 in 2021 who had a past year MDE, 40.6 percent (or 2.0 million people) received treatment for depression in the past year (Figure 61 and Table A.35B). Among the 3.7 million adolescents aged 12 to 17 in 2021 who had a past year MDE with severe impairment, 44.2 percent (or 1.6 million people) received treatment for depression in the past year. Stated another way, however, most adolescents aged 12 to 17 in 2021 who had a past year MDE or a past year MDE with severe impairment did not receive treatment for depression in the past year.

Treatment for Depression among Adults

Adults aged 18 or older who met the criteria for having a past year MDE were asked whether they had received treatment for their depression in the past year. Recall that adults aged 18 or older who had a past year MDE include those who had an MDE with severe impairment and those who did not have an MDE with severe impairment in the past year. Adults aged 18 or older were classified as having received treatment for their depression in the past year if they reported seeing or talking to a health professional or taking prescription medication for their depression in that period.¹¹⁷

As previously noted, missing data for measures of MDE and MDE with severe impairment among adults aged 18 or older were statistically imputed for 2021. However, missing data were not statistically imputed for treatment for depression among adults aged 18 or older. Therefore, to reduce the potential for bias, a break-off analysis weight was used for estimates of treatment for depression among adults aged 18 or older.

Among the 21.0 million adults aged 18 or older in 2021 who had a past year MDE, 61.0 percent (or 12.6 million people) received treatment for depression in the past year (Figure 62 and Table A.36B). Among the 14.5 million adults aged 18 or older in 2021 who had a past year MDE with severe impairment, 64.8 percent (or 9.2 million people) received treatment for depression in the past year.

The percentage of adults in 2021 with a past year MDE (regardless of their level of impairment) who received treatment for depression in the past year was lower among young adults aged 18 to 25 (51.1 percent or 3.1 million people out of 6.2 million people with an MDE) than among adults aged 26 to 49 (63.5 percent or 6.0 million people out of 9.5 million people with an MDE) or adults aged 50 or older (68.2 percent or 3.5 million people out of 5.3 million people with an MDE). Similarly, the percentage of adults in 2021 with a past year MDE with severe impairment who received treatment for depression in the past year was lower among young adults aged 18 to 25 (56.7 percent or 2.5 million people out of 4.4 million people with an MDE with severe impairment) than among adults aged 26 to 49 (66.6 percent or 4.3 million people out of 6.6 million people with an MDE with severe impairment) or adults aged 50 or older (71.8 percent or 2.4 million people out of 3.4 million people with an MDE with severe impairment).

By Race/Ethnicity

Among adults aged 18 or older in 2021 with a past year MDE (regardless of their level of impairment), Black adults were less likely than White adults to receive treatment for depression (51.0 vs. 64.0 percent) (Table B.25B). The percentage of adults with a past year MDE who received treatment for depression in the past year could not be calculated with sufficient precision for American Indian or Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander adults.¹³ Similarly, among adults who had a past year MDE with severe impairment, Black adults were less likely than White adults to receive treatment for depression (52.5 vs. 68.6 percent). The percentage of adults with a past year MDE with severe impairment who received treatment for depression in the past year could not be calculated with sufficient precision for American Indian or Alaska Native, Asian, Multiracial, or Native Hawaiian or Other Pacific Islander adults.¹³

Mental Health Service Use among Adolescents

In addition to asking adolescents aged 12 to 17 about treatment for depression, the 2021 NSDUH included questions that asked about their receipt of any service for emotional or behavioral problems (i.e., not just depression) not caused by substance use. The youth mental health service utilization section of the interview asked adolescent respondents aged 12 to 17 whether they received any treatment or counseling within the 12 months prior to the interview for problems with emotions or behavior in the following settings: (a) specialty mental health settings,¹¹⁸ (b) education settings (talked with a school social worker, psychologist, or counselor about an emotional or behavioral problem; participated in a program for students with emotional or behavioral problems while in a regular school; or attended a school for students with emotional or behavioral problems), (c) general medical settings (care from a pediatrician or family physician for emotional or behavioral problems), (d) juvenile justice settings (services for an emotional or behavioral problem in a detention center, prison, or jail), or (e) child welfare settings (foster care or therapeutic foster care).

Also, adolescents aged 12 to 17 in 2021 were asked if they had received professional counseling, medication, or treatment in the past 12 months for their mental health, emotions, or behavior over the phone, by email, or through video calling (i.e., virtual or telehealth services). Virtual mental health services were categorized separately from the mental health settings described in the preceding paragraph.

Receipt of Mental Health Services in Specialty and Nonspecialty Settings among Adolescents

In 2021, 18.3 percent of adolescents aged 12 to 17 (or 4.7 million people) received mental health services in a specialty setting, including 17.5 percent (or 4.5 million people) who received mental health treatment in an outpatient setting and 2.5 percent (or 629,000 people) who received mental health treatment in an inpatient setting (Figure 63 and Table A.37B).

An estimated 14.7 percent of adolescents aged 12 to 17 (or 3.7 million people) received mental health services in a nonspecialty setting, including the following percentages:

• 11.9 percent (or 3.0 million people) who received mental health services in an educational setting (such as from a school social worker, school psychologist, or school counselor, or as part of a special school or program),
• 3.8 percent (or 977,000 people) who received mental health services in a general medicine setting,
• 0.4 percent (or 96,000 people) who received mental health services in a child welfare setting, and
• 0.1 percent (or 30,000 people) who received mental health services in a juvenile justice setting.⁵

An estimated 7.9 percent of adolescents aged 12 to 17 received mental health services in a combination of specialty and nonspecialty settings. These adolescents who received services in specialty and nonspecialty settings are included in the 18.3 percent of adolescents aged 12 to 17 who received services in specialty settings and in the 14.7 percent of adolescents aged 12 to 17 who received services in nonspecialty settings.

Receipt of Virtual (Telehealth) Mental Health Services among Adolescents

In 2021, 10.6 percent of adolescents aged 12 to 17 received mental health services as virtual (i.e., telehealth) services (Table A.37B). This percentage corresponds to 2.7 million adolescents aged 12 to 17.

Mental Health Service Use among Adults

Adult respondents aged 18 or older were asked whether they received treatment or counseling for any problem with emotions, nerves, or mental health in the past year in any inpatient or outpatient setting or if they used prescription medication in the past year for a mental or emotional condition. Adults aged 18 or older in 2021 also were asked if they received professional counseling, medication, or treatment for their mental health, emotions, or behavior over the phone, by email, or through video calling (i.e., virtual or telehealth services) in the past 12 months.

All adult respondents aged 18 or older (i.e., not just those with mental illness) were asked these questions about their use of mental health services. Respondents were asked not to include treatment for their use of alcohol or illicit drugs. Unlike the previously discussed questions about treatment for depression, general questions about the receipt of treatment or counseling for mental health issues among adults did not ask about treatment for a particular mental disorder. Consequently, references in this section to treatment or counseling for any problem with emotions, nerves, or mental health are described broadly as “mental health services” or “mental health care.“

In 2021, 18.8 percent of adults aged 18 or older (or 46.5 million people) received any of the following mental health services in the past year: inpatient or outpatient mental health services, prescription medication for a mental health issue, or virtual (i.e., telehealth) services (Figure 64 and Table A.38B). An estimated 13.9 percent of adults aged 18 or older (or 34.4 million people) took prescription medication, 11.3 percent (or 28.1 million people) received virtual services, 8.1 percent (or 20.1 million people) received outpatient services, and 1.0 percent (or 2.5 million people) received inpatient services. Adults aged 50 or older were less likely than young adults aged 18 to 25 or adults aged 26 to 49 to have received any of these mental health services in the past year. Specifically, 15.3 percent of adults aged 50 or older (or 17.7 million people) received any of these mental health services compared with 22.5 percent of young adults aged 18 to 25 (or 7.3 million people) and 21.6 percent of adults aged 26 to 49 (or 21.5 million people).

Adults aged 50 or older in 2021 were less likely than young adults aged 18 to 25 or adults aged 26 to 49 to have taken prescription medication for a mental health issue or to have received virtual mental health services in the past year (Table A.38B). An estimated 12.4 percent of adults aged 50 or older (or 14.3 million people) took prescription medication in the past year compared with 14.5 percent of young adults aged 18 to 25 (or 4.8 million people) and 15.4 percent of adults aged 26 to 49 (or 15.4 million people). Among adults aged 50 or older, 7.5 percent (or 8.7 million people) received virtual mental health services in the past year compared with 15.5 percent of young adults aged 18 to 25 (or 5.1 million people) and 14.4 percent of adults aged 26 to 49 (or 14.3 million people).

The percentage of adults aged 18 or older in 2021 who received outpatient mental health services in the past year was highest among young adults aged 18 to 25 (11.3 percent or 3.7 million people), followed by adults aged 26 to 49 (9.5 percent or 9.4 million people), then by adults aged 50 or older (6.1 percent or 7.0 million people) (Table A.38B). The percentage of adults who received inpatient mental health services in the past year also was highest among young adults aged 18 to 25 (1.6 percent or 539,000 people), followed by adults aged 26 to 49 (1.1 percent or 1.1 million people), then by adults aged 50 or older (0.7 percent or 857,000 people).

By Race/Ethnicity

Among adults aged 18 or older in 2021, Multiracial (25.8 percent) or White adults (22.2 percent) were more likely than Black (13.5 percent), Hispanic (12.9 percent), or Asian adults (8.3 percent) to receive any of these four types of mental health services in the past year (Table B.26B). Asian adults were less likely to have received any of these mental health services in the past year compared with adults in most other racial or ethnic groups.

Adults who were Multiracial or White also were more likely than adults who were Black, Hispanic, or Asian to receive specific types of mental health services in the past year, except for inpatient mental health services (Table B.26B). For the receipt of virtual mental health services in the past year, Multiracial (17.3 percent) or White adults (12.8 percent) also were more likely than American Indian or Alaska Native adults (7.7 percent) to receive this type of service. However, Black adults were more likely than White adults to receive inpatient mental health services in the past year (1.7 vs. 0.8 percent). In addition, Asian adults were less likely than adults in most other racial or ethnic groups to receive specific mental health services in the past year, including inpatient mental health services.

Mental Health Service Use among Adults with AMI

Among the 57.8 million adults aged 18 or older in 2021 with AMI in the past year, 47.2 percent (or 26.5 million people) received mental health services in the past year (i.e., inpatient or outpatient services, prescription medication for a mental health issue, or virtual services) (Figure 65 and Table A.39B). An estimated 3.1 percent of adults aged 18 or older with AMI (or 1.8 million people) received inpatient services, 24.2 percent (or 13.4 million people) received outpatient services, 36.1 percent (or 20.3 million people) took prescription medication, and 31.6 percent (or 17.8 million people) received virtual (i.e., telehealth) services. The percentages of adults aged 18 or older with AMI who received any of these services in the past year were similar across age groups (44.6 percent of young adults aged 18 to 25, 48.1 percent of adults aged 26 to 49, and 47.4 percent of adults aged 50 or older). These percentages correspond to 4.9 million young adults aged 18 to 25, 13.4 million adults aged 26 to 49, and 8.2 million adults aged 50 or older with AMI who received any of these services in the past year.

Consistent with the pattern for the receipt of any of these four types of mental health services, percentages of adults aged 18 or older in 2021 with AMI who received inpatient or outpatient mental health services in the past year did not differ significantly by age group (Table A.39B). However, adults aged 50 or older with AMI were less likely than young adults aged 18 to 25 or adults aged 26 to 49 with AMI to have received virtual mental health services in the past year. Specifically, 27.1 percent of adults aged 50 or older with AMI (or 4.7 million people) received virtual mental health services in the past year compared with 32.2 percent of young adults aged 18 to 25 (or 3.6 million people) and 34.2 percent of adults aged 26 to 49 with AMI (or 9.5 million people).

In addition, young adults aged 18 to 25 with AMI were less likely than adults aged 26 to 49 or adults aged 50 or older with AMI to have taken prescription medication to treat a mental health condition in the past year (Table A.39B). Specifically, 30.6 percent of young adults aged 18 to 25 with AMI (or 3.4 million people) took prescription medication to treat a mental health condition in the past year compared with 36.3 percent of adults aged 26 to 49 (or 10.1 million people) and 39.1 percent of adults aged 50 or older with AMI (or 6.8 million people).

By Race/Ethnicity

Among adults aged 18 or older in 2021 who had AMI in the past year, White (52.4 percent) or Multiracial adults (52.2 percent) were more likely than Black (39.4 percent), Hispanic (36.1 percent), or Asian adults (25.4 percent) to have received any of these mental health services in the past year (Figure 66 and Table B.27B). Asian adults with AMI were less likely to receive mental health services in the past year compared with Black or Hispanic adults with AMI.

When compared with adults with AMI in many other racial or ethnic groups, White adults were more likely to have received specific mental health services in the past year. White adults with AMI were more likely than Black, Hispanic, or Asian adults with AMI to have taken prescription medication in the past year for a mental health issue or to have received virtual mental health services in the past year (Table B.27B). In addition, White adults with AMI were more likely than Hispanic or Asian adults with AMI to have received outpatient mental health services in the past year. However, the percentages of adults with AMI who received inpatient mental health services in the past year did not differ significantly among racial or ethnic groups.

Mental Health Service Use among Adults with SMI

Among the 14.1 million adults aged 18 or older in 2021 with SMI in the past year, 65.4 percent (or 9.1 million people) received mental health services in the past year (i.e., inpatient or outpatient services, prescription medication for a mental health issue, or virtual services) (Figure 65 and Table A.40B). An estimated 6.9 percent of adults aged 18 or older with SMI (or 966,000 people) received inpatient services, 40.5 percent (or 5.5 million people) received outpatient services, 53.2 percent (or 7.4 million people) took prescription medication, and 49.7 percent (or 6.9 million people) received virtual (i.e., telehealth) services.

At least half of adults with SMI in each age group in 2021 received mental health services in the past year. However, young adults aged 18 to 25 with SMI in the past year were less likely than adults aged 26 to 49 or adults aged 50 or older with SMI to receive any of these services in the past year. Specifically, 57.9 percent of young adults aged 18 to 25 with SMI (or 2.2 million people) received any of these mental health services in the past year compared with 67.0 percent of adults aged 26 to 49 with SMI (or 4.8 million people) and 71.0 percent of adults aged 50 or older with SMI (or 2.1 million people).

Except for taking prescription medication, differences by age group in 2021 for the receipt of specific mental health services in the past year were not statistically significant for adults with SMI. However, young adults aged 18 to 25 with SMI were less likely than adults aged 26 to 49 with SMI or adults aged 50 or older with SMI to have taken prescription medication to treat a mental health condition in the past year. Specifically, 43.8 percent of young adults aged 18 to 25 with SMI (or 1.7 million people) took prescription medication to treat a mental health condition in the past year compared with 54.8 percent of adults aged 26 to 49 with SMI (or 3.9 million people) and 61.1 percent of adults aged 50 or older with SMI (or 1.8 million people).

By Race/Ethnicity

Among adults aged 18 or older in 2021 with SMI in the past year, there were no racial or ethnic differences in the receipt of any of these mental health services in the past year or for the receipt of inpatient, outpatient, or virtual mental health services in the past year. However, Hispanic adults with SMI were less likely to have taken prescription medication for a mental health issue in the past year compared with White adults with SMI (41.8 vs. 58.3 percent) (Table B.28B).

Perceived Unmet Need for Mental Health Services among Adults with Mental Illness

This section discusses estimates of perceived unmet need for mental health services among adults aged 18 or older with AMI or SMI in the past year. The section also discusses the reasons adults aged 18 or older with AMI or SMI did not receive these services in the past year if they had a perceived unmet need.

Perceived unmet need for mental health services among adults is estimated from a question that asked all adults aged 18 or older whether there was any time in the past 12 months when they thought they needed treatment or counseling for mental health issues but did not receive services. However, this section presents estimates of perceived unmet need for mental health services among adults aged 18 or older with AMI or SMI, regardless of whether they received mental health services in the past 12 months. If adult NSDUH respondents—including those with AMI or SMI—perceived an unmet need for mental health services but also reported that they received mental health services in the past year, the timing of the unmet need cannot be determined from respondents' answers. For some respondents, the unmet need could refer to a need they felt before they received services. For other respondents, the unmet need could refer to the need for additional services they did not receive.

Perceived Unmet Need for Mental Health Services among Adults with AMI

Among the 57.8 million adults aged 18 or older in 2021 with AMI in the past year, 27.6 percent (or 15.5 million people) perceived an unmet need for mental health services in the past year (Figure 67 and Tables A.41A and A.41B). The percentage of adults in 2021 with AMI in the past year who had a perceived unmet need for mental health services was highest among young adults aged 18 to 25 (43.9 percent or 4.8 million people), followed by adults aged 26 to 49 (29.5 percent or 8.2 million people), then by adults aged 50 or older (14.2 percent or 2.5 million people) (Figure 67 and Tables A.41A and A.41B).

Among the 15.5 million adults with AMI and a perceived unmet need for mental health services, 46.1 percent (or 7.1 million people) did not receive any mental health services in the past year (Table A.42B). Young adults aged 18 to 25 and adults aged 26 to 49 with AMI and a perceived unmet need for mental health services in the past year were more likely than their counterparts aged 50 or older not to have received any of these mental health services in the past year. Specifically, 49.6 percent of young adults aged 18 to 25 (or 2.4 million people) and 47.0 percent of adults aged 26 to 49 (or 3.9 million people) with AMI and a perceived unmet need did not receive mental health services in the past year. In comparison, 36.4 percent of adults aged 50 or older with AMI and a perceived unmet need for mental health services (or 894,000 people) did not receive any of these mental health services in the past year.

Perceived Unmet Need for Mental Health Services among Adults with SMI

Among the 14.1 million adults aged 18 or older in 2021 with SMI in the past year, 51.5 percent (or 7.2 million people) perceived an unmet need for mental health services in the past year (Figure 67 and Tables A.41A and A.41B). The percentage of adults in 2021 with SMI in the past year who had a perceived unmet need for mental health services was highest among young adults aged 18 to 25 (65.1 percent or 2.5 million people) compared with percentages among adults aged 26 to 49 (49.1 percent or 3.5 million people) and adults aged 50 or older (40.0 percent or 1.2 million people) (Figure 67 and Tables A.41A and A.41B). Thus, nearly two thirds of young adults aged 18 to 25 and nearly half of adults aged 26 to 49 with SMI had a perceived unmet need for mental health services.

Among the 7.2 million adults with SMI and a perceived unmet need for mental health services, 39.7 percent (or 2.8 million people) did not receive any mental health services in the past year (Table A.42B). Similar percentages of young adults aged 18 to 25 and adults aged 26 to 49 with SMI and a perceived unmet need for mental health services in the past year did not receive any mental health services in the past year (44.8 percent of young adults aged 18 to 25 and 38.5 percent of adults aged 26 to 49). These percentages of adults with SMI and a perceived unmet need for mental health services correspond to 1.1 million young adults aged 18 to 25 and 1.4 million adults aged 26 to 49 who did not receive services. Estimates for adults aged 50 or older with SMI and a perceived unmet need for mental health services in the past year who did not receive any mental health services could not be calculated with sufficient precision.

Reasons for Not Receiving Mental Health Services among Adults with Mental Illness and a Perceived Unmet Need

Among adults aged 18 or older in 2021 who had mental illness in the past year and a perceived unmet need for mental health services but who did not receive services in the past year, the most common reason for not receiving services was they could not afford the cost of care (47.8 percent for these adults aged 18 or older with AMI and 54.5 percent for these adults aged 18 or older with SMI) (Table A.43B). Estimates are not compared between adults aged 18 or older with AMI and those with SMI because all adults aged 18 or older with SMI also have AMI. Other common reasons for not receiving services included not knowing where to go for services (38.3 percent for these adults aged 18 or older with AMI and 38.9 percent for these adults aged 18 or older with SMI) and believing they could handle the problem without treatment (31.4 percent for these adults aged 18 or older with AMI and 36.1 percent for these adults aged 18 or older with SMI).

Receipt of Services for Co-Occurring Mental Health Issues and Illicit Drug or Alcohol Use Disorder

The relationship between SUDs and mental disorders is known to be bidirectional. The presence of a mental disorder may contribute to the development or exacerbation of an SUD. Likewise, the presence of an SUD may contribute to the development or exacerbation of a mental disorder. The combined presence of SUDs and mental disorders (hereafter referred to as co-occurring disorders) results in more profound functional impairment; worse treatment outcomes; higher morbidity and mortality; increased treatment costs; and higher risk for homelessness, incarceration, and suicide than if people had only one of these disorders.^119,120,121 Current treatment guidelines recommend that people with co-occurring disorders receive treatment for both disorders.^122,123,124

This section presents estimates of the receipt of services among adolescents aged 12 to 17 and adults aged 18 or older with co-occurring mental health issues and illicit drug or alcohol use disorder. Estimates are presented for the receipt of services among people with co-occurring mental health issues and illicit drug or alcohol use disorder because respondents in 2021 who reported lifetime use of alcohol or illicit drugs (i.e., marijuana, cocaine [including crack], heroin, hallucinogens, inhalants, or methamphetamine or the lifetime misuse of prescription psychotherapeutic drugs) were asked questions about their receipt of substance use treatment. Estimates for the receipt of virtual (i.e., telehealth) services among adolescents aged 12 to 17 and adults aged 18 or older with co-occurring mental health issues and illicit drug or alcohol use disorder are presented separately from estimates for the receipt of other services because virtual services were considered to be distinct from substance use treatment at a specialty facility and the receipt of other mental health services described in this report. Estimates are presented overall and by age group.

Receipt of Services among Adolescents with a Co-Occurring MDE and an Illicit Drug or Alcohol Use Disorder

Among the 842,000 adolescents aged 12 to 17 in 2021 with a co-occurring MDE and an illicit drug or alcohol use disorder in the past year, 56.1 percent (or 471,000 people) received either substance use treatment at a specialty facility or mental health services in the past year; 52.4 percent (or 440,000 people) received only mental health services, and 3.6 percent (or 31,000 people) received both substance use treatment at a specialty facility and mental health services (Figure 68 and Table A.44B).

Most of the 471,000 adolescents aged 12 to 17 with a co-occurring MDE and an illicit drug or alcohol use disorder who received either substance use treatment at a specialty facility or mental health services in the past year received only mental health services (93.5 percent) (Figure 68). An estimated 6.5 percent of these adolescents aged 12 to 17 received both services.²⁷

Receipt of Services among Adults with Co-Occurring AMI and an Illicit Drug or Alcohol Use Disorder

Among the 17.9 million adults aged 18 or older in 2021 with co-occurring AMI and an illicit drug or alcohol use disorder in the past year, 52.5 percent (or 9.0 million people) received either substance use treatment at a specialty facility or mental health services in the past year, and 47.5 percent (or 8.2 million people) received neither service (Figure 69 and Table A.45B). Stated another way, nearly half of adults aged 18 or older with co-occurring AMI and an illicit drug or alcohol use disorder in the past year did not receive substance use treatment at a specialty facility or mental health services for either condition. An estimated 44.1 percent of adults aged 18 or older with co-occurring AMI and an illicit drug or alcohol use disorder in the past year (or 7.6 million people) received only mental health services, 1.4 percent (or 251,000 people) received only substance use treatment at a specialty facility, and 6.6 percent (or 1.2 million people) received both substance use treatment at a specialty facility and mental health services.

Among adults aged 18 or older with co-occurring AMI and an illicit drug or alcohol use disorder who received either substance use treatment at a specialty facility or mental health services in the past year, most received only mental health services. Specifically, among the 9.0 million adults aged 18 or older with co-occurring AMI and an illicit drug or alcohol use disorder who received either substance use treatment at a specialty facility or mental health services in the past year, 84.0 percent received only mental health services, 2.8 percent received only substance use treatment at a specialty facility, and 13.0 percent received both services (Figure 69).²⁷

Among adults aged 18 or older in 2021 with co-occurring AMI and an illicit drug or alcohol use disorder in the past year, young adults aged 18 to 25 were less likely than adults aged 26 to 49 or adults aged 50 or older to have received either substance use treatment at a specialty facility or mental health services in the past year (Table A.45B). Specifically, 46.1 percent of young adults aged 18 to 25 with co-occurring AMI and an illicit drug or alcohol use disorder in the past year (or 2.0 million people) received either substance use treatment at a specialty facility or mental health services in the past year compared with 52.6 percent of adults aged 26 to 49 (or 5.0 million people) and 60.0 percent of adults aged 50 or older (or 2.1 million people) with co-occurring AMI and an illicit drug or alcohol use disorder in the past year.

Receipt of Services among Adults with Co-Occurring SMI and an Illicit Drug or Alcohol Use Disorder

Among the 5.8 million adults aged 18 or older in 2021 with co-occurring SMI and an illicit drug or alcohol use disorder in the past year, 66.9 percent (or 3.9 million people) received either substance use treatment at a specialty facility or mental health services in the past year, and 33.1 percent (or 1.9 million people) received neither service (Figure 70 and Table A.45B). Stated another way, about one third of adults aged 18 or older with co-occurring SMI and an illicit drug or alcohol use disorder in the past year (representing nearly 2.0 million people) did not receive substance use treatment at a specialty facility or mental health services for either condition. An estimated 54.6 percent of adults aged 18 or older with co-occurring SMI and an illicit drug or alcohol use disorder in the past year (or 3.1 million people) received only mental health services, 1.4 percent (or 84,000 people) received only substance use treatment at a specialty facility, and 10.7 percent (or 620,000 people) received both substance use treatment at a specialty facility and mental health services.

Among adults aged 18 or older with co-occurring SMI and an illicit drug or alcohol use disorder who received either substance use treatment at a specialty facility or mental health services in the past year, most received only mental health services. Specifically, among the 3.9 million adults aged 18 or older with co-occurring SMI and an illicit drug or alcohol use disorder who received either substance use treatment at a specialty facility or mental health services in the past year, 81.5 percent received only mental health services, 2.2 percent received only substance use treatment at a specialty facility, and 16.1 percent received both services.²⁷

Among adults aged 18 or older in 2021 with co-occurring SMI and an illicit drug or alcohol use disorder in the past year, young adults aged 18 to 25 were less likely than adults aged 26 to 49 to have received either substance use treatment at a specialty facility or mental health services in the past year. Specifically, 57.9 percent of young adults aged 18 to 25 with co-occurring SMI and an illicit drug or alcohol use disorder in the past year (or 1.0 million people) received either substance use treatment at a specialty facility or mental health services in the past year compared with 70.4 percent of adults aged 26 to 49 (or 2.2 million people) with co-occurring SMI and an illicit drug or alcohol use disorder in the past year (Table A.45B).

Perceived Recovery

Respondents aged 18 or older were asked whether they thought they ever had a problem with their use of drugs or alcohol or whether they ever had a problem with their mental health. Respondents who reported that they ever had a problem with their drug or alcohol use were asked whether they considered themselves (at the time they were interviewed) to be in recovery or to have recovered from their drug or alcohol use problem. Similarly, respondents aged 18 or older who reported that they had a problem with their mental health were asked whether they considered themselves (at the time they were interviewed) to be in recovery or to have recovered from their mental health issue.

Among adults aged 18 or older in 2021, 11.5 percent (or 29.0 million people) perceived that they ever had a problem with their use of drugs or alcohol (Table A.46B). Young adults aged 18 to 25 were less likely than adults aged 26 or older to perceive that they ever had a problem with their use of drugs or alcohol (7.1 vs. 12.2 percent). These percentages correspond to 2.4 million young adults aged 18 to 25 and 26.6 million adults aged 26 or older who perceived that they ever had a problem with their use of drugs or alcohol. These findings contrast with the findings noted in prior sections of this report that young adults aged 18 to 25 in 2021 tended to be more likely than adults aged 26 or older to be binge alcohol users in the past month, to have used illicit drugs in the past year, or to have had an SUD in the past year.

Among the 29.0 million adults in 2021 who perceived that they ever had a substance use problem, 72.2 percent (or 20.9 million people) considered themselves to be in recovery or to have recovered from their drug or alcohol use problem (Table A.47B). Adults aged 26 or older who perceived that they ever had a substance use problem were more likely than corresponding young adults aged 18 to 25 to consider themselves to be in recovery or to have recovered from their substance use problem. About three fourths of adults aged 26 or older who perceived that they ever had a substance use problem considered themselves to be in recovery or to have recovered (72.7 percent or 19.4 million people) compared with about two thirds of young adults aged 18 to 25 who perceived that they ever had a substance use problem (67.0 percent or 1.6 million people).

In 2021, 23.3 percent of adults aged 18 or older (or 58.7 million people) perceived that they ever had a problem with their mental health (Table A.46B). Young adults aged 18 to 25 were more likely than adults aged 26 or older to perceive that they ever had a problem with their mental health (37.6 percent of young adults aged 18 to 25 or 12.5 million people vs. 21.1 percent of adults aged 26 or older or 46.2 million people).

Among the 58.7 million adults in 2021 who perceived that they ever had a problem with their mental health, 66.5 percent (or 38.8 million people) considered themselves to be in recovery or to have recovered from their mental health issue (Table A.47B). Young adults aged 18 to 25 who perceived that they ever had a problem with their mental health were less likely than corresponding adults aged 26 or older to consider themselves to be in recovery or to have recovered from their mental health issue (63.0 percent of young adults aged 18 to 25 or 7.8 million people vs. 67.4 percent of adults aged 26 or older or 31.0 million people).

By Race/Ethnicity

The percentage of adults aged 18 or older in 2021 who perceived that they ever had a problem with their use of drugs or alcohol was higher among Multiracial (18.0 percent), American Indian or Alaska Native (16.6 percent), or White adults (13.7 percent) than among adults in most other racial or ethnic groups (Table B.29B). Asian adults (3.7 percent) were least likely to perceive that they ever had a problem with their use of drugs or alcohol compared with adults in most other racial or ethnic groups. However, among adults aged 18 or older who perceived that they ever had a substance use problem, there were no differences among White (73.5 percent), Black (69.2 percent), or Hispanic adults (67.6 percent) who considered themselves to be in recovery or to have recovered from their drug or alcohol use problem (Table B.30B).

The percentage of adults aged 18 or older in 2021 who perceived that they ever had a problem with their mental health was higher among Multiracial adults (38.8 percent) than among White (26.7 percent), American Indian or Alaska Native (21.7 percent), Black (17.5 percent), Hispanic (17.3 percent), or Asian adults (12.7 percent) (Table B.29B). Asian adults were least likely to have perceived they ever had a problem with their mental health compared with adults in other racial or ethnic groups. However, among adults who perceived that they ever had a problem with their mental health, percentages of those who considered themselves to be in recovery or to have recovered from their mental health issue did not differ among racial or ethnic groups (Table B.30B).

Substance Use, Mental Health Issues, and the COVID-19 Pandemic

The COVID-19 pandemic, and the requisite measures taken to combat it, created challenges in the lives of Americans. To describe ongoing effects of the COVID-19 pandemic on people's substance use, mental health, and other parts of their lives, the 2021 NSDUH included questions about people's perceptions of how the COVID-19 pandemic affected their lives. These questions asked respondents to describe how the COVID-19 pandemic affected their mental health; substance use; financial security; housing; and access to substance use treatment, mental health services, and medical care. This section provides estimates of the effect of the COVID-19 pandemic on substance use and mental health issues.¹⁸

Data from most of these questions reflect respondents' subjective perceptions of how their lives changed during the COVID-19 pandemic. The questions concerning mental health and substance use asked respondents to rate the effects of the COVID-19 pandemic on their mental or emotional health using a scale of responses (“not at all,” “a little,” “some,” “quite a bit,” or “a lot”). Similarly, respondents were asked how much the COVID-19 pandemic affected their substance use, with responses for using a substance “much less,” “a little less,” “about the same,” “a little more,” or “a lot more” than they did before the COVID-19 pandemic began.

However, there are no objective indicators to define the categories on these subjective measures. For example, one respondent could define negative effects on mental health as having “some” negative effect, and another respondent could define the same effects as negatively affecting their mental health “quite a bit.” Similarly, one respondent could define a change in substance use as “much less,” and another respondent could define the same change as “a little less.” Also, these are sensitive questions, and some respondents may have given responses they felt were more socially desirable. Some respondents may have been reluctant to accurately report negative changes in their mental health during the COVID-19 pandemic. Some respondents whose substance use increased during the COVID-19 pandemic may have been reluctant to report that they were using substances more than they did before the COVID-19 pandemic began.

Also, the accuracy of respondents' recall of how their mental health and substance use have changed since the COVID-19 pandemic began in the United States in early 2020 could depend on when respondents were interviewed in 2021. Respondents who were interviewed earlier in 2021 (and potentially within a year of the start of the COVID-19 pandemic) could recall changes in their mental health and substance use more accurately than respondents who were interviewed later in 2021.

An additional consideration is that the COVID-19 pandemic has not been a single event. Data from the Centers for Disease Control and Prevention showed three peaks in the number of daily COVID-19 cases in the United States in 2021: (1) in January as part of an increase that began in October 2020, (2) in late August to early September for the Delta variant, and (3) at the end of the year for the Omicron variant.¹²⁵ In addition, the number of daily cases started to decline in January 2021 and reached a low point in June 2021 before the emergence of the Delta and Omicron variants. Also, public health responses in many states were more stringent in spring to early summer 2020 and were progressively relaxed over time. Therefore, responses to these questions about impacts of the COVID-19 pandemic on mental health, substance use, and access to services could depend on the period(s) of the COVID-19 pandemic that respondents recalled when answering the questions.

Perceived Negative Effects of the COVID-19 Pandemic on Mental Health

Respondents were asked to rate the COVID-19 pandemic's negative effect on their mental health on a five-category scale ranging from “not at all” to “a lot.” To facilitate analysis, responses were collapsed into three categories: “not at all,” “a little or some,” and “quite a bit or a lot.” As previously noted, the resulting data reflect respondents' subjective perceptions and are not objective indicators of mental health issues. In addition, asking respondents how much (if at all) the COVID-19 pandemic negatively affected their mental health presupposes that the COVID-19 pandemic had a negative effect. Respondents were not offered a choice to indicate improvement in mental health since the COVID-19 pandemic began.

Perceived Negative Effects of the COVID-19 Pandemic on Mental Health among Adolescents Aged 12 to 17

In 2021, most adolescents aged 12 to 17 perceived a negative effect of the COVID-19 pandemic on their mental health. About 1 in 5 adolescents aged 12 to 17 (19.2 percent or 4.9 million people) perceived that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot,” and an additional 47.0 percent (or 12.0 million people) perceived “a little or some” negative effect on their mental health (Figure 71 and Table A.48B). About 1 in 3 adolescents aged 12 to 17 (33.8 percent or 8.6 million people) perceived no negative effect on their mental health because of the COVID-19 pandemic.

Adolescents aged 12 to 17 who had a past year MDE or a past year MDE with severe impairment were more likely than those without a past year MDE to perceive that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot.” Among adolescents aged 12 to 17 with a past year MDE, nearly half (45.1 percent or 2.2 million people) perceived that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot,” as did about half of adolescents aged 12 to 17 who had a past year MDE with severe impairment (50.9 percent or 1.9 million people). In comparison, 12.4 percent of adolescents aged 12 to 17 without a past year MDE (or 2.4 million people) perceived this level of a negative effect on their mental health because of the COVID-19 pandemic. Among adolescents aged 12 to 17 who had a past year MDE or a past year MDE with severe impairment, an unknown number may have had an MDE that started before the COVID-19 pandemic and became worse during the COVID-19 pandemic as opposed to those who experienced an MDE that started during the COVID-19 pandemic.

In addition, almost half of adolescents aged 12 to 17 who did not have a past year MDE (47.8 percent or 9.4 million people), 43.4 percent (or 2.2 million people) of adolescents aged 12 to 17 with a past year MDE, and 38.3 percent (or 1.4 million people) of adolescents aged 12 to 17 with a past year MDE with severe impairment perceived that the COVID-19 pandemic negatively affected their mental health “a little or some.” It is unclear whether these negative effects were temporary or longer lasting. Even if adolescents aged 12 to 17 did not have a past year MDE, they could have needed mental health services during the COVID-19 pandemic.

Perceived Negative Effects of the COVID-19 Pandemic on Mental Health among Adults Aged 18 or Older

Most adults aged 18 or older in 2021 perceived a negative effect of the COVID-19 pandemic on their mental health. About 1 in 7 adults aged 18 or older (14.4 percent or 36.1 million people) perceived that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot,” and about half (49.7 percent or 124.4 million people) perceived “a little or some” negative effect on their mental health (Figure 72 and Table A.49B). However, slightly more than 1 in 3 adults aged 18 or older (35.8 percent or 89.7 million people) perceived no negative effect on their mental health because of the COVID-19 pandemic. The percentage of adults who perceived that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot” was highest among young adults aged 18 to 25 (21.5 percent or 7.1 million people), followed by adults aged 26 to 49 (17.3 percent or 17.5 million people), then by adults aged 50 or older (10.0 percent or 11.6 million people).

In 2021, adults aged 18 or older with AMI or SMI in the past year were more likely than those who did not have mental illness in the past year to perceive that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot.” Among adults aged 18 or older with AMI in the past year, 36.2 percent (or 20.4 million people) perceived the COVID-19 pandemic to have negatively affected their mental health “quite a bit or a lot,” as did nearly half of adults aged 18 or older with SMI in the past year (48.9 percent or 6.8 million people). In comparison, about 1 in 12 adults aged 18 or older with no mental illness in the past year (8.1 percent or 15.7 million people) perceived the COVID-19 pandemic to have negatively affected their mental health “quite a bit or a lot.” The percentage of adults with AMI who perceived that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot” was highest among adults aged 18 to 25 (41.9 percent or 4.6 million people), followed by adults aged 26 to 49 (38.5 percent or 10.8 million people), then by adults aged 50 or older (28.9 percent or 5.0 million people). However, it is not known from these data whether adults aged 18 or older had preexisting AMI or SMI that they perceived to have worsened or whether they had AMI or SMI for the first time during the COVID-19 pandemic. Nevertheless, these data indicate the need for adults aged 18 or older with AMI and SMI to receive mental health services during the COVID-19 pandemic.

Perceived Effects of the COVID-19 Pandemic on Substance Use

Stressors and feelings of social isolation during the COVID-19 pandemic could have negatively affected Americans' substance use. In many states, establishments that sold alcohol for off-premises consumption (e.g., liquor stores, grocery stores) remained open during periods when stay-at-home orders were in effect in 2020. Some states also changed laws to allow “to-go” drinks from bars and restaurants or loosened restrictions on home delivery of alcohol.¹²⁶ By mid-February 2021, however, all restaurants were allowed to be open in the large majority of states, and all bars were allowed to be open in a majority of states (although many states that allowed bars and restaurants to be open continued to have restrictions in place). In all states except Hawaii, any remaining restrictions on bars and restaurants were lifted by September 15, 2021.

Questions in the 2021 NSDUH asked respondents to rate how the COVID-19 pandemic affected their use of alcohol and other drugs. Respondents who used alcohol or other drugs in the past 12 months could report substance use in five categories ranging from “much less” to “a lot more” than use before the COVID-19 pandemic. Respondents answered separate questions about effects of the COVID-19 pandemic on their alcohol and other drug use. To facilitate analysis, responses were collapsed into three categories: “a little less or much less,” “about the same,” and “a little more or much more.“¹²⁷ However, these questions were not asked of respondents who abstained from using alcohol or drugs throughout the past 12 months.

Some people could have increased their substance use in the early phases of the COVID-19 pandemic, then later returned to their previous level of use, but this pattern would not be captured by the 2021 survey data. It is also unknown whether people might return to their earlier patterns of substance use in the future.

In addition, adolescents aged 12 to 17 and young adults aged 18 to 25 could have increased their substance use as they got older, even if there had not been a COVID-19 pandemic. As discussed in the Initiation of Substance Use section, for example, more than 2 million people in 2021 did not initiate alcohol use until they were aged 18 or older. Also, nearly 40 percent of past year initiates of marijuana use in 2021 did not use marijuana until they were aged 21 or older.

Perceived Effects on Alcohol Use

Among people aged 12 or older in 2021 who drank alcohol in the past year, more than half (56.9 percent or 95.6 million people) perceived that they drank “about the same” amount as they did before the COVID-19 pandemic began (Figure 73 and Table A.50B). In addition, 29.6 percent of past year alcohol users (or 49.8 million people) perceived that they drank “a little less or much less” alcohol than they did before the COVID-19 pandemic began, and 13.5 percent (or 22.7 million people) perceived that they drank “a little more or much more” than they did before.

About 1 in 6 adolescents aged 12 to 17 in 2021 who drank alcohol in the past year (16.6 percent or 638,000 people) perceived that they drank “a little more or much more” than they did before the COVID-19 pandemic began. The percentage of adolescent alcohol users aged 12 to 17 who perceived that they drank “a little more or much more” than they did before the COVID-19 pandemic was higher than the corresponding percentage among past year alcohol users aged 26 or older (13.2 percent or 18.9 million people). In addition, 14.6 percent of young adults aged 18 to 25 who drank alcohol in the past year (or 3.1 million people) perceived that they drank “a little more or much more” than they did before the COVID-19 pandemic began. Some increases in alcohol use among young adults aged 18 to 25 since the beginning of the COVID-19 pandemic may be because they reached the legal drinking age of 21 after the COVID-19 pandemic began; as noted previously, these increases could have occurred even in the absence of the COVID-19 pandemic.

In 2021, the percentage of people who drank alcohol in the past year and perceived that they were drinking “a little less or much less” was highest among adolescents aged 12 to 17 (40.9 percent or 1.6 million people), followed by young adults aged 18 to 25 (33.2 percent or 7.1 million people), then by adults aged 26 or older (28.8 percent or 41.1 million people). It is unknown whether people who were drinking less than they did before the COVID-19 pandemic began will return to their earlier patterns of alcohol consumption. For example, college-age young adults who were living with their parents during the height of the COVID-19 pandemic could resume their earlier patterns of alcohol consumption once they return to a campus environment. Adolescents may increase their drinking as the continued lifting of restrictions on social gatherings creates more opportunities for social activities without parental supervision.

Perceived Effects on Drug Use

Among people aged 12 or older in 2021 who used drugs other than alcohol in the past year (subsequently referred to as “drugs”),¹²⁷ about 3 in 8 (37.1 percent or 39.7 million people) perceived that they used these drugs “a little less or much less” than they did before the COVID-19 pandemic began, and more than half (53.3 percent or 57.0 million people) perceived that they used these drugs “about the same” as they did before the COVID-19 pandemic began (Figure 74 and Table A.51B). An estimated 9.6 percent of past year users of drugs other than alcohol (or 10.2 million people) perceived that they used these drugs “a little more or much more” during the COVID-19 pandemic than they did before.

In 2021, more than half of adolescents aged 12 to 17 who used drugs in the past year (52.0 percent or 2.7 million people) perceived that they used these drugs “a little less or much less” than they did before the COVID-19 pandemic began. This percentage among adolescents was higher than the corresponding percentages among young adults aged 18 to 25 (36.4 percent or 5.5 million people) and those aged 26 or older (36.4 percent or 31.6 million people) who used these drugs. As previously noted in relation to perceived reductions in alcohol use, these adolescents could increase their use of drugs as they have more opportunities to engage in social activities with peers over time.

The percentage of people in 2021 who used drugs in the past year and perceived that they used these drugs “a little more or much more” than they did before the COVID-19 pandemic was highest among young adults aged 18 to 25 (17.0 percent or 2.5 million people), followed by adolescents aged 12 to 17 (12.8 percent or 654,000 people), then by adults aged 26 or older (8.1 percent or 7.0 million people). It is unknown, however, whether these will be short- or long-term increases in drug use that persist beyond the COVID-19 pandemic.

Perceived Effects of the COVID-19 Pandemic on Access to Services

The COVID-19 pandemic may have affected access to substance use treatment, mental health services, and medical care in different ways. In response to the COVID-19 pandemic, for example, health care providers (including behavioral health care providers) turned to virtual (i.e., telehealth) services as a means of delivering services while also limiting in-person contact that could spread COVID-19.¹²⁸ As discussed in the Substance Use Treatment in the Past Year section, telehealth services for substance use treatment refer to the delivery of services over the phone or Internet. Reimbursement for virtual services was expanded during the COVID-19 pandemic, including reimbursement for services delivered over the phone (i.e., using only audio).

To assess the various effects of the COVID-19 pandemic on access to behavioral health and medical services, respondents were asked if they experienced the following circumstances because of the COVID-19 pandemic: (1) appointments moved from in-person to telehealth format, (2) delays or cancellations in appointments, (3) delays in getting prescriptions, and (4) inability to access needed care resulting in moderate to severe impact on health. Respondents were asked separately about each of these situations in relation to their access to substance use treatment, mental health treatment, and medical care.

Changes during the COVID-19 pandemic supported increased use of virtual services for medical care of all types, including substance use treatment and mental health services. However, it is unknown whether people considered this shift in the delivery of care to be a positive or negative effect of the COVID-19 pandemic.

Access to Substance Use Treatment

Among people aged 12 or older in 2021 who used illicit drugs or alcohol in the past year, 8.2 percent (or 14.8 million people) had substance use treatment appointments moved from in person to telehealth, and 7.1 percent (or 12.9 million people) experienced delays or cancellations in appointments (Table A.52B). An estimated 3.3 percent of people who used illicit drugs or alcohol in the past year (or 6.0 million people) experienced delays in getting prescriptions, and 2.4 percent (or 4.3 million people) were unable to access needed care resulting in a perceived moderate to severe impact on health. The COVID-19 pandemic's effect on access to substance use treatment would not be relevant to people who did not use alcohol or illicit drugs.

Among people aged 12 or older in 2021 who had an illicit drug or alcohol use disorder in the past year (and would be classified as needing substance use treatment), 11.9 percent (or 5.0 million people) had substance use treatment appointments moved from in person to telehealth, and 10.5 percent (or 4.4 million people) experienced delays or cancellations in appointments (Table A.52B). In addition, 6.1 percent of people with a past year illicit drug or alcohol use disorder (or 2.5 million people) experienced delays in getting prescriptions, and 5.2 percent (or 2.2 million people) were unable to access needed care resulting in a perceived moderate to severe impact on health.

Among the 4.1 million people aged 12 or older in 2021 who received any substance use treatment in the past year, 44.5 percent (or 1.8 million people) had substance use treatment appointments moved from in person to telehealth, and 30.9 percent (or 1.2 million people) experienced delays or cancellations in appointments (Figure 75 and Tables A.53A and A.53B). In addition, 17.6 percent of people who received substance use treatment in the past year (or 705,000 people) experienced delays or cancellations in getting prescriptions, and 14.8 percent (or 586,000 people) were unable to access needed care resulting in a perceived moderate to severe impact on health.

Access to Mental Health Services

Among adolescents aged 12 to 17 in 2021 who received mental health services in the past year, nearly 4 in 10 (38.9 percent or 2.5 million people) had appointments moved from in person to telehealth, and 3 in 8 (37.5 percent or 2.4 million people) experienced delays or cancellations in appointments (Table A.54B). In addition, about 1 in 9 (11.6 percent or 745,000 people) experienced delays in getting prescriptions, and 1 in 12 (8.3 percent or 534,000 people) were unable to access needed mental health services resulting in a perceived moderate to severe impact on health.

Among adults aged 18 or older in 2021 who received mental health services in the past year, more than half (56.5 percent or 26.5 million people) had appointments moved from in person to telehealth, and about 3 in 8 (37.1 percent or 17.4 million people) experienced delays or cancellations in appointments (Figure 76 and Table A.55B). The finding that more than half of adults aged 18 or older who received mental health services in the past year had appointments moved from in person to telehealth likely reflects the use of virtual (i.e., telehealth) services to continue delivering mental health services and the expansion of reimbursement for virtual services.

In addition, about 1 in 6 adults aged 18 or older in 2021 who received mental health services in the past year (16.8 percent or 7.9 million people) experienced delays in getting prescriptions, and 1 in 10 (10.3 percent or 4.8 million people) were unable to access needed care resulting in a perceived moderate to severe impact on health. That 4.8 million adults aged 18 or older perceived their health to have been negatively affected because they were unable to access needed mental health services is an important indicator of adverse impacts of changes in access to these services during the COVID-19 pandemic.

Among adults aged 18 or older in 2021 who received mental health services in the past year, adults aged 18 to 25 or 26 to 49 were more likely than adults aged 50 or older to perceive that the COVID-19 pandemic affected their access to that care. Specifically, 60.7 percent of young adults aged 18 to 25 (or 4.4 million people) and 63.3 percent of adults aged 26 to 49 who received mental health services in the past year (or 13.8 million people) had appointments moved from in person to telehealth compared with 46.5 percent of their counterparts who were aged 50 or older (or 8.3 million people). In addition, 39.1 percent of young adults aged 18 to 25 (or 2.9 million people) and 40.6 percent of adults aged 26 to 49 (or 8.8 million people) who received mental health services in the past year experienced delays or cancellations in appointments compared with 32.1 percent of adults aged 50 or older who received services (or 5.7 million people).

Young adults aged 18 to 25 and adults aged 26 to 49 who received mental health services in the past year were more likely to be unable to access needed care resulting in a perceived moderate to severe impact on health (12.9 percent of young adults aged 18 to 25 or 947,000 people; 11.7 percent of adults aged 26 to 49 or 2.6 million people). In comparison, 7.5 percent of adults aged 50 or older who received mental health services in the past year (or 1.3 million people) were unable to access mental health care that resulted in a moderate to severe impact on their health.

Access to Medical Services

Among people aged 12 or older in 2021, 30.0 percent (or 82.4 million people) had medical appointments moved from in person to telehealth (Figure 77 and Table A.56B).

In addition, 24.5 percent of people aged 12 or older in 2021 (or 67.3 million people) experienced delays or cancellations in medical appointments or preventive services. An estimated 8.5 percent of people (or 23.2 million people) experienced delays in getting prescriptions, and 5.2 percent (or 14.2 million people) were unable to access needed medical care resulting in a perceived moderate to severe impact on health. That 14.2 million people whose health was negatively affected because they were unable to access needed medical care is particularly concerning.

Adults aged 26 or older in 2021 were more likely than adolescents aged 12 to 17 and young adults aged 18 to 25 to have had two or more outpatient medical visits in the past year.²⁷ Therefore, perceptions of whether the COVID-19 pandemic affected people's access to medical care would be especially relevant to adults aged 26 or older. In general, adults aged 26 or older were more likely than adolescents aged 12 to 17 and young adults aged 18 to 25 to perceive COVID-19 pandemic effects on their access to medical care. Among adults aged 26 or older in 2021, 33.0 percent (or 71.6 million people) had medical appointments moved from in person to telehealth, 26.3 percent (or 57.1 million people) experienced delays or cancellations in medical appointments or preventive services, 8.9 percent (or 19.3 million people) experienced delays in getting prescriptions, and 5.5 percent (or 12.0 million people) were unable to access needed medical care resulting in a perceived moderate to severe impact on health.

Appendix A: Special Tables of Estimates for Substance Use and Mental Health Indicators in the United States