Medical debt doubles risk of skipping mental health care for depression and anxiety

Medical debt is significantly more prevalent among adults with depression or anxiety compared to adults without these mental disorders, according to a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health. Among adults with depression or anxiety, those with medical debt were twice as likely to report having delayed or forgone mental health care in the previous 12 months compared to those without medical debt.

For their study, the researchers analyzed data from the Centers for Disease Control and Prevention's 2022 National Health Interview Survey of 27,651 U.S. adults. The researchers measured the prevalence of medical debt among those with depression or anxiety-;both currently and in the past over their lifetime-;and evaluated the relationship of medical debt with delayed and forgone mental health care over the previous 12 months.

Among adults with current depression and medical debt, 36.9 percent delayed mental healthcare and 38 percent did not seek out care in the previous 12 months. In comparison, for those reporting current depression and no medical debt, 17.4 percent reported delaying mental health care in the previous 12 months and 17.2 percent reported forgoing it altogether in the past 12 months.

Among adults with current anxiety and medical debt, 38.4 percent delayed care and 40.8 percent did not seek care in the previous 12 months. For adults reporting current anxiety and no medical debt, 16.9 percent reported delaying care and 17.1 percent reported forgoing care in the previous 12 months.

The results were published online July 17 in JAMA Psychiatry.

The prevalence of medical debt in the U.S. is already quite high, and the prevalence was significantly higher among adults with depression and anxiety. On the flip side, a relatively high number of adults with no medical debt also report delaying or forgoing mental health care, and medical debt appears to compound the problem."

Kyle Moon, PhD Studen, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health

The study found that 27.3 percent of adults with current depression and 26.2 percent with current anxiety reported having medical debt going back 12 months, versus 9.4 percent of adults without current depression and 9.6 percent without current anxiety.

The researchers captured medical debt and delaying or foregoing mental health care from responses to the following CDC survey questions:

• In the past 12 months, did you have problems paying or were unable to pay medical bills? 
• During the past 12 months, have you DELAYED getting counseling or therapy from a mental health professional because of the cost?
• During the past 12 months, was there any time when you needed counseling or therapy from a mental health professional, but DID NOT GET IT because of the cost?

To ascertain current depression or anxiety, the researchers used the Patient Health Questionnaire-8 and Generalized Anxiety Disorder-7 scales, respectively. A score of 10 or greater corresponds to moderate or severe symptoms with both scales. Both were administered as part of the CDC's 2022 National Health Interview Survey.

Consumer credit report data shows that medical debt is the biggest contributor to personal debt, which impacts access to health care treatment. The inability to pay medical debt has been shown to cause delays to needed care, especially when it comes to seeking treatment for mental disorders: Less than half of U.S. adults with mental disorders receive treatment.

Medical debt remains common despite insurance coverage: Over 90 percent of individuals in this study were insured, yet 19.4 to 27.3 percent reported having medical debt over the last 12 months. 

The researchers also looked at adults who reported having been diagnosed with depression or anxiety in their lifetime. Among adults with a lifetime depression diagnosis and medical debt, 29 percent delayed care because of cost, while 29.4 percent did not seek out mental health care at all. Among adults with a lifetime diagnosis of anxiety and medical debt, 28 percent reported delaying care, and 28.2 percent forwent care altogether. 

"Health systems have a critical role to play," says Moon. "They could expand services for patients by improving the processes to determine patient eligibility for financial assistance."

The authors note that economic stressors and financial strain are risk factors for both depression and anxiety. This means that while medical debt may be a risk for poor mental health, illness and disability are also risk factors for medical debt. The authors suggest further studies to evaluate state policies that can protect against medical debt and break down barriers to seeking mental health care for those who need it. 

"Medical Debt and the Mental Health Treatment Gap Among U.S. Adults" was written by Kyle Moon, Sabriya L. Linton, and Ramin Mojtabai.