Mental Health, Substance Abuse, and COVID-19 in Tennessee

Woman comforting man on sofa

For the last decade, Tennessee – like other states – has taken aggressive steps to combat an evolving opioid epidemic and launched new initiatives to address the mental health care needs of K-12 students. Yet, challenges remain. To help policymakers decide how to use new federal funding for behavioral health, this report examines recent data on mental health and substance use in Tennessee leading up to and during the COVID-19 pandemic.

Key Takeaways

  • Many metrics of behavioral health in Tennessee – especially drug overdose deaths – were moving in the wrong direction when the COVID-19 pandemic began.
  • The pandemic has exacerbated mental health needs and substance abuse in Tennessee while limiting access to care.
  • Tennessee has access to $52 million in new federal funding to spend on behavioral health. The state could also tap billions of dollars in flexible federal aid and surplus state revenue.
  • Deciding how best to allocate new funding will require a careful consideration of both Tennesseans’ needs and the state’s current capacity for prevention and treatment.

New Funding Available

The American Rescue Plan – the largest of six federal funding packages passed since the COVID-19 pandemic began – committed billions of additional dollars to behavioral health. Tennessee will get $52 million in new, targeted behavioral health funding to use through September 2025 plus billions of dollars in flexible aid that policymakers could put toward similar purposes. (1) The total includes:

  • $27 million in supplemental funds for the Community Mental Health Block Grant – on top of Tennessee’s regular $58 million FY 2021 allotment. (2)(3)
  • $25 million in supplemental funds for the Substance Abuse Prevention and Treatment Block Grant – in addition to the state’s regular $81 million FY 2021 award. (4) (3)
  • $3.7 billion in state Fiscal Recovery Funds. Behavioral health needs exacerbated by the pandemic are among the permissible uses. To date, Tennessee has not allocated any of this money toward that purpose. (5) (6)

Tennessee also has at least a $2.1 billion budget surplus from the last fiscal year and is already ahead of projections for the current year by over $900 million. The FY 2021 surplus are one-time dollars that Gov. Lee and lawmakers can use as they see fit. They could also increase the FY 2022 recurring budget based on faster-than-expected growth in these early months of the fiscal year.

The balance of this report provides context for policymakers deciding how best to allocate these funds. It provides a high-level picture of the state of behavioral health among all Tennesseans and is not a review of any specific state policies or programs to address behavioral health. Prior reports, however, provide some additional information on funding increases for behavioral health and efforts to curb the state’s opioid epidemic.

Behavioral Health in Brief

Adults Before the Pandemic

Nearly every measure of substance abuse and mental health among adult Tennesseans worsened in the five years before the COVID-19 pandemic (Figure 1). While use of many illicit drugs became less common, the most lethal drugs grew even more common. This shift drove the starkest trend: a 50% increase in the overdose death rate between 2015 and 2019. Meanwhile, heavy drinking, alcohol-related deaths, and depression all rose significantly over this period. (9) (7) (8)

Adults in Tennessee fare better than those nationwide across most measures of behavioral health, except for the most dire outcome – mortality (Figure 1). Our rates of mental illness, suicidal ideation, drug use, and drinking are all better than most states’. However, we are more likely to die from these things than the typical American. (7) (8) (9)

Figure 1

Nearly Every Measure of Adult Tennesseans’ Behavioral Health Got Worse in the Last 5 Years

Teens & Young Adults Before the Pandemic

Many mental health metrics for younger Tennesseans worsened leading up to the pandemic, but substance abuse has fallen across the board (Figure 2). Use of alcohol declined precipitously for over a decade, and the use of substances like heroin and methamphetamine are below recent peaks. Feelings of sadness, thoughts of suicide, suicide attempts, and suicide deaths, however, were all at historically high levels going into the pandemic. (7) (10) (8)

Tennessee teens and young adults tended to have worse mental health than their peers before the pandemic, while drug and alcohol use varied by substance (Figure 2). Tennessee was among the bottom half of states with available data for measures related to suicide and chronic feelings of sadness. Our high-schoolers were more likely to have tried heroin and methamphetamine but less likely to have tried prescription drugs, use marijuana, or drink. (7) (10) (8)

Figure 2

Substance Abuse Among Younger Tennesseans Improved Over the Last 5 Years, But Mental Health Worsened

Impact of COVID

Available data and early studies suggest the COVID-19 pandemic has exacerbated mental health needs and substance abuse in Tennessee and nationwide. A majority of Tennessee adults experienced symptoms of depression and anxiety at some point in the last 18 months. Meanwhile, drug overdose deaths have surged, and it appears that more people consumed more alcohol more often than perhaps ever before. At the same time, the necessities and strains of the pandemic have often limited access to behavioral health care.

The sections that follow examine these trends in greater detail.

Mental Health in Tennessee Before the Pandemic

Nearly one in five adult Tennesseans had a mental illness in 2019, and almost 8% had depression (Figure 3). (8) (9) Mental illnesses include a wide range of conditions – including anxiety, depression, eating disorders, post-traumatic stress, and bipolar disorders. (11) The latest data show Tennessee had comparable rates of both mental illness (5.7% vs. 6.5%) and depression (7.8% vs. 7.5%) compared to the rest of the country. While it varies from year to year, self-reported mental health status has been similar among black and white Tennesseans over the last decade. (8) (9)

Figure 3

Nearly 1 in 5 Tennesseans Had a Mental Illness and 8% Had Had Major Depressive Episode in 2019

About one in 20 Tennessee adults had serious suicidal thoughts in 2019 and over 1,200 died by suicide (Figure 4). The rise in both metrics outpaced national trends over the last decade. Tennessee’s suicide death rate was nearly 20% higher than the national rate and the 20th highest in the country. Within Tennessee, whites were much more likely to die by suicide than black residents (Figure 4) – as were those in more rural parts of the state (Figure 5). Suicide rates were lowest among youth and highest among Tennesseans ages 35-44 and 75-84 (Figure 6).

Figure 4

Tennesseans’ Suicidal Ideations and Suicide Death Rates Climbed Steadily for the Last Two Decades

Figure 5

Tennessee’s Rural Areas Tend to Have Higher Suicide Rates Than Urban Areas

Figure 6

Suicide Rates in Tennessee Lowest Among Youth and Highest Among Those Ages 35-44 and 75-84

More children, teens, and young adults in Tennessee also reported mental health issues in recent years than in the past. In 2019, nearly two out of five Tennessee high school students reported feeling sad or hopeless almost every day, and suicide deaths reached historic highs for ages 15-24 (Figures 7 and 8). (10) (7) An estimated one in five high-schoolers in the state seriously considered suicide in 2019, and one in ten actually attempted it. In total, 135 teens and young adults ages 15-24 died from suicide that year – making it their second leading cause of death. Meanwhile, as of 2019, nearly 16% of Tennessee children and teens had a diagnosed mental or behavioral condition (e.g. conduct problems, anxiety) – compared with 13% nationally. (12)

Figure 7

More Tennessee Children and Teens Reported Mental Health Issues in Recent Years Than in the Past

Figure 8

Suicide Attempts and Deaths Among Young Adult Tennesseans Reached Historic Highs in 2019

Drug Use in Tennessee Before the Pandemic

All Tennesseans

An estimated 11% of Tennessee adults used an illicit drug in the past month – including 3.2% for drugs other than marijuana – according to the most recent National Survey on Drug Use and Health (Figure 9). Tennesseans used marijuana or misused opioid prescriptions more than any other drugs (Figure 10). With the exception of methamphetamine, however, drug use was less common in Tennessee than in other states. (8)

Figure 9

Use of Most Illicit Drugs Is Down in Tennessee, but Overdose Deaths Are Surging

Figure 10

Marijuana and Opioids Are the Most Common Illicit Drugs Used by Tennesseans

More Tennesseans reported using marijuana and methamphetamine in 2019 than in recent years, but the use of other illicit drugs has declined (Figure 11). Tennessee’s estimated rates of illicit drug use disorder have remained relatively stable at about 3% over the last two decades. (8) The share of Tennesseans age 18+ who had used marijuana in the past year rose steadily since 2012 to about 14% in 2019. Meanwhile, the misuse of pain relievers declined since the mid-2000s, cocaine and heroin remained relatively stable, and meth increased substantially (Figure 11).

Figure 11

Tennesseans Report Increasing Marijuana and Meth Usage, Less Use of Most Other Illicit Drugs

Overdose Deaths

Tennessee’s unintentional drug overdose deaths reached an all-time high in 2019 to claim almost 2,000 lives (Figure 10). The state’s rate was 53% above than the national rate that year and the 10th highest in the country. Tennesseans ages 25-54 had the highest rates of overdose deaths (Figure 12).

County-level unintentional drug overdose death rates across the state vary by a factor of five, with the highest rates largely concentrated in East Tennessee (Figure 13). Between 2015-2019, Cheatham County had the highest drug overdose death rate at nearly 51 deaths per 100,000 people – five times higher than Madison County on the low end. (7) Data were not available for 29 counties with very few people and/or overdose deaths.

Figure 12

Tennesseans Ages 25-54 Had the Highest Rates of Overdose Deaths in 2019

Figure 13

Counties with the Highest Drug Overdose Death Rates Are Largely Concentrated in East Tennessee

Racial disparities in unintentional overdose deaths narrowed since the early 2000s as mortality rates among black Tennesseans increased sharply (Figure 9). Black Tennesseans remained less likely to die from a drug overdose than white Tennesseans in 2019, but the gap is closing fast. Since 2014, for example, the rate of drug overdose among black residents rose by over 270% compared with about 58% for white residents. (7)

Fentanyl and heroin drove Tennessee’s rapid increase in drug overdose deaths in recent years (Figure 14). Two decades ago, synthetic opioids like fentanyl were involved in about 4% of all drug overdose deaths in Tennessee and heroin in less than 2%. By 2019, they were involved in nearly 60% and 20%, respectively. At the same time these began to spike, deaths involving prescription opioids declined sharply. (13) These data suggest that as the supply of prescription opioids declined, people who had grown dependent turned to more lethal alternatives.

Figure 14

Fentanyl and Heroin Drive Tennessee’s Surge in Drug Overdose Deaths

Teens and Young Adults

Marijuana and prescription pain relievers were the most commonly-used drugs by Tennessee high school students in 2019, but on the whole, teen drug use was historically low (Figure 15). Almost 18% used marijuana and nearly 14% had tried prescription pain relievers in 2019. Historical data for opioid use is not available, but marijuana use had fallen four percentage points in just six years. The share that had ever tried heroin was down two points from 2013, and historically low rates said they had ever tried cocaine or meth. (10) The state’s own survey of 8th, 10th, and 12th graders found lower rates of marijuana and prescription drug use in 2018-2019 – 11% and 9%, respectively – but historical and national data are not available for comparison. (14)

Despite promising trends in teen drug use, unintentional overdose deaths among Tennesseans ages 15-24 also reached an all-time high in 2019 (Figure 16). Rates of youth overdose deaths nationally and in Tennessee were similar until about 2016 when Tennessee’s rates began to rapidly increase (with a drop in 2018). All told, 139 people ages 15-24 died from a drug overdose in Tennessee in 2019.

Figure 15

Marijuana and Rx Opioids Were the Most Common Drugs Used by Tennessee High-Schoolers in 2019

Figure 16

Drug Overdose Deaths Among Tennesseans Ages 15-24 Reached an All-Time High in 2019

Alcohol Use in Tennessee Before the Pandemic

In 2019, an estimated 6% of Tennessee adults were heavy drinkers, and over 930 died from alcohol poisoning. While alcohol use disorder declined steadily from the late 2000s to 2018, heavy drinking and alcohol-induced deaths grew faster than national trends for much of the last decade (Figure 17). Within Tennessee, alcohol-induced deaths are most common in the middle and eastern parts of the state (Figure 18) and among adults ages 55-64 (Figure 19).

Figure 17

Heavy Drinking and Alcohol-Related Deaths in Tennessee Were Historically High in 2019

Figure 18

Alcohol-Induced Deaths Appear to Be Most Common in Middle and East Tennessee

Figure 19

Alcohol-Induced Deaths in Tennessee Were Highest Among 55-64 Year Olds in 2019

While adult drinking is on the rise, drinking among teenagers dropped precipitously over the last decade and a half. In 2015, 42% of Tennessee high school students reported drinking alcohol at least one day in the last month. By 2019, it had dropped to just under 22% – about a quarter less than the national rate (Figure 20). In 2019, about 9% of Tennessee high-schoolers reported binge drinking (defined as four or more drinks within a couple of hours for females and five for males) – compared to 14% nationally. (10) The state’s own survey of 8th, 10th, and 12th graders found lower rates of drinking in 2018-2019 – 17% in the past days – but historical and national data are not available for comparison. (14)

Figure 20

Drinking Among Tennessee High Schoolers Down by Half Since 2003

Access to Behavioral Health Care in Tennessee

Available measures suggest that more than half of children and adults with behavioral health needs in Tennessee do not receive treatment (Figure 21). In survey data from recent years, 52% of Tennessee adults with a mental illness, 57% of children diagnosed with mental and behavioral health conditions, and 83% of adults with drug treatment needs said they had not received care in the prior year. (15) (12)

Figure 21

More Than Half of Children and Adults with Behavioral Health Needs in Tennessee Do Not Receive Treatment

Provider availability may contribute to high rates of unmet need. Tennessee recently expanded its safety net for uninsured adults with behavioral health needs, but those services target only about 11% of people with serious mental illness and substance use disorder. The rest rely on private providers, where access may not match needs. (19) (20) (21) For example, Tennesseans have less access to mental health care providers than other Americans and experience stark urban-rural differences within the state (Figure 22). (17) (18) Prior studies and recent data suggest opioid abuse treatment capacity across the state and local opioid addiction and overdose rates do not always align. (22) For example, access to medication-assisted treatment varies considerably even among counties with both the lowest and highest opioid overdose rates (Figures 23). (23) (24) (13) (25) (22)

Figure 22

There Are Stark Urban-Rural Differences in the Availability of Behavioral Health Providers Across Tennessee

Figure 23

Access to Opioid Treatment Varies Considerably Even Among Counties with Both the Highest and Lowest Overdose Rates

Measuring access to behavioral health care is tricky. The concept of “access” to health care of any kind can be complicated – ranging from affordability to provider availability to timeliness of care. Furthermore, people with untreated mental health or substance abuse issues may not acknowledge a need for treatment nor seek it out due to stigma or fear of discrimination. (27) (28) (29) The demand (or lack thereof) for services, in turn, affects the supply of providers. Together, these complexities pose challenges for measuring whether there is adequate access to treatment.

How the Pandemic Is Affecting Behavioral Health

Available data suggest that mental health and substance use disorder (SUD) needs have increased during the pandemic while access to care has decreased.

Behavioral Health Needs During the Pandemic

The COVID-19 pandemic’s swift and widespread health, economic, and social effects have generated significant stress. In the early months of the pandemic, more than a quarter of adults across the country reported being worried about the health of their family and loved ones, feeling isolated and alone, getting sick from COVID-19, and/or the losing their job or income. (30)

Mental Health Tracked COVID Hospitalizations

Stress related to the pandemic has negatively influenced Tennesseans’ mental health, according to available data. Adult Tennesseans reported peak levels of anxiety (Figure 24) and depression (Figure 25) symptoms in June 2020 and January 2021. (31) These rates were strongly correlated with trends in new COVID-related hospitalizations in Tennessee the week prior. (31) (32) Nationwide, rates of anxiety and depression symptoms more than tripled from pre-pandemic levels at certain points in the last 18 months. (33) (34) (35) Symptoms were especially common among parents, children in virtual schooling and their parents, family caregivers, health care and public health workers, and Hispanic adults. (36) (37) (30) (38)

Figure 24

More Tennesseans Report Symptoms of Anxiety When COVID-19 Surges

Figure 25

More Tennesseans Report Symptoms of Depression When COVID-19 Surges

Early studies show the pandemic did not exacerbate overall suicide rates in the U.S. in 2020, but the decline may mask increases among some demographic groups. (39) (40) (41) (42) (43) For example, studies have found increases in suicide among black individuals in Maryland and in mental health emergency department visits for youth and young adults across the country. (44) (45) (46) It may also be too early to know the long-term effects. Experiences from past pandemics and disasters show suicide rates often decline initially but tick back up in the aftermath for reasons that researchers do not fully understand. (47) (48) (49)

Sharp Rise in Drug Overdoses

Tennessee’s unintentional drug overdoses increased dramatically during the pandemic. Over 3,000 Tennesseans died from a drug overdose in 2020 – a 44% increase over the prior year (Figure 26), compared with 29% nationally. Statewide, all but three of Tennessee’s 95 counties had at least one overdose death, and cases more than doubled in 21 counties (Figure 27). More than 2,000 of the statewide overdose deaths involved a synthetic opioid like fentanyl – an 85% annual increase compared with 55% nationally. (50) (51) (26) Meanwhile, non-fatal opioid overdose hospitalizations were 24% higher in March-December 2020 compared to the same period a year earlier. They were particularly high during the first six months of the pandemic (Figure 28). (52)

Figure 26

Tennessee’s Drug Overdose Deaths Increased Dramatically in 2020

Figure 27

Drug Overdose Deaths More than Doubled in 21 of Tennessee’s 95 Counties in 2020

Figure 28

Nonfatal Opioid Overdose Hospitalizations in Tennessee Surged in the Early Months of the COVID-19 Pandemic

Alcohol Intake Surged

Evidence also points to surges in alcohol consumption during the pandemic. Recent studies found that Americans drank more heavily and more often during the pandemic than before. These trends were more pronounced among those with depression and anxiety and those who reported COVID-related stress, women, younger adults, and those subject to stay-at-home orders. (53) (54) (55) (56) (57)

Access to Behavioral Health Care During the Pandemic

Overall, the COVID-19 pandemic reduced access to and use of behavioral health services across the country. National surveys of private behavioral health care providers found that many closed programs, laid off or furloughed employees, decreased staff hours, and/or canceled patient appointments – usually in an effort to mitigate the spread of COVID-19. Patients also forwent many appointments, which contributed to the provider cutbacks. (33) The result was an overall increase in Americans’ self-reported unmet behavioral health care needs. (35)

However, the availability of telehealth services for behavioral health needs has increased. To mitigate the spread of COVID-19, health care providers, policymakers, and insurance plans took steps that quickly expanded the use of telehealth across many service areas. (58) The use of telehealth has been particularly high for psychiatry and SUD treatment. (59)

Parting Words

Even before COVID-19, many Tennesseans lived with mental health and substance use issues that contributed to elevated rates of suicide, drug overdose, and alcohol-induced death. The pandemic and its health, economic, and social consequences generally increased these challenges while limiting access to care. Deciding how best to allocate new funding will require a careful consideration of both Tennesseans’ needs and the state’s current capacity for prevention and treatment.

References

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