Editorial: The Impact of the COVID-19 Pandemic on Racial Disparities in Pediatric Mental Health

Abstract

The COVID-19 pandemic has resulted in a devastating impact on youth mental health concerns, with rates of anxiety, depression, and suicidality doubling.¹ With 1 in 5 youth now experiencing a mental health disorder, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Children’s Hospital Association, and the US Surgeon General have all declared a national state of emergency in child and adolescent mental health.^2,3 Although youth mental health has declined overall since the onset of the pandemic, racial minority youth have been disproportionately negatively impacted. Unfortunately, racial disparities in youth mental health have been a long-standing concern, and the impact of COVID-19 has only served to worsen this gap.² This is consistent with broader population health trends observed throughout the pandemic across age groups, where a higher proportion of racial and ethnic minorities have experienced poverty, violence, educational and vocational disruptions, and poorer health outcomes, including COVID-19−related hospitalizations and deaths.^3,4

The COVID-19 pandemic has resulted in a devastating impact on youth mental health concerns, with rates of anxiety, depression, and suicidality doubling.¹ With 1 in 5 youth now experiencing a mental health disorder, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Children’s Hospital Association, and the US Surgeon General have all declared a national state of emergency in child and adolescent mental health.^{2 , 3} Although youth mental health has declined overall since the onset of the pandemic, racial minority youth have been disproportionately negatively impacted. Unfortunately, racial disparities in youth mental health have been a long-standing concern, and the impact of COVID-19 has only served to worsen this gap.² This is consistent with broader population health trends observed throughout the pandemic across age groups, where a higher proportion of racial and ethnic minorities have experienced poverty, violence, educational and vocational disruptions, and poorer health outcomes, including COVID-19−related hospitalizations and deaths.^{3 , 4}

Disparities in rates of access to mental health services for racial minority youth have been a long-established public health concern.⁵ Numerous barriers to accessing mental health services have been identified, including insurance coverage, health literacy, lack of interpreters, racial discrimination, limited time/scheduling constraints, transportation, and childcare.⁶ Prior to the pandemic, telehealth had been identified as a potential mechanism through which mental health services could become more readily accessible and convenient, thereby reducing certain barriers (eg, transportation, childcare, scheduling, etc) that contribute to difficulties in accessing services. Because of COVID-19, many obstacles to telehealth adoption were removed (eg, policy, licensing, reimbursement, etc), and most mental health services promptly transitioned to a telehealth format, thereby allowing for empirical investigation into this hypothesized benefit.

One such study, conducted by Williams et al. ⁷ sought to evaluate whether racial disparities in accessing outpatient mental health services were impacted by telehealth offerings by examining available data in electronic health records at 2 large children’s hospitals (Children’s Hospital of Philadelphia [CHOP] and Boston Children’s Hospital [BCH]) during pre- and within-pandemic periods. CHOP’s data captured visits that took place during the same 1-month period (March-April) in 2019 and 2020 and consisted of 2,522 unique patient visits in 2019, which decreased to 673 in 2020. Data from BCH captured both a 1-month (March-April) and a 6-month (March-September) period in 2019 and 2020. Unique patient visits examined in the 1-month dataset included 3,500 in 2019 and 3,958 in 2020; there were 19,071 visits in 2019 and 18,585 visits in 2020 included in the 6-month data. Datasets from both hospitals included patients’ self-identified race (white vs racial minority), location of service (urban vs non-urban), insurance provider (commercial vs non-commercial), and type of mental health service used (new vs established patient).

Overall, results from this study revealed that racial disparities in mental health service use were exacerbated following the transition to telehealth. However, when comparing results across the 2 hospitals, some interesting findings emerged that highlight the complexities of the relationship between racial disparities and telehealth implementation. A commonality shared across sites was how disparities were further amplified for patients seen in urban vs non-urban clinic sites, with a significant decrease in racial minority youth being seen in city-based locations following the transition to telehealth. Specific to CHOP, new patient evaluations were paused during the initial telehealth transition, resulting in a significant increase in the proportion of follow-up visits from 78% in 2019 to 97% in 2020. Although racial minority youth represented a greater percentage of new patient (43%) vs follow-up (34%) visits, when comparing only established patient visits at both time points, a widening in racial disparities was still observed. When examining changes in insurance carriers at pre- vs within-pandemic periods, no significant changes were noted at CHOP. Conversely, when assessed over a 6-month period, the total proportion of non-commercial users at BCH significantly decreased during the pandemic, and when controlling for insurance type, no significant changes in racial disparities were observed following the transition to telehealth services.

There are several limitations to this study that are noted by the authors, including constraints in electronic health care demographic data, the cross-sectional methodology, and the inability to distinguish telehealth appointments that were audio-only vs audio/video. The pausing of new patient visits and shorter duration of both time points at CHOP also limit analyses and ability to compare findings across sites. Despite these limitations, this study is an important contribution to the emerging literature on the complex relationship between telehealth implementation and widening racial disparities in accessing mental health services. Although telehealth has been identified as a possible solution for addressing certain barriers in accessing care, pandemic-related studies have consistently demonstrated that potential for expanded access does not result in guaranteed access for all populations and, in fact, may widen pre-existing disparities.3, 4, 5 ^{, 7}

The COVID-19 pandemic has highlighted, and likely worsened, the significant systemic inequalities that exist in the US. The same factors that have been implicated in the disproportionate impact of the pandemic on racial and ethnic minorities are presumably also responsible for the widening racial disparities seen in accessing mental health services via telehealth. Perhaps most importantly, social determinants of health (eg, early childhood development, income, employment, housing, community violence, education, etc) and structural racism have been identified as critical and modifiable risk factors for poor mental health across the lifespan.² The complex interplay among these risk factors highlights the importance of developing a comprehensive and multidimensional solution that addresses public policy, socioeconomic barriers, and structural racism.

As researchers, educators, and providers, we are uniquely positioned to positively contribute to efforts aimed at reducing disparities in pediatric mental health. First, and perhaps most importantly, we must develop a robust and integrated data infrastructure to better understand the complex relationships discussed between youth mental health trends, associated risk factors, and the impact of changes in policy, prevention, and intervention efforts. Second, we must devote increased attention and resources to developing and implementing prevention strategies that promote healthy child development, particularly for those youth with multiple risk factors. Third, to identify at-risk youth and families and to provide them with timely access to evidence-based and culturally informed services, we must develop collaborative relationships with community partners including primary care providers, schools, and other community agencies. Finally, we must invest in dissemination and implementation science that allow for the development of innovative, accessible, and scalable treatments for youth mental health concerns.

We can, and we must, do better.