One in Five Older Americans Uses Mental Health Care, and Comorbidity Helps Explain Who

Millions of middle-aged and older adults in the United States live with mental health needs that go unmet, and a new analysis of national survey data offers one of the clearest pictures yet of who actually receives care and who slips through the cracks. Drawing on six consecutive waves of the National Health Interview Survey from 2019 through 2024, researchers examined the mental health care experiences of 128,261 adults aged 40 and older, making this one of the largest investigations of its kind in an ageing population. The findings, published in PLOS Mental Health, arrive at a moment when the United States is grappling with a growing burden of depression, anxiety, and chronic disease among its older citizens, and they suggest that the architecture of mental health care access is more uneven than many clinicians and policymakers might assume.

The headline number is deceptively simple: roughly one in five middle-aged and older American adults reported using some form of mental health care in the previous twelve months. That care could take any of three forms, which the researchers treated as a single composite outcome: counseling or psychotherapy, the use of mental health medications, or a visit to a mental health specialist. By pooling six years of survey data, the team was able to capture patterns that would be invisible in any single year, smoothing out the disruptions of the pandemic era and the gradual expansion of telehealth services that followed. Yet beneath that one-in-five figure lies a striking stratification, with utilization rates varying dramatically across lines of age, race, income, insurance status, geography, and physical health.

At the analytical heart of the study is the question of comorbidity, meaning the co-occurrence of multiple chronic physical conditions in the same person. The researchers categorized participants into three groups: those with no chronic conditions, those with one, and those with two or more. Comorbidity burden served as the primary predictor of mental health care use, and its influence proved substantial. Adults living with multiple chronic conditions were significantly more likely to receive mental health services than their counterparts without such conditions, a pattern that held even after the researchers statistically adjusted for a wide range of other characteristics. This makes intuitive sense, since chronic illness and psychological distress are deeply intertwined: diabetes, heart disease, chronic pain, and other long-term conditions can fuel depression and anxiety, while poor mental health can undermine the self-management of physical disease.

To organize the many factors that shape whether someone seeks or receives care, the research team turned to a longstanding framework in health services research known as Andersen’s Behavioral Model of Health Services Use. This model sorts determinants of care into three domains. Predisposing factors are the demographic and social characteristics people bring with them, such as age, sex, race and ethnicity, marital status, and education. Enabling factors are the resources that make care possible or impossible, including income, health insurance coverage, and place of residence. Need factors capture the actual health circumstances that generate demand for care, including diagnosed depression, anxiety, and the comorbidity burden at the center of the analysis. By mapping predictors onto these domains and running survey-weighted multivariable logistic regressions that accounted for the complex design of the National Health Interview Survey, the researchers could estimate the independent contribution of each factor while holding the others constant.

The results paint a detailed portrait of advantage and disadvantage. Utilization was higher among women, non-Hispanic White adults, unmarried adults, smokers, and adults who were overweight or living with obesity. It was also higher among those with lower incomes, an initially counterintuitive finding that likely reflects both greater psychological distress in financially strained households and the operation of safety-net programs that extend coverage to low-income Americans. Health insurance coverage itself emerged as a powerful enabler: insured adults were markedly more likely to use mental health services than the uninsured, underscoring how financial access gates the path to treatment. Geography mattered as well, with residents of the Midwest showing higher utilization than those in other regions, a difference that may reflect regional variation in provider availability, cultural attitudes toward mental health care, or state-level policy environments.

Equally revealing are the groups whose utilization lagged behind. Adults in every older age bracket, from 50 to 64, from 65 to 74, and aged 75 and above, were less likely to use mental health care than adults in their forties, even though psychological distress does not simply vanish with age. Non-Hispanic Black and Asian adults showed lower utilization than non-Hispanic White adults, a disparity consistent with a long record of evidence on barriers that include stigma, mistrust of the health care system, language obstacles, and a shortage of culturally concordant providers. Perhaps most striking, adults with higher educational attainment were less likely to use mental health services, a finding that runs against the usual gradient in which more education predicts more health care of every kind. The authors of the study suggest this may reflect differences in how distress is recognized, reported, or managed across educational groups, though the precise mechanisms remain an open question for future research.

The need domain told the most expected but still consequential story. Adults with diagnosed depression or anxiety were, unsurprisingly, far more likely to be receiving mental health care than those without such diagnoses, which is precisely what a functioning system should deliver. Yet the fact that only about one in five adults in the entire sample used any mental health care, in an era when epidemiological surveys consistently find substantial rates of psychological distress among middle-aged and older populations, implies that a considerable share of need goes unaddressed. The interplay between physical and mental health compounds the concern. Older adults with multiple chronic conditions face a double burden, contending both with the diseases themselves and with the elevated risk of depression and anxiety that accompanies them, and the data show that this comorbid group does reach the mental health system more often. The question the study cannot fully answer is whether that heightened utilization is adequate to the need, or whether it merely represents the visible tip of a much larger iceberg of untreated distress.

Methodologically, the study’s strength lies in its scale and its statistical discipline. Pooling 128,261 respondents across six survey waves gives the analysis the power to detect differences among relatively small subgroups, and the use of sampling weights and design-based variance estimation means the reported associations are meant to generalize to the entire noninstitutionalized civilian population of U.S. adults aged 40 and older. The cross-sectional design, however, imposes real limits. The survey captures who used care in a given year, not whether that care was appropriate, sufficient, or effective, and it cannot establish causal direction. Lower utilization among some groups may reflect lower expressed demand rather than lower underlying need, and the composite outcome blends medication use, psychotherapy, and specialist visits into a single measure, which can obscure meaningful differences in the type and quality of care people receive.

Even with those caveats, the implications are hard to ignore. The United States population is ageing rapidly, and the adults at the center of this analysis, those aged 40 and above, will dominate the patient population of the coming decades. The finding that mental health care utilization is shaped jointly by comorbidity burden and by predisposing, enabling, and need-related factors argues against one-size-fits-all policy responses. Expanding insurance coverage addresses the enabling domain, but the persistent disparities along racial, ethnic, and age lines point to barriers that insurance alone cannot remove, including stigma, workforce shortages, and the cultural responsiveness of services. The authors call for targeted and culturally responsive strategies to improve equitable access, and the data give that call its empirical backbone. As the cohort of middle-aged Americans moves into older age, carrying with it rising rates of chronic disease and, in many cases, untreated psychological distress, the gap between mental health need and mental health care identified in this study is likely to widen unless the system changes deliberately. The one-in-five figure is not just a statistic; it is a benchmark against which the next decade of mental health policy will be measured.

Subject of Research: Mental health care utilization among middle-aged and older U.S. adults

Article Title: Mental health care utilization among middle-aged and older U.S. adults: Findings from the National Health Interview Survey

Article References: Mental health care utilization among middle-aged and older U.S. adults: Findings from the National Health Interview Survey. (n.d.). https://doi.org/10.1371/journal.pmen.0000744

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000744

Keywords: mental health care, National Health Interview Survey, comorbidity, older adults, health disparities, Andersen Behavioral Model, depression, anxiety, health insurance, health services research, ageing population, PLOS Mental Health