Addressing the state of behavioral health in New York City

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As a state, New York spends more on behavioral health (BH), which includes both mental illness and substance use disorders (see sidebar “Definitions”), than almost all other US states: $196 more a year per person than the national average.1 Yet New York’s BH burden is nearly the same: 25 percent of its residents have a behavioral-health condition while the national average is 27 percent.2 And despite New York’s above-average expenditures, it ranks among the bottom half of all states by some BH metrics, including the proportion of adults, youth, and children with depression who did not receive treatment in 2021.3

The importance of BH within overall well-being and economic health is an evolving focus of healthcare research. BH conditions have a disproportionate impact on overall healthcare spending: around 60 percent of overall healthcare spending is attributable to the roughly one-quarter of the population diagnosed with BH conditions. Unaddressed BH conditions can also affect productivity in the workplace and mortality rates, in addition to having a pronounced effect on an individual’s emotional and social well-being.4

Building on the work of McKinsey’s “Twelve insights for an inclusive economic recovery for New York City,” we set out to understand the state of behavioral health and population-specific gaps in New York City (NYC), the most populated metropolis in America and one of its great engines for economic growth. We analyzed McKinsey consumer sentiment surveys,5 aggregated external data, gathered insights from McKinsey experts on healthcare and inclusive economies, and reviewed the academic literature (see sidebar “Behavioral health in New York City”).6

Our research has uncovered disparities in behavioral-health access for different populations in NYC—specifically among racial and ethnic minorities, the LGBTQ+ community, and Generation Z. These three groups exemplify the city’s diverse profile, and each experiences particular challenges: its racial and ethnic minorities have higher BH needs and lower access to care; its LGBTQ+ community faces disproportionate challenges and is generally well informed about BH; and its Gen Z population has above-average levels of mental distress and challenges in accessing BH help.

Our research has uncovered disparities in behavioral-health access for different populations in New York City—specifically, among racial and ethnic minorities, the LGBTQ+ community, and Generation Z.

It is critical for public, social, and private stakeholders to recognize the city’s wide and growing disparities in accessing BH care and to address its residents’ unique BH challenges. In this article, we also present three considerations for strengthening BH care in NYC.

Three NYC groups with unique behavioral-health challenges

As we have noted, our research and insights focus on three distinct subpopulations in NYC: racial and ethnic minorities, the LGBTQ+ community, and Generation Z. These groups experience unique challenges and worse average outcomes for BH and other, broader social determinants of health indicators.7 In some instances, just as the COVID-19 pandemic exacerbated already existing inequities in NYC, it also exacerbated BH issues in these populations.8 The true burden of BH conditions may be even greater, given stigma-driven underreporting,9 which could be higher in populations that experience higher prevalence levels of stigma, such as certain ethnic and racial minority groups, than it is in populations that feel empowered to seek help.10

Although the challenges faced by these three groups are not comprehensive of all the disparities that exist in NYC, these groups are significantly represented (in absolute or relative terms) in the city compared with the overall US population.11 Disparities in access are also present in other geographies throughout the United States and are not specific to New York City.

NYC’s racial and ethnic minorities: Higher BH needs and lower access to care

McKinsey research has highlighted the inequities and barriers to economic inclusion for racial and ethnic minorities and for immigrants. These populations have higher BH needs and lower access to quality care. Nationally, higher rates of Black respondents—52 percent, compared with 36 percent of the overall population—reported having a BH condition, our research shows. Individuals reporting that they have been diagnosed with BH conditions also report higher rates of experiencing isolation, burnout at work, and negative perceptions of their current mental state as compared with the recent past (Exhibit 1).

New York City’s racial and ethnic minorities have disproportionate behavioral- health needs.

The experience of receiving needed care also varied by racial groups in NYC: half of the non-White respondents to our surveys reported challenges accessing counseling for mental-health issues or substance use disorders, compared with 42 percent of White respondents. Over half of Black respondents and Asian respondents (compared with 37 percent of White respondents) said they expected to face challenges in obtaining help if they were to have a BH crisis.

BH providers are unevenly distributed across the city’s communities and vary significantly by borough. One-fourth of non-White respondents said it would take them more than 30 minutes to get to an in-person doctor’s appointment, versus 18 percent of White respondents.12 Racial minorities are also more likely to be uninsured or underinsured: 56 percent of non-White respondents report having employer-sponsored health insurance, including mental-health benefits, versus 66 percent of White respondents (Exhibit 2).

Non-White respondents report having lower rates of employer-sponsored  health coverage, including mental-health benefits.

In addition, the provider population of NYC does not mirror the city’s diversity: 84.2 percent of its psychologists, for example, identify as White, in a city with a population that is 32 percent White, 29 percent Latinx, 22 percent Black, and 14 percent Asian.13 This potential lack of cultural or linguistic competency may serve as a barrier to care.14 Cultural competency in BH care is especially important, because culture influences how individuals experience, understand, express, and address emotional and mental distress and likelihood to seek treatment.

Various populations in NYC, including racial minorities, may also have more stigma around mental health.15 Only 12 percent of Asians would mention their mental-health problems to a friend or relative, compared with 25 percent of White respondents; 4 percent of Asian respondents would seek help from a psychiatrist or other specialist, compared with 26 percent of White respondents; and only 3 percent of Asian respondents would seek help from a physician, compared with 13 percent of White respondents.16

NYC’s LGBTQ+ community: Disproportionately challenged but informed

Understanding the challenges facing the LGBTQ+ community—especially in the epicenter of the LGBTQ+ rights movement—is crucial for understanding the overall status of BH in NYC. More than 750,000 LGBTQ+ people call NYC home, and our research reveals substantial disparities between their BH needs and those of non-LGTBQ+ communities. In our survey of NYC residents, more than two-thirds (69 percent) of LGBTQ+ identifying New Yorkers self-reported having BH conditions, compared with one-third (33 percent) of straight respondents.17

Our research indicates that New York’s LGBTQ+ residents are not only twice as likely as straight ones to experience mental illness but also three times as likely to struggle with substance use issues. LGBTQ+ New Yorkers are also twice as likely to report often feeling stressed and anxious. These conditions have worsened over the course of the pandemic: LGBTQ+ New Yorkers are twice as likely to report that their BH state was better three years ago than it is today.

Three times as many LGBTQ+ New Yorkers reported feeling physically or emotionally unsafe in their communities compared with straight New Yorkers (51 percent versus 17 percent). These challenges also persist in the workplace, where LGBTQ+ employees are far more likely to feel a sense of stigma regarding behavioral-health issues and to feel less comfortable discussing them with their supervisors, and twice as likely to experience burnout in the workplace. LGBTQ+ New Yorkers also reported significant adversity in digital spaces; 29 percent of LGBTQ+ New Yorkers said that social media has a negative impact on their mental health, compared with 17 percent of straight New Yorkers. LGBTQ+ New Yorkers are 2.5 times more likely to experience cyberbullying on social media, as well (Exhibit 3).

LGBTQ+ respondents are more likely to report having negative experiences on social media.

More LGBTQ+ New Yorkers than straight ones reported that they were familiar with the availability of BH resources, including counseling, outpatient therapy, and crisis services: 62 percent versus 38 percent, respectively. More of them also reported that they were willing to access BH resources through telemedicine services and that they used digital health apps.

NYC’s younger populations: Generation Z at particular risk

In the country as a whole, Gen Z reported emotional distress at levels nearly twice those of millennial and Gen X respondents, and three times the levels of baby boomer respondents. Generation Z’s unemployment rate is nearly twice the national average: 15 percent versus 7 percent,18 and its members are 1.6 to 1.8 times less likely than older generations to seek treatment for mental illness, substance use issues, or both.

The relatively high proportion of youths in NYC,19 combined with its structural realities (the high cost of living and space constraints, among others), may further exacerbate BH challenges in this group. Nearly one-third of NYC’s Gen Zers believe that their health is worse than it was three years ago, compared with the national Gen Z average of 21 percent. And 65 percent of NYC Gen Zers reported feeling burned out from work over the past year, compared with 50 percent of Gen Zers nationally.

New York City’s Gen Z population is especially uncomfortable talking about mental-health or substance use issues with supervisors at work: 53 percent versus the 30 percent national average for Gen Z. In addition, 43 percent of NYC Gen Zers found it at least moderately challenging to find help for a BH crisis, compared with 29 percent of other NYC residents. Gen Z New Yorkers who used to receive treatment for BH issues but don’t do so currently are also more concerned about its cost than the nationwide Gen Z average (11 percent versus 6 percent, respectively). Despite Gen Z’s comfort with technology, Gen Z respondents in the country as a whole also reported the lowest level of satisfaction of all generations with tele-BH.

Generation Z everywhere, unsurprisingly, spends more time on social media than other generations do, and New York’s Gen Zers are more likely to cite it as a problem in their lives (Exhibit 4). Yet NYC Gen Zers used digital mental-health apps less in the past year: just 20 percent, compared with 39 percent of Gen Zers nationwide. New York’s Gen Zers are also 10 percent less likely to report having experienced cyberbullying than the national Gen Z average—though the rate of cyberbullying remains high, with nearly half of NYC Gen Zers reporting it.

Gen Zers in New York City report higher rates of regular social-media usage, which may have a negative impact on their behavioral health.

How to improve access

The public, private, and social sectors can all play a role in improving access to services for people with BH conditions. In NYC, additional attention is needed to ensure that the unique needs of all groups are met, especially given the city’s uneven access and affordability of care across neighborhoods and populations.

New York City has a unique opportunity to address BH access for its residents given its landscape of pioneering healthcare innovators and forward-leaning initiatives, and a population with above-average levels of BH awareness. It is already a mental-health front-runner thanks to a variety of public initiatives conducted by the mayor’s office and other institutions, as well as private efforts that include numerous successful mental-health start-ups founded in the city. But to improve BH holistically at the city level, collaborative leadership across jurisdictions at the city, state, and federal level is required.

Stakeholders can consider the following three questions as they work to help address the city’s supply–demand inequities in BH services.

1. How can NYC expand equitable access to behavioral-health services with the unique needs of its diverse populations in mind?

Evidence-based treatment—backed by scientific evidence and clinical studies—includes such BH practices as cognitive behavioral therapy. The relatively short supply of BH providers across the city, as well as longer wait times among some of its racial minority groups, indicates that affordability and levels of access vary. The city has an opportunity to tap into its relatively high levels of awareness on BH issues and provide commensurate access.

There are a number of areas to explore. One is expanding the capabilities of nonspecialists such as pediatricians and nurses to address mild to moderate BH conditions in primary care or other non-BH specialty settings. This could help increase access, especially among providers with skills, capabilities, and interest in working with underrepresented communities such as racial minorities and the LGBTQ+ communities. More options for BH services could be provided in geographically underserved areas of the city, potentially integrated with existing community services and the physical centers providing them. The adoption of telehealth services could be increased to and beyond the national average by ensuring that the available platforms fit the needs of the populations with lower access. Ensuring services for people with severe mental illness also requires thoughtful consideration, especially with the context of national opportunities such as the rollout of the 988 hotline and the national suicide prevention network.

2. How can NYC tailor BH services to address the unique needs of its diverse populations?

Different subsets of NYC’s population experience behavioral health in different ways. Each of these groups needs access to services and the BH service system must be equipped to deal with the diverse needs of the populations they serve. For example, providing training and other supportive resources—digital training programs, hub and spoke models, centers of excellence—to providers may help them to better understand the unique needs of and deliver better care for the populations they serve. NYC has a wealth of public, social, and private organizations that can understand these needs deeply and offer tailored services.

3. How can NYC foster and strengthen community prevention, especially given the city’s economic prowess?

New York City attracts some of the nation’s best talent, partially thanks to its base of large employers and innovators. A focus on expanding employer-sponsored behavioral-health services coverage to be at parity with those of physical-health benefits could provide financial stability for more residents and help mitigate access-related issues. NYC’s employers can focus on eliminating stigma in the workplace and ensuring that work environments are places that alleviate, not exacerbate, BH issues. Employers can also offer programs such as behavioral-health literacy training, wellness seminars, and personalized feedback to educate employees about the signs of psychological distress and available treatment options. Outside the workplace, there are opportunities to strengthen community supports offered by the broader ecosystem, such as community-based organizations that can be embedded in neighborhoods.

Our research shines a light on disparities—some accelerated by the COVID-19 pandemic—in access to behavioral-health services for several NYC populations. New York City is uniquely positioned to address these disparities given the recognition of the importance of behavioral health by public, private, and social stakeholders. Concerted action to address the unique needs of diverse populations and strengthen community prevention can help position the city as a leader in behavioral health for all its residents.

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