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Inaugural report: Disconnect between increased stress and diagnoses rates

People in America have shared that the pandemic has negatively affected their mental health. However, in spite of the many additional stressors that they felt in 2020, including social unrest, a tumultuous election and a declining economy, there wasn’t a corresponding increase in people seeking mental health treatment, according to the inaugural State of the Nation’s Mental Health report.

Children and adults older than 75 appeared to have the largest overall downturn with both groups reporting significantly fewer mental health diagnoses in 2020 compared to 2019. Younger adults, meanwhile, had a smaller than expected increase in mental health diagnoses for the full year of 2020. Further, in spite of the overall downturn, there were two conditions for which diagnoses and treatment grew in 2020: anxiety and PTSD for adults.

These findings, part of a new State of the Nation’s Mental Health report based on 27 million Anthem, Inc.-affiliated health plan claims, show the pandemic disconnect between feeling stressed and depressed and being diagnosed and seeking treatment.

National context

In this century, we have become more comfortable seeking mental health services. In 2002, the percentage of adults aged 18 and older receiving mental health services was 13 percent, according to the Substance Abuse and Mental Health Services Administration. By 2019, that percentage grew to a little more than 16 percent.

In 2020, the pandemic strained our mental health. A recent study revealed that four in 10 adults reported symptoms of anxiety or depression during the pandemic, up from one in 10 in 2019. Further, 42 percent of people younger than 30 are experiencing symptoms of anxiety and depression, according to a CDC survey from August 2020 through February 2021. Not surprisingly, the social distancing and quarantining recommended to protect our physical health is the very thing that paradoxically can have a damaging effect on our mental health.

In contrast to the reported increase in mental distress, Anthem’s 2020 data for its affiliated health plan members show little change in the rate of diagnoses: the rate was flat from 2019-2020, compared to an increase in 2018-2019. A conclusion to be drawn is that, regardless of the pandemic’s effect on individuals’ mental health, the pandemic is the likely explanation for the flat rate of diagnoses in 2020.

Indeed, the pandemic has disrupted people’s patterns of care in spite of increased need. For example, specific to mental health, the World Health Organization reports that the pandemic disrupted mental health services in 93 percent of countries.

Youngest, oldest are the outlier groups

The youngest and oldest members of the population were the only two groups to show a decline in diagnoses in 2020. The State of the Nation’s Mental Health report revealed that there was a 10 percent drop in the rate of young children and a 5 percent drop for adolescents treated for mental health diagnoses compared to 2019. At the opposite end of the age spectrum, people older than 75 – also known as the Silent Generation – showed a 5 percent drop. The conditions that showed the greatest drops were ADHD for children (-13%) and adolescents (-8%) and dementia for the Silent Generation (-8%). Interestingly, anxiety and depression emerged in the top three diagnoses for all age groups, except for depression among children 12 and younger.

An Anthem-commissioned survey of behavioral health specialists and primary care physicians supports the State of the Nation’s Mental Health report’s findings. For example, respondents reported that children and adolescents have experienced the most significant short- and long-term impacts on their mental health due to the pandemic. Additionally, the survey confirmed anxiety and depression as top diagnoses, with providers reporting that they have been treating anxiety (90%) and depression (95%) more frequently than before the pandemic’s onset.

Additional Anthem data from IngenioRx, its pharmacy benefits manager, supports the report’s finding that people didn’t access treatment in 2020 at as high of a rate as they did in 2019, in spite of the rising need. For example, while the overall utilization for medications to treat depression was up in 2020, much of that increase can be attributed to existing users being more adherent to their dosing regimens, according to IngenioRx medication-adherence data. New users of these medications in 2020 increased at the same rate as 2019.

Lessons learned

The COVID-19 pandemic has changed the world as we knew it. How long those changes will last or whether some of them may be permanent remains to be seen. However, healthcare has learned important lessons, one of which is the growing acknowledgement of mental health as essential to overall health and wellbeing.

That acknowledgment starts with the providers themselves. Nine out of 10 of those surveyed said that COVID-19 has made them more aware of the mental health conditions their patients are facing. Further, their patients are opening up about mental health concerns: 70 percent of surveyed providers said their patients have been more willing to proactively bring up mental health during appointments.

We need to be ahead of the curve as our nation’s mental health unfolds post-pandemic. Based on the report’s findings that people aren’t accessing services when they need them the most, a call to action emerges: we must be proactive about identifying those individuals and connecting them to care.

For more information, resources and insights about the state of the nation’s mental health, click here.

24 Comments. Leave new

I have found that all age groups have experienced fear and anxiety and added stress to their lives. My practice has increased more than 33% since the pandemic. And I am not alone.
I think these added burdens will take up to 5 years for recovery.


I have experienced an uptick in High School students for depression and anxiety – especially among high achievers. The lack of social opportunities leads to a mild depression. This in turn leads to decreased motivation to do schoolwork and an increase in anxiety. The personal identity of high achievers is heavily invested in their grades. When grades begin to drop these kid’s depression and anxiety worsen.


Ditto. I concur completely.


Thank you for taking the time to explore this complex and important topic. As a group practice owner and licensed clinician in Connecticut I am surprised to hear your findings. My experience regarding the fluctuation of patients seeking care over the course of the pandemic thus far is as follows: In the beginning there was an acute drop off of patients seeking mental health care as many were uncertain and perhaps optimistic regarding how long the pandemic would last and reported that they would “prefer to wait” rather than continue services via telehealth. Over the course of the year people became both more in need of services and increasingly comfortable and familiar with virtual visits and slowly began to seek out online therapy. While there have been some positive changes overall in the status of the epidemic in recent months, we have found that there is now a huge surge of people seeking services, so much so that there are wait lists and very few providers with availability. I have also conferred with nurses in the local hospitals who reports a large increase in teen suicide attempts, mostly using household medications such as overdosing on Tylenol. There is now a shortage of providers in relation to the local population seeking services at this point. Every licensed clinician you talk to in our county and the neighboring New Haven County and Naugatuck Valley is completely booked with wait lists that are months long. If your research is a collection of data averaged from the beginning of Covid-19 to now and is showing an decline in diagnoses, it is not an accurate representation of our current state of operations.

Dale Seamans
May 10, 2021 5:29 pm

Thank you for your comment. Our data analysis was from 27 million members, which translated to approximately 63 claims, from across the entire country, and not all states showed patterns exactly reflecting the report’s findings. As your comment shows, one of those states was Connecticut. For example, overall, Connecticut had an 11% increase in mental health diagnoses, and children and seniors did not have as much as a downturn as the national average.


I am a psychologist in Western South Dakota. Although we were supposed to have an easier time because “we never shut down” we are also experiencing surges in people seeking services. We were underserved to start with so waitlists are now months long. We have to turn away clients on a regular basis. Things have become so severe that our office has been getting phone calls from SD’s largest metropolitan area, Sioux Falls, to see if we have availability. Parents have literally said that they would drive their children 340 miles across state once a week for their child’s therapy. We have also been frustrated when trying to find long-term care for our clients with severe conditions. Although a few of my clients did not want to switch to telehealth, many did. As a matter of fact, I kept a full schedule even though I was 100% telehealth two weeks after the start of the pandemic. For those clients that switched they were very consistent and my no-show/cancellation rate dropped dramatically. Because of this, I was unable to take the same number of new patients which were available in great supply.

Lea Boriskin
May 6, 2021 3:40 pm

The question is whether this report is only based on those who seek therapy covered by insurance. Since many therapists are no longer taking low paying insurances, patients are having trouble obtaining therapy and are therefore not included the report. They are constantly stressing about the long waitlists for therapy and overwhelmed with their symptoms.

Sandra Blase
May 6, 2021 3:49 pm

Many people who lost jobs also lost insurance coverage which would have impacted their ability to seek mental health services. Children with ADHD would not have struggled with school structures as much on home programs but their educational development would have suffered.


The report findings will, I hope, be nuanced, because the conclusions don’t match my clinical experience. We had a big increase in demand for services, so much so that we had to hire more clinicians. The availability of remote sessions made a significant positive difference on whether consumers could start or continue sessions. Many are hoping that remote sessions can continue.

Dale Seamans
May 10, 2021 5:30 pm

Thank you for your interest in our report and for taking the time to comment. As noted in another response, our data analysis was based on 27 million members from across the country, translating to 63 claims, and not all states reflected the national average.

Ed Schmookler, PhD
May 6, 2021 4:13 pm

In my practice there has been increased suicidal thinking , especially among those with attachment trauma, who are isolated.

Gloria S Rothenberg, PhD
May 6, 2021 4:34 pm

This is partially due to the challenges in providing teletherapy services to children and older adults. Children generally need more interactive or play-oriented interventions that are difficult to deliver online. Older adults may be less tech-savvy and therefore less inclined to engage in or access teletherapy.

Diana Rubin
May 8, 2021 6:04 pm

Thank you! This is exactly what I have found too.

Joel S. Richman, Ph.D.
May 6, 2021 4:57 pm

Interesting results, but not what I have been experiencing. True, starting in March/April of 2020 and throughout most of 2020, I was not getting new referrals and therefore not adding to an increased rate of diagnoses. However during this period, my existing patients of all ages both recent and past, were experiencing greater stress and difficulty adapting to the new world created by the pandemic. Thus, I was being called upon to see my existing patients more frequently than prior to the pandemic, resulting in more mental health visits albeit by telehealth. Also, I have observed that since early in 2021, as a solo practitioner, I have been receiving 3-5 calls per week from new patients using insurance company website clinician lists who are asking to be seen. Because I and many other clinicians have been so fully booked since the beginning of the pandemic with existing patients, these new patients and therefore the new diagnoses rate which should be going up, may be being held down due to the shortage of clinician availability. There is still much to be learned.

Shaun Griffen
May 6, 2021 5:06 pm

Hi, I’m a practice manager for a small group of therapists in southern California . A couple of things this makes me think about with regard to “why people are not accessing services when they need them the most:”
Our patients report that it has been very difficult over this past year to access their behavioral health benefits through their insurance, as many therapists are “not taking new patients,” in large part due to the increased volume of referrals (that can be attributed to pandemic-related causes). MANY patients resort to seeking care outside their insurance, so their diagnoses would seemingly not be included in these statistics. Additionally, as insurance contract rates remain so much lower than cash-pay rates, many therapists cannot afford to provide services through insurance contracts, so many panels do not have enough therapists to manage the volume of behavioral health needs, even prior to Covid-19.

Among all the life changes patients have been trying to navigate is the loss of childcare/in person schooling. Parents who must work from home while also caring for children have very little time to pursue and engage in therapy, either for themselves or their children. Finding a therapist who is on a patient’s insurance, taking new patients, has availability when they can make appointments (either in-person or via telehealth), and has the appropriate expertise and clinical orientation is pretty difficult and sometimes impossible – and these must surely be statistically relevant factors as regards the capture of diagnoses, as many parents end up seeking help outside their insurance panels.

Senior patients seeking behavioral health support have been particularly hard hit. They are often not technologically savvy enough to use telehealth platforms, are more vulnerable and frightened about Covid 19 in general and so less likely to pursue in-office care, and have been isolated from their support systems (who previously provided transportation and assisted with navigating insurance benefits). Additionally, if they have a Medicare HMO, often their benefits are limited to low-cost/high-volume provider panels with whom their assigned medical groups have contracted for behavioral health. These kinds of organizations tend to provide only minimal behavioral health interventions (such as group medication management sessions, brief psychiatric evaluation and meds prescription vs. psychotherapy for stress/depression/anxiety/PTSD); the culture of these organizations and their patient-management procedures are often off-putting to seniors seeking support, who then chose simply not to pursue care, or, again to seek help outside their insurance benefit.

Medical groups, and some insurances, have lately been touting online behavioral health resources (e.g. Silver Cloud), but it has been our experience that these are viewed by patients (and PCP’s alike) on the one hand as impersonal and unhelpful, and on the other as inappropriately intrusive into a patient’s emotional life. Responding to questions about one’s mental health in an online format when people are increasingly worried about the capture and misuse of personal data by unknown entities can be a bridge too far for many. We have received reports from incredulous patients who, having responded honestly to questions designed to measure the severity of their symptoms have received phone calls from strangers “following up” on their responses. This is unnerving at best. Also, I wonder if these online resources may have decreased the number of patients diagnosed with behavioral health conditions by PCP’s, since they are instructed to refer patients to use these platforms instead of providing evaluative services in the office or via telehealth.

I guess my thoughts are that, in order to “be proactive about identifying these individuals and connecting them to care,” a rather large culture-change in the insurance industry writ large will be necessary, and must include a re-examination of the priority mental healthcare receives in the benefit design. Insurance contract rates need to better reflect the realities of doing business as a mental health provider, the idea of “economies of scale” as pertains mental health benefit provision needs to be thrown out and replaced with “economies of appropriate care.” The trend over the past 20 years seems to have been towards the creation of more behavioral health management organizations and levels of administration that create more cost between the patient and their premium and the provision of care, less quality, and less access. I have to feel that a more direct approach to providing care, while perhaps seemingly more costly, would net a more profitable and certainly more effective and productive mental healthcare landscape…

Semi-coherent diatribe complete 😉


I agree with you Shaun. I have a small part-time practice of Medi-Cal and private pay. I have more referrals than I can handle and people are saying they are having a hard time finding anyone, especially with Medi-Cal or insurance. There are so many factors that could impact on this and it is not appropriate to apply this to the larger population. This is a very selective population. Also everyone I’ve seen as discussed how the virus has been stressful and intensifying underlying problems.


Your “diatribe” wonderfully expressed what most therapists likely think and feel about the complexities of navigating the healthcare system for mental health services. Having worked in hospitals (discharge planning) and day treatment programs with chronically mentally-ill adults, EAP services and finally outpatient psychotherapy, I can attest to the frustrations associated with the business aspect of the profession as well as the difficulty in finding appropriate mental health providers to meet the needs of the patient. The insurance industry must do better to acknowledge the value of mental health professionals in order to meet the needs of their customers.


My practice is dealing more with work overwhelm and relational problems due to stress working at home and husbands entertainment with social media


This is no surprise to behavioral health providers. However, since medical providers are often the first to learn of patients’ distress — either through exacerbation of pre-existing conditions or development of new ones — there needs to be an awareness that treatment of mental health issues ought not end with medication or brief in-office pats on the knee.

An interesting poll would question medical providers about their rates of referral to behavioral health providers. For example, recently a client told me that her visit to primary care for diagnosis and treatment of palpitations resulted in referral to a cardiologist. The primary care prescribed anxiolytics while the cardiologist prescribed beta-blockers.

Neither doctor made mention of mental health counseling. This is an example of incomplete care.

I do not object to medical intervention. In fact, mental health providers are trained to recommend a visit to their physician as part of the treatment plan. It’s when medical treatment falls short of complete treatment that I object: How can a complete diagnosis and treatment plan be developed in 15 minutes? Though the client with palpitations had told both doctors about her pending divorce, neither prescribed mental health counseling as part of her care plan even though palpitations are a classic descriptor of anxiety, a mental disorder.

While collaboration among treatment providers is touted, that seems to occur only in hospital settings. In 25 years of practice as a Marriage & Family therapist, never have I been contacted by a doctor’s office seeking to build a list of mental health resources. With notable exceptions, despite trying I have not succeeded in becoming part of patients’ medical treatment.

Proactivity in connecting patients to mental health care when needed has to involve multiple entities that educate, encourage, and clear the path for connection to happen. That has to start with medical schools and counselor training that teach providers how to collaborate economically and effectively. Insurance companies need to act on the belief that a mentally healthy society can be profitable. Public education must bang the drum louder, normalizing the need for mental health.

It is unfortunate that the nation’s mental health seems to be economically driven, but that seems to be the reality. Also unfortunate are the institutional beliefs about mental health. And, despite an increase in the numbers of Americans looking to mental health treatment as a resource, too many Americans still hold beliefs that are shame- or ignorance-based.

Commitment to proactivity about mental health can’t be abandoned once “normalcy” returns. Do we metaphorically stop washing our hands as much? In a society of short attention will we turn off the spotlight on need? Can the world’s fear, suffering, and death be a positive impetus? Will the voices calling for action fall to whispers?

Lots of changes need to be made before any change is profound.


Actually that was a very cogent and coherent analysis of the present situation and why either can’t or won’t access mental health services. I agree with everything you said, and can confirm that from my own experience. Thank you.


Yes my clients are struggling with the mask wearing-isolation mandated-social distancing requirements-imposed by the Covid regulations. There is increased family and couple conflict- less motivation to resolve the conflict-increased family stress-and constant stream of medical
Personnel seeking therapy! My telehealth practice has increased significantly.

Morgan Wangerin, LPC-S
May 6, 2021 7:00 pm

I have been working in private practice with client’s aged 8-90 for the last 3 years. I have to admit that I have found that during the pandemic the requests for ADHD evaluations of my children and pre-teen client’s dropped from completing on average 2 assessments a month to completing 2 in a year. However, I also noticed that the rate of suicidal ideations, depression, and social anxiety cases that I saw in this same population doubled in that same time period. Therefore, I can see how the issues that we as society are focusing on tend to be the issues that present in the office. Therefore, We as a Nation need to do better to screen and focus on a comprehensive wellness model in the post-pandemic environment to foster health and wellness amongst our clients.


I was quite busy with providing service via telehealth all through the pandemic. Anyone who wanted to be seen was seen. Front line health care providers were too busy to seek help for themselves during the worst of it, they are now trickling in with strained marriages and PTSD. A small portion of OCD contamination folks worsened, and ADHD students really struggled with all remote learning. It was interesting that most presenting issues were typical anxiety and depression. I did think that the concept of shared misery may have deterred many from seeking help. ” If we are all in this together” then the anxiety and distress specific to the pandemic became normalized.
Now its time to help the the anxious resume expectations of going to that family event, or tolerate the stress of their commute to the work place. Now we serve those front line workers and help restore them and their marriages. Good Luck and Good work wished to my Peers!

Maureen McGovern
May 7, 2021 2:56 pm

Absolutely true.


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