Serious Mental Health Challenges among Older Adolescents and Young Adults

In Brief

Combined 2010 to 2012 NSDUH data indicate that 1 in 10 older adolescents aged 16 to 17 had a major depressive episode (MDE) in the past year. One in five young adults aged 18 to 25 (18.7 percent) had any mental illness (AMI) in the past year and 3.9 percent had a serious mental illness (SMI). In the past year, 3.1 percent of older adolescents had co-occurring MDE and substance use disorder (SUD); 6.4 percent of young adults had co-occurring AMI and SUD, and 1.6 percent of young adults had co-occurring SMI and SUD. Among older adolescents with MDE, 60.1 percent did not receive treatment for depression in the past year. Among young adults with AMI, 66.6 percent did not receive mental health services in the past year. Among young adults with SMI, 47.0 percent did not receive treatment. Older adolescents with MDE and young adults with mental illness generally had poorer quality of life than those without mental illness.

In the United States, the transition into adulthood begins in the late teens and continues through the mid-20s. This can be a stressful process because young people become more self-sufficient and make decisions that shape their futures. For example, they are finding their own places to live, making educational plans, starting careers, and entering serious relationships. The challenges that older adolescents and young adults face are made more difficult if they have a mental disorder (e.g., schizophrenia or bipolar disorder) or substance use disorder (SUD).^1,2

Mental disorders can emerge in young people during their transition into adulthood.² Furthermore, the prevalence of major depressive episode (MDE) and SUD generally increases with age through the adolescent years.³ Studies have shown that there is nearly a twofold increase in mood disorders from the 13-to-14-year-old age group to the 17-to-18-year-old age group.⁴ Older adolescents have higher rates of mental issues than younger adolescents.^3,4 Young adults have higher rates of co-occurring mental illness and SUD than older adults.⁵ When compared with adults aged 26 or older, the rate of SUD among young adults aged 18 to 25 is more than twice as high (19.1 vs. 6.8 percent), and young adults also have higher rates of co-occurring mental illness and SUD than adults aged 26 or older.^5,6

Although older adolescents and young adults have mental health vulnerability, many do not receive mental health services.^5,6 Clinical interventions can minimize impairments associated with mental health problems while supporting the transition to independence and adulthood.⁷ Thus, older adolescence and young adulthood are important periods for both promoting positive mental health and reducing the negative consequences of mental illness.⁷ Ensuring that the behavioral health needs of this age group are met is an important priority and has long-term consequences.

This issue of The CBHSQ Report focuses on mental health problems, co-occurring mental health problems and SUD, and mental health service use among persons aged 16 or 17 (hereafter referred to as "older adolescents") and persons aged 18 to 25 (hereafter referred to as "young adults"). Data from the National Survey on Drug Use and Health (NSDUH) are used to provide a snapshot of mental health issues among older adolescents and young adults overall and by key issues for the transition into adulthood (e.g., housing, employment, education, and insurance coverage).⁸ Data are presented separately for older adolescents and young adults as questions asked of each age group varied and estimates could not be combined.

NSDUH asks persons aged 12 to 17 about past year psychological symptoms to estimate if they had MDE in the past year. MDE is defined using the diagnostic criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).⁹ Adolescents were assessed as having MDE if they had a period of 2 weeks or longer during which there was either depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-worth.

NSDUH asks persons aged 18 or older about past year psychological symptoms to estimate if they had any mental illness (AMI) or serious mental illness (SMI) in the past year. AMI and SMI are determined by using diagnostic criteria from DSM-IV.⁹ AMI is defined as having any mental, behavioral, or emotional disorder in the past year that met DSM-IV criteria (excluding developmental and substance use disorders). Adults were assessed as having SMI if they had any mental, behavioral, or emotional disorder that caused substantial functional impairment (i.e., substantially interfered with or limited one or more major life activities).

NSDUH also includes a series of questions to assess dependence on or abuse of alcohol or illicit drugs.¹⁰ These questions are designed to measure dependence and abuse based on criteria specified in the DSM-IV. For the purpose of this report, individuals with either alcohol or drug dependence or abuse are defined as having a SUD. Individuals with both a mental health issue and a substance use disorder are defined as having a co-occurring mental health problem and SUD.

All estimates in this report are annual averages based on combined 2010 to 2012 NSDUH data. Only comparisons that are statistically significant are discussed in this report.¹¹

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Older Adolescents

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Major Depressive Episode and Co-Occurring Substance Use Disorder

Understanding the challenges that older adolescents face as they begin to transition into adulthood is important. Therefore, it is essential to know how many have MDE or co-occurring MDE and SUD.

• Approximately 938,000 U.S. adolescents aged 16 to 17 had MDE in the past year. This represents 1 out of every 10 older adolescents in this country (11.2 percent) (Figure 1).
• Older adolescents aged 16 or 17 were more likely than younger adolescents aged 12 to 15 to have had MDE in the past year (11.2 vs. 7.0 percent).
• About 214,000 older adolescents (3.1 percent) had co-occurring MDE and SUD in the past year.
• Nearly three quarters of adolescents aged 16 to 17 with MDE were female (71.2 percent).

Treatment for Depression and Substance Use

Overall, 4.5 percent of all adolescents aged 16 or 17 (374,000 persons) had MDE and received treatment for depression in the past year.¹² Many older adolescents with MDE do not receive treatment for their depression.

• Among the 938,000 older adolescents aged 16 or 17 with MDE, 60.1 percent did not receive treatment for depression in the past year (Figure 2).
• Older adolescents with MDE had a higher rate of treatment for depression than younger adolescents with MDE (39.9 vs. 35.7 percent).

Of the 214,000 older adolescents who had both MDE and SUD in the past year:

• 53.3 percent did not receive treatment for depression or specialty substance use treatment¹³ (Figure 3);
• 40.7 percent received treatment for depression only;
• 0.5 percent received specialty substance use treatment only; and
• 5.5 percent received both treatment for depression and substance use treatment.

Transitioning into Adulthood, by MDE Status

As older adolescents begin to transition into young adulthood, it is important to understand if they have a stable housing situation, are enrolled in school, have insurance coverage, or exhibit delinquent behavior.

Residential Stability. Although becoming an adult is often marked by moving out of the parental home, adolescents typically do not relocate repeatedly during a single year. However, frequent relocations can make it difficult for youths to develop the foundations needed for the transition to adulthood. For example, relocating can make it difficult for youths to complete their high school education. Additionally, if a young person has mental health issues, relocating may hinder his or her ability to receive consistent mental health services. To assess residential stability, NSDUH asks youths how many times they have moved in the past year. In this report, youths who have moved three or more times in the past year are considered to have high residential instability.

• Compared with older adolescents without MDE, those with MDE were more likely to have moved three or more times in the past year (4.9 vs. 3.2 percent).
• About 7.7 percent of older adolescents with co-occurring MDE and SUD moved three or more times in the past year.

Education. Obtaining a high school diploma has a lasting economic impact on youths as they transition into adult roles. Among adolescents aged 16 to 17, youths with MDE were equally likely to be enrolled in high school as their peers without MDE; however, adolescents with MDE do not share the same level of academic success as their peers.

• Among older adolescents who were enrolled in school, those with MDE were more likely than those without MDE to have a grade average of "D" or lower (7.2 vs. 5.1 percent).
• More than 1 in 10 adolescents with co-occurring MDE and SUD who were enrolled in school (13.5 percent) had a grade average of "D" or lower.

Health Insurance Coverage. Having health insurance may impact whether a youth receives mental health services.¹⁴ Adolescents aged 16 or 17 with MDE were as likely to have health insurance as adolescents aged 12 to 15 with MDE (91.9 and 92.7 percent, respectively). Furthermore, the rate of having at least some type of insurance coverage is similar for older adolescents regardless of whether they have MDE or co-occurring MDE and SUD; however, specific types of insurance can vary by MDE status.

• Older adolescents with MDE were more likely than their counterparts without MDE to be covered by Medicaid or the Children's Health Insurance Program (32.2 vs. 29.2 percent) and less likely to be covered by private insurance only (54.7 vs. 58.1 percent).

Delinquency and Criminal Activity. Delinquency, including criminal activity, can make the transition to adulthood more difficult. For example, juvenile incarceration is associated with lower high school completion rates, lower wages as adults, and higher likelihood of future criminal activity.¹⁵ Youths with early depressive symptoms are more likely to engage in delinquent behaviors as they get older.¹⁶ NSDUH asks adolescents if they have engaged in delinquent behaviors in the past year and if they were on probation or parole in the past year.

• Older adolescents with MDE were more likely than those without MDE to have engaged in delinquent behaviors in the past year. Specifically, older adolescents with MDE were more likely than those without MDE to:
  
  
  • get into a serious fight at school or work (23.7 vs. 15.9 percent),
  • take part in a group-against-group fight (14.1 vs. 11.3 percent), or
  • attack someone with the intent to seriously hurt them (10.8 vs. 5.6 percent).
• Among older adolescents with co-occurring MDE and SUD, 40.2 percent got into a serious fight at school or work, 25.3 percent took part in a group-against-group fight, and 18.8 percent attacked someone with the intent to seriously hurt them.
• Older adolescents with co-occurring MDE and SUD were 3 times as likely to have been on probation or parole in the past year as those without either MDE or SUD (10.0 vs. 3.1 percent).

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Young Adults

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Mental Illness

To understand the challenges that young adults face, it is important to know how many young adults have mental illness or co-occurring mental illness and SUD.

• About 6.4 million U.S. adults aged 18 to 25 had AMI in the past year. This represents nearly one in five young adults in this country (18.7 percent of this population) (Figure 4).
• About 1.4 million young adults had SMI in the past year. Thus, 3.9 percent of all young adults had SMI in the past year.
• Among young adults with AMI, one in five had SMI in the past year (21.0 percent of young adults with AMI).
• About 2.2 million (6.4 percent) young adults had co-occurring AMI and SUD in the past year, and 555,000 (1.6 percent) had co-occurring SMI and SUD in the past year.
• More than 60 percent of young adults aged 18 to 25 with AMI or SMI were female.

Use of Mental Health Services and Substance Use Treatment

Overall, 11.4 percent of all young adults (3.9 million persons) received mental health services in the past year.¹⁷ NSDUH data suggest that young adults were less likely to access services than adults aged 26 or older (11.4 vs. 14.4 percent). Many young adults with AMI and SMI do not receive mental health services.

• Among the 6.4 million young adults aged 18 to 25 with AMI in the past year, 66.6 percent did not receive mental health services in the past year (Figure 5).
• Among the 1.4 million young adults with SMI in the past year, 47.0 percent did not receive treatment.
• Young adults with AMI had a lower rate of mental health service use than adults aged 26 or older with AMI (33.4 vs. 42.8 percent).
• Mental health service use was lower among young adults with SMI than among adults aged 26 or older with SMI (53.0 vs. 67.1 percent).

Of the 2.2 million young adults who had both AMI and SUD in the past year:

• 61.2 percent did not receive mental health services or specialty substance use treatment (Figure 6);
• 30.7 percent received mental health services only;
• 2.9 percent received specialty substance use treatment only; and
• 5.2 percent received both mental health services and substance use treatment.

Of the 555,000 young adults who experienced both SMI and SUD in the past year:

• 43.2 percent did not receive mental health services or substance use treatment (Figure 6);
• 46.1 percent received mental health services only;
• 2.1 percent received specialty substance use treatment only; and
• 8.5 percent received both mental health services and substance use treatment.

Key Markers/Issues of Adulthood, by Mental Illness Status

Young adults with mental illness are likely to have a difficult transition to adulthood. Addressing the behavioral health needs of this age group is a critical public health issue because mental health disorders are associated with residential instability, lower educational attainment, unemployment, and poorer access to health services.^18,19

Residential Stability. Residential instability makes it difficult for young persons to transition into adult roles. For example, relocating can make it difficult to maintain employment or enter into serious relationships. Furthermore, if a young person is experiencing mental illness, relocating may hinder his or her ability to receive consistent mental health services.

• Compared with young adults without mental illness, young adults with AMI or SMI were more likely to have moved three or more times in the past year (6.7 vs. 12.0 and 15.2 percent).
• About 15.2 percent of young adults with co-occurring AMI and SUD and 18.5 percent of those with co-occurring SMI and SUD moved three or more times in the past year.

Employment. Employment is a goal for many young adults as they transition away from financial dependence on their parents. Because they are just beginning their careers, young adults form the backbone of the entry-level workforce in the United States, and their ability to participate in the labor force is critical to the U.S. economy. However, for young adults with a mental illness, obtaining employment can be a challenge.

• Compared with young adults without mental illness, young adults with AMI and SMI were more likely to be unemployed (12.3 vs. 14.6 and 16.2 percent) and less likely to have full-time employment (38.3 vs. 33.0 and 29.7 percent).
• About 16.7 percent of young adults with co-occurring AMI and SUD and 17.4 percent of those with SMI and SUD were unemployed.

When young adults with mental illness are able to gain employment, they can still have difficulty maintaining employment. To assess instability in employment, NSDUH asks adults how many employers they have had in the past year. Those who have had more than three employers are considered to have high employment instability.

• Young adults with AMI or SMI were also more likely than their peers without mental illness to have had more than three employers in the past year (3.9 and 4.5 vs. 2.6 percent).
• About 4.4 percent of young adults with co-occurring AMI and SUD and 3.8 percent of those with SMI and SUD had more than three employers in the past year.

Education. Having a high school diploma has a tremendous impact on young adults' ability to obtain employment. Having a mental illness, however, can make high school graduation difficult to accomplish.

• Young adults with AMI were slightly less likely to have a high school diploma/GED as their highest level of education than young adults with no mental illness (33.0 vs. 34.4 percent).
• Young adults with co-occurring AMI and SUD were less likely to have a high school diploma/GED as their highest level of education than those with no mental illness or SUD (32.5 vs. 34.9 percent).
• Young adults with SMI who received treatment in the past year were more likely to be high school graduates than their peers with SMI who did not receive treatment (86.3 vs. 81.5 percent).

Health Insurance Coverage. Some studies have indicated that having health insurance may be a factor impacting whether mental health services are received, and this may be particularly salient for young adults.²⁰ Young adults aged 18 to 25 were less likely to have health insurance than adults aged 26 or older (74.8 vs. 85.1 percent). However, insurance coverage was similar among young adults regardless of whether they had mental illness.

• Young adults with AMI or SMI were as likely as their peers without mental illness to have health insurance (75.1, 74.2, and 74.8 percent, respectively).
• Young adults with co-occurring AMI and SUD and co-occurring SMI and SUD were as likely as their peers without mental illness to have health insurance (74.9, 73.8, and 74.9 percent, respectively).
• Young adults with AMI were more likely than their peers without mental illness to be covered by Medicaid or the Children's Health Insurance Program (16.9 vs. 15.1 percent) and less likely to be covered by private insurance (51.3 vs. 53.4 percent).

Probation or Parole. Being incarcerated can make it more difficult to succeed in adulthood. For example, former prisoners typically have trouble obtaining adequate employment and stable housing; additionally, many suffer from stress-related illnesses.^21,22 NSDUH asks respondents if they were on probation or parole in the past year.

• Young adults with AMI or SMI were more likely to be on probation or parole in the past year than their peers without mental illness (6.8 and 7.1 vs. 4.7 percent).
• Young adults with co-occurring AMI and SUD were 3 times as likely to have been on probation or parole in the past year as young adults without either AMI or SUD (11.8 vs. 3.5 percent).

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Discussion

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To help older adolescents and young adults become healthy and productive members of society, it is essential to understand the mental health and co-occurring substance use issues in this population and how these problems impact their ability to succeed in life. As this report shows, 938,000 adolescents aged 16 to 17 had MDE in the past year, and 6.4 million young adults aged 18 to 25 had any mental illness in the past year (1.4 million of these young adults had SMI). Early intervention may help these older adolescents and young adults successfully transition into their adult roles.⁷

The data in this report indicate that older adolescents with MDE are less likely than their peers without MDE to have the foundation needed to succeed as young adults. For example, compared with their peers without MDE, these youth were more likely to do poorly in school and to engage in delinquent behaviors. Among those who are already in their young adult years, NSDUH data indicate that young adults with mental illness or co-occurring mental illness and SUD have poorer quality of life. For example, they were less likely to be employed and more likely to experience residential instability than those without mental illness.

Older adolescents and young adults comprise the next generation of the U.S. population, and regardless of whether they have a mental illness, depression, or SUD, their success will reflect the success of the Nation. Resources to help parents, teachers, and caregivers recognize the signs and symptoms of mental illness and locate mental health services are available from http://www.mentalhealth.gov/. Information on locating substance abuse treatment is available from http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Resources and information about the importance of youths' mental health is also available on SAMHSA's National Children's Mental Health Awareness Day Web site: https://www.samhsa.gov/children/national.asp.

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End Notes

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¹ Sham, P. C., MacLean, C. J., & Kendler, K. S. (1994). A typological model of schizophrenia based on age at onset, sex and familial morbidity. Acta Psychiatrica Scandinavica, 89(2), 135-141.
² Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustün, T. B. (2007). Age of onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry, 20(4), 359-364.
³ Center for Behavioral Health Statistics and Quality. (2011). The NSDUH Report: Major depressive episode and treatment among adolescents: 2009. Rockville, MD: Substance Abuse and Mental Health Services Administration.
⁴ Merikangas, K. R., He, J.-P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980-989.
⁵ Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Mental health findings (HHS Publication No. SMA 13-4805, NSDUH Series H-47). Rockville, MD: Substance Abuse and Mental Health Services Administration.
⁶ Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA 13-4795, NSDUH Series H-46). Rockville, MD: Substance Abuse and Mental Health Services Administration.
⁷ Government Accountability Office. (2008). Young adults with serious mental illness: Some States and Federal agencies are taking steps to address their transition challenges (GAO-08-678). Washington, DC: Author.
⁸ Although NSDUH provides the most up-to-date assessment of the mental health of the Nation, the survey excludes subpopulations that may have high rates of mental illness, such as homeless persons who do not use shelters and long-term residents of jails or prisons. Other sources can be used to examine mental health problems among these subpopulations. For example, according to the 2004 Survey of Inmates in State and Federal Correctional Facilities, 62.6 percent of State prison inmates and 57.8 percent of Federal prison inmates aged 24 or younger had a mental health problem. Bureau of Justice Statistics. (2006, September). Bureau of Justice Statistics Special Report: Mental health problems of prison and jail inmates. Washington, DC: Author.
⁹ American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
¹⁰ NSDUH defines illicit drugs as marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, or prescription-type drugs used nonmedically.
¹¹ Statistical tests have been conducted for all statements appearing in the text that compare estimates between subgroups of the population. All statements that described differences are significant at the .05 level.
¹² Treatment for depression is defined as seeing or talking to a professional or using prescription medication for depression in the past year. Respondents with unknown treatment data were excluded.
¹³ Specialty substance use treatment is defined as treatment received at drug or alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), and mental health centers. Specialty substance use treatment excludes treatment in an emergency room, private doctor's office, self-help group, prison or jail, or hospital as an outpatient.
¹⁴ Miller, S., Ringeisen, H., Munoz, B., Rohloff, H., Hedden, S., Colpe, L., & Embry, V. (2014). Predictors of mental health service use in young adulthood: Results from the National Survey on Drug Use and Health. Unpublished manuscript.
¹⁵ Aizer, A., & Doyle, J. J. Jr. (2013, June). Juvenile incarceration, human capital and future crime: Evidence from randomly-assigned judges (NBER Working Paper No. 19102). Cambridge, MA: National Bureau of Economic Research
¹⁶ Kofler, M. J., McCart, M. R., Zajac, K., Ruggiero, K. J., Saunders, B. E., & Kilpatrick, D. G. (2011). Depression and delinquency covariation in an accelerated longitudinal sample of adolescents. Journal of Consulting and Clinical Psychology, 79(4), 458-469.
¹⁷ Mental health treatment/counseling is defined as having received inpatient care or outpatient care or having used prescription medication for problems with emotions, nerves, or mental health. Respondents were not to include treatment for drug or alcohol use. Respondents with unknown treatment/counseling information were excluded.
¹⁸ Gibb, S. J., Fergusson, D. M., & Horwood, J. L. (2010). Burden of psychiatric disorder in young adulthood and life outcomes at age 30. British Journal of Psychiatry, 197(2), 122-127.
¹⁹ Gralinski-Bakker, J. H., Hauser, S., Billings, R., Allen, J., Lyons, P., Jr., & Melton, G. (2005, July). Transitioning to adulthood for young adults with mental health issues. Network on Transitions to Adulthood Policy Brief, 21.
²⁰ Elhai, J. D., & Ford, J. D. (2007). Correlates of mental health service use intensity in the National Comorbidity Survey and National Comorbidity Survey Replication. Psychiatric Services, 58(8), 1108-1115.
²¹ Pager, D. (2003). The mark of a criminal record. American Journal of Sociology, 108(3), 937-975.
²² Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and other stress-related illnesses. Journal of Health and Social Behavior, 49(1), 56-71.

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Suggested Citation

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Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (May 6, 2014). The CBHSQ Report: Serious Mental Health Challenges among Older Adolescents and Young Adults.. Rockville, MD.

The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The 2010 to 2012 data used in this report are based on information obtained from 23,200 persons aged 16 or 17 and 68,200 persons aged 18 to 25. The survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence. The CBHSQ Report is prepared by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA, and by RTI International in Research Triangle Park, North Carolina. (RTI International is a trade name of Research Triangle Institute.) Information on the most recent NSDUH is available in the following publication: Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA 13-4795, NSDUH Series H-46). Rockville, MD: Substance Abuse and Mental Health Services Administration. Also available online: https://www.samhsa.gov/data/.

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