Mental and behavioral health

Challenges with mental and behavioral health are not uncommon. The National Institute of Mental Health reported that 1 in 5 adults in the United States is living with a mental illness. As of 2019, there were 51.5 million individuals with a diagnosed mental and behavioral health conditions. However, these may be underestimates since they only include adults who report or seek help for mental and behavioral health conditions.

Nationally, the prevalence of mental illness by age bracket in 2019 ranged between:

  • 18-25 years old: 29.4%
  • 26-49 years old: 25%
  • 50+ years old: 14%

Due to the wide variety of influential elements that shape mental and behavioral health, the process of unpacking the potential origins of the disorders and challenges that impact millions is vastly complex. There are various causal pathways that lead to mental health challenges and disorders in relation to the social, environmental, and structural drivers.

Several mental and behavioral health disorders can begin as early as birth and intensify later in life if untreated. Stimulation through literacy, language, and social relationships creates a foundation for better mental and behavioral health in our youth. Whether these are consistent within the developmental stages depends primarily on caregivers and the environment. If central areas in early brain development and mental stimulation are neglected, trauma and mental health disorders may be more prominent in the future.

Mental and behavioral health challenges can also emerge later in life. For adolescents and adults, the most prevalent mental health challenges derive from trauma and stress. Furthermore, according to the National Alliance on Mental Illness, of those provided with a mental and behavioral health diagnosis:

  • 20.6% of U.S. adults experienced mental illness struggles in 2020. This represents 1 in 5 adults.
  • 5.2% of U.S. adults dealt with serious mental illness challenges in 2020 (13.1 million people). This represents 1 in 20 adults.
  • 33.3% of U.S. young adults (age 18-25) are diagnosed with a mental health illness in 2020. This represents 1 in 3 young adults.
  • 3.8% of U.S. adults experienced a co-occurring substance use disorder and mental illness in 2019 (9.5 million people).

As research and data on the mental health status of the nation continue to grow, the reality that mental and behavioral health challenges are widely experienced becomes more concrete. It also demonstrates the need for further progress in reframing mental health as an aspect of health, which requires routine monitoring and tending. There is a spectrum that exists for trauma and mental health, in which everyone experiences, to some degree, from small daily inconveniences to life-threatening trauma. Based on the frequency of encounters with stress, trauma, and crisis, some individuals become more susceptible to severe mental health challenges and disorders.

The annual prevalence among U.S. adults, by condition in 2019:

  • Major Depressive Episode: 7.8% (19.4 million people)
  • Schizophrenia: <1% (estimated 1.5 million people)
  • Bipolar Disorder: 2.8% (estimated 7 million people)
  • Anxiety Disorders: 19.1% (estimated 48 million people)
  • Post-traumatic Stress Disorder: 3.6% (estimated 9 million people)
  • Obsessive-Compulsive Disorder: 1.2% (estimated 3 million people)
  • Borderline Personality Disorder: 1.4% (estimated 3.5 million people)

Undoubtedly, we have made great strides through public health, medicine, and community-based efforts to provide interventions and treatments for mental and behavioral health challenges. However, in the face of structural and social barriers that still exist, there is more work to be done.

Treatment rates by the numbers:

  • 43.8% of U.S. adults received mental illness treatment in 2019
  • 65.5% of U.S. adults received treatment for serious mental illness conditions in 2019
  • 50.6% of U.S. youth aged 6-17 with a mental health disorder received treatment in 2016

Annual treatment rates among U.S. adults with any mental illness by demographic group in 2019:
Female: 49.7%
Male: 36.8%
Lesbian, Gay, or Bisexual: 49.2%
Hispanic or Latino: 33.9%
Non-Hispanic Asian: 23.3%
Non-Hispanic Black or African-American: 32.9%
Non-Hispanic mixed/multiracial: 43.0%
Non-Hispanic White: 50.3%

There is a need to figure out a better way to make treatment for mental and behavioral health more accessible:

  • 10.9% of U.S. adults with mental illness had no insurance coverage in 2019
  • 11.9% of U.S. adults with serious mental illness had no insurance coverage in 2019
  • 55% of U.S. counties do not have a single practicing psychiatrist
  • People with depression have a 40% higher risk of developing cardiovascular and metabolic diseases than the general population. People with serious mental illness are nearly twice as likely to develop these conditions
  • 18.4% of U.S. adults with mental illness also experienced a substance use disorder in 2019 (9.5 million individuals)
  • The rate of unemployment is higher among U.S. adults who have mental illness (5.8%) compared to those who do not (3.6%)
  • High school students with significant symptoms of depression are more than twice as likely to drop out compared to their peers

Current mental health data illustrates the broad gaps and areas for improvement in access, support, and reducing stigma for trauma and mental health. Overall, there need to be more effective ways to streamline treatments and solutions for addressing mental and behavioral health challenges affecting populations today.

Awareness and critical conversation around the topic of mental health and well-being have demonstrated powerful effects in reducing stigma and helping communities build resiliency. Among younger generations, there has been increased recognition and discussion surrounding mental health elements such as self-care, wellness, and signs of burnout. Adaptation of terminology to advocate and measure thresholds regarding mental health are tremendous indications of societal progress and growth.

Together, we can work to build healthier communities and change the conversation around mental and behavioral health. Sharing personal accounts, understanding terminology, and identifying resources such as this, are the first step in recognizing mental and behavioral health and its impact on individuals, families, and communities. We hope this page provides a greater understanding that mental and behavioral health is an essential component of overall health and well-being for all. Hopefully, it serves as inspiration for potential actions and strategies to improve mental and behavioral health in your community and workplace.

chapter 1

Evaluation of prevention and harm reduction strategies

The subject of mental and behavioral health can make people feel uncomfortable. Many are unsure how to provide support to someone in need or which questions to ask. Moreover, it is difficult to determine which mental and behavioral health interventions are best due to varying levels of need specific to each individual. Dr. Jaimie Gradus of the Boston University School of Public Health (BUSPH) has conducted research that shines a light on mental health evaluations and the types of trauma and social inequities that can lead to trauma and mental health challenges. In a recent study, she explored the “constellation of factors” that shape mental health and uncovered the growing ways social determinants of health such as class, race, ethnicity, neighborhood, gender, sexuality, and other factors shape an individual’s life. Crucial data resulting from such studies can better inform strategies for advancing mental health evaluation and treatment.

To prevent and reduce harm regarding mental and behavioral health, we need to understand the environment surrounding each case to push forward with more evidence-based solutions. The social determinants of health play a vast role in the development of these issues and working to understand and define how factors may trigger mental and behavioral health.

Comparative to numerical data, the evaluation of prevention and harm reduction strategies is equally essential to fostering progress in mental and behavioral health. It is a crucial component, emphasized by Public Health Analyst and BUSPH MPH alumna, Ashley King, who explains, “our qualitative work is just as valuable as our quantitative work. We can offer programs and provide health communication materials, but we have to know if we’re making an impact and doing the things that we intended to do.” This telling statement from King stresses that not all trauma and mental health can be measured by data. To best understand the factors that can trigger some of the larger mental and behavioral health concerns, like harm or substance use, we must invest in research that uncovers the causal pathways. Once the web is untangled, we can offer more compassionate guidance to reduce the risk of harm, manage substance use, and prevent substance use disorder and other adverse outcomes.

Other resources:

Understanding the Complex ‘Constellation of Factors’ That Shape Mental Health – Jaimie Gradus

COVID Has Likely Tripled Depression Rates in the US. – Sandro Galea, Catherine Ettman, Salma Abdalla, Gregory Cohen

As Latin American Populations Urbanize, Neighborhood Impacts Mental Health – Sandro Galea

PHX Webinar – Mental Health Stigma webinar: Sarah Ketchen Lipson –

Trump-Era Opioid Use Disorder Treatment Proposal Should Go Forward Richard Saitz and colleagues

‘Evaluation Is So Important’ – Ashley King (SPH alum)

chapter 2

Social determinants of mental health and illness

To best understand the factors that can trigger more severe trauma and mental health concerns, like trauma or substance misuse, we must take a deeper and more thoughtful look at the social determinants of mental health and illness.

The social determinants of health, and the offshoot of social determinants of mental health, are a widely accepted way of measuring the impact of “conditions in which people are born, live, learn, work, play, age, etc. affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These categories for social determinants go beyond the traditional scope of health diagnosis, as they connect health to interdependent factors such as race, ethnicity, gender, age, income level, sexual orientation, geographic location, and social interactions.

Due to existing research, we know these social determinants are inextricably linked to mental and behavioral health. An individual’s identity, lifestyle, and environment are all conditions that serve as indicators of mental and behavioral health habits and challenges. Ensuring these factors are addressed can lead to healthier communities.

Social determinants of mental health include:

  • Race/ethnicity
  • Age
  • Income level
  • Neighborhood
  • Gender and sexuality
  • Other factors

Social inequities are a large factor in the social determinants of mental health, and they go hand in hand with health inequities. One Boston University study conducted by our colleagues at the Black Women’s Health Study found that those who experienced racism may have lower cognitive function and memory damage later in life. Oftentimes, historically excluded and underrepresented groups – many of whom experience racism at some point in their life – have less access to mental health care and resources. These groups are also less likely to seek treatment for mental health concerns. 

According to The National Alliance on Mental Illness, the annual reported prevalence of mental illness among U.S. adults by demographic group: 

Non-Hispanic Asian: 14.4%

Non-Hispanic white: 22.2%

Non-Hispanic Black or African-American: 17.3%

Non-Hispanic American Indian or Alaska Native: 18.7%

Non-Hispanic mixed/multiracial: 31.7%

Non-Hispanic Native Hawaiian or Other Pacific Islander: 16.6%

Hispanic or Latino: 18.0%

Further, they determined that 44.1% of those who identify as lesbian, gay, or bisexual experienced a mental illness. 

These statistics suggest under-reporting in historically underrepresented demographic groups. These are groups we know can be negatively affected by conditions that play an important role in shaping mental health, including socioeconomic status and financial stability. This creates a complicated web of social and health inequities and highlights the need for improved awareness and access to mental and behavioral health care.

An article entitled “Social Determinants of Mental Health: Where we are and where we need to go” by our peers at Harvard Medical School presents the notion that mental health and social determinants have reciprocal effects:

“Although less frequently discussed than the converse pathway, mental illness can also impact social determinants, including homelessness, school dropout, marital instability, and economic insecurity. A two-way relationship exists between mental health disorders and social determinants, as poor mental health can aggravate personal choices and affect living conditions that limit opportunities.” 

The underlying current across these social determinants of mental health is stress. There is a spectrum of stress on a continuum that are infused across each of these factors. Nobody is immune from the complexities of trauma and mental health; however, vulnerable populations often experience higher levels of stress due to systems and policies that work against their health and wellbeing. Unfortunately, health systems are poorly designed to address the full spectrum of stress, lacking the appropriate resources, tools, and programs necessary to support it. In recognition, health structures are slowly beginning to change to provide better access and minimize mental health-related stigmas.


Other resources: 

Thinking beyond health care to improve health

New BU Lab Studies Medicaid Where Racism, Poverty, and COVID-19 Meet

Youth Mental Health Access during COVID-19 Trish Elliott, Emily Feinberg

chapter 3

Mental health and stress in the workplace

Mental health in the workplace is important – as multiple studies show, healthy and stable employees lead to better productivity. That said, there is increasing attention on the need to support mental health and stress in the workplace. Some employers openly encourage mental health awareness in their onboarding materials and the organization’s mission statement. Despite the public embrace, some employers struggle to translate support into action, which places mental health benefits in the workplace at a standstill.

Mental health in the workplace is impacted by stress and looming deadlines. Many employees are juggling tasks simultaneously, and, with the COVID-19 pandemic, the blending of work and home life can further increase stress levels. This is especially true with women who are found to share an unequal burden within COVID-19’s economic fallout.

Historically excluded populations also carry an unequal burden of stressors as they are more likely to hold positions within high-risk occupations such as the transportation sector, essential shop work, and the health sector. The increased risk of COVID-19 within these roles, mixed with the already prevalent inequities, heightens the risk of increased stress and poor mental health in the workplace.

The CDC has outlined how poor mental health and stress can negatively affect an employee in ways such as:

  • Job performance and productivity
  • Engagement with the work at hand
  • Communication with coworkers
  • Physical capability and daily functioning

Further, the CDC writes: 

  • Depression interferes with a person’s ability to complete physical job tasks about 20% of the time and reduces cognitive performance about 35% of the time.
  • Only 57% of employees who report moderate depression and 40% of those who report severe depression receive treatment to control depression symptoms.

High levels of stress and poor mental health in the workplace can bleed into home and social life, as well as physical health. A work-life balance is necessary to avoid serious effects such as burnout, chronic stress, and anxiety, which all negatively impact overall health and wellbeing.

The CDC suggests businesses may proactively aid in fostering improved mental health in the workplace by:

  • Promoting mental health and stress management educational programs for working adults through public health departments, parks and recreational agencies, and community centers.
  • Supporting community programs that indirectly reduce risks, such as increasing access to affordable housing, opportunities for physical activity (like sidewalks and trails), tools to promote financial wellbeing, and safe and tobacco-free neighborhoods.
  • Creating a system that employees, employers, and health care providers can use to find community-based programs (for example, at churches and community centers) that address mental health and stress management.
  • Allowing the space for “mental health days.”

These statistics exemplify the need for a merger between mental health in the workplace. It is also evident the demand is only expected to increase, especially with the pandemic exacerbating stress and mental health challenges. Researchers at the Boston University School of Public Health found that 32.8% of US adults experienced depressive symptoms in 2021, compared to 8.5% before the pandemic. With all communities feeling the effects of mental health challenges, we need to uncover how the workplace might be contributing to poor mental health, as well as how it can aid in developing potential solutions. Based on recent research, there is evident business value in fostering positive mental health and supporting the wellbeing of employees.


Other resources:

The Dangers of Trying to Be Superwoman – Jasmine Abrams

Depression Rates Tripled and Symptoms Intensified during First Year of COVID – Sandro Galea, Catherine Ettman, Gregory Cohen, Salma Abdalla

COVID-19’s Economic Fallout: Women Shouldering an Unequal Burden – BUSPH Sharecare, Sandro Galea

Public Health Conversation: Antiracism as Health Policy: Race, COVID-19, and Policy Reform

chapter 4

Adolescent and child mental health

As we strive for equitable mental health solutions and treatments, it is crucial to ensure that adolescent and child mental health is viewed as a priority. An article from November 2019 entitled “Pediatric Behavioral Health Care Integration Shows Promise” starts with:

“Although an estimated one in five children in the U.S. has a behavioral health issue, there are substantial unmet needs and systemic barriers to accessing behavioral health care. Progress to integrate behavioral health into pediatric primary care has been slow, especially for low-income communities.”

The idea of improving access to mental health care is necessary for this vulnerable population, especially for those unaware that they need it. The NAMI reported that 50% of all lifetime mental illnesses develop by age 14, and 75% develop a mental illness by age 24. This statistic highlights the glaring need to bring awareness to the frequency of mental health conditions among teens and young adults. Not only that, but it could be due to inherent underlying child mental health issues that are left undiagnosed or noticed. Considering, the sooner a beneficial intervention method is introduced, the greater the chances of preventing more adolescent and child mental health issues and inequities.

As it stands today, the COVID-19 pandemic is proving to be an alarming event that jeopardizes many people’s trauma and mental health faculties, including college students. A recent survey suggests that 83% of students claimed their mental health negatively impacted their academic performance. Additionally, two-thirds of college students were struggling with a feeling of loneliness and isolation, which is an all-time high due to the impacts of social distancing, quarantine, and loss felt during the COVID-19 pandemic.

To keep adolescent and child mental health in a positive place, mental stimulation should persist from childhood up until college-aged years. Youth thrive in group settings and engaging with peers. Low levels of child mental health care may lead to issues as that child progresses into adolescence and adulthood.


Other resources:

Professor Launches ‘Return on Investment Tool for College Student Mental Health – Sarah Lipson

Depression, Anxiety, Loneliness Are Peaking in College Students – Sarah Lipson 

Gathering Data on College Student Mental Health, and Putting It to Use. – Sarah Lipson

Professor Studies Impact of Chemical Exposures on Child Brain Development – Birgit Claus Henn

In College Students, COVID-19 Has Increased Depression Rate and Raised New Barriers to Mental Health Care. – Sarah Lipson

Pediatric Behavioral Health Care Integration Shows Promise – Megan Cole, R. Christopher Sheldrick

Youth Mental Health Access during COVID-19 – Patricia Elliott

Among College Students, Mental Health Diagnosis and Treatment Up, Stigma Down – Sarah Lipson

Privacy Law Gaps in High School STI Health Services – Emily Feinberg

chapter 5

Aging and mental health

* We acknowledge elderly is increasingly becoming a term that does not accurately describe the aging community. The term ‘elderly’ is used throughout this chapter to align more closely with the official language in health data and research journals.

In 2019, there were over 54.1 million adults over the age of 65 in the U.S. By 2050, that number is expected to grow to almost 90 million. This shift comes with many considerations for the aging population, including mental health in aging populations. Dementia and Alzheimer’s disease are a significant concern for mental health in aging populations. Currently, there are 55 million people around the world living with dementia. Older populations have the highest prevalence of dementia cases, with the global prevalence projected to rise to 82 million people by 2030.

Dementia and Alzheimer’s is considered a mental health concern and is characterized by:

  • Forgetfulness
  • Losing track of the time
  • Becoming lost in familiar places
  • Enduring an increasing difficulty with communication
  • Needing help with personal care
  • Behavior changes
  • Having difficulty recognizing relatives and friends

Unfortunately, to date, there is no cure for dementia; there are only ways to manage it if one is fortunate enough to have the means to afford the treatment and management practices. Managing dementia in 2021 will cost the US $355 billion, including $239 billion in Medicaid and Medicare costs. Mental health in aging populations is a key concern, partly due to the impact dementia and Alzheimer’s will have on the growing older population.

Some of the common risk factors for dementia laid out by the CDC include:

  • Age
  • Family history
  • Traumatic brain injury
  • Race/ethnicity

Older African Americans are twice as likely to have dementia than whites. Similarly, Hispanics are 1.5 times more likely to have dementia than whites. In exploring potential causal pathways for the disparate health outcome, our colleague, Professor Lynn Rosenberg, is taking a closer look at how racism is associated with the triggering and progression of dementia. She stated:

“We found an association between experiencing racism—which is a stressor—and lower cognitive function. There’s a lot of evidence that stressors are related to poorer cognitive function. The part of the brain called the hippocampus, which has a lot to do with memory, is affected by stress hormones called cortisol. Chronic stress increases cortisol levels, which actually causes the tissue of the hippocampus to shrink over time.”

The report goes on to state, “Black women who reported experiencing the highest levels of interpersonal racism (for example, hearing racial slurs) had 2.75 times the risk of poor subjective cognitive function as women who reported experiencing the lowest levels of interpersonal racism. Those who experienced the highest levels of institutional racism (for example, having been discriminated against in pay or promotions in the workplace) had 2.66 times the risk of poor subjective cognitive function as those who reported no such experiences.”

Stress is one of the primary driving forces compromising trauma and mental health in aging populations, which is the basis of Professor Jaimie Gradus’s study showcasing how stress disorders such as PTSD increase the risk of dementia later in life.

The study, published in the American Journal of Epidemiology, “found that a stress disorder diagnosis was associated with a nearly three-fold increase in the rate of developing dementia. The association between most stress disorder diagnoses, and dementia was more pronounced among men, except for PTSD, which had a stronger association for women.”

Elderly mental health takes on many shapes and sizes, and dementia is just one area that our researcher explored on a deeper level. However, the significance of assessing elderly mental health does not begin and end with dementia. Depression is also an important concern for mental health in aging populations. Additional effort and support towards mental health in aging populations is needed to ensure those in our lives receive necessary care for this age demographic today and in the future. On the slightest level, mental health in aging populations can be improved by interaction with others and assurance of supportive caregivers. On a population level, new programs and technologies devised to help discover causes, treatments, and preventions for those struggling with mental health challenges can be monumental.

* We acknowledge ‘elderly’ is increasingly becoming a less preferred term for referring to the aging community. It is used throughout this chapter to align with the official language in health data and research journals. Learn why “elderly” is no longer politically correct.


Other resources:

Stress Disorders Increase Risk of Dementia – Jaimie Gradus

Experiencing Racism May Damage Memory, Cognition – Lynn Rosenberg

chapter 6

Trauma and PTSD

Trauma and PTSD, or post-traumatic stress disorder, play a significant role in viewing and measuring overall mental and behavioral health assessments. While trauma and PTSD are frequently thought of as health issues that are particularly relevant to military members and veterans specifically, a high prevalence of trauma has been documented among civilians. Trauma is common, with some estimates suggesting over 70% of people will experience at least one traumatic event in their lifetime. Post-traumatic stress disorder (or PTSD) is a psychiatric disorder that a minority of people will experience following a traumatic event. PTSD is commonly comorbid with other psychiatric disorders, such as depression and substance use, and some recent research has shown that these and other diagnoses can also follow trauma in the absence of PTSD. The National Center for PTSD states that 8-10% of people will suffer from PTSD at some level.

The Mayo Clinic reports that “post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event. These symptoms cause significant problems in social or work situations as well as in relationships. They can also interfere with your ability to go about your normal daily tasks.”

PTSD symptoms are generally grouped into four broad categories: 

  • Intrusive memories
  • Avoidance
  • Negative changes in thinking and mood
  • Changes in physical and emotional reactions. 

Symptoms can vary over time or vary from person to person.

According to an article by Professor Jaimie Gradus, “post-traumatic stress disorder is a potentially chronic and debilitating condition associated with significant injury and death, as well as disruptions in family, workplace, and social contexts. Extensive research has documented the negative consequences of PTSD, including other forms of psychopathology, such as depression, cardiovascular disease, a decline in quality of life because of poor health, and increased rates of suicide.” 

To add further concern, trauma and PTSD can significantly decrease physical health. People who have experienced trauma and PTSD are prone to heart disease, stroke, obesity, diabetes, and cancer. Trauma and PTSD also nearly double a person’s chance of different infections – adding more layers of complication. 

For example, a former Post-Doctoral Fellow at BUSPH, Tammy Jiang, led a study published in the Journal of Epidemiology examining the relationship between PTSD and dozens of different infection types in a nationwide cohort. According to the article, this study was “the first to find that PTSD affects infection risks for men and women differently, having, for example, more of an effect on a woman’s risk of urinary tract infection and a man’s risk of skin infection.”

The study shows:

“After adjusting for other physical and mental health diagnoses and for marriage/registered partnership… that people with PTSD were 1.8 times as likely to have any infection as those without PTSD. This ranged from being 1.3 times as likely to have meningitis, to 1.7 times as likely to have influenza, to 2.7 times as likely to have viral hepatitis.” 

This research helps us better understand that trauma and PTSD have more serious detriments to physical, mental, and behavioral health over time.


Other resources: 

Identifying new pharmacologic treatments for post-traumatic stress disorder – Jaimie Gradus

PTSD Nearly Doubles Infection Risk – Jaimie Gradus, Henrik Sorensen

Streamlining PTSD Diagnosis with Machine Learning – Jaimie Gradus, Tammy Jiang

Professor Receives $2.3 Million to Explore Medications for PTSD– Jaimie Gradus

chapter 7

Gender identity and mental health

Although there is still a vast need for improvement, in recent times, we have increased national recognition that the complexity of gender identity extends far beyond the perceived binary biological sex markers: male or female. According to Planned Parenthood, “gender identity is how you feel inside and how you express your gender through clothing, behavior, and personal appearance.” Most importantly, this form of expression is unique to each individual. 

However, whether through personal reflection, or a review of the historical track record of gender oppression and discrimination from the government and society, we know exercising these freedoms of expression does not come as easy to everyone.

Gender expression can be heavily limited by a multitude of societal expectations, social norms, systemic barriers, traditions, and cultural standards. The elements can be manifested through laws, health care services, and social circles – all serving as forceful deterrents, preventing an individual from willingly expressing oneself. These hurdles can easily serve as triggers for countless individuals grappling with gender identity and mental health through a mental health lens.

Unfortunately, the internal and external struggles do not cease entirely as one begins to openly embrace and express their true gender identity. By accepting deviation from what is safe and known, an individual may be subject to increased feelings of being unsafe, uncomfortable, and out of place.

According to the headspace National Youth Mental Health Foundation, additional experiences regarding gender identity that can impact wellbeing and vulnerability to mental health challenges are identified as: 

  • Feeling different from other people around you
  • Transphobic bullying about your gender identity, whether verbal or physical
  • Feeling pressure to deny your feelings regarding your gender identity
  • Worries that your gender identity will not be accepted by friends and family members, along with the possibility of being rejected or isolated
  • Feeling unsupported or misunderstood by family or friends
  • Feeling stressed and anxious in relation to the pressure to conform with your biological sex

The sobering reality that these experiences are a common result of gender identity and expression stress that gender identity and mental health go hand in hand. These pressures can be very taxing, especially when combined with other life circumstances such as forming relationships, career, and academic pursuits.

To better understand the connection between gender identity and mental health from the perspective of college students, Dr. Julia Raifman, Assistant Professor of Health Law, Policy & Management at Boston University School of Public Health; Dr. Sari Reisner of Harvard Medical School and The Fenway Institute; and Dr. Sara Abelson of the University of Michigan School of Public Health, studied rates of depression, anxiety, eating disorders, self-injury, and suicidality in a sample of over 1,200 gender-minority students from 71 colleges and universities. The term “gender minority” refers to individuals whose gender expression and/or identity is different from their biological sex assigned at birth. 

According to Dr. Raifman, “about 78% of the gender-minority students included in the study met the criteria for one or more mental health problems, with nearly 60% of gender-minority students screening positive for clinically significant depression, compared to 28% of cisgender students (those whose gender assigned at birth aligns with their current gender identity).” They continued, “reports that more than 40% of transgender people have attempted suicide in their lifetimes suggested, to me, that there is a large and disproportionate burden of disease among [people in the gender minority] that public health research can contribute to addressing.” 

As alluded to by Dr. Raifman, the gap in adverse health outcomes among gender minority communities is far too extensive to ignore. Although culture change is happening to broaden understandings of gender identity and expression, it is happening very slowly, and we cannot afford to wait as society continues to grapple with the multiple dimensions involved. There is a dire need for immediate services and protections to support gender identity and mental health in current times.

If you are experiencing suicidal thoughts of any kind and need someone to talk to, don’t hesitate to reach out to the following resources:

Other resources: 

Transgender College Students Face Enormous Mental Health Disparities – Sarah Lipson, Julia Raifman

COVID-19 and LGBTQ Populations – Ulrike Boehmer, Sarah Lipson, Julia Raifman, Harold Cox, Kim Nelson, Allegra Gordon 

Queer Teens Say ‘Physical Sex Is Over for Now’ – Kim Nelson, Allegra Gordon

More Teens Coming Out, But Suicide Attempts Still HighMichael Stein 

chapter 8

Racial and ethnic gaps in equity in mental health

Undoubtedly, the impacts of race and ethnicity manifest in various sectors of life – and due to a growing body of research, it is evident there are links between racial identity and mental health. 

However, the American Psychiatric Association reports underrepresented racial and ethnic groups are less likely to receive mental health care. “In 2015, among adults with any mental illness, 48% of whites received mental health services, 31% of Blacks and Hispanics, and 22% of Asians.”

For a host of reasons, there is a noticeable lack of access to treatment within communities of color. Even when accounting for conceptual barriers such as medical distrust and mental illness stigmas that deter people of color from seeking mental health services, they are outnumbered by a considerable number of structural barriers.

Amplifying a concept that BUSPH researcher, Dr. Jaime Gradus, describes as a “constellation of factors that shape mental health,” authorities like the CDC and U.S. Surgeon General have marked various disparities at the intersection of race, ethnicity, and mental health. They include a lack of cultural humility, competency, and diversity among mental health providers and services. There are also numerous gaps between provider and patient standards of care in healthcare systems, all of which impact help-seeking utilization, persistence, retention, and trust.

Documented racial and ethnic inequities in trauma and mental health are largely due to racism, ranging from structural to interpersonal. In acknowledgment of the overwhelming influence these discriminations and biases have on the mental wellbeing, and by extension, physical health, for people of color, Boston University School of Public Health held a symposium on Reducing Health Inequities: Advancing Meaningful Change. The forum highlighted racial inequity directly harms health status, and experiences of discrimination, whether major events to everyday instances, can lead to a form of chronic stress. Several speakers echoed this sentiment, particularly how this negative effect on mental health straddles communities across stages of the life course and identity.

Dr. Sarah Lipson of BUSPH is determined to explore the startling disparity in treatment utilization along ethnic and racial lines for college students. Drawing from survey data collected during the Healthy Minds Study, an article published in the Journal of Adolescent Health stated:

“42 percent of the students met criteria for a mental health problem…among African American students with a mental health problem, only 21 percent had received a diagnosis…while Asian/Asian American students had the lowest prevalence of treatment at 23 percent, and international Asian students had an even lower prevalence, at 19 percent.”

In discussing mental health disparities among college students of color, Dr. Lipson indicates the necessity of meeting the mental health needs of racially diverse students has implications beyond degree completion. She says, “it is essential to supporting their success and creating equity in other dimensions.”

In light of these disproportionate factors, researchers such as BUSPH alum, Sukhmani Bal, are utilizing their experiences and knowledge in navigating a discriminatory mental healthcare system to promote change. Dr. Bal’s work recently presented at the National Alliance on Mental Illness (NAMI) focuses on “advocacy understanding around mental health and mental illness, specifically among Asian and South Asian populations, which often creates a significant barrier to seeking and receiving care.”

Overall, there is a dire need for more mental and behavioral health support for diverse communities. Though increasing data on mental health disparities at the intersection of race and ethnicity are cause for alarm, it is also a site of resiliency, advocacy, and hopeful futurity. These findings are critical to informing future policy and practice, as well as ongoing community empowerment and engagement efforts.


Additional resources:


Healthy Minds Study Sarah Lipson

Significant Disparities in College Student Mental Health Treatment Across Race/Ethnicity

Reducing Health Inequities: Advancing Meaningful Change

Alum Educates on Intersection of Identity and Mental Illness

chapter 9

Global mental health

Mental health disorders are common worldwide. It’s estimated that around 11% of our global population lives with a mental health disorder. Further, according to the Global Burden of Diseases, Injuries, and Risk Factors Study, mental disorders were the 2nd leading cause of disability worldwide in 2019 – with the majority being depressive and anxiety disorders. 

Despite the high prevalence of global mental health disorders, countless people lack access to mental health services needed, especially in low- and middle-income countries. A BUSPH alumna, Damilola Iyiola, worked in Zanzibar to understand the challenges around mental health services and identified access as the primary issue.

In Zanzibar, the self-governing state off the coast of Tanzania, most of the barriers preventing patients and families from seeking mental health care were centered on transportation costs, travel time, and work delays. Iyiola explains these barriers persist even if the need for psychiatric treatment is realized to be more effective than more traditional or spiritual remedies. Building on the qualitative data and personal accounts, Damilola Iyiola concluded, “Many people would prefer more community-based services, so they don’t have to leave their communities to get care.”

With similar realizations of access barriers happening across the globe, the integration of trauma and mental health services into primary and community-based care is becoming a central priority within global mental health. In practice, non-specialist health care and community health workers will be trained to deliver mental health care. The implementation of integrated services is already underway in Zanzibar and is expected to have various benefits. In addition to increasing treatment, this solution is economically sustainable for many developing and low-income countries experiencing severe shortages in psychiatrists, psychologists, and other resources to help people take charge of their own wellbeing. Additionally, having primary care providers administer mental health care allows the discretion needed to combat the shame powered by stigmas in seeking clinic- and center-specific mental health services.

According to the World Health Organization, “many mental health conditions can be effectively treated at relatively low cost, yet the gap between people needing care and those with access to care remains substantial.” To ensure more access and benefits to better care moving forward, “increased investment is required on all fronts: for global mental health awareness to increase understanding and reduce stigma.” Through collaboration and sharing of resources and information, we can collectively work to reduce the degree of mental and behavioral health issues that exist globally.


Additional sources: 

United Nations Sustainable Development Goals for 2030

Busting the myth that depression doesn’t affect people in poor countries

Studying Mental Health in Zanzibar

Stigma of mental illness and cultural factors in Pacific Rim region: a systematic review

chapter 10

Climate change, natural disasters, and mental health

The links between climate change and health are seemingly endless. In the face of climate change, global populations are experiencing a plethora of growing challenges due to extreme weather ranging from extreme heat, wildfires, hurricanes, flooding, and drought. In addition to the physical environment, economic stability, and basic resources of countless people directly impacted, the culmination of these detrimental stressors influences mental health outcomes. 

Amruta Nori-Sarma, an Assistant Professor of Environmental Health at BUSPH, explores the mental health implications of climate change, natural disasters, and extreme weather events. She explains: “There are a host of mental health outcomes that have been associated with extreme weather events. Those most studied include PTSD in the wake of natural disasters, which can cause chronic illness in the long term, but we are also interested in changes in anxiety and depression, as well as psychosocial wellbeing and emotional resilience.”

As the consequences of climate change increase, so will the demand and need for mental health resources. Population displacement, trauma and PTSD from these extreme events can cause financial and social instability and contribute to substantial mental health burdens. Further, climate events which may cause trauma can also interrupt delivery of mental health services due to supply chain issues that prohibit the accessibility of necessary medical supplies and support.

A recent article on natural disasters and climate health stated:

“Populations feel the effects of large-scale natural disasters long after the immediate aftermath. Rates of PTSD after a disaster can be as high as 40 percent, and while the symptoms fade with time for most people, nearly a quarter of cases can be chronic and severe. Previous research has shown that lower-income people and people who are economically harmed by a disaster, such as by losing their homes, are most likely to develop PTSD.”

Although natural disasters and extreme weather events differ by region, the resulting stress and mental health challenges are more universal. Considering this, we mitigate adverse mental health outcomes following environmental calamity on a global scale.

According to a new simulation study led by School of Public Health researchers, “helping individuals restore economic resources and housing after a natural disaster would significantly reduce the mental health burden in the population.” They reference a publication by Dr. Gregory Cohen and colleagues in The Lancet Planetary Health that assesses the effects of social services case management approaches after a natural disaster. Due to the efforts of caseworkers providing expedited access to personal loans and mental health services, the number of people who recover from PTSD one year after a disaster could be increased 1.5 to six-fold with the appropriate interventions in place.


Other resources: 

After Natural Disaster, Economic Help Reduces PTSD – Michelle Samuels, Gregory Cohen, Catherine Ettman, Benjamin Linas, Sandro Galea

Climate Change and a ‘Host of Mental Health Outcomes’ – Amruta Nori-Sarma, Greg Wellenius, Sandro G

Promising data for prediction of post-disaster mental health needs in an evolving disaster landscape – Greg Cohen

What’s the deal with climate change and health? (part one)

chapter 11

Mental health and suicide

The relationship between mental health and suicide is one that has been studied for decades. Globally, nearly 700,000 people die due to suicide every year. Death by suicide is the fourth leading cause of death among 15–19-year-olds, according to the WHO. Despite early interventions, prediction and prevention continue to be more difficult compared to the treatment of other public health conditions.

According to the National Alliance on Mental Health, socioeconomic factors and environmental stressors are often key risk factors for impaired mental health and suicide, including:

  • Physical health
  • Trauma and PTSD
  • Access to firearms
  • Substance use
  • Family history
  • Gender
  • Chronic health conditions

Additionally, adolescents who identify as lesbian, gay, or bisexual were reported to have had suicide attempts at a rate nearly four times higher than their straight peers in 2017. This is due to the societal pressures and unjust stigma they often face in and out of school.

The list is far from complete, and work continues to explore possible factors relating to mental health and suicide for effective prediction and prevention strategies.

Dr. Jaimie Gradus, associate professor of epidemiology at the Boston University School of Public Health, is part of a team of researchers examining risk factors for mental health and suicide. She has partnered with researchers at Aarhus University in Denmark to gain more insight into this topic.

“Every suicide death is the result of multiple interacting risk factors in one’s life,” she said. “One of the reasons that the suicide rate has not really improved despite decades of research is because studies have been hampered by what traditional statistics will allow us to look at once.”

Over the last few years, researchers have developed new models and updated others to help assess risk. But more work remains to be done to make further progress. 

Along with this, public policy can and will play an essential role in mental health and suicide prevention. One avenue would be exploring gun laws and safety education since handguns account for more than half of all suicide deaths, even in adolescents.


Other resources: 

Rural Gun Suicide Risks Shaped by Socioeconomic and Environmental Factors. – Bindu Kalesan

Young Adult Suicide Rate Linked to States’ Handgun Purchase Age Laws – Julia Raifman, Michael Siegel, Michael Ulrich, Sandro Galea

Predicting Suicide – Jaimie Gradus, Henrik Sorensen

More Teens Coming Out, But Suicide Attempts Still High – Julia Raifman, Michael Stein

Ziming Xuan – a pilot study on The Impact of State Anti-bullying Policies on Youth Suicidal Behaviors: A Pilot Policy Coding and Analysis Project

SPH This Year 2016 – various researchers 

Workplace Injuries Contribute to Rise in Suicide, Overdose Deaths – Leslie Boden, Yorghos Tripodis

Alcohol Policies Contribute to Suicide Prevention – Ziming Xuan, Richard Saitz, Timothy Naimi

White Men Over 50 Most Likely to Use Gun in Suicide – Bindu Kalesan, Sandro Galea

Firearm Ownership Closely Tied to Suicide Rates – Michael Siegel, Emily Rothman

More Teens Coming Out, But Suicide Attempts Still HighMichael Stein

chapter 12

Substance use and mental health

Substance use disorder is a serious trauma and mental health condition resulting from repeated use of substances leading to dysfunctional behavior. Often people use substances to self-medicate when experiencing stress, anxiety, or depression. You may have experienced something similar when a particularly stressful day triggers a desire to eat excessively or drink alcohol. For some, even relatively small amounts of substance use can lead to a rewiring of the brain’s reward pathway and the inability to control the use of a substance. 

With the epidemic of opioid misuse in the United States, more than 70,000 deaths alone were due to opioid overdose in 2016. The stress of the COVID-19 pandemic has led to an even more dramatic increase in substance use disorders. 

As a person becomes increasingly dependent on alcohol and/or other drugs, their quality of life can suffer. They may lose their ability to manage different parts of their life, like work or school, which can lead to other challenges such as housing instability and lack of access to healthcare. Though health professionals have worked to change how society perceives these challenges, people with substance use disorders often face unjust stigma, causing them to feel or become isolated from their community.

Substance use disorder and mental health can be intertwined, as well. According to the National Institute of Mental Health, about 50% of those with substance use disorders have a co-occurring mental health disorder and vice versa. To effectively manage a person’s recovery, both need to be treated.

Data surrounding substance use disorder can often be incomplete, making it harder to provide treatment or identify new prevention methods. At the Massachusetts Department of Public Health, researchers are working to build a system that better analyzes and breaks down the available data from the state’s Public Health Data Warehouse to better understand trends and patterns surrounding substance use disorder. This information will then be used to help create more cost-effective, accessible treatment options.

Boston University researchers have teamed up with Boston Medical Center to test and develop effective strategies for finding proven prevention and treatment methods for those with substance use disorders, with the ultimate goal of reducing overdose deaths by 40% over the course of three years.

If you are experiencing substance use disorder of any kind and need someone to talk to, don’t hesitate to reach out to the following resources:

Other resources:

Big data analytics to tackle substance use disorders – Laura White

Massive Study Will Reduce Opioid Overdose Deaths – Richard Saitz, Jeffrey Samet, Patricia Elliott, Traci Green, Megan Sandel, Mari-Lynn Drainoni, Traci Battaglia

Adolescent Cocaine Use Increasing Again – Ziming Xuan

Alcohol Consumption Has Spiked During the Pandemic. Could the Consequences Outlast the Coronavirus? – Craig Ross, David Jernigan

Substance use disorder vs. substance abuse – A disease NOT a personality flaw or moral failingCraig Ross

Jen Beard – a pilot study on Documentation of HIV Prevalence among People Who Inject Drugs (PWID) in Kumasi, Ghana: Evidence Needed to Develop and Evaluate the First Harm Reduction Program in Ghana

chapter 13

Substance use treatment

Substance use disorder treatment can be a challenge, as only about 20% of individuals receive treatment. Without treatment, those with substance use disorder remain at high risk for serious health complications or death.

Some of the most common barriers to receiving substance use disorder treatment include:

  • Patient eligibility
  • Treatment capacity
  • Understanding of options 
  • Communication problems

A team of researchers led by Michael Stein from Boston University’s School of Public Health sought to better understand patients’ barriers to receiving prompt treatment for substance use disorders. Researchers made several recommendations to improve the referral process, including a database with clear eligibility criteria, real-time information on treatment capacity, and increased education and training for providers on substance use disorder treatment.

In their publication, the researchers reported, “the demand for substance use disorder treatment is increasing, fueled by the opioid epidemic and the Affordable Care Act mandate to treat substance use disorders.” Additionally, they highlighted “the increased demand for treatment, however, is not being met by a corresponding increase in access to or availability of treatment.” Promoting the need for increased support from employers and the government to provide treatment and support options. 

Another method is to determine the effectiveness of current substance use disorder treatments. Are those going through these programs getting the help they need to begin their path to recovery and maintain it for the long term? Or do current treatment options only provide short-term solutions? Recovery from substance use disorder is a long journey, and effective treatments must take that into consideration. 

Racial and ethnic disparities can fuel substance use while inhibiting access to substance use disorder treatments. For example, a group of BUSPH researchers found in 2017 that those who are Black or Hispanic, unemployed, or have hepatitis C are more likely to disengage from treatment. Working to bridge inequities in healthcare and improve strategies for treating addiction can positively impact society as a whole while addressing many issues, including substance use disorder treatment.


Other resources:

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment – Mari-Lynn Drainoni

Brief Interventions in Doctor’s Offices Can Reduce Drinking by One Day Per Month – Richard Saitz

With $7.1M Grant, Professors to Study Unhealthy Drinking, Chronic Pain, Inactivity among People Living with HIV – Richard Saitz, Michael Stein

Does Vitamin D Deficiency Play a Role in Opioid Addiction? – Richard Saitz

Physical Therapy Access May Reduce Opioid Prescriptions – Michael Stein

Opioid monthly: Why—and how—the American Society of Addiction Medicine is redefining ‘addiction’ – Michael Stein

chapter 14

Family and caregiver mental health support

Family mental health support can provide unmeasurable benefits when dealing with serious or chronic illnesses. At times, the experience of having a mental illness can be isolating, and this support system can let an individual know they are not alone and others are advocating for them.

It’s important to note that family mental health support doesn’t always need to come from biological relatives. “Chosen family” support systems and caregivers are just as valuable when dealing with trauma and mental health conditions. 

For one, family mental health support combats loneliness. In 2018, a study by Cigna found that nearly 40% of survey participants reported feelings of isolation, in which some or all of their relationships feel meaningless. Loneliness can have a large detrimental impact on one’s mental and physical health. Alternatively, caregivers giving support to those experiencing mental illness can also impact their feelings of loneliness and isolation.

According to the American Psychological Association, these feelings put individuals at risk of: 

  • Substance use disorder
  • Sleep problems
  • Cognitive decline
  • Poor cardiovascular function
  • Depression, and
  • Impaired immunity

A strong support system for all parties experiencing poor mental health is important. Caregivers and those who provide family mental health support may have gone through similar experiences in the past. This shared experience helps ease the anxiety of treatment by providing insight into treatment options and pathways to healing and recovery.

Family mental health support also allows for accountability. For example, family members can help bring a person with a mental illness to and from appointments or provide stable housing while attending treatment. This can ease the burden of some of the most common challenges people face when accessing treatment.

Numerous studies show the positive effects of caregiving and family mental health support, especially for those dealing with serious or chronic illnesses. Research derived from the Community Health Sciences department at BUSPH investigated the effects of caregiver support for women with breast cancer. Studies found that patients with caregiver support were less likely to feel distressed and share more personal information. Similarly, researchers found that caregivers felt less distressed when working closely with others to support patients and perceived higher fighting spirits among patients.


Other resources: 

Intensive Caregiving May Have Health Benefits – Lisa Fredman

For LGBT Caregivers, Dual Stresses May Contribute to Worse Health, with Exceptions – Lisa Fredman

LGBT Caregivers Younger, More Diverse Than Non-LGBT Counterparts – Lisa Fredman

A pilot study on Social Support of Women with Breast Cancer – Ulrike Boehmer

chapter 15

Veteran and military mental health

Despite military veterans being disproportionately impacted by mental health challenges, more than half are not receiving the care needed. Nearly 1 in 4 active-duty members showed signs of a mental health condition in 2014, according to a study published in the Journal of the American Medical Association.

The three most common military mental health conditions, according to the National Alliance on Mental Illness, are post-traumatic stress disorder (PTSD), depression, and Traumatic Brain Injury (TBI). 

As shown in other sections, behavioral and mental health conditions such as PTSD, depression, and traumatic brain injury can impact an individual’s physical health and increase their risk of developing risky or dangerous behaviors. Officials changed rules around military mental health disclosures in 2014 to allow those serving to disclose or seek treatment for a mental health condition without fear of it affecting their careers. This positive step acknowledges the importance of addressing mental health concerns before they progress further.

When transitioning back to civilian life, veteran mental health care is just as important as physical health care. According to the U.S. Department of Veteran Affairs, the most common challenges associated with veteran mental health and readjusting to civilian life include:

  • Relating to those who don’t know or understand what military personnel have experienced
  • Reconnecting with family and re-establishing a role within the family dynamic.
  • Joining or creating a community
  • Entering the workforce
  • Creating structure
  • Adjusting to a different pace of work and life, including providing basic necessities (food, clothing, housing, etc.)
  • Adapting a more individualistic mindset versus a culture of service and teamwork

chapter 16

Novel methods to understand mental health

Understanding mental health is complex. With so many influencing factors, it can be difficult to fully determine how risk factors interact and the best ways to treat and support individuals and their specific needs. But BUSPH faculty are hard at work creating novel, innovative solutions for all stages of life, particularly regarding mental health care and substance use disorder. These solutions, in turn, can reduce the impact on an individual and help them live healthier lives.

Dr. Jaimie Gradus has a portfolio of novel research centered on mental health, with several studies centered on the mental health challenges experienced by veterans. Her recent work with colleagues from the Veterans Health Administration discovered a potential new use for Hepatitis C drugs in the treatment of PTSD. These discoveries are still a ways away from being standard treatment for PTSD, but it is a step closer to better understanding mental health and finding support for mental and behavioral health diagnoses. 

Dr. Sarah Ketchen Lipson, Assistant Professor of Health Law Policy and Management, explores the impact of internal and external stigma when seeking and continuing with mental health care. Through her Healthy Minds study, she found that an increasing number of college students reported experiencing some type of mental health issue and that stigma has become a “social contagion” among college peers. Her work is centered around breaking down this stigma and ensuring that programs can adapt to a student’s individual needs. Understanding mental health through the impact of internal and external stigma sets the baseline for future interventions that can help prevent negative mental health outcomes in future college students. 

Dr. Jacey Greece, a Clinical Assistant Professor for the Department of Community Health Sciences, created a course on ways to effectively plan and execute interventions. These include leveraging programs, policies, media campaigns, or other initiatives to change behaviors or environmental conditions to promote healthier living. Her framework provides evidence-based, sustainable solutions developed around the needs of a specific population so the interventions can have a lasting positive impact. 

Additionally, faculty are creating resources for families to better understand the mental health of their loved ones that help support them as they seek treatment for mental health challenges or substance use disorders. 

Altogether, these resources help us understand mental health challenges and the support systems needed to live happier, healthier lives.


Other resources: 

Family toolkit for mental health

Mental Health Stigma: Addressing Student Needs on Campus

Intervention Strategies in Public Health Course Design

Finding Compassion in a World of Chaos

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