This 2025 NRI report examines how State Mental Health Agencies (SMHAs) are organized across 48 states and highlights significant variation in their structure, governance, and responsibilities. The report found that 45 states have combined mental health and substance use disorder services within a single agency, reflecting a continued trend toward behavioral health integration, while SMHAs collectively administer more than $55 billion in services for over 8.4 million people annually.

The report also notes that nearly one-third of SMHAs have undergone reorganization since 2023, with states modifying agency structures, financing approaches, and service delivery systems to improve coordination, access, and system effectiveness. It further documents how responsibilities for community mental health services, Medicaid coordination, intellectual and developmental disabilities services, and state psychiatric hospitals vary considerably across states.