The number of those who cited mental health issues as their top cause of unemployment is up 2 percentage points from March, the survey by business consulting firm McKinsey on Monday found.

The findings, based on a survey of 5,000 Americans, show the pandemic’s huge toll on mental health and its impact on employment. During the pandemic, about four in 10 adults in the U.S. reported symptoms of anxiety or depressive disorder, according to the Kaiser Family Foundation. That’s up from one in 10 adults who reported these symptoms from January to June 2019. 

In another sign of mental health struggles during the pandemic, more than one in 10 adults have reported starting or increasingly use alcohol since COVID arrived. Deaths from drug overdoses also grew, largely due to synthetic opioids. About 93,000 drug overdose deaths were reported in 2020, the highest on record and a 30% increase from 2019. 

Health, in general, is playing a huge role in unemployment, with physical and mental health representing the biggest barrier to finding work, according to the survey. When asked why they were currently unemployed, 30% of respondents (up from 27% in March) cited physical health as a reason.

Those who had stopped looking for work altogether also cited health concerns as the main cause of joblessness. 

The survey also found that access to affordable healthcare is the greatest barrier to people’s wellbeing, followed by access to nutritious food. About 40% of respondents who struggle with access to healthcare reported having been diagnosed with a mental-health issue or substance abuse disorder.

Overall, unemployment rates have recovered from their spike during pandemic, returning to a pre-COVID-era low of 4.2% in the most recent unemployment report. The low rate is helping to fuel increasing optimism among workers, with nearly half now saying good jobs are available to them, up 7 percentage points from March. 

Still, not everyone is thriving. The number of people who have lost permanent jobs is still higher than it was in February of 2020, just before the pandemic. And the number of long-term unemployed, who make up 32% of total unemployment, is little changed.

Additionally, McKinsey found that most Americans are teetering on the financial brink. Just 48% of respondents said this fall that they could cover more than two months of expenses if they lost their jobs, a slight decline from 50% in March.

That decline comes as inflation reached a 40-year high, increasing the cost of living considerably. Worker’s wages, meanwhile, have not risen to keep up with the higher prices of consumer goods.