Abstract
Objectives. To investigate the prevalence of serious psychological distress (SPD), mental health treatment, unmet need for mental health treatment, social isolation, and barriers to treatment access among emerging adults, aged 18 to 24 years, and compared with older adults.
Methods. We use data from the New York City (NYC) Neighborhood Wellness Survey (2023), a representative survey of adults in NYC (n = 43 606), to calculate weighted prevalence estimates and fit logistic regression models controlling for sociodemographic characteristics.
Results. Emerging adults had higher odds of SPD and social isolation than adults aged 35 to 44 years, 45 to 64 years, and 65 years or older, and lower odds of past-year mental health treatment among those with SPD compared with all other age groups. Emerging adults reported different reasons for unmet need for mental health treatment than other age groups. Among emerging adults, individuals who identified as noncisgender, bisexual, or unsure of their sexual orientation, or who experienced financial strain, violence, or discrimination, had poorer mental health outcomes.
Conclusions. These findings demonstrate the need for expanded efforts to increase mental health treatment access focused on those aged 18 to 24 years, as their needs may differ from those of other age groups. (Am J Public Health. 2025;115(9):1426–1435. https://doi.org/10.2105/AJPH.2025.308163)
Age has been established as a robust predictor of mental health outcomes; recent data show concerning trends in mental health outcomes for younger people.1,2 On top of stressors including rising income inequality, racism, gun violence, and climate change, today’s youths faced widespread disruption to schooling, employment, and socialization during the COVID-19 pandemic.3 Ubiquitous use of social media also has the potential to directly and indirectly harm youth mental health.4,5
While the domain of youth mental health is often thought of as ending at age 18 years, another closely related group of concern is individuals aged 18 to 24 years who are transitioning from adolescence to adulthood. By using 18 years as the age to separate adolescence from adulthood, researchers risk overlooking the unique experiences and challenges of this transitionary age group. Service provision and policy often do not align with the cut-off at 18 years, as many health services for youths are offered until age 21 or 24 years (e.g., New York City [NYC] Family and Youth Peer Support Program6). In addition, becoming an adult is a longer social process than in previous generations, as more young people pursue further schooling and start families later.7,8 The period between 18 and 24 years is a unique, nonhomogeneous, transitionary period that can be considered “late adolescence” or “emerging adulthood.”9
There are several reasons to investigate the mental health of emerging adults. Previous literature has established poorer mental health outcomes among emerging adults compared with older age groups.1,2 Emerging adulthood is a critical period in the development of psychiatric disorders, with 62.5% of people experiencing a mental disorder having an onset when aged younger than 25 years.10 While many serious mental health problems emerge in late adolescence, this period is simultaneously associated with a large drop in service utilization, because of factors such as decreased parental oversight, difficulty navigating the transition between child and adult services, and changes to insurance.11 Stressors unique to this transitionary period include major life transitions such as living independently for the first time or adjusting to a new job or school. Contemporary 18- to 24-year-old adults are among the first of Gen Z (born between 1997 and 2012) to transition to adulthood, and they are the first generation who had smartphones and social media throughout their youth.12 They experienced high susceptibility to food insecurity and employment loss during the COVID-19 pandemic, which has been associated with anxiety and depression.13,14 Young adults may also be especially vulnerable to social isolation, which is highly correlated with psychological distress.15,16
Furthermore, among emerging adults, there may be inequities in mental health outcomes. Individuals who identify as lesbian, gay, bisexual, transgender, queer, or other identities (LGBTQ+) face stigma and discrimination that can harm their mental health.17,18 Social drivers of health shape an individual’s ability to lead a healthy life and their physical and mental health status; experiencing adverse social drivers of health, such as financial strain, intimate partner violence (IPV), neighborhood violence, or racial or ethnic discrimination, may further harm the mental health of this vulnerable population.19
Our aims were to (1) investigate mental health outcomes and differences in outcomes by sociodemographic characteristics and social drivers of health among individuals aged 18 to 24 years (emerging adults), (2) compare mental health outcomes among emerging adults to older age groups, and (3) compare reported barriers to mental health treatment among those aged 18 to 24 years with other age groups.
METHODS
We used data from the NYC Neighborhood Wellness Survey (NWS), a sample of noninstitutionalized adults aged 18 years and older in NYC. The NYC NWS was conducted from May 2023 to September 2023 through a collaboration between the NYC Health Department and the City University of New York (CUNY) Graduate School of Policy and Public Health. The NWS used a probability-based approach using address-based sampling methods to mail surveys to randomly selected households in NYC. The adult aged 18 years or older with the “next birthday” was eligible for the survey. Most surveys were completed by mail, with some online completion. The paper survey was available in English and Spanish and online in English, Spanish, Traditional Chinese, Simplified Chinese, French Creole, and Russian. The response rate using the 2023 American Association for Public Opinion Research calculator was 21.3%.20
We weighted survey data to adjust for design, nonresponse, and population representation. The design weight adjusted for probability of selection. Respondent values used for weighting included age, sex assigned at birth, education, race, Hispanic or Latino/a ethnicity, household income, and homeownership. We imputed missing values for sex at birth using first name and cell-based imputation and imputed missing values for the other weighting variables using random hot-deck imputation. We matched and weighted respondent and population demographic characteristics at the borough and city level. We applied multivariate adjustments, or “raking,” to the weights using demographic characteristic distributions from the 2021 American Community Survey to ensure these distributions aligned.
We checked the variables not imputed for weighting for levels of missingness. Most covariate and outcome variables were 1% or less missing, except SPD, insurance status, and sexual orientation, which were less than 5% missing. We conducted sensitivity analyses to test the impact of the missing data; the direction and significance of the findings did not change.
Outcome Variables
The main outcomes of interest for this study were (1) SPD, (2) mental health treatment among those with SPD, (3) unmet need for mental health treatment among those with SPD, and (4) social isolation. We defined SPD as having a score greater than or equal to 13 on the Kessler 6 (K6) scale, a validated six-item scale developed to identify people highly likely to have a diagnosable mental illness and associated functional limitations. K6 scores range from 0 to 24 and are calculated by scoring the frequency of 6 symptoms of psychological distress (e.g., feeling nervous, hopeless) in the past 30 days.21 We defined mental health treatment as answering yes to 1 or both of the following questions about the past 12 months: “Did you take any prescription medication for your emotions, nerves, or mental health?” and “Did you receive any therapy or counseling for your emotions, nerves, or mental health?” We defined unmet need as reporting that there was a time in the past 12 months when the individual needed treatment for their emotions, nerves, or mental health, but did not get it. We adapted treatment and unmet need items from the NYC Community Health Survey.22 We defined social isolation, adapted from the Brief Grief Questionnaire,23 as answering “somewhat” or “a lot” to the question: “In the past 30 days, how much have you been feeling cut off or distant from other people?”
Additional outcomes of interest included reported barriers to mental health treatment, adapted from the National Survey on Drug Use and Health.24 Individuals who reported an unmet need for mental health treatment selected from 8 multiple-choice reasons for their unmet need (e.g., could not afford the cost). Participants could select multiple reasons and could also select “other” and write in a response. Three independent coders (R. S., J. C., M. C.) coded “other” responses to identify additional barriers to treatment.
Sociodemographics and Social Drivers
Sociodemographic characteristics and social drivers of health included in the descriptive analyses were collected by multiple choice survey items and defined in Table 1: race and ethnicity, gender identity, sexual orientation, LGBTQ+ identity, financial strain, place of birth, employment status, insurance status, experienced racial or ethnic discrimination, experienced IPV, and witnessed neighborhood violence. Adjusted regression models included the covariates of race and ethnicity, gender identity, sexual orientation, and financial strain. We hypothesized these covariates based on literature to be associated with both the exposure (age) and outcome variables.
TABLE 1—
Sociodemographic Characteristics of New York City Neighborhood Wellness Survey Sample: 2023
| Unweighted No. (Weighted %) | |||||
| Aged 18–24 Years | Aged 25–34 Years | Aged 35–44 Years | Aged 45–64 Years | Aged ≥ 65 Years | |
| Overall | 2 028 (100) | 6 775 (100) | 6 824 (100) | 14 438 (100) | 13 541 (100) |
| Race and ethnicitya | |||||
| Asian/Pacific Islander | 518 (22.2) | 1 386 (17.3) | 1 320 (17.8) | 2 065 (13.3) | 1 611 (11.4) |
| Black | 223 (15.7) | 659 (14.8) | 974 (19.4) | 3 251 (26.5) | 2 878 (25.3) |
| Latino | 643 (35.1) | 1 624 (27.3) | 1 735 (28.6) | 3 757 (27.4) | 2 820 (20.4) |
| Whiteb | 557 (24.9) | 2 804 (38.3) | 2 492 (31.9) | 4 733 (30.8) | 5 792 (41.5) |
| Another racec | 87 (2.1) | 302 (2.2) | 303 (2.3) | 632 (2.1) | 440 (1.4) |
| Gender identity | |||||
| Cisgender man | 783 (46.8) | 2 385 (45.1) | 2 510 (47.0) | 5 466 (45.9) | 5 421 (41.0) |
| Cisgender woman | 1 163 (49.1) | 4 179 (52.1) | 4 224 (51.8) | 8 861 (53.4) | 8 025 (58.4) |
| Another gender identityd | 82 (4.1) | 211 (2.8) | 90 (1.2) | 111 (0.7) | 95 (0.6) |
| Sexual orientation | |||||
| Gay or lesbian | 120 (5.6) | 585 (8.4) | 429 (5.7) | 706 (4.1) | 342 (2.8) |
| Heterosexual | 1 453 (75.1) | 5 126 (78.8) | 5 751 (87.2) | 12 497 (91.3) | 11 578 (92.5) |
| Bisexual | 207 (9.0) | 635 (8.0) | 251 (3.3) | 279 (1.7) | 154 (1.0) |
| Something else | 32 (1.9) | 89 (1.3) | 56 (0.8) | 68 (0.5) | 90 (0.9) |
| Not sure | 171 (8.5) | 226 (3.6) | 184 (3.1) | 324 (2.4) | 333 (2.7) |
| LGBTQ+ identity | |||||
| Cisgender and heterosexual | 1 445 (74.6) | 5 098 (78.3) | 5 736 (86.8) | 12 446 (90.9) | 11 531 (92.1) |
| LGBTQ+ | 539 (25.4) | 1 564 (21.7) | 940 (13.2) | 1 426 (9.1) | 971 (7.9) |
| Place of birth | |||||
| Born outside the United States and US territories | 465 (24.1) | 1 921 (29.9) | 2 817 (45.9) | 6 218 (47.3) | 5 601 (43.6) |
| US born, including US territories | 1 555 (75.9) | 4 837 (70.1) | 3 987 (54.1) | 8 118 (52.7) | 7 804 (56.4) |
| Employment | |||||
| Employed | 1 128 (49.9) | 5 550 (79.7) | 5 474 (79.3) | 9 731 (67.9) | 2 529 (18.8) |
| Unemployed | 319 (16.8) | 754 (12.7) | 752 (11.5) | 1 454 (10.2) | 528 (4.0) |
| Not in labor forcee | 576 (33.3) | 439 (7.6) | 561 (9.2) | 3 091 (21.9) | 10 280 (77.1) |
| Insurance status | |||||
| Insured | 1 891 (95.8) | 6 321 (94.1) | 6 386 (93.9) | 13 616 (96.2) | 13 082 (99.1) |
| Not insured | 80 (4.1) | 339 (5.9) | 319 (6.0) | 467 (3.7) | 97 (0.8) |
| Financial strainf | |||||
| No financial strain | 1 008 (50.2) | 3 844 (52.6) | 3 688 (50.3) | 7 377 (48.7) | 8 474 (61.2) |
| Some financial strain | 750 (37.6) | 2 143 (34.5) | 2 234 (35.5) | 5 167 (38.2) | 3 947 (30.8) |
| High financial strain | 250 (12.3) | 755 (12.9) | 864 (14.2) | 1 786 (13.1) | 995 (8.0) |
| Experienced intimate partner violence | |||||
| No | 1 788 (90.5) | 5 428 (81.9) | 5 311 (81.0) | 11 590 (83.3) | 11 931 (90.3) |
| Yes | 235 (9.5) | 1 324 (18.1) | 1 479 (19.0) | 2 726 (16.7) | 1 429 (9.7) |
| Experienced discrimination on basis of race and ethnicity | |||||
| Never or rarely | 1 176 (59.6) | 4 127 (60.2) | 3 935 (57.0) | 7 836 (54.7) | 8 478 (64.0) |
| Sometimes | 635 (30.3) | 1 952 (29.2) | 2 159 (32.2) | 4 844 (33.7) | 3 799 (28.0) |
| Often or always | 214 (10.1) | 658 (10.6) | 702 (10.8) | 1 680 (11.6) | 1 155 (8.0) |
| Witnessed violence in neighborhood | |||||
| No | 1 455 (72.5) | 4 862 (71.6) | 4 797 (71.2) | 10 721 (75.7) | 11 445 (86.2) |
| Yes | 557 (27.5) | 1 858 (28.4) | 1 941 (28.8) | 3 524 (24.3) | 1 858 (13.8) |
Note. LGBTQ+ = lesbian, gay, bisexual, transgender, queer, or other identities.
Latino includes people of Hispanic or Latino origin, as identified by the survey question “Are you Hispanic or Latino?” and regardless of reported race. All other race categories exclude Latino ethnicity.
White race includes Middle Eastern or North African.
Another race includes respondents who are multiple races, American Indian/Alaska Native, or selected “other race.”
Another gender identity includes respondents who identified as transgender, nonbinary or genderqueer, or “other gender identity.”
Not in labor force includes student, homemaker, retired, and unable to work.
Financial strain was measured using the question, “In the PAST 12 MONTHS, how hard was it for you to pay for basic needs, like food, housing, utilities, and medical care?” Response options were “not hard” (no financial strain), “somewhat hard” (some financial strain), and “very hard” (high financial strain).
Statistical Analysis
We calculated the weighted prevalence of the main outcome variables by sociodemographic and social drivers of health variables among those aged 18 to 24 years. Using SAS version 9.4 (SAS Institute Inc, Cary, NC) with callable SUDAAN 11.0.1 (Research Triangle Institute, Research Triangle Park, NC) to analyze the data, we evaluated the differences in prevalence estimates using the 2-sided t test with a level of significance of P < .05. When comparing 2 groups, the SUDAAN PROC DESCRIPT’s CONTRAST statement performs the independent 2-sample t test to test the difference between the means or percentages of the 2 groups. SUDAAN applies logistic regression to categorical variables to obtain a common variance to calculate a t test statistic. We used unadjusted and adjusted logistic regression models to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the outcomes of interest with age group (18–24, 25–34, 35–44, 45–64, and ≥ 65 years) as the predictor variable and 18 to 24 years as the reference group.
RESULTS
The final analytic sample contained 43 606 adult New Yorkers. Characteristics of the analytic sample are found in Table 1.
Serious Psychological Distress
The prevalence of SPD among those aged 18 to 24 years was 13.0%. Those with another gender identity had a higher prevalence of SPD (30.6%) compared with cisgender men (11.0%) and cisgender women (13.0%). Bisexual emerging adults (23.3%) and emerging adults not sure of their sexual orientation (17.6%) had a higher prevalence of SPD compared with heterosexual emerging adults (10.4%). Select social drivers of health, including financial strain, experiencing IPV, and witnessing neighborhood violence, were also associated with SPD among emerging adults. SPD increased as the frequency of experiencing discrimination based on race and ethnicity increased (10.5% never or rarely, 15.3% sometimes, 21.7% often or always; Table 2). Unemployed emerging adults also had a higher prevalence of SPD than employed adults (23.8% vs 12.3%; Table A, available as a supplement to the online version of this article at https://ajph.org). Additional results for all outcomes are in Table A.
TABLE 2—
Prevalence of Mental Health Outcomes Among 18- to 24-Year-Old Adults: New York City, 2023
| Serious Psychological Distress (SPD) | Past-Year Mental Health Treatment Among Those With SPDa | Past-Year Unmet Need for Mental Health Treatment Among Those With SPDa | Social Isolation | |||||
| Weighted % (95% CI) | P b | Weighted % (95% CI) | P b | Weighted % (95% CI) | P b | Weighted % (95% CI) | P b | |
| Emerging adults (ages 18–24 y) | 13.0 (11.4, 14.9) | 38.5 (31.7, 45.7) | 54.8 (47.5, 61.9) | 50.1 (47.5, 52.7) | ||||
| Gender identity | ||||||||
| Cisgender man (Ref) | 11.0 (8.8, 13.8) | 32.0 (21.8, 44.2) | 48.5 (36.6, 60.5) | 46.6 (42.6, 50.6) | ||||
| Cisgender woman | 13.5 (11.2, 16.1) | .18 | 37.7 (28.8, 47.6) | .45 | 60.7 (50.7, 69.8) | .13 | 52.3 (48.9, 55.8) | .032 |
| Another gender identityc | 30.6 (20.4, 43.1) | .001 | 68.2 (43.8, 85.5) | .004 | 49.8 (28.8, 70.9) | .92 | 63.1 (50.2, 74.3) | .012 |
| Sexual orientation | ||||||||
| Gay or lesbian | 19.2 (11.7, 30.0) | .06 | 49.4 (24.9, 74.3) | .21 | 52.3 (26.9, 76.5) | .77 | 64.0 (53.5, 73.3) | .002 |
| Heterosexual (Ref) | 10.4 (8.6, 12.4) | 31.2 (23.3, 40.5) | 48.0 (38.7, 57.5) | 47.3 (44.3, 50.3) | ||||
| Bisexual | 23.3 (16.9, 31.1) | .001 | 51.9 (34.8, 68.6) | .039 | 78.8 (64.3, 88.5) | < .001 | 68.5 (60.6, 75.4) | < .001 |
| Something else | 26.1 (12.7, 46.2) | .07 | 69.7 (29.0, 92.8) | .045 | 35.3 (9.9, 73.1) | .51 | 56.8 (37.2, 74.5) | .35 |
| Not sure | 17.6 (11.8, 25.4) | .044 | 34.6 (17.8, 56.3) | .76 | 60.4 (39.4, 78.1) | .28 | 48.0 (39.4, 56.8) | .87 |
| Financial straind | ||||||||
| No financial strain (Ref) | 7.3 (5.6, 9.5) | 36.8 (24.6, 50.8) | 49.0 (35.5, 62.6) | 42.2 (38.6, 45.8) | ||||
| Some financial strain | 16.1 (13.1, 19.5) | < .001 | 31.0 (22.1, 41.6) | .5 | 53.1 (42.2, 63.7) | .65 | 55.6 (51.4, 59.8) | <.001 |
| High financial strain | 29.0 (22.8, 36.1) | < .001 | 53.2 (39.8, 66.2) | .09 | 63.9 (50.4, 75.5) | .12 | 65.2 (57.8, 71.9) | <.001 |
| Experienced discrimination on basis of race and ethnicity | ||||||||
| Never or rarely (Ref) | 10.5 (8.6, 12.8) | 36.9 (27.5, 47.5) | 54.7 (44.0, 64.9) | 43.6 (40.3, 47.0) | ||||
| Sometimes | 15.3 (12.2, 19.0) | .019 | 35.9 (25.5, 47.9) | .9 | 55.4 (43.4, 66.8) | .93 | 59.0 (54.4, 63.5) | < .001 |
| Often or always | 21.7 (15.7, 29.2) | .002 | 48.0 (31.2, 65.2) | .29 | 53.9 (36.5, 70.4) | .94 | 61.3 (53.4, 68.7) | < .001 |
| Experienced intimate partner violence | ||||||||
| No (Ref) | 11.4 (9.7, 13.3) | 34.4 (27.0, 42.5) | 51.7 (43.5, 59.9) | 47.2 (44.5, 50.0) | ||||
| Yes | 27.5 (21.0, 35.1) | < .001 | 55.7 (40.3, 70.1) | .015 | 65.5 (49.8, 78.5) | .11 | 76.6 (69.5, 82.4) | < .001 |
| Witnessed violence in neighborhood | ||||||||
| No (Ref) | 11.4 (9.6, 13.6) | 42.6 (33.8, 52.0) | 48.8 (39.7, 58.1) | 46.4 (43.4, 49.5) | ||||
| Yes | 17.8 (14.3, 21.9) | .003 | 31.5 (22.0, 42.8) | .12 | 65.1 (53.5, 75.1) | .027 | 59.5 (54.7, 64.2) | < .001 |
Unweighted n = 253.
T test P value.
Another gender identity includes respondents who identified as transgender, nonbinary or genderqueer, or “other gender identity.”
Financial strain was measured using the question, “In the PAST 12 MONTHS, how hard was it for you to pay for basic needs, like food, housing, utilities, and medical care?” Response options included “not hard” (no financial strain), “somewhat hard” (some financial strain), and “very hard” (high financial strain).
Mental Health Treatment
Among emerging adults with SPD (unweighted n = 253), 38.5% had received mental health treatment in the past year. Groups with a higher prevalence of past-year mental health treatment included those with another gender identity (68.2%) compared with cisgender men (32.0%) and cisgender women (37.7%), bisexual adults compared with heterosexual adults (51.9% vs 31.2%), and those who experienced IPV compared with those who did not (55.7% vs 34.4%; Table 2).
More than half (54.8%) of emerging adults with SPD reported an unmet need for mental health treatment in the past year. Among emerging adults with SPD, bisexual adults reported a higher prevalence of unmet need than heterosexual adults (78.8% vs 48.0%). Emerging adults with SPD who witnessed violence in their neighborhood were more likely to report an unmet need for mental health treatment (65.1% vs 48.8%; Table 2).
Social Isolation
Among emerging adults, 50.1% felt socially isolated. Groups more likely to feel socially isolated included cisgender women (52.3%) and those with another gender identity (63.1%) compared with cisgender men (46.6%), and gay or lesbian (64.0%) and bisexual adults (68.5%) compared with heterosexual adults (47.3%). Social isolation was also higher among emerging adults experiencing financial strain, experiencing IPV, witnessing neighborhood violence, or experiencing discrimination on the basis of race and ethnicity (Table 2).
Associations Between Study Outcomes and Age Group
Emerging adults had a higher prevalence of SPD (13.0%) compared with all other age groups (Table B, available as a supplement to the online version of this article at https://ajph.org). In adjusted models, odds of SPD were significantly higher among those aged 18 to 24 years versus those aged 35 to 44 years (OR = 0.65; 95% CI = 0.53, 0.80), 45 to 64 years (OR = 0.55; 95% CI = 0.45, 0.67), and 65 years or older (OR = 0.43; 95% CI = 0.35, 0.53), but not those aged 25 to 34 years.
Among individuals with SPD, all older age groups had more than double the adjusted odds of past-year mental health treatment compared with those aged 18 to 24 years. Among individuals with SPD, the adjusted odds of reporting a past-year unmet need for mental health treatment did not differ significantly between those aged 18 to 24 years and 25 to 34 years or 35 to 44 years but was higher among emerging adults compared with those aged 45 to 64 years and 65 years or older (Table 3).
TABLE 3—
Estimated Adjusted Odds Ratios for Associations Between Mental Health Outcomes and Age Group: New York City, 2023
| Serious Psychological Distress (SPD), AORa (95% CI) | Past-Year Mental Health Treatment Among Those With SPD,b AORa (95% CI) | Past-Year Unmet Need for Mental Health Treatment Among Those With SPD,b AORa (95% CI) | Social Isolation, AORa (95% CI) | |
| Age group, y | ||||
| 18–24 (Ref) | 1 | 1 | 1 | 1 |
| 25–34 | 0.83 (0.68, 1.02) | 2.14 (1.46, 3.14) | 0.82 (0.57, 1.19) | 0.97 (0.85, 1.10) |
| 35–44 | 0.65 (0.53, 0.80) | 2.31 (1.53, 3.49) | 0.72 (0.49, 1.06) | 0.72 (0.64, 0.82) |
| 45–64 | 0.55 (0.45, 0.67) | 2.31 (1.57, 3.38) | 0.62 (0.43, 0.89) | 0.55 (0.48, 0.62) |
| ≥ 65 | 0.43 (0.35, 0.53) | 2.43 (1.62, 3.66) | 0.42 (0.28, 0.63) | 0.44 (0.39, 0.50) |
Note. AOR = adjusted odds ratio; CI = confidence interval.
Adjusted regression models included the covariates of race and ethnicity, gender identity, sexual orientation, and financial strain.
Unweighted n = 3 049.
The adjusted odds of reporting social isolation most or all of the time was also higher among emerging adults compared with all older age groups except those aged 25 to 34 years (Table 3).
Barriers to Mental Health Treatment
Among emerging adults reporting an unmet need for mental health treatment in the past year (unweighted n = 439), 58.0% reported that their reason for unmet need was that they thought they could handle their mental health without treatment. The next most cited reasons were that they did not know who to contact or where to go (50.5%) and they could not afford the cost (46.0%; Table C, available as a supplement to the online version of this article at https://ajph.org). The most cited barrier in the “other” category was insurance (e.g., respondent did not have insurance, could not find a provider that accepted their insurance, or had difficulty navigating their insurance; unweighted n = 224). All remaining barrier categories were cited by fewer than 150 respondents and are not presented here. Among all adults with past-year unmet need (unweighted n = 5728), emerging adults had higher adjusted odds than all other age groups of reporting that their reason for unmet need was that they thought they could handle their mental health without treatment, that they did not know who to contact or where to go, or that they were worried that people would think badly of them (Table 4).
TABLE 4—
Associations Between Mental Health Outcomes and Age Group (Among Those Reporting an Unmet Need): New York City, 2023
| Age Group (Ref = 18–24 Years), AORa (95% CI) | ||||
| 25–34 Years | 35–44 Years | 45–64 Years | ≥ 65 Years | |
| Thought I could handle my mental health without treatment | 0.69 (0.53, 0.91) | 0.63 (0.47, 0.84) | 0.58 (0.44, 0.77) | 0.45 (0.33, 0.61) |
| Didn’t know who to contact or where to go | 0.64 (0.49, 0.83) | 0.47 (0.36, 0.63) | 0.44 (0.34, 0.59) | 0.43 (0.31, 0.59) |
| Could not afford cost | 1.35 (1.02, 1.77) | 0.80 (0.60, 1.07) | 0.60 (0.45, 0.80) | 0.43 (0.31, 0.59) |
| Hours or locations were not convenient | 1.10 (0.81, 1.48) | 0.89 (0.64, 1.24) | 0.79 (0.57, 1.09) | 0.59 (0.40, 0.87) |
| Worried people would think badly of me | 0.64 (0.44, 0.92) | 0.57 (0.38, 0.85) | 0.61 (0.42, 0.88) | 0.61 (0.39, 0.95) |
| Worried it could affect my job | 0.99 (0.63, 1.56) | 0.99 (0.60, 1.63) | 1.07 (0.68, 1.70) | 0.28 (0.13, 0.59) |
| Could not find a provider who spoke my language or understood my culture | 1.10 (0.65, 1.86) | 1.13 (0.65, 1.99) | 1.43 (0.84, 2.43) | 1.33 (0.75, 2.36) |
| Problems using telehealth services | 1.60 (0.98, 2.62) | 1.10 (0.63, 1.93) | 1.40 (0.83, 2.35) | 2.97 (1.75, 5.02) |
| Insurance issuesb | 2.30 (1.11, 4.77) | 2.82 (1.34, 5.95) | 1.67 (0.76, 3.65) | 0.80 (0.32, 2.01) |
Note. AOR = adjusted odds ratio; CI = confidence interval. The unweighted number of those reporting an unmet need was 5728.
Adjusted regression models included the covariates of race and ethnicity, gender identity, sexual orientation, and financial strain.
Insurance issues was not included as an original multiple-choice answer option. Category derived from open-ended responses of “other, please specify.”
DISCUSSION
There are some groups of emerging adults for whom focused research and policy efforts to improve mental health outcomes are needed. An increasing number of Gen Z individuals identify as lesbian, gay, or bisexual compared with millennials at the same age, and they may face stigma and discrimination that can harm their well-being.25 In our study, bisexual emerging adults showed particularly concerning trends across all mental health outcomes. Emerging adults unsure of their sexual orientation also showed higher rates of SPD than heterosexual individuals. This is consistent with previous research that found that bisexual youths and those questioning their sexuality have a higher risk of poor mental health outcomes compared with those with other sexual identities.17
The population of transgender and gender-diverse individuals is also growing, especially among youths. This group is currently facing stigma, violence, and attacks on their rights in the United States, which increases vulnerability to psychological distress.18 Our findings show that emerging adults who identify with a gender identity besides cisgender reported high levels of SPD and social isolation. As Gen Z transitions from adolescence to adulthood, additional mental health resources should be allocated toward meeting the mental health needs of the LGBTQ+ population, along with efforts to address the discrimination and stigma that contribute to these health disparities.8 It is notable that these inequalities persist in NYC despite the New York metropolitan area having the largest LGBTQ+ population in the country26 and a relatively supportive political environment. While current antidiscrimination policies are a necessary first step, more action is needed at the city, state, and federal levels.
Another subpopulation on which to focus policy efforts is emerging adults experiencing adverse social drivers of health. Financial strain can influence mental health through multiple pathways, including increasing stress27 and serving as a barrier to treatment. In our data, financial strain was associated with a higher prevalence of SPD and social isolation among emerging adults; emerging adults experiencing high financial strain had a prevalence of SPD 4 times higher than those not experiencing financial strain. Financial strain was not significantly associated with mental health treatment, suggesting that differential access to treatment is not driving the poor mental health outcomes. Financial strain is a particularly salient risk factor for mental illness among emerging adults, who are more susceptible to employment loss13 and earn lower wages. Unemployment was also significantly associated with SPD among emerging adults in our study. In recent decades in the United States, poverty among those aged 18 to 24 years has spiked, with poverty rates for those aged 18 to 24 years among the highest across the entire age distribution, yet young adults are less likely to be eligible for public benefits compared with older adults.28 To mitigate financial strain among emerging adults that can lead to poor mental health outcomes, it is necessary to expand the social safety net and eligibility for government antipoverty programs for this age group, as well as to implement broader redistributive policies to reduce economic inequality and poverty, such as raising the minimum wage and increasing the availability of public and affordable housing.19,29
Emerging adults experiencing IPV or neighborhood violence also had a higher prevalence of SPD and social isolation. Violence is a significant source of mental health problems among adolescents and emerging adults. Addressing this risk factor requires interventions at both the individual level (such as education about healthy relationships) and structural level (such as school policies to address sexual harassment8 and blight remediation of buildings and land30). SPD also increased on a gradient as the frequency of discrimination based on race and ethnicity increased. Social media may contribute to increased exposure, both directly and vicariously, to bullying, racism, and hate speech among youths of color.31
Emerging adults reported a higher prevalence of SPD than all other age groups, supporting previous reports of increased burden of mental illness among this age group.1,2 After controlling for sociodemographic variables, those aged 18 to 24 years had higher odds of both SPD and social isolation compared with those aged 35 to 44, 45 to 64, and 65 years or older, although they did not differ significantly from those aged 25 to 34 years. While those aged 18 to 24 years may share some unique characteristics, no strict age cut-off completely captures the experiences of an age group; future work should explore mental health among those aged 25 to 34 years.
A key finding from this study was that among individuals with SPD, emerging adults had lower odds of past-year mental health treatment compared with all other age groups. One potential explanation for this disparity is differences in perceived need for treatment. Emerging adults with SPD did not report higher levels of unmet need than those aged 25 to 34 or 35 to 44 years, despite lower treatment levels. Emerging adults who did report an unmet need were more likely than older adults to report that they thought they could handle their mental health on their own, with more than half reporting this barrier. Both findings suggest that those aged 18 to 24 years may have more difficulty identifying symptoms of psychological distress and when they may need professional help. Interventions such as Mental Health First Aid training, an evidence-based intervention that seeks to teach skills needed to identify and respond to signs of mental health challenges and crises, could help address this gap in awareness.32
In addition, stigma may play a role in emerging adults not seeking or receiving treatment. Emerging adults had higher odds than all other age groups of concern that others would think badly of them if they received mental health treatment. Campaigns targeted at this population, such as social media campaigns, could help reduce stigma and educate emerging adults about mental health.
Lower treatment rates among emerging adults may also reflect their uncertainty about how or where to access care. Emerging adults had higher odds than all other age groups of attributing their unmet need to not knowing who to contact or where to go for treatment. In addition to education campaigns, efforts to connect emerging adults to care in places they already frequent, such as community centers, athletic clubs, libraries, and schools, may help bridge the treatment gap. App-based mental health interventions have also shown promise for addressing some symptoms of mental illness in this age group.33 Finally, young adults may have trouble navigating the transition from child to adult care systems. Efforts to enhance referral streams and shared planning between these 2 systems could help facilitate continuity of care and increase treatment rates.11,34
Interestingly, emerging adults were less likely to report that insurance or cost was the reason for their unmet need than those aged 25 to 34 years, perhaps because of access to treatment through their parent’s insurance or school health services. However, cost was still 1 of the top reasons for unmet need, with nearly half of emerging adults (46%) reporting an unmet need identifying this barrier to treatment. There is a need to increase affordable and insurance-covered mental health treatment options for adults across all ages, which could be accomplished by a universal, publicly funded health care system.
The study’s focus on NYC serves as both a strength and a limitation. The size and diversity of NYC allow for examination of different identities, such as noncisgender adults, which may face sample size constraints in other geographical areas. Furthermore, because NYC has made mental health a public priority,35 an understanding of inequalities that persist can inform where additional efforts should be directed. While results may not be directly generalizable to populations outside NYC, many of the upstream determinants of mental health operate at the national and societal levels.
Major strengths of this study include that it is a large, representative sample. Limitations include that the NWS is cross-sectional and self-reported, so causality cannot be inferred, and there may have been respondent recall bias when reporting mental health symptoms. Small sample sizes of some populations occasionally resulted in unstable prevalence estimates. Sample size constraints also limited further analysis incorporating the intersection of gender identity and sexual orientation. Furthermore, because the survey sampling is address-based, homeless and institutionalized individuals are not represented by the data; efforts to reach these individuals should be made in future studies.
Public Health Implications
Overall, these findings demonstrate the need to expand efforts to address poor mental health and treatment needs among emerging adult populations. Additional resources should be allocated toward meeting the mental health needs of the growing Gen Z LGBTQ+ population, especially adults who identify as noncisgender or bisexual, or who are unsure of their sexual orientation. Campaigns to increase education about mental health stigma and help emerging adults navigate the transition from youth to adult care systems are needed. Finally, strategies to improve mental health outcomes should prioritize programs and policies that address upstream, systems-level drivers of mental health, such as poverty and discrimination.
ACKNOWLEDGMENTS
The NYC Neighborhood Wellness Survey was funded by the NYC Health Department.
The authors would like to thank our many colleagues who contributed to the NYC Neighborhood Wellness Survey, including Sasha Fleary and Monique Millington at the City University of New York (CUNY) Graduate School of Public Health and Health Policy. The authors would also like to thank Meghan Hamwey, Benjamin McCarthy, and Thinh Vu at the NYC Health Department for their writing support.
CONFLICTS OF INTEREST
All authors declare that they have no potential or actual conflicts of interest.
HUMAN PARTICIPANT PROTECTION
This study has been approved by the CUNY institutional review board.
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