Key Points
Question
Was there a change between 2019 and 2021 in the percentage of US children and adolescents with severe mental health impairment and the percentage of youth using outpatient mental health care?
Findings
This survey study including 8331 participants found that the percentage of youth with severe mental health impairment was 9.7% in 2019 and 9.4% in 2021. Controlling for age, sex, and impairment, outpatient mental health care declined among Black youth and increased among White youth.
Meaning
There was no overall increase in parent-reported youth impairment during the pandemic, while expansion of the outpatient mental health treatment gap between Black and White youth increases the urgency to eliminate this disparity.
Abstract
Importance
Despite a federal declaration of a national child and adolescent mental health crisis in 2021, little is known about recent national trends in mental health impairment and outpatient mental health treatment of US children and adolescents.
Objective
To characterize trends in mental health impairment and outpatient mental health care among US children and adolescents from 2019 to 2021 across demographic groups and levels of impairment.
Design, Setting, and Participants
Survey study with a repeated cross-sectional analysis of mental health impairment and outpatient mental health care use among youth (ages 6-17 years) within the 2019 and 2021 Medical Expenditure Panel Surveys, nationally representative surveys of US households. Race and ethnicity were parent reported separately from 15 racial categories and 8 ethnic categories that were aggregated into Black, non-Hispanic; Hispanic; Other, non-Hispanic; and White, non-Hispanic.
Exposure
Time period from 2019 to 2021.
Main Outcomes and Measures
Age- and sex-adjusted differences between 2019 and 2021 in mental health impairment measured with the Columbia Impairment Scale (a score ≥16 indicates severe; 1-15, less severe; and 0, no impairment) and age-, sex-, and Columbia Impairment Scale strata–adjusted differences in the use of any outpatient mental health care in 2019 and 2021.
Results
The analysis involved 8331 participants, including 4031 girls and 4300 boys; among them, 1248 were Black and 3385 were White. The overall mean (SE) age was 11.6 (3.4) years. The percentage of children and adolescents with severe mental health impairment was 9.7% in 2019 and 9.4% in 2021 (adjusted difference, −0.3%; 95% CI, −1.9% to 1.2%). Between 2019 and 2021, there was also no significant difference in the percentage of children and adolescents with less severe impairment and no impairment. The overall annual percentages of children with any outpatient mental health care showed little change: 11.9% in 2019 and 13.0% in 2021 (adjusted difference, 1.3%; 95% CI, −0.4% to 3.0%); however, this masked widening differences by race. Outpatient mental health care decreased for Black youth from 9.2% in 2019 to 4.0% in 2021 (adjusted difference, −4.3%; 95% CI, −7.3% to −1.4%) and increased for White youth from 15.1% to 18.4% (adjusted difference, 3.0%; 95% CI, 0.0% to 6.0%).
Conclusions and Relevance
Between 2019 and 2021, there was little change in the overall percentage of US children and adolescents with severe mental health impairment. During this period, however, there was a significant increase in the gap separating outpatient mental health care of Black and White youth.
This survey study using a repeated cross-sectional analysis investigated trends in mental health impairment and outpatient mental health care in US children and adolescents overall and by race between 2019 and 2021.
Introduction
During the COVID-19 pandemic, US federal authorities1 and health care professional organizations2 declared a national child and adolescent mental health crisis. The stress, adversities, and disruptions of the pandemic were assumed to have driven an increase in mental health challenges and service needs for US children and adolescents.
Following the pandemic’s onset, depression and suicidal symptoms increased among US adolescents. The percentage of adolescents with past-year major depressive episodes increased from 15.7% in 2019 to 20.1% in 2021,3,4 and the percentage of high school students who seriously considered suicide increased from 24.1% in 2019 to 30.0% in 2021 among girls and from 13.3% in 2019 to 14.3% in 2021 among boys.5 Unfortunately, US national data on changes in the mental health impairment of children and adolescents during this period are scant.
Little is also known about changes in outpatient mental health care for children and adolescents during the pandemic. Analyses of insurance claims have yielded conflicting results, with reports of decreasing6 and increasing7 mental health encounters from the prepandemic (2019) to pandemic (2020-2021) periods. A key limitation of claims analyses is that they do not offer insights into the proportion of youth in need of mental health care who receive it.
With the goal of informing public policy regarding access to child and adolescent outpatient mental health services, we estimated national changes from 2019 to 2021 in mental health and outpatient treatment of US children and adolescents following the pandemic’s onset.
Methods
In this survey study, we used a repeated cross-sectional design to analyze data from the 2019 and 2021 Medical Expenditure Panel Surveys (MEPS), which are representative of the US noninstitutionalized population, for changes in mental health impairment and outpatient mental health care of persons aged 6 to 17 years. With respondent oral consent, MEPS collects information on health visits by all health care professionals and payment sources. Mental health impairment was measured with the Columbia Impairment Scale (CIS), a 13-item parent-reported measure of interpersonal relations, psychopathologic symptoms, school functioning, and leisure time use.8 Scores of 16 or higher were classified as severe impairment; 1 to 15, less severe impairment; and 0, no impairment.9 Missing values were imputed from means of nonmissing values. The 2021 MEPS did not include the CIS. Outpatient mental health care was defined as at least 1 visit with a mental health diagnosis; at least 1 visit with psychotherapy or mental health counseling as the main visit reason; at least 1 visit to a psychiatrist, social worker, psychologist, or mental health counselor; or at least 1 psychotropic medication for a mental health condition.
Owing to the use of deidentified data, these analyses were exempted from human participants review by the New York State Psychiatric Institute Institutional Review Board.
Statistical Analysis
Separately for the 2019 and 2021 surveys, we determined the percentage of youth with each impairment level overall and by age (6-11 and 12-17 years), sex, and parent-reported race and ethnicity (Black, non-Hispanic; Hispanic; Other, non-Hispanic; and White, non-Hispanic) groups. Parent respondents had been provided with 15 racial category options (American Indian or Alaska Native; Asian Indian; Black or African American; Chinese; Filipino; Guamanian or Chamorro; Japanese; Korean; Native Hawaiian; Other Asian; Other Pacific Islander; Samoan; Vietnamese; White; and Other: specify) and 8 ethnic category options (Central or South American; Cuban or Cuban American; Dominican; Mexican; Mexican American or Chicano; Puerto Rican; Other Hispanic, Latino, or Spanish origin; and Other Latin American); these categories were aggregated into Black, non-Hispanic; Hispanic; Other, non-Hispanic; and White, non-Hispanic. Linear probability models tested for differences adjusted by age and sex in the percentage of youth with each impairment level in 2019 and 2021 (year association). Similar models assessed year associations for outpatient mental health care adjusted for age, sex, and CIS score. Results are presented as adjusted percentage differences with 95% CIs. For the outpatient mental health care outcome, group indicators interacted with year indicators tested for differential change across groups.
All analyses were performed using R version 4.2.0 statistical software (R Foundation) and corrected for the complex multistage clustered and stratified design of the MEPS using the survey library, which also accounts for the overlapping panel design.10,11 Two-tailed P < .05 was considered statistically significant.
Results
The analysis involved 8331 participants, including 4031 girls and 4300 boys; among them, 1248 were Black and 3385 were White. The overall mean (SE) age was 11.6 (3.4) years. The overall percentage of children and adolescents with severe mental health impairment was 9.7% in 2019 and 9.4% in 2021 (adjusted difference, −0.3%; 95% CI, −1.9% to 1.2%) (Table 1). Differences from 2019 to 2021 in the percentages of children and adolescents with less severe mental health impairment and no impairment were also not statistically significant. In stratified analyses, there was a significant decrease in Black youth with less severe impairment (from 52.0% in 2019 to 44.1% in 2021; adjusted difference, −7.9%; 95% CI, −15.7% to −0.1%) and a significant increase in Black youth with no impairment (from 38.7% in 2019 to 47.3% in 2021; adjusted difference, 8.5%; 95% CI, 1.2% to 15.9%).
Table 1. Percentages of Children and Adolescents by Level of Mental Health Impairment, United States, 2019 and 2021a.
| Mental health impairment by characteristicb | Participants, No. (%) | Adjusted difference, % (95% CI)c | |
|---|---|---|---|
| 2019 | 2021 | ||
| Total | (n = 4448) | (n = 3801) | |
| Severe | 455 (9.7) | 385 (9.4) | −0.3 (−1.9 to 1.2) |
| Less severe | 2472 (57.1) | 2064 (55.9) | −1.2 (−4.2 to 1.8) |
| None | 1521 (33.2) | 1352 (34.7) | 1.5 (−1.4 to 4.4) |
| Age, y | |||
| 6-11 | (n = 2173) | (n = 1874) | |
| Severe | 193 (8.3) | 165 (7.5) | −0.7 (−2.6 to 1.2) |
| Less severe | 1247 (58.7) | 1046 (57.4) | −1.3 (−5.4 to 2.8) |
| None | 733 (33.0) | 663 (35.1) | 2.0 (−1.9 to 6.0) |
| 12-17 | (n = 2275) | (n = 1927) | |
| Severe | 262 (11.1) | 220 (11.2) | 0.1 (−2.2 to 2.3) |
| Less severe | 1225 (55.5) | 1018 (54.5) | −1.0 (−4.6 to 2.6) |
| None | 788 (33.4) | 689 (34.4) | 0.9 (−2.6 to 4.5) |
| Sex | |||
| Female | (n = 2161) | (n = 1832) | |
| Severe | 192 (8.8) | 186 (9.7) | 1.0 (−1.1 to 3.0) |
| Less severe | 1231 (56.8) | 988 (55.6) | −1.2 (−5.4 to 2.9) |
| None | 756 (34.4) | 658 (34.7) | 0.3 (−3.7 to 4.3) |
| Male | (n = 2287) | (n = 1969) | |
| Severe | 263 (10.6) | 199 (9.1) | −1.6 (−3.7 to 0.6) |
| Less severe | 1259 (57.3) | 1076 (56.2) | −1.1 (−4.8 to 2.6) |
| None | 765 (32.0) | 694 (34.7) | 2.6 (−0.9 to 6.2) |
| Race and ethnicityd | |||
| Black, non-Hispanic | (n = 676) | (n = 558) | |
| Severe | 77 (9.2) | 56 (8.6) | −0.6 (−5.0 to 3.8) |
| Less severe | 338 (52.0) | 266 (44.1) | −7.9 (−15.7 to −0.1) |
| None | 261 (38.7) | 236 (47.3) | 8.5 (1.2 to 15.9) |
| Hispanic | (n = 1446) | (n = 1355) | |
| Severe | 115 (8.3) | 111 (7.8) | −0.6 (−3.2 to 1.9) |
| Less severe | 700 (50.3) | 632 (49.4) | −0.8 (−5.6 to 4.1) |
| None | 631 (41.4) | 612 (42.9) | 1.4 (−3.2 to 6.0) |
| Other, non-Hispanic | (n = 450) | (n = 409) | |
| Severe | 43 (9.8) | 35 (7.1) | −2.5 (−7.2 to 2.3) |
| Less severe | 207 (44.3) | 221 (50.1) | 5.8 (−2.6 to 14.2) |
| None | 200 (45.9) | 153 (42.8) | −3.3 (−11.8 to 5.2) |
| White, non-Hispanic | (n = 1876) | (n = 1479) | |
| Severe | 220 (10.6) | 183 (11.2) | 0.6 (−2.1 to 3.3) |
| Less severe | 1227 (64.6) | 945 (64.8) | 0.2 (−4.4 to 4.7) |
| None | 429 (24.8) | 351 (24.1) | −0.7 (−4.9 to 3.4) |
Data are from Medical Expenditure Panel Surveys. Percentages are presented as weighted annualized percentages.
Mental health impairment was based on the Columbia Impairment Scale score, with scores of 16 or higher denoting severe; 1 to 15, less severe; and 0, no impairment.
Estimates represent age- and sex-adjusted differences of percentages of participants with impairment in 2021 compared with 2019 as the reference.
Race and ethnicity data were based on parent report. Respondents had been provided with 15 racial category options (American Indian or Alaska Native; Asian Indian; Black or African American; Chinese; Filipino; Guamanian or Chamorro; Japanese; Korean; Native Hawaiian; Other Asian; Other Pacific Islander; Samoan; Vietnamese; White; and Other: specify) and 8 ethnic category options (Central or South American; Cuban or Cuban American; Dominican; Mexican; Mexican American or Chicano; Puerto Rican; Other Hispanic, Latino, or Spanish origin; and Other Latin American); these categories were aggregated into Black, non-Hispanic; Hispanic; Other, non-Hispanic; and White, non-Hispanic.
The percentage of youth who received outpatient mental health care was 11.9% in 2019 and 13.0% in 2021 (adjusted difference, 1.3%; 95% CI, −0.4% to 3.0%) (Table 2). For youth with severe impairment, the corresponding percentages were 39.0% and 42.1% (adjusted difference, 3.0%; 95% CI, −5.8% to 11.8%). Interaction terms of year by mental health impairment, age, and sex groups were not significant. Between 2019 and 2021, there was a significant decrease in outpatient mental health care for Black youth from 9.2% to 4.0% (adjusted difference, −4.3%; 95% CI, −7.3% to −1.4%) and an increase for White youth from 15.1% to 18.4% (adjusted difference, 3.0%; 95% CI, 0.0% to 6.0%) (interaction, P = .002).
Table 2. Use of Any Outpatient Mental Health Care by Children and Adolescents, United States, 2019 and 2021a.
| Group | Participants using outpatient mental health care, No./total No. (%) | Adjusted difference, % (95% CI)b | P value for interactionc | |
|---|---|---|---|---|
| 2019 | 2021 | |||
| Total | 554/4493 (11.9) | 465/3838 (13.0) | 1.3 (−0.4 to 3.0) | NA |
| Mental health impairmentd | ||||
| Severe | 187/455 (39.0) | 167/385 (42.1) | 3.0 (−5.8 to 11.8) | Reference |
| Less severe | 325/2472 (13.1) | 253/2064 (14.3) | 1.2 (−1.4 to 3.7) | .60 |
| None | 40/1521 (2.0) | 41/1352 (3.0) | 1.0 (−0.3 to 2.3) | .58 |
| Age, y | ||||
| 6-11 | 218/2198 (9.2) | 181/1892 (10.5) | 1.7 (−0.5 to 4.0) | Reference |
| 12-17 | 336/2295 (14.4) | 284/1946 (15.3) | 0.9 (−1.7 to 3.5) | .34 |
| Sex | ||||
| Female | 252/2180 (11.0) | 220/1851 (13.2) | 1.9 (−0.7 to 4.5) | .82 |
| Male | 302/2313 (12.7) | 245/1987 (12.8) | 0.7 (−1.5 to 2.9) | Reference |
| Race and ethnicitye | ||||
| Black, non-Hispanic | 74/684 (9.2) | 32/564 (4.0) | −4.3 (−7.3 to −1.4) | .002 |
| Hispanic | 132/1461 (9.0) | 124/1370 (10.4) | 1.4 (−1.4 to 4.3) | .19 |
| Other, non-Hispanic | 36/452 (7.1) | 41/415 (8.8) | 2.5 (−1.3 to 6.3) | .34 |
| White, non-Hispanic | 312/1896 (15.1) | 268/1489 (18.4) | 3.0 (0.0 to 6.0) | Reference |
Abbreviation: NA, not applicable.
Data are from Medical Expenditure Panel Surveys. Percentages are presented as weighted annualized percentages.
Estimates represent the age-, sex-, and Columbia Impairment Scale strata–adjusted differences of the percentages of participants with outpatient mental health care in 2021 compared with 2019 as the reference.
Interaction P values test whether changes in outpatient mental health care use differed over time across strata adjusted for age, sex, and Columbia Impairment Scale strata.
Mental health impairment was based on the Columbia Impairment Scale score, with scores of 16 or higher denoting severe; 1 to 15, less severe; and 0, no impairment.
Race and ethnicity data were based on parent report. Respondents had been provided with 15 racial category options (American Indian or Alaska Native; Asian Indian; Black or African American; Chinese; Filipino; Guamanian or Chamorro; Japanese; Korean; Native Hawaiian; Other Asian; Other Pacific Islander; Samoan; Vietnamese; White; and Other: specify) and 8 ethnic category options (Central or South American; Cuban or Cuban American; Dominican; Mexican; Mexican American or Chicano; Puerto Rican; Other Hispanic, Latino, or Spanish origin; and Other Latin American); these categories were aggregated into Black, non-Hispanic; Hispanic; Other, non-Hispanic; and White, non-Hispanic.
Discussion
Between 2019 and 2021, little change occurred in the percentage of US children and adolescents with parent-reported severe mental health impairment. These results, which contrast with earlier reports of increasing self-reported depression3,4 and suicidal5 symptoms among adolescents, suggest that by 2021 the pandemic had not increased the percentage of US youth with severely impaired psychosocial functioning. By 2021, children and adolescents had returned to school, which may have reduced their isolation, enhanced social engagement, and supported their mental health.12 Family work and economic stresses may have also started to subside by this time. These results contrast with declining youth impairment between 1996 and 2012.9
The absence of an increase in child and adolescent severe mental health impairment from 2019 to 2021 should not lull health care policymakers into complacency regarding the need to increase public funding for outpatient child and adolescent mental health services. In 2019 and 2021, more than half of US youth with severe mental health impairment did not receive any outpatient mental health care. It is also important to place these findings in a longer-term context of increasing youth mental health challenges over the last decade.13
After accounting for age, sex, and impairment level, there was a significant increase in differences between Black and White children and adolescents in outpatient mental health care. By 2021, White youth were more than 4 times as likely as their Black counterparts to receive care. The widening gap in outpatient mental health care between Black and White youth brings particular urgency to expanding mental health care access for Black children and adolescents. Beyond structural racism, cultural attitudes, and racial and ethnic biases in clinical recognition of mental health issues of Black youth,14 an increase in telemental health and decrease in in-person medical care might have further widened racial and ethnic disparities in mental health care.15
Limitations
This study has several limitations. First, the CIS is not a diagnostic measure and does not distinguish whether impairment is associated with a psychiatric disorder or social determinants of health. Parent-child discordance may exist, especially for depression and other internalizing symptoms. In addition, CIS scores were not available in 2020. Second, the MEPS relies on parent respondent recall and diaries that may underestimate the use of youth mental health care. Third, some children and adolescents who received mental health care might receive lower CIS scores than they would have received without treatment. Finally, the MEPS provides no information on the clinical effectiveness of mental health care received.
Conclusions
Youth mental health and mental health care–seeking behavior arise from a complex interplay of individual, family, community, environmental, and societal factors. While the absence of an increase in child and adolescent mental health impairment from 2019 to 2021 suggests successful adaptation to pandemic-related psychosocial disruptions, broadening racial and ethnic differences in outpatient mental health care underscore the urgency of addressing structural factors that may drive this racial and ethnic disparity.
Data Sharing Statement
References
- 1.US Surgeon General . Protecting Youth Mental Health: The US Surgeon General’s Advisory. US Surgeon General; 2021. Accessed January 3, 2024. https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf
- 2.American Academy of Pediatrics . AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. Updated October 19, 2021. Accessed January 3, 2024. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
- 3.Substance Abuse and Mental Health Services Administration . Key Substance Use and Mental Health Indicators in the United States: Results From the 2021 National Survey on Drug Use and Health. Center for Behavioral Health Statistics & Quality, Substance Abuse & Mental Health Services Administration; 2022. HHS publication PEP22-07-01-005, NSDUH series H-57. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report
- 4.Substance Abuse and Mental Health Services Administration . Key Substance Use and Mental Health Indicators in the United States: Results From the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics & Quality, Substance Abuse & Mental Health Services Administration; 2020. HHS publication PEP20-07-01-001, NSDUH series H-55. [Google Scholar]
- 5.Centers for Disease Control and Prevention . High school YRBS. Accessed January 3, 2024. https://nccd.cdc.gov/youthonline/
- 6.Zhu JM, Myers R, McConnell KJ, Levander X, Lin SC. Trends in outpatient mental health services use before and during the COVID-19 pandemic. Health Aff (Millwood). 2022;41(4):573-580. doi: 10.1377/hlthaff.2021.01297 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kalmin MM, Cantor JH, Bravata DM, Ho PC, Whaley C, McBain RK. Utilization and spending on mental health services among children and youths with commercial insurance. JAMA Netw Open. 2023;6(10):e2336979. doi: 10.1001/jamanetworkopen.2023.36979 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bird HR, Andrews H, Schwab-Stone M, et al. Global measures of impairment for epidemiologic and clinical use with children and adolescents. Int J Methods Psychiatr Res. 1996;6(4):295-307. [Google Scholar]
- 9.Olfson M, Druss BG, Marcus SC. Trends in mental health care among children and adolescents. N Engl J Med. 2015;372(21):2029-2038. doi: 10.1056/NEJMsa1413512 [DOI] [PubMed] [Google Scholar]
- 10.Agency for Healthcare Research and Quality . MEPS-HC panel design and data collection process. Accessed December 15, 2023. https://meps.ahrq.gov/survey_comp/hc_data_collection.jsp
- 11.Agency for Healthcare Research and Quality . Accounting for clustering in the analysis of MEPS data: frequently asked questions (FAQ). Accessed December 15, 2023. https://meps.ahrq.gov/survey_comp/hc_clustering_faq.pdf
- 12.Jones SE, Ethier KA, Hertz M, et al. Mental health, suicidality, and connectedness among high school students during the COVID-19 pandemic—Adolescent Behaviors and Experiences Survey, United States, January-June 2021. MMWR Suppl. 2022;71(3):16-21. doi: 10.15585/mmwr.su7103a3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health-related emergency department visits among youth, 2011-2020. JAMA. 2023;329(17):1469-1477. doi: 10.1001/jama.2023.4809 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Mensah M, Ogbu-Nwobodo L, Shim RS. Racism and mental health equity: history repeating itself. Psychiatr Serv. 2021;72(9):1091-1094. doi: 10.1176/appi.ps.202000755 [DOI] [PubMed] [Google Scholar]
- 15.Blanco C, Wall MM, Olfson M. Implications of telepsychiatry for cost, quality, and equity of mental health care. JAMA Psychiatry. 2022;79(12):1147-1148. doi: 10.1001/jamapsychiatry.2022.3330 [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Data Sharing Statement