More than 40 million Americans suffer from some form of mental illness, and nearly 10 million struggle with a serious condition such as chronic depression, bipolar disorder, and schizophrenia.

While most people with mental illness are high-functioning in their daily lives, more serious conditions can take an enormous toll on health, quality of life, and economic productivity. Worse, many people who are mentally ill do not receive the care they need. According to an estimate by the National Alliance on Mental Illness, over half of those afflicted with bipolar disorder or schizophrenia go untreated.

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Many types of mental illness are hereditary, but genetics is not the only contributing factor. Many other factors can lead to the development of mental health disorders, including substance abuse, traumatic experiences, the lack of personal connections, and stress. Combined, these factors can lead to mental illness being more common in certain states.

Click here to see the 14 states struggling with mental illness.

In several of the states on this list, a high share of adults reports alcohol or illicit drug abuse or dependence, and many have very high rates of drug overdoses. In New Hampshire, which has the highest share of adults with a serious mental illness, about one in 10 residents 18 years and older report substance abuse — the second highest share in the country. In West Virginia, which has the second highest rate of serious mental illness, the drug overdose rate is the highest in the country, and double the national rate.

Those who exhibit symptoms of mental illness are much more likely to report substance abuse. People experiencing mental illness are more likely to self-medicate as a way to alleviate symptoms. Substance abuse can also lead to the development of mental illness, or the exacerbation of existing symptoms.

Stress can also lead to the development of severe depression and other psychological disorders. Individuals in poverty are more likely to face stressful conditions. For example, they are more likely to live in high crime areas and to struggle with financial difficulties — conditions that over time have been shown to lead to the development of serious mental illness.

Of the 14 states with the highest shares of adults with a serious mental illness, 11 have median household incomes below the national figure of $55,775 a year.

Americans with certain health conditions, such as diabetes and heart disease, are more likely to develop a psychological disorder. Of the 14 states with high rates of serious mental illness, nine have above average diabetes incidence rates, and 12 have higher heart disease rates than the national average.

While states with the highest incidence of serious mental illness are alike in some respects, mental illness can affect people of any economic background, gender, race, or social and health status.

Click here to read our methodology.

These are the 14 states struggling the most with mental illness.

14. Utah
> Pct. of adults w/ serious mental illness: 4.5%
> Total adults w/ serious mental illness: 93,000 (18th fewest)
> Pct. adults abusing alcohol or illicit drugs: 7.8% (3rd lowest)
> Median household income: $62,912 (13th highest)

About one in every five adults in Utah suffers from some form of mental illness, and nearly one in 20 endure a more severe illness — such as bipolar disorder, schizophrenia, or chronic depression — that seriously impairs their ability to live normal lives.

Serious mental illness can have a debilitating impact on the lives of those it affects, it also increases the risk of patients ending their own lives. According to the National Alliance on Mental Illness, about 90% of those who commit suicide have experienced mental illness at some point. In Utah, 5.1% of state adults have seriously contemplated suicide in the past year, the highest share of any state.

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13. North Carolina
> Pct. of adults w/ serious mental illness: 4.5%
> Total adults w/ serious mental illness: 350,000 (7th most)
> Pct. adults abusing alcohol or illicit drugs: 8.7% (20th lowest)
> Median household income: $47,830 (10th lowest)

Numerous factors can lead to mental illness, including personal, financial, and environmental causes. While some people have a genetic history for certain conditions, environmental factors, such as stress and loss, can contribute to depression, severe anxiety, and eating disorders. Financial stress, particularly severe debt, has been shown to lead to mental illness and suicide.

The typical household in North Carolina earns about $8,000 less than the typical household nationwide. The state also has one of the higher poverty rates in the country. North Carolina has slowly reduced provisions and funding for mental health over the years. The number of state psychiatric hospital beds has declined by more than 90% since 1955. It is one of just a few states to reduce its budget for mental health each year from 2013 through 2015.

12. Alabama
> Pct. of adults w/ serious mental illness: 4.5%
> Total adults w/ serious mental illness: 170,000 (22nd most)
> Pct. adults abusing alcohol or illicit drugs: 7.9% (4th lowest)
> Median household income: $44,765 (4th lowest)

While the causes of mental illness are varied and complicated, stress can certainly lead to depression and other serious conditions. Those living with low incomes and in poverty are subject to many kinds of stress, including that of living paycheck-to-paycheck, or potentially living in serious debt. In Alabama, 18.5% of residents live in poverty, the fifth highest rate in the country. And the typical household’s annual income is about $11,000 below the national median household income.

Alabama has the fourth highest prescription drug use rate in the country. For each resident, some 17 prescriptions are filled annually.

11. Missouri
> Pct. of adults w/ serious mental illness: 4.6%
> Total adults w/ serious mental illness: 214,000 (17th most)
> Pct. adults abusing alcohol or illicit drugs: 8.5% (18th lowest)
> Median household income: $50,238 (15th lowest)

The rate of serious mental illness among adults in Missouri is one of the highest of any state, but it is an outlier compared to most states on this list. When including less serious conditions such as attention deficit disorder, seasonal affective disorder, and many social phobia, the rate of mental illness is roughly in line with the national share. The state is similarly average in the share of adults who have had suicidal thoughts and of those who have had a major depressive episode, each of which tends to correlate with the share of adults with serious mental illness.

One thing potentially leading to higher incidence of mental illness in Missouri is the presence of serious, chronic illnesses, which can lead to depression and other psychological conditions. The state has one of the 10 highest shares of adults with obesity, as well as the 10th highest rate of cancer deaths.

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10. Oregon
> Pct. of adults w/ serious mental illness: 4.6%
> Total adults w/ serious mental illness: 147,000 (25th fewest)
> Pct. adults abusing alcohol or illicit drugs: 9.8% (8th highest)
> Median household income: $54,148 (25th lowest)

About 21% of adults in Oregon have some kind of mental illness, the second highest share of any state. About one in five of these are serious, debilitating illnesses such as schizophrenia, bipolar disorder, and severe depression.

Substance abuse often coincides with mental illness for a number of reasons. People living with a condition such as depression, anxiety, or schizophrenia are more likely to self-medicate. Drugs and alcohol can also increase the risk of developing a mental illness, and substance abuse can exacerbate the symptoms of existing conditions. In Oregon, around one in 10 adults abuse or are dependent on illicit drugs or alcohol, one of the higher rates in the country. Also, the share of residents who need but do not receive treatment for illicit drug use is one of the highest.

9. Indiana
> Pct. of adults w/ serious mental illness: 4.7%
> Total adults w/ serious mental illness: 237,000 (14th most)
> Pct. adults abusing alcohol or illicit drugs: 9.3% (17th highest)
> Median household income: $50,532 (16th lowest)

More than 1 million Indiana adults, about one in five, suffer from some form of mental illness. The state also has one of the highest shares of adults enduring serious mental illnesses such as bipolar disorder, eating disorders like bulimia, and schizophrenia. Adults in the state also report higher rates of problems associated with mental illness. Some 7.7% of adults in the state have had a major depressive episode in the past year, and about 4.5% have seriously contemplated suicide, each among the higher shares of any state.

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8. Vermont
> Pct. of adults w/ serious mental illness: 4.7%
> Total adults w/ serious mental illness: 24,000 (4th fewest)
> Pct. adults abusing alcohol or illicit drugs: 10.1% (5th highest)
> Median household income: $56,990 (20th highest)

Mental illness has been largely misunderstood, underfunded, and under-treated — even for those with health insurance. Vermont, where only 3.8% of adults do not have health insurance, second lowest uninsured rate of all states, seems to have made mental health issues a priority. In 2015, the legislature enacted Senate Bill 139, which was intended to improve access and quality of mental health services.

This year, the Vermont House passed a bill granting emergency responders access to workers’ compensation benefits for mental health injuries.
Substance abuse is closely associated with mental illness. Vermont residents report the fifth highest alcohol or illicit drug use rate. According to the Vermont Department of Health, there were 105 opiate overdose deaths in 2016, a record high for the state.

7. Kentucky
> Pct. of adults w/ serious mental illness: 4.9%
> Total adults w/ serious mental illness: 169,000 (23rd most)
> Pct. adults abusing alcohol or illicit drugs: 7.9% (5th lowest)
> Median household income: $45,215 (5th lowest)

Nearly 20 prescriptions are filled per capita in Kentucky annually, well above the national rate of 12.5 prescriptions per capita and second most of any state. While there are several possible explanations for this, including what appears to be a dangerous overprescription of opioid painkillers, the high prescription rate may be related to the high incidence of mental illnesses needing medication in the state. The state is in the top 10 nationwide for serious and less severe mental illnesses, as well as major depressive episodes and suicidal thoughts among adults.

The stresses associated with poverty and debt may be contributing to Kentucky’s poor mental health record. The typical state household earns around $45,200 a year, about $10,000 below the median household income nationwide.

6. Maine
> Pct. of adults w/ serious mental illness: 5.0%
> Total adults w/ serious mental illness: 54,000 (11th fewest)
> Pct. adults abusing alcohol or illicit drugs: 8.2% (8th lowest)
> Median household income: $51,494 (21st lowest)

One in every 20 adults in Maine suffers from a serious mental illness. Such disorders include schizophrenia, bipolar disorder, obsessive compulsive disorder, eating disorders, and other maladies.

Residents of rural areas not only need to travel further to health facilities to receive treatment, but also they may be more vulnerable to social isolation — a major driver of a number of mental illnesses. The relatively high proportion of Mainers living in very rural areas may help partially explain the state’s high prevalence of serious mental illness.

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5. Montana
> Pct. of adults w/ serious mental illness: 5.1%
> Total adults w/ serious mental illness: 41,000 (9th fewest)
> Pct. adults abusing alcohol or illicit drugs: 9.8% (9th highest)
> Median household income: $49,509 (14th lowest)

Drugs and alcohol dependence is closely tied to mental illness. Substance abuse can lead to the development of disorders, it can exacerbate symptoms, and it is often used as a coping mechanism by those who suffer from such disorders. In Montana, which has one of the highest shares of adults with a serious mental illness, nearly one in 10 adults abuse or are dependent on alcohol or drugs.

In addition, about 12% of Montana residents lack health insurance, compared to 9.4% of all Americans and one of the highest uninsured rates in the country. This could mean that many who suffer from a serious mental health condition are unable to get treatment.

4. Ohio
> Pct. of adults w/ serious mental illness: 5.1%
> Total adults w/ serious mental illness: 459,000 (5th most)
> Pct. adults abusing alcohol or illicit drugs: 9.3% (18th highest)
> Median household income: $51,075 (17th lowest)

Nearly 460,000 Ohioans suffer from a serious form of mental illness, including schizophrenia, bipolar disorder, bulimia, anorexia, and major depressive disorders. About 7.6% of the state’s adult population has had a major depressive episode in the past year alone.

Ohio, like many states, is battling a heroin and prescription painkiller epidemic. Drug abuse is correlated with mental health issues because it can lead to the development of disorders and aggravate existing conditions and because those who have disorders often self-medicate to alleviate symptoms. In March, Ohio Gov. John Kasich proposed that opioid prescriptions in his state be limited to seven days, potentially combatting abuse.

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3. Arkansas
> Pct. of adults w/ serious mental illness: 5.1%
> Total adults w/ serious mental illness: 117,000 (22nd fewest)
> Pct. adults abusing alcohol or illicit drugs: 7.7% (2nd lowest)
> Median household income: $41,995 (2nd lowest)

The causes of mental health disorders are many, including genetic dispositions for illness as well as environmental conditions such as loss and financial stress. Economic stressors may be contributing to mental illness in Arkansas, which has the third highest rate of serious mental illness of all states. An estimated 19% of the population lives in poverty, the fourth highest poverty rate in the country. Households in Arkansas earn the second lowest median income in the country, with the typical household making about $13,800 less a year than the typical household nationwide.

While drug and alcohol abuse frequently is tied to mental illness, just 7.6% of state adults abuse or are dependent on illicit drugs, the second smallest share of any state.

2. West Virginia
> Pct. of adults w/ serious mental illness: 5.3%
> Total adults w/ serious mental illness: 78,000 (15th fewest)
> Pct. adults abusing alcohol or illicit drugs: 9.2% (19th highest)
> Median household income: $42,019 (3rd lowest)

More than one in five West Virginians suffers from some form of mental illness, and the state has the second highest share of adults with a serious mental illness, such as severe depression, bipolar disorder, and schizophrenia.

Like many other states, West Virginia is also struggling with an opioid epidemic. Drug use is correlated with mental illness, and the state’s high rate may help explain why so many residents are abusing drugs. The state averaged over 30 drug-related deaths per person per year between 2012 and 2014, the highest overdose rate in the country, and more than double the national rate.

1. New Hampshire
> Pct. of adults w/ serious mental illness: 5.3%
> Total adults w/ serious mental illness: 57,000 (12th fewest)
> Pct. adults abusing alcohol or illicit drugs: 10.3% (2nd highest)
> Median household income: $70,303 (7th highest)

About 21% of the 18 and over New Hampshire population suffers from some form of mental illness, and 5.3% suffer from a serious, debilitating mental disorder — each the highest share of any state. Some 8.5% of the state’s adult population has had a serious depressive episode in the past year alone, also the highest share.

Compared to many of the states on this list, New Hampshire stands out as unusual. Financial stress has been shown to correlate with the prevalence of mental illness, but while many of the other states on this list report high poverty rates and low incomes, New Hampshire has the lowest poverty rate in the country and one of the highest median household incomes.

Still, New Hampshire fits the profile in other ways. More than 1 in 10 state adults abuse or are dependent on alcohol or illicit drugs, the second highest share of any state.

Methodology

To determine the 14 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 2014 and 2015 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.

Heart disease, cancer, drug overdose, and diabetes rates came from the Centers for Disease Control and Prevention, and are for the most recent available year.

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 2015 American Community Survey (ACS) as well as 2016 annual unemployment rates from the Bureau of Labor Statistics.

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