Close to 10 million Americans suffer from chronic depression, bipolar disorder, or another serious mental illness. Depression alone is the leading cause of disability worldwide. In the United States, mental illness — including depression — takes an enormous toll on health outcomes, quality of life, and economic productivity.

Despite its importance, mental illness is often poorly understood and subject to misperceptions by the general population, government officials, and even those who suffer from mental illness. Partially as a consequence, just under one-third of individuals with serious mental illness — defined as diagnosable mental, behavioral, or emotional disorders that result in functional impairment — are untreated in the United States. In 2014, an estimated 44.7% of the 43.6 million adults with any mental illness, and 68.5% of the 9.8 million adults with serious mental illness received mental health services in the past year.

24/7 Wall St. reviewed the 12 states where the highest shares of the adult population suffers from serious mental illness.

Click here to see the 12 states struggling with mental illness.

Depression and mental disorders are treatable psychiatric illnesses. Therapy, as well as many prescription drugs such as anti-depressants, anti-psychotics and mood stabilizers are used to treat serious mental illnesses. Because of this, states with a high share of adults with serious mental illness also tend to have more psychiatric drugs prescribed per capita. The number of these and other kinds of retail drugs prescribed exceeded the national average of 12.7 prescriptions per capita in all but four of these 12 states. In West Virginia and Kentucky, more than 20 drugs are prescribed per person each year.

While the 12 states struggling the most with mental illness do not necessarily have the nation’s highest poverty rates, mental illness is far more common among people living in poverty. Of adults living in poverty, 8.7% report serious psychological distress, in contrast with 1.2% of adults with incomes at least four times higher than the poverty level, according to the CDC.

A number of socioeconomic factors are associated with mental illness, either as contributors or outcomes. People with mental illnesses are more likely than others to abuse alcohol or illicit drugs. Residents of states struggling the most with mental illness are not necessarily among the most likely to abuse drugs and alcohol. However, in the majority of states with the highest prevalence of serious mental illness, higher shares of adults report needing, but not receiving, treatment for drug use than the 2.2% national average.

States assign different levels of importance to mental illness. Budget allocation for mental health issues varies considerably between states. Only 12 states have increased their respective mental health authority’s budget in each of the past three years. Idaho is the only state with a disproportionately high share of mentally ill residents to have increased its mental health budget annually over this period. Meanwhile North Carolina, which is also home to one of the highest shares of mentally ill adults, is one of just three states to have reduced its mental health budget every year since 2013.

Several states with a relatively high share of adults with mental illness are implementing progressive policies to better address societal issues associated with mental illness. Indiana, for instance, implemented a policy last year requiring state police academies to provide a crisis intervention overview to all police trainees for emergency situations involving the mentally ill.

To determine the 12 states struggling the most with mental illness, 24/7 Wall St. reviewed the share of the adult population with a serious mental illness in each state based on surveys conducted between 2013 and 2014 from the Substance Abuse and Mental Health Services Administration (SAMHSA). Serious mental illness is defined as “having, at any time during the past year, a diagnosable mental, behavioral, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.” The prevalence of any mental illness, including serious mental disorders that may not have impaired life activities for example, also came from SAMHSA. The percentage of adults reporting at least one major depressive episode in the past year, the share of adults who had suicidal thoughts in the past year, and alcohol and illicit drug abuse rates also came from SAMHSA. Per capita drug prescription rates came from the Kaiser Family Foundation. State mental health legislation and spending was compiled by the National Alliance on Mental Illness. We also considered poverty rates, uninsured rates, and educational attainment rates from the Census Bureau’s American Community Survey (ACS) as well as 2015 annual unemployment rates from the Bureau of Labor Statistics.

These are the 12 states struggling the most with mental illness.

12. North Carolina
> Pct. of adults with serious mental illness: 4.7%
> Total adults with serious mental illness: 361,000 (8th highest)
> Pct. of adults abusing alcohol or illicit drugs: 8.7% (20th lowest)
> Poverty rate: 17.6% (13th highest)

Of North Carolina adults, an estimated 4.7% have a diagnosable mental, behavioral, or emotional disorder — that is, serious mental illnesses such as schizophrenia, bipolar disorder, post-traumatic stress, and eating disorders. This is the 12th highest share of all states. Mental illness is associated in particular with thoughts of suicide. In North Carolina, 4.3% of adults reported having thoughts of suicide in the past year, the eighth highest percentage in the nation.

Like only two other states, North Carolina has cut mental health spending in the last three years. Last year, despite the governor’s proposed 4% mental health spending increase, the legislature cut the budget by $84 million, or 14%.

11. Indiana
> Pct. of adults with serious mental illness: 4.7%
> Total adults with serious mental illness: 237,000 (13th highest)
> Pct. of adults abusing alcohol or illicit drugs: 9.3% (17th highest)
> Poverty rate: 15.5% (24th highest)

In Indiana, 7.6% of adults reported having at least one major depressive episode last year, one of the largest shares in the country. Chronic and persistent depression that interferes with day-to-day functioning is one of several serious mental illnesses that an estimated 4.7% of adults in Indiana struggles with.

In light of the relative prevalence of mental illness in the state, Indiana increased its mental health authority’s budget in 2015. The same year, Senate Bill 380 directed the Indiana Criminal Justice Institute to create a central resource for training, funding, and other technical assistance for crisis intervention teams across the state. The bill also requires state police academies to provide mental health crisis intervention overviews to all police trainees.

10. Utah
> Pct. of adults with serious mental illness: 4.8%
> Total adults with serious mental illness: 97,000 (19th lowest)
> Pct. of adults abusing alcohol or illicit drugs: 7.8% (3rd lowest)
> Poverty rate: 12.8% (15th lowest)

Slightly more than one in every five adults in Utah are living with some form of mental illness, which includes serious mental illness as well as a range of other less severe disorders, a larger share than in all but four other states. The share of adults living with serious mental illness such as bipolar disorder, schizophrenia, or chronic depression, at 4.8% is considerably higher than the 4.0% of American adults with such an illness.

Unlike some states, Utah is taking active measures to treat mental health issues. Last year, the state was applauded by NAMI for passing House Bill 209, requiring certain behavioral health specialists to complete additional suicide prevention training to renew their license to practice. Of Utah adults, an estimated 4.8% reported having thoughts of suicide in the past year, the highest percentage in the country.

9. Mississippi
> Pct. of adults with serious mental illness: 4.8%
> Total adults with serious mental illness: 109,000 (21st lowest)
> Pct. of adults abusing alcohol or illicit drugs: 8.3% (10th lowest)
> Poverty rate: 22.6% (the highest)

Psychological distress is far more common among people living in poverty than it is among more financially well-off individuals. Financial distress may partially explain the relatively high prevalence of serious mental illness in Mississippi, where 22.6% of people live in poverty, the highest poverty rate in the nation. Furthermore, 4.8% of adults in Mississippi are estimated to have a serious, diagnosable mental illness, among the highest percentages nationwide.

In addition to therapy, anti-psychotics, anti-depressants, and mood stabilizers are frequently used to treat serious mental illness. In Mississippi, 17.7 of these and other kinds of medications are prescribed per resident in a single year, the fourth highest prescriptions per capita in the country.

8. Ohio
> Pct. of adults with serious mental illness: 4.8%
> Total adults with serious mental illness: 434,000 (5th highest)
> Pct. of adults abusing alcohol or illicit drugs: 9.3% (18th highest)
> Poverty rate: 15.9% (19th highest)

Substance use is more common among those suffering from mental distress. Substances such as tobacco, alcohol and other drugs are frequently used as self-medication. In Ohio, 9.3% of adults abuse or are dependent on alcohol or illicit drugs, higher than the 8.8% national substance abuse rate. Adults in the state are also more likely than most American adults to suffer from short-term episodes of major depression. Of Ohio adults, 7.2% reported suffering from at least one major depressive episode within the past year, the ninth highest share of any state. Along with substance abuse and depression, adults in the state are also more likely to suffer from serious mental illness than most Americans. In Ohio, 4.8% of adults are living with a serious mental illness, one of the largest such shares in the country.

With relative prevalence of mental illness, Ohio residents are some of the most medicated in the country. Each year, roughly 17.5 prescriptions are filled for every state resident, considerably more than the 12.7 prescriptions filled for every American annually.

7. Idaho
> Pct. of adults with serious mental illness: 4.9%
> Total adults with serious mental illness: 59,000 (12th lowest)
> Pct. of adults abusing alcohol or illicit drugs: 9.1% (23rd highest)
> Poverty rate: 15.6% (20th highest)

In Idaho, 20.3% of adults have some sort of mental disorder, including serious mental illnesses as well as less severe mental disorders, one of the largest shares in the country and considerably more than the 17.8% share of American adults suffering from a mental illness. Of the state’s mentally ill residents, roughly 59,000 suffer from a serious mental illness — schizophrenia, severe depression, and other disorder that can cause severe functional impairment.

Perhaps because mental illness is more common in Idaho than in much of the rest of the country, the state is investing more in treatment programs. While many states are reducing funding for mental health services, Idaho’s Mental Health Services department’s budget has increased in each of the last three years, one of only 12 states to do so.

6. Missouri
> Pct. of adults with serious mental illness: 4.9%
> Total adults with serious mental illness: 230,000 (16th highest)
> Pct. of adults abusing alcohol or illicit drugs: 8.5% (18th lowest)
> Poverty rate: 15.6% (20th highest)

Nearly one in every 20 adults in Missouri report serious mental illness, which include a range of psychiatric ailments from schizophrenia to eating disorders. Mental illness in the United States has been largely misunderstood, underfunded, and undertreated — even for those with health insurance. Some states have taken notable steps to address the issue. Missouri’s legislature last year enacted Senate Bill 145, an act mandating health care providers to cover eating disorders.

Like most states struggling the most with serious mental illness, Missourians are more likely than adults nationwide to report at least one depressive episode or thoughts of suicide within the past year.

5. Kentucky
> Pct. of adults with serious mental illness: 4.9%
> Total adults with serious mental illness: 168,000 (21st highest)
> Pct. of adults abusing alcohol or illicit drugs: 7.9% (5th lowest)
> Poverty rate: 18.9% (5th highest)

Kentucky is home to a relatively high share of adults with a serious mental illness. Roughly 168,000 Kentucky adults have a diagnosable serious mental illness, 4.9% of the state’s adult population. By contrast, only 4.0% of American adults grapple with a serious mental illness. Since anti-depressants, anti-psychotics, and mood stabilizers are frequently used to treat mental illness, the relative prevalence of mental illness in Kentucky may explain the high level of drug prescriptions in the state. Each year, there are 22 of these and other kinds of prescriptions filled per state resident in a single year, the highest drug prescription rate in the country. Despite the relative prevalence of serious mental health issues, Kentucky has cut funding for its mental health department in each of the last two years.

4. Arkansas
> Pct. of adults with serious mental illness: 5.1%
> Total adults with serious mental illness: 115,000 (22nd lowest)
> Pct. of adults abusing alcohol or illicit drugs: 7.7% (2nd lowest)
> Poverty rate: 19.2% (4th highest)

In Arkansas, 7.1% of adults reported having a major depressive episode within the past year, and 4.5% reported having thoughts of suicide, each among the highest shares of any state in the country. Some of those reporting such incidents likely partially comprise the 5.1% of adults in the state with a serious mental illness such as bipolar disorder or schizophrenia. Like other states with high relative prevalence of mental illness, Arkansas is home to one of the most medicated populations in the country. There are 15.8 prescriptions filled per state resident annually, considerably more than the 12.7 per capita prescription drug rate nationally.

3. Maine
> Pct. of adults with serious mental illness: 5.2%
> Total adults with serious mental illness: 56,000 (11th lowest)
> Pct. of adults abusing alcohol or illicit drugs: 8.2% (8th lowest)
> Poverty rate: 13.9% (22nd lowest)

Maine is one of only four states where an estimated more than one in every 20 adults suffer from serious mental illness. Accounting for less serious forms of psychiatric illness, more than one in every five adults report some form of mental illness, the seventh largest proportion in the country. Roughly 87,000 Maine adults reported at least one major depressive episode within the past year, or 8.1% of the population, the highest percentage of all states.

Residents of rural areas not only need to travel further to health facilities, but also they may be more vulnerable to social isolation — a major driver and component of a number of mental illnesses. High proportions of Mainers live in very rural areas, which may help partially explain the state’s high prevalence of serious mental illness.

2. Vermont
> Pct. of adults with serious mental illness: 5.3%
> Total adults with serious mental illness: 27,000 (5th lowest)
> Pct. of adults abusing alcohol or illicit drugs: 10.1% (5th highest)
> Poverty rate: 12.0% (13th lowest)

Approximately 27,000 Vermonters are beset with serious mental illnesses, comprising 5.3% of the state’s adult population, the second highest percentage of all states. Mental illness in the United States has been largely misunderstood, underfunded, and under-treated — even for those with health insurance. In Vermont, however, the legislature last year enacted Senate Bill 139, a law intended to improve access to and quality of mental health services. Health insurance coverage in the state, which at about 93% is nearly the highest in the nation, may in the future be more valuable to the mentally ill. The state also enacted a law in 2015 prohibiting some state residents from possessing firearms due to mental illness.

People with mental health disorders are more likely to abuse alcohol or other substances than individuals without serious mental illnesses. Of adults in Vermont, 10.1% report abusing or dependence on alcohol or illicit drugs, the fifth highest share nationwide.

1. West Virginia
> Pct. of adults with serious mental illness: 5.4%
> Total adults with serious mental illness: 79,000 (15th lowest)
> Pct. of adults abusing alcohol or illicit drugs: 9.2% (19th highest)
> Poverty rate: 18.1 (10th highest)

Serious mental illness is treated with therapy, as well as with drugs such as anti-psychotics, anti-depressants, and mood stabilizers. In West Virginia, 21.8 medications are prescribed per resident in a single year, the second highest per capita prescriptions in the country and significantly higher than the national level of 12.7 prescriptions per capita. The 9.2% share of West Virginia adults dependent on illicit drugs or reporting alcohol abuse within the past year, while slightly higher than the national prevalence, is not especially high. However, 2.6% of adults in the state report needing but not receiving treatment for illicit drug use, the fourth highest such percentage nationwide.

According to the CDC, psychological distress is far more common among people living in poverty than it is among financially stable individuals. The typical West Virginia household earns $41,576 annually, nearly the lowest median household income in the nation. The poverty rate of 18.1% is also among the highest in the country. Such conditions may have contributed to the high prevalence of serious mental illness in the state.

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