Expand Options For Behavioral Health

By John Hood

RALEIGH — Do you or someone you know suffer from mental illness? I suspect most readers will say yes. According to the National Alliance on Mental Illness, behavioral-health disorders affect a fifth of adults and a sixth of school-aged children in North Carolina. One in 18 of us lives with a “severe mental illness,” defined as “a mental, behavioral, or emotional disorder that results in serious impairment and interferes with or limits one or more major life activities.”

My own family history is full of such cases, ranging from alcoholism and depression to schizophrenia and bipolar disorder. Several of my ancestors and relatives died as a result of their afflictions. Others were incarcerated or institutionalized.

Again, none of this sets me apart. Mental illness isn’t rare. It directly or indirectly touches millions of North Carolinians, and tens of millions of Americans.

One way our state is distinct from others, however, is that it is particularly challenging to seek treatment for such conditions here. A North Carolina Institute of Medicine study published in 2025 ranked us last in the nation for access to behavioral health. All but six of our 100 counties are considered “professional mental health shortage areas,” with nearly a quarter of counties lacking a single practicing psychiatrist and more than a quarter lacking a single practicing psychologist.

Although funding is always an issue, we don’t appear to be significantly out of alignment with our peers. According to an analysis published last year, per-capita public expenditures on mental health in North Carolina were higher than those of any of our neighbors, or of such large states as Ohio, Florida, Texas, and Illinois.

It’s a complicated picture, one so daunting to interpret that some policymakers may be tempted to throw up their hands in confusion. That would be unwise. In addition to the obvious human suffering, untreated mental illness has larger social consequences. It imperils public safety and lowers student achievement. It reduces labor-force participation and makes it hard for employers to fill key jobs. And despite North Carolina’s many attractive assets and amenities, it harms our ability to compete for households, businesses, investment, and talent.

Here’s a set of reforms state lawmakers and regulators can tackle right now: strike a better balance between provider access and training.

A massive, costly effort to train and deploy psychiatrists with M.D.s all across North Carolina would likely yield modest results and fail a cost-benefit test. Behavioral health encompasses a far broader spectrum of providers, including advanced-practice nurses, psychologists, social workers, marriage and family therapists, and peer and pastoral counselors. We should remove any barriers that unnecessarily limit their capacity to meet the behavioral-health needs of North Carolinians.

Seven states allow specially trained psychologists to prescribe medications to treat mental illness. This practice “is not only safe and evidence-based,” wrote researcher and licensed psychologist Jacqueline Marie Gallios in Regulation magazine, “but also a vital solution to America’s escalating mental health crisis.”

Other states allow nurse practitioners to operate independently, social workers and counselors to deliver a broader array of services, and peer counselors to obtain certification with less time and expense. Telehealth is another promising tool. North Carolina has taken some steps in these directions but should go further. Jarrett Dieterle, a Manhattan Institute fellow, noted that studies conducted before and after the COVID-19 pandemic found comparable results for behavioral-health treatment in the office vs. treatment by telehealth — but the latter is, naturally, less expensive and more accessible.

“American’s mental-health challenges are complex, nuanced, and multi-variated,” Dieterle wrote in National Affairs. No single reform, or even set of reforms, “cannot be expected to magically ‘fix’ the problem overnight. But policymakers are not powerless to respond, and neither are the rest of us.”

I agree. My argument isn’t merely that, given the stakes, we can’t afford to let the perfect be the enemy of the good. There is no such thing as perfection here. There are only differences in priorities. Let’s elevate access to the top.

John Hood is a John Locke Foundation board member. His books Mountain Folk, Forest Folk, and Water Folk combine epic fantasy with American history (FolkloreCycle.com).