Abstract
Purpose
This study evaluated the relationship between sociodemographic factors including family structure and mental health service (MHS) utilization before and during the COVID-19 pandemic. We also investigated the moderation effects of the COVID-19 pandemic on MHS utilization.
Methods
Our retrospective cohort study analyzed adolescents aged 12–17 years with a mental health diagnosis as identified in the electronic medical record enrolled in Kaiser Permanente Mid-Atlantic States in Maryland and Virginia, a comprehensive integrated health system. We used logistic regression models with an interaction term for the COVID-19 pandemic year to determine the relationship between family structure and adolescent MHS utilization ≥ one outpatient behavioral health visit within the measurement year, while adjusting for age, chronic medical condition (= physical illness lasting > 12 months), mental health condition, race, sex, and state of residence.
Results
Among 5,420 adolescents, only those in two-parent households significantly increased MHS utilization during COVID-19 compared to the prepandemic year (McNemar's χ2 = 9.24, p < .01); however, family structure was not a significant predictor. Overall, the odds of adolescents using MHS were associated with a 12% increase during COVID-19 (odds ratio 1.12, 95% confidence interval [CI]: 1.02–1.22, p < .01). Higher odds of using MHS was associated with chronic medical condition (adjusted odds ratio = 1.15; 95% CI: 1.05–1.26, p < .01) and with White adolescents compared to all racial/ethnic minorities. The odds ratio of females using MHS compared to their male counterparts increased by 63% (ratio of adjusted odds ratio = 1.63; 95% CI: 1.39–1.91, p < .01) during the COVID-19 pandemic.
Discussion
Individual-level demographic factors served as predictors of MHS utilization with effects moderated by COVID-19.
Keywords: Adolescent mental health, Family structure, Mental health service utilization, COVID-19 pandemic
Implications and Contribution.
While prior studies demonstrate a rise in mental health service utilization in the emergency department setting, we found the odds of adolescents accessing outpatient behavioral health visits were 12% higher during the COVID-19 pandemic compared to the prior year. The degree of utilization varied by family structure and individual-level factors.
The United States Surgeon General has deemed adolescent mental health an urgent public health crisis as the COVID-19 pandemic has heightened the rising rates of depression, anxiety, and suicidality among U.S. youth [1,2]. Subsequent growth in mental health service utilization is expected; however, gaps in adolescent mental health services exist [3,4]. More than half of adolescents have unmet mental health service needs [5,6].
Family structure characterizes the individuals living within a household [7,8]. Historically, family structure has played a significant role in accounting for differing levels of child healthcare utilization [9,10]. U.S. national survey data report children living in single-parent households have a greater likelihood of having unmet healthcare needs [11]. Prior to the COVID-19 pandemic, youth from single-parent households were more likely to seek mental health–related care [12,13]. Moreover, a single-parent household was also associated with lower adolescent sense of wellbeing and more anxiety and depressive symptoms during the COVID-19 pandemic compared to two-parent households [14]. Even when prior studies hold constant socioeconomic and demographic factors, children in single-mother families and grandparent-only families had poorer physical and mental health compared to children living with two biological parents [15].
Insurance coverage is also a historic predictor of mental health service utilization [16]. Prior literature demonstrates differing treatment outcomes for adolescents with a mental health diagnosis based on insurance coverage but little data exist on the relationship between family structure and adolescent mental health service utilization in a population with similar insurance coverage [17]. Cross-sectional studies hypothesize that differing outcomes between household types could be described by a greater likelihood of employer-based health insurance in two-parent homes [15].
Yet, the extent to which adolescent mental health services have been affected by the COVID-19 pandemic has been insufficiently described in the United States among insured adolescents. Population-based Canadian data demonstrate an initial decline following above expected growth in mental health utilization [18]. However, data were limited by not including nonphysician-based mental health service utilization. In addition, individual-level predictors were not available for analysis to provide more detail in patterns of mental health service utilization. Therefore, this study investigates the relationship between family structure and sociodemographic factors with adolescent mental health service utilization of physician and psychologist visits within Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated healthcare system servicing more than 50,000 adolescents prior to and during the COVID-19 pandemic.
Methods
Study design and setting
This retrospective cohort study used a population of adolescents with mental health diagnoses measured during a prepandemic (March 1, 2019 to February 28, 2020) and pandemic timeframe (March 1, 2020 to February 28, 2021) to assess the association between family structure and mental health service utilization among adolescents receiving comprehensive medical care from KPMAS (Supplement 1). KPMAS is an integrated healthcare delivery system serving more than 50,000 adolescents aged 12–17 years in 33 medical offices in the District of Columbia, Maryland, and Virginia. Members have access to behavioral health visits via in-person, video, or telephonic appointments and patient secure messaging, a HIPAA-compliant texting feature within the Kaiser Permanente mobile application. We included adolescents with continuous KPMAS commercial insurance plan types. Commercial plans can include employer-sponsored plans, Affordable Care Act marketplace plans, and self-pay.
KPMAS Institutional Review Board approved this study and waived informed consent. This study followed the Strengthening the Reporting of Observed Studies in Epidemiology reporting guidelines [19].
Study cohort
We included adolescents with KPMAS commercial insurance plans aged 12–17 years by the first date of the first measurement year, March 1, 2019, with a mental health diagnosis documented in both measurement years: prepandemic, March 1, 2019 to February 28, 2020, and during COVID-19 pandemic, March 1, 2020 to February 28, 2021, in the electronic health record (Supplement 2). Cohort members were included in the analysis if they had continuous insurance coverage, every day during the prepandemic and pandemic measurement years. Adolescents were defined as having a mental health diagnosis by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes corresponding to mental health diagnoses associated with at least one outpatient visit within five years prior to the first measurement year, March 1, 2019.
We excluded adolescents who did not live in the catchment area serviced by KPMAS (Maryland, District of Columbia, and Northern Virginia). We also excluded adolescents with missing or inconsistent data on the following sociodemographic characteristics: race/ethnicity, sex, and family structure.
We defined adolescent mental health service (MHS) utilization as having at least one outpatient behavioral health visit within the measurement year. Visits included outpatient encounters (video visits, office visits, telephone visits, and group visits). Henceforth, MHS will be used to describe the outpatient mental healthcare services.
Provider types included psychiatrist, psychologist, primary care providers, physician assistant, licensed professional counselor, and psychological social worker. Nurse practitioners, physician assistants, and advanced practice registered nurses were excluded due to the lack of clinical responsibilities in this population with providing adolescent mental health domain of the KPMAS infrastructure.
Independent variables
Family structure was defined as the most recent family structure documented by the provider in the social history category of the electronic health record as a response to “lives with”. Text analysis was performed on unstructured data to classify family structure. Family structure was categorized as two-parent, single-parent, extended family, and no parent households. A two-parent household was defined as a response to either “mom and dad”, “mother and stepfather”, “mom and mom”, “dad and dad”, or foster parents. A single-family household was defined as a response of either “mom” or “dad” only. An extended family household was defined as having either one or both parents and one other adult residing in the home. No parent household was defined as a family structure of a nonparent adult primary caregiver.
Mental health diagnoses were categorized as (1) attention deficit hyperactivity disorder (ICD-10 codes F90-F90.2; F90.8-F90.9); (2) anxiety (ICD-10 codes F40.10, F40.11, F40.2, F93.0, F41.0, F41.1, F41.9, F42.0, F43.22); (3) mood disorder/depression (ICD-10 codes F06.30, F33.0, F33.1, F33.2, F33.3, F33.4, F33.40, F33.41, F33.42, F33.8, F33.9; F43.23, F91.9); (4) dual diagnosis of anxiety and mood disorder/depression; and (5) psychosis and multiple psychiatric disorders (ICD-10 codes F20-F29). The COVID-19 index was defined as the first year of the COVID-19 pandemic, March 1, 2020 to February 28, 2021.
Sociodemographic characteristics
Sociodemographic factors were included based on literature reporting differences in MHS utilization by age group (12–13.9 years, 14–15.9 years, 16–17.9 years), sex (female, male), race/ethnicity (Asian/Pacific Islander, Black/African American, White, Hispanic, Other), as per self-identified data in the electronic health record, chronic medical condition defined as a health condition that lasts from 3 months to a lifetime (e.g., sickle cell anemia, asthma), and state of residence (Maryland, District of Columbia, and Virginia) aligning with prior findings demonstrating differences in mental health rates and outcomes by rural and metropolitan locales [[20], [21], [22]].
Statistical analysis
The prevalence of mental health diagnoses among all adolescents with active KPMAS insurance was determined. We compared the proportion of adolescents with mental health diagnoses who used MHS prepandemic and during the pandemic. Descriptive statistics were used to determine frequencies and percentages. Bivariate analyses were performed using χ2 tests to evaluate differences in mental health diagnoses and sociodemographic covariates by family structure type. McNemar's test was used to compare proportions of MHS utilization between pre-COVID-19 and the COVID-19 pandemic by sociodemographic covariates.
Logistic regression models using generalized estimating equations assessed the association between adolescent MHS utilization and family structure adjusting for sociodemographic covariates. Data were analyzed by using SAS version 9.4 statistical software (SAS Institute, Inc, Cary, North Carolina) and Oracle SQL programming language. Figures were formatted using Tableau Desktop Professional Edition (version 2021.4.4). Horton Horton et al. goodness of fit χ2 statistic provided no evidence for lack of fit for the final model [23]. Statistical significance was based at a level of significance of 0.05 for a two-tailed test.
Results
Sample description
A total of 5,420 adolescents, 10% of our total KPMAS adolescent population, with a mental health diagnosis and family structure identified in the electronic health record were included in this analysis. The median age of adolescents’ pre-COVID-19 pandemic was 14.6 years.
More than half were female (2,941; 54.3%) and the most predominant race/ethnicity included were Black/African American at 2,090 (38.6%) with the next largest group being White (1,937; 35.7% and 754; 13.9%) self-identifying as Hispanic. Most adolescents did not have a chronic medical condition (3,523; 65%). More than half of adolescents resided in the state of Maryland (Table 1 ).
Table 1.
Sample characteristics of adolescents with a mental health condition by family structure (Pre-COVID)
| Two parent household | Single parent household | Extended family household | No parent household | Total | χ2 | ||
|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N | % | p value | |
| Mental Health Condition | .001 | ||||||
| Anxiety Disorder | 1,321 (35.8%) | 348 (31.9%) | 162 (30.6%) | 22 (20.2%) | 1,853 | 34.2% | |
| Attention Deficit Hyperactivity Disorder | 601 (16.3%) | 177 (16.2%) | 84 (15.9%) | 24 (22.0%) | 886 | 16.3% | |
| Anxiety & Mood Disorder/Depression | 772 (20.9%) | 245 (22.5%) | 132 (25.0%) | 30 (27.5%) | 1,179 | 21.8% | |
| Mood Disorder/Depression | 158 (4.3%) | 57 (5.2%) | 37 (7.0%) | 13 (11.9%) | 265 | 4.9% | |
| Psychosis & Multiple Diagnoses | 840 (22.8%) | 263 (24.1%) | 114 (21.6%) | 20 (18.3%) | 1,237 | 22.8% | |
| Adolescent Age (years) | .14 | ||||||
| 12–13.9 | 1,335 (36.2%) | 406 (37.2%) | 216 (40.8%) | 36 (33.0%) | 1,993 | 36.8% | |
| 14–15.9 | 1,602 (43.4%) | 435 (39.9%) | 209 (39.5%) | 48 (44.0%) | 2,294 | 42.3% | |
| 16–17.9 | 755 (20.4%) | 249 (22.8%) | 104 (19.7%) | 25 (22.9%) | 1,133 | 20.9% | |
| Sex | .27 | ||||||
| Female | 1,985 (53.8%) | 589 (54.0%) | 300 (56.7%) | 67 (61.5%) | 2,941 | 54.3% | |
| Male | 1,707 (46.2%) | 501 (46.0%) | 229 (43.3%) | 42 (38.5%) | 2,479 | 45.7% | |
| Race/Ethnicity | .001 | ||||||
| Asian/Pacific Islander | 361 (9.8%) | 46 (4.2%) | 64 (12.1%) | 1 (0.9%) | 472 | 8.7% | |
| Black/African American | 1,132 (30.7%) | 645 (59.2%) | 242 (45.7%) | 71 (65.1%) | 2,090 | 38.6% | |
| White | 1,564 (42.4%) | 266 (24.4%) | 81 (15.3%) | 26 (23.9%) | 1,937 | 35.7% | |
| Hispanic | 516 (14.0%) | 107 (9.8%) | 124 (23.4%) | 7 (6.4%) | 754 | 13.9% | |
| Othera | 119 (3.2%) | 26 (2.4%) | 18 (3.4%) | 4 (3.7%) | 167 | 3.1% | |
| Chronic Medical Condition | .04 | ||||||
| Yes | 1,251 (33.9%) | 416 (38.2%) | 186 (35.2%) | 44 (40.4%) | 1,897 | 35.0% | |
| No | 2,441 (66.1%) | 674 (61.8%) | 343 (64.8%) | 65 (59.6%) | 3,523 | 65.0% | |
| State of Residence | .001 | ||||||
| Maryland | 1,898 (51.4%) | 665 (61.0%) | 281 (53.1%) | 72 (66.1%) | 2,916 | 53.8% | |
| District of Columbia | 187 (5.1%) | 108 (9.9%) | 45 (8.5%) | 8 (7.3%) | 348 | 6.4% | |
| Virginia | 1,607 (43.5%) | 317 (29.1%) | 203 (38.4%) | 29 (26.6%) | 2,156 | 39.8% | |
| Total (%) | 3,692 (68.1%) | 1,090 (20.1%) | 529 (9.7%) | 109 (2.0%) | 5,420 | ||
∗∗∗Chronic Medical Condition (CMC) refers to a health condition that lasts anywhere from 3 months to a lifetime. Common Pediatric CMCs include Asthma, Anemia, Eczema, Sickle Cell Anemia, Diabetes, Seizures, and Allergies.
Other Race includes American Indian/Alaska Native and Other.
Family structure and mental health disorders
The most prevalent family structure in our study population was the two-parent household (n = 3,692; 68.1%) and the least prevalent family structure was a no-parent household (n = 109, 2.0%). The greatest proportion of adolescents with anxiety was found in two-parent households (n = 1,321; 35.8%). Conversely, single-parent households had the greatest proportion of adolescents with psychosis and multiple diagnoses (24.1%). Adolescents living in no-parent households have the greatest proportion of attention deficit/hyperactivity disorder (22.0%), anxiety and mood disorder/depression (27.5%), and mood disorder/depression (11.9%) (Table 1).
Family structure and sociodemographic covariates
There was no significant difference between adolescent age, sex and chronic medical condition, and family structure type in bivariate analyses. The greatest difference among race/ethnicity existed between White and Black/African American households where 80.7% of White adolescents lived in a two-parent household compared to 54.2% of Black/African American households. Among single-parent households, only 9.7% were comprised of Asian/Pacific Islander adolescents compared to 30.9% of Black/African American households. More than 16% of Hispanic adolescents live in an extended family household compared to 4.2% of White adolescents. Almost two-thirds (65.1%) of no parent households house Black/African American adolescents (Table 1).
Family structure and adolescent MHS utilization
Half of adolescents with a mental health diagnosis used MHS prior to COVID-19 (n = 2,739; 50.5%), which increased to more than half (n = 2,855; 52.7%) during COVID-19. The odds of adolescents using MHS were associated with a 12% increase during COVID-19 (OR 1.12; 1.02–1.22, p < .01). The pattern of adolescent MHS utilization demonstrated similar trends by family structure type. In our subgroup analysis, two-parent households had a significant increase in adolescent MHS utilization during the COVID-19 pandemic compared to prepandemic utilization (McNemar's χ2 = 9.24, p < .01). However, in the bivariate analysis (Figure 1 ) and in the full adjusted model (Figure 2 ), there was no significant association between the family structure covariate and adolescent MHS utilization.
Figure 1.
Associations between covariates and COVID-19 with adolescent mental health service utilization.
Figure 2.
Multivariable logistic regression analysis of predictive factors for adolescents mental health service utilization during the first year of the COVID-19 pandemic.
Mental health condition and adolescent MHS utilization
The most prevalent mental health condition was anxiety (n = 1,853; 34.2%) in our study cohort prior to the COVID-19 pandemic, whereas the least prevalent mental health condition was mood disorder/depression (n = 265, 4.9%). Irrespective of the COVID-19 pandemic, adolescents with mood disorder/depression have the least proportion of MHS utilization (prepandemic, 31%; during COVID-19, 34%) compared to those with psychosis and multiple diagnoses (prepandemic, 72%; during COVID-19, 68%) (Figure 3 ).
Figure 3.
Differences in adolescent mental health service utilization by sociodemographic covariates.
In contrast to adolescents with anxiety, those with attention deficit/hyperactivity disorder (adjusted odds ratio [aOR] = 2.37; 1.99–2.83, p < .01) and psychosis and multiple diagnoses (aOR = 4.43; 3.77–5.20, p < .01) were more likely to use MHS prior to the COVID-19 pandemic. However, pattern of MHS use changed during COVID-19. Compared to adolescents with anxiety, the odds ratio of MHS utilization for adolescents with attention deficit/hyperactivity disorder decreased by 45% (ratio of OR = 0.55 [0.44–0.68], p < .01) the odds ratio prior to the COVID-19 pandemic. Similarly, the odds ratio of adolescents with psychosis and multiple diagnoses (ratio of OR = 0.70; 0.57–0.86, p < .01) using MHS decreased by 30% during the COVID-19 pandemic when compared to having a diagnosis of anxiety.
Sociodemographic covariates and adolescent MHS utilization
Prior to the COVID-19 pandemic, less than half of females used MHS (Figure 3) which significantly increased during the COVID-19 pandemic (McNemar's χ2 = 61.64, p < .001). In contrast, male MHS utilization declined during the COVID-19 pandemic (McNemar's χ2 = 27.80, p < .001). In the adjusted model, female adolescents had higher odds of using MHS compared to male (aOR = 1.17; 1.04–1.32, p = .01) prior to the COVID-19 pandemic. During the COVID-19 pandemic, a greater proportion of female adolescents used MHS compared to male adolescents. The COVID-19 interaction term was significant (ratio of OR = 1.63; 1.39–1.91, p < .01) (Figure 2).
Adolescents who identify as Asian/Pacific Islander had a significant increase in MHS utilization between COVID-19 and the prepandemic measurement year (McNemar's χ2 = 5.84, p = .02). Still, when compared to White counterparts, Asian/Pacific Islander adolescents had lower odds of using MHS and this relationship did not significantly change during the COVID-19 pandemic (ratio of aOR = 1.13; 0.86, 1.49, p = .39) (Figure 2). Hispanic adolescents were the only racial/ethnic subpopulation to show a decline in MHS utilization during COVID-19. Compared to White adolescents, the odds ratio of Hispanic adolescents using MHS declined by 26% during COVID-19 (ratio of aOR = 0.74; 0.58–0.93, p < .01). White adolescents had higher odds of using MHS compared to minoritized groups as indicated in Figure 2.
Age was a significant predictor of MHS utilization before the COVID-19 pandemic; however, patterns of utilization differed by COVID-19 index. Compared to older adolescents, aged 16–17.9 years, adolescents aged 12–13.9 years had lower odds of MHS utilization (aOR = 0.83; 0.71–0.97, p = .02). However, during COVID-19, the odds ratio of younger adolescents aged 12–13.9 years and 14–15.9 years using MHS increased by 36% and 26%, respectively.
Chronic medical conditions and adolescent MHS utilization
Having a chronic medical condition was associated with higher odds of using MHS for adolescents in our cohort (aOR = 1.15 [1.05–1.26], p < .01). The COVID-19 pandemic was associated with increased MHS utilization for adolescents irrespective of chronic medical condition (Figure 1). The insignificant interaction effect indicates that the COVID-19 pandemic did not significantly change the relationship between MHS utilization and chronic medical condition.
Discussion
This study adds to the burgeoning literature examining predictors of outpatient adolescent MHS utilization in the United States. Our study evaluated predictors uniquely during the COVID-19 pandemic timeframe, marked by unprecedented challenges to service delivery due to federal isolation policies. We found that among adolescents with mental health diagnoses receiving care at KPMAS, the odds of using MHS during the first year of the COVID-19 pandemic increased by 12%. Notably, the rate of rise in MHS utilization among adolescents during the COVID-19 pandemic was less than European estimates but more than other North American countries [24,25]. Similar to European trends, we found an increase in MHS utilization in adolescents with anxiety and a dual diagnosis of anxiety and mood disorder/depression during the COVID-19 pandemic.
Increased utilization patterns were not ubiquitous across all mental health conditions. Namely, adolescents with attention deficit and hyperactivity disorder and psychosis and multiple psychiatric diagnoses showed a decline in utilization. This finding contrasts European estimates which note an increase in primary care mental health consultations by nearly 50% within the first five months of the COVID-19 pandemic with a less dramatic increase in attention deficit/hyperactivity disorder. Yet, these results exist in context of low COVID-19 mortality rates and overall low levels of mental health diagnoses [26]. Norwegian registry data demonstrated a 1.0% use of mental health consultation use in primary care and 1.7% in specialist care in any given month compared to prepandemic U.S. survey data reporting 6%–9% use in children and adolescents aged 6–17 years [27].
Our cohort study uniquely characterizes a subpopulation of adolescents with commercial insurance, eliminating a major constraint for MHS utilization [28]. Here, only two-parent households showed significant increases in MHS utilization. This finding is similar to prior studies which demonstrate worse mental health outcomes in children living in nontwo-parent homes compared to the two-parent family structure, both pre-COVID-19 and during COVID-19 [13]. Indeed, we found a downtrend in MHS utilization for adolescents living within a no-parent household during the pandemic. This adds to recent concern for a subpopulation of vulnerable youth during the COVID-19 pandemic where stay-at-home orders may increase their risk for harm, poor wellbeing, and mental health illness [29]. As the COVID-19 pandemic continues, policy makers can also consider expanding access to a system of care focusing on adolescents living in homes with parental alternatives as caregivers.
Distinct patterns of MHS utilization occurred by racial/ethnic categorization. In fact, there was a decline in the Hispanic adolescent population's use of mental healthcare services during COVID-19. Excluding access to health insurance, cross-sectional studies postulate alternate factors to account for disparate utilization within the Latino community such as low levels of mental health literacy, linguistic barriers, and stigma [30,31]. Systemic change in our mental health services can help combat historic barriers where mental health providers are equipped to provide culturally responsive services that include linguistic support and specified training on cultural competence to maximize efficacy of mental health treatment. Asian/Pacific Islander adolescents showed a significant rise in mental healthcare services during the COVID-19 pandemic. The rise in Asian/Pacific Islander use of MHS could reflect a shift facilitated by the COVID-19 pandemic in cultural attitudes and health literacy on mental health conditions shared in this community [32]. Future qualitative studies can continue to provide an insight into underlying facilitators which aided the rise in MHS utilization during the COVID-19 pandemic.
Our study demonstrated the presence of chronic medical condition as a significant predictor of adolescent MHS utilization irrespective of the COVID-19 pandemic. Previous literature has cited a similar relationship in which there are higher odds of mental health conditions with physical health conditions with subsequently higher healthcare costs to the families [[33], [34], [35]]. Prior work posits greater engagement in MHS may stem from coping with a chronic condition in the setting of continued neurocognitive development during adolescence [36]. Increased MHS utilization in this population can also signal the benefits of an integrated healthcare system where there are greater opportunities for early identification and care coordination.
Limitations
We acknowledge some limitations in this study. Our study did not capture marital status of the parents and family income data. Substantial data support a positive relationship between poverty and adolescent mental health diagnoses [37]. Furthermore, U.S. Census data describe a greater proportion of children living in a single, female-he1aded household in poverty compared to children living in married couple household [38]. Our cohort did not include adolescents with a public insurance plan, Medicaid, where access to MHS is exclusively provided due to a non-KPMAS carved-out contract. Hence, missing data on this subpopulation limit the findings generalizability to other populations. Mental health services provided outside of the clinical outpatient setting were not analyzed and may limit the interpretation of findings in alternative care infrastructures. In addition, we recognize that our cohort is limited to adolescents who were activated to seek the healthcare system for support for mental health and does not capture data on adolescents whose mental health service needs are not met.
Finally, due to the retrospective nature of our study, we had limited information on family structure changes during the COVID-19 pandemic. Recent studies report > 140,000 children in the United States experienced the death of a parent or grandparent caregiver during the pandemic [39]. This population of adolescents experiencing COVID-19 associated parental loss may be at a higher risk for unmet healthcare needs due to custodial change can potentially lead to gaps in healthcare insurance coverage. Future work to provide longitudinal data on MHS utilization during the COVID-19 pandemic can provide a better lens into trends developed over time and can further characterize the association between predictors of use.
Conclusion
In this cohort study, we identified adolescents at a higher likelihood for using mental healthcare services as White, females, with a chronic medical condition, and multiple mental health diagnoses. The COVID-19 pandemic moderated the predictive effects of sex, age, race/ethnicity, and mental health diagnosis. Two-parent household types experienced higher MHS utilization during the COVID-19 pandemic. These findings lend to divergent levels of healthcare access supporting the need for greater advocacy efforts for adolescents living in alternative household types. Our findings can be useful for strengthening prevention programming for adolescent mental healthcare by addressing inequities, incorporating supportive systems for the family unit, and tailoring policies toward vulnerable youth. Knowledge on the subpopulations of adolescents with a higher likelihood of mental healthcare utilization can help inform local and national policy creation on egalitarian resource allocation while prioritizing adolescent wellbeing during pandemic recovery.
Acknowledgments
We would like to acknowledge Mamta Bhatia, M.S. for editing and formatting this manuscript.
Footnotes
Conflicts of interest: The authors have no conflicts of interest to declare.
Data Statement: As a clinical healthcare system, Kaiser Permanente (KP) is responsible for the confidentiality and protection of our members' data. As such, we are required by organizational policy to ensure outside access and/or procurement requests involving clinical data regardless of data de-identification are reviewed by the proper personnel within the Mid-Atlantic Permanente Research Institute (MAPRI) for appropriate research use, purpose, disclosure tracking, and potential for security risks. Research data that are to be made publicly available for published manuscripts are required to remain behind Kaiser Permanente's firewall until it can be released to outside entities through secure file transfer protocols, provided all stipulations listed above for the data request are met.
Supplementary data related to this article can be found at 10.1016/j.jadohealth.2023.01.018.
Funding sources
This research was supported by the Mid-Atlantic Permanente Medical Group.
Supplementary data
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