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Mental Health Should Be Addressed at a Community Level – Here’s How

By: Jane Chai & Elizabeth Bobo


People with mental disorders have an average life expectancy that can be 8 to 25 years shorter than those without mental disorders. ​May is Mental Health Month — a time to bolster awareness of mental health and the services that support it. 

Unmet mental health needs have significant impacts on health and quality of life, not just for individuals but also within communities overall. This is why health departments, not-for-profit hospitals, and collaboratives across the country often identify mental and behavioral health as a priority and include it in their community health assessments.  

Rather than leaving mental health only to clinicians who address it at an individual level, we must also support community health practitioners in using data-driven approaches. In this way, they can best understand mental health at the community level to foster shared action. Here are some tips on how to get started. 

Use data-driven approaches to understand mental health 

When trying to understand a problem and track its progress, data is often a good starting point. Look for credible data sources that use validated methodology, get published regularly, and are granular enough to show disparities. Some reliable data sources for mental health at the national level include the CDC, Claritas, and the National Survey on Drug Use and Health (NSDUH). Local and state health departments may also provide hospitalization data or vital records that can offer additional insights. 

Community mental health data can be categorized into three general categories: 

  • Access to services: Indicators that describe access to mental health, such as health insurance coverage or individuals receiving mental health services.  
  • Behaviors and needs: Indicators that describe behaviors or needs, such as depression, isolation, or Adverse Childhood Events (ACEs).  
  • Mental health outcomes: Indicators that describe outcomes, such as hospitalizations, ER admission rates, or deaths due to mental health conditions or suicide 

Explore local data and disparities 

To better understand mental health in your community, you’ll find the most valuable insights using local data. Paint a broad picture of your community’s mental health status by comparing local values to state and national values or trends over time. Additionally, a public platform allows you to identify and track these issues with partner organizations and community members. 

Most communities struggle with disparities in health access and outcomes between different populations. To identify populations that are more at risk in your community, examine data by demographics such as age, race/ethnicity, and gender. In the below chart showing hospitalizations due to mental health, it is clear that young adults and adults who are 85+ are at higher risk for admission. In addition to viewing data by demographic disparities, map data by city, zip code or another regional grouping to provide a visually compelling understanding of which communities are most under-resourced.  

Probe for deeper insights 

While quantitative data tell part of the story, we must supplement those data sets with qualitative data that capture lived experiences.  Consider holding focus groups, key informant interviews, or conducting a community survey. Work with community partners to learn from local leaders and community residents and be sure to pose questions broad enough to capture in-depth insights that may not be apparent from the quantitative data. 

Questions to learn deeper insights

  • Which groups in your community seem to struggle the most?
  • How would you describe attitudes toward mental health in your community?
  • What ways do you see people coping with life stressors or mental health challenges?
  • What barriers might prevent someone in your community from accessing mental health services?
  • What programs or services would you like to see more of? 

These types of questions can bring out important community knowledge about which groups struggle most, overall attitudes toward mental health, barriers to access, and observations of which strategies are currently most utilized.   

Work through multi-sector partnerships to address social determinants of mental health  

Finally, many of us are familiar with the social determinants of health, or the notion that health begins where we live, work and play. Efforts to improve health must, therefore, address these factors in relation to the root causes of health outcomes. For example, the New York State Office of Mental Health released a white paper on The Social Determinants of Mental Health, identifying 16 of these determinants in four broad categories: highly detrimental societal problems, socioeconomic status, physical environment and basic needs. Data and insights about housing, education and income are thus an important aspect of understanding unmet mental health needs.  












Finding overlaps between mental health needs and social determinants of health can highlight opportunities for multi-sector collaboration. For instance, look at the two maps above. The map on the left compares hospitalization rates related to adult mental health for zip codes within one county to other county rates across the state. The map on the right shows Conduent’s SocioNeeds Index, in which darker green zip codes show areas of higher socioeconomic need.  

In comparing the two maps, you can see that many of the zip codes experiencing higher hospitalization rates also have higher socioeconomic need. Identifying these overlaps can guide collaboration across sectors to jointly improve mental wellness and socioeconomic status in the highest-need communities. In contrast, zip codes that show higher hospitalization rates due to mental health issues but have a lower SocioNeeds Index value might benefit from additional mental health services outside of socioeconomic assistance.  

Public platforms that feature rich data and track collaborative initiatives make it easier not only to find community-focused solutions but also to support the visibility and success of their efforts. 

In addition to clinical services, the mental health care system is composed of numerous partners including housing services, food pantries, community-based organizations, and the justice system. Using a common platform to track mental health data at the community level can create mutual understanding and foster a shared vision, leading to action for improved mental health in our communities.


About Healthy Communities Institute 

Conduent Healthy Communities Institute provides an end-to-end solution for community health that links health and social determinants of health with technology and expertise. The HCI platform brings stakeholders together with a centralized dashboard of more than 150 health, social, and economic indicators, high value analytics, and evidence-based practices at the user’s fingertips. HCI’s Consulting Services team provide expert guidance for assessing community needs, developing strategies, and implementing evaluation and monitoring processes. Contact Conduent Healthy Communities Institute at

About the Author

Jane Chai, MPH is a community health expert with Conduent Healthy Communities Institute. She has been a leader in the field of public health and community health planning for more than 20 years at various organizations in Southern California. Elizabeth Bobo, MPH, is an account manager with Conduent Healthy Communities Institute. She is a passionate community health advocate with over a decade of experience in community development and public health programs in New Orleans and throughout Latin America.