Utilization of Mental Health Services Among Black Adolescents During the COVID-19 Pandemic: a Narrative Review of the Literature

Abstract

Purpose of Review

Black youth have disproportionately experienced inequities and barriers to care in accessing mental health services. The purpose of this review is to offer a summary of the currently available literature on mental health service utilization by Black youth during the COVID-19 pandemic, compared to prior. A narrative review was conducted in PubMed, Web of Science, psychINFO, and Embase from March 1, 2020 to September 1, 2022, to find studies that examined differences in the utilization of mental health services among Black youth.

Recent Findings

Our results found only 3 studies which examined pre and during the COVID-19 mental health utilization rates among Black youth. Among these studies, time period, study design, sample size, race data, and change in mental health utilization were evaluated.

Summary

From these results, we found that Black youth were overall less likely to utilize services for mental health during the pandemic. However, there were also findings that offer insights into innovative strategies to meet the needs of this unique population. As mental health service utilization has decreased and been slower to rebound from the pandemic compared to other health services, additional research on this topic is needed to ensure that the mental health needs of Black youth are being met.

Introduction

Inequities in access to mental health care services have been a long-standing and pervasive issues among Black Americans. The Centers for Disease Control (CDC) defines health disparities as the preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations [1]. Prior studies have shown that only 1 in 3 Black individuals who need mental health care receive it [2]. Additionally, compared to non-Hispanic Whites, Black individuals are less likely to receive care consistent with evidence-based guidelines, are less likely to be included in mental health research, and are more likely to use emergency departments or primary care (rather than mental health specialist) for mental health concerns [3]. These disparities can have significant downstream effects, as Black individuals with mental health conditions, particularly schizophrenia, bipolar disorders, and other psychosis, are more likely to be incarcerated than individuals of other races and incarceration in itself can lead to worsened mental health outcomes [4].

Inequities in the accessibility of screening and support, diagnosis, and treatment for mental health conditions also occur among Black youth, as prior studies have reported that Black youth have lower rates of mental health utilization even after adjusting for health insurance [5]. In 2019, suicide was the second leading cause of death for Black youth, while Black youth also received mental health services in a specialty setting at 11.8%, compared to 17.2% for White youth [6, 7]. Inequities also exist in mental health diagnosis as evidenced by the fact that Black youth who do receive clinical attention for mental health concerns are often diagnosed with behavioral problems, rather than other mental health conditions [8]. Adding to these disparities, Black youth are more likely to receive poor quality care and are less likely to receive follow-up care after discharge from crisis or hospital services [9]. Even among Black youth who receive mental health treatment, a majority continue to experience poorer mental health outcomes [10].

There are many systemic and sociocultural reasons why inequities in mental health care exist among Black youth including mistrust of mental health services, stigma, a lack of perceived need for mental health services, and inaccessible services [11]. In addition, the lack of child and adolescent mental health providers, particularly Black providers, also plays a crucial role in limiting the utilization of mental health services among Black youth as prior studies have acknowledged increased retention [11].

While anxiety, depression, and suicide in children and teens in the USA have been rising in the last few years, the COVID-19 pandemic has exacerbated inequities in this already vulnerable population [12]. At the beginning of the pandemic, Black Americans were more susceptible to contracting COVID-19 due to the economic and environmental effects of systemic racism with new data finding that Black youth were 2.4 times more likely than White youth to have a parent or grandparent caregiver die as a result of COVID-19 [13]. As COVID-19 ravaged Black families and communities, the death of George Floyd on May 25th, 2020, led to unprecedented levels of anger and sadness among Black Americans with one study citing a significant increase in anxiety and depression among Black Americans in the weeks immediately following George Floyd’s death [14]. At the same time in which Black youth were experiencing the effects of the pandemic, racism, and social isolation, mental health services were rapidly decreasing. One study reported that for youth under age 19 with Medicaid or Children’s Health Insurance Program (CHIP), there was a 34% reduction in mental health services from March through October 2020 [15]. The same study shows that while many healthcare utilization rates have rebounded to near pandemic levels, mental health utilization has been slower to rebound [15]. Changes to mental health access, services, and utilization will be important to consider as programs are designed to meet the unique mental health needs of Black youth in the present and beyond the pandemic.

The purpose of this review will be to offer a summary of the currently available literature on mental health service utilization by Black youth during the COVID-19 pandemic.

Methods

A comprehensive literature search with narrative methods was used to identify relevant articles that addressed the utilization of mental health services among Black youth during the COVID-19 pandemic. A narrative review was conducted as the primary goal of this study was to identify gaps in current literature to inform future initiatives and research.

The following databases were searched in September, 2022: PubMed, psychINFO, Embase, CINAHL, and Web of Science. The following terms were searched within each database: ‘mental health utilization’ OR ‘mental health access’ OR ‘mental health care’ OR ‘behavioral health utilization’ OR ‘behavioral health access’ OR ‘behavioral health care’ AND ‘Black’ OR ‘African American’ OR ‘underserved’ OR ‘minorities’ OR ‘youth of color’ AND ‘adolescents’ OR ‘teens’ OR ‘youth’ AND ‘COVID-19 pandemic’ OR ‘pandemic’.

Eligibility criteria included articles published in English; studies conducted in the USA; articles published between January 2020 to July 2022; and articles that included youth under age 24 years old. Exclusion criteria included articles that did not collect race and ethnicity data; articles where the primary objective of the study was to evaluate mental health utilization among special groups such as unsheltered youth, incarcerated youth, or youth who are sexual and/or gender minorities; and articles in which the primary objective was changes in the prevalence of specific mental health conditions without mention of changes in mental health utilization.

All abstracts meeting inclusion criteria were evaluated by the primary study author for relevance. Abstracts were deemed relevant if they addressed mental health utilization during the COVID-19 pandemic. Full-text articles were then reviewed independently by two study authors to ensure that studies included specific race data in addition to pre and during pandemic mental health utilization data. Full-text articles deemed to not meet inclusion criteria were removed with any disagreements resolved by discussion among all study authors. Finally, included studies were organized by study design, study objective, and outcomes. The primary study measure was any change (increase, decrease, or no change) in mental health utilization among Black adolescents during the COVID-19 pandemic.

Figure 1 outlines the search process.

Fig. 1.

Flowchart of the process of study selection

Results

A total of 344 studies were captured using the search terms after duplicates were removed. Of this total, 337 studies were excluded after evaluating study titles and abstracts. Of the 7 full texts screened, 1 was excluded due to a lack of pre and during COVID-19 data (Wood 2020), and 3 were excluded because their results highlighted changes in mental health screening without commenting or offering variables on mental health utilization (Hill 2020, Lantos 2022, Mayne 2021) [16•, 17•, 18•, 19•]. Finally, 3 studies (Campos-Castillo 2022, Leff 2021, Penner 2022) offered information on Black youth that included pre and during pandemic utilization of services for mental health concerns [20••, 21••, 22••]. See Table 1.

Table 1.

Eligible study summaries

Authors	Study design	Time period	Sample size; location	Racial demographics	Summary
Penner, F et al. Racial and demographic disparities in emergency department utilization for mental health concerns before and during the COVID-19 pandemic. Psychiatry Res. 2022 Apr;310:114,442	Retrospective cohort chart review of emergency department use	March 1–December 31, 2019 and March 1–December 31, 2020	2842 pediatric participants (ages 4–17 years); rural Mississippi	53.8% Black or African American	Black children less likely to visit emergency department for behavioral concerns (odd ratio 0.61, p = 0.005)
Leff RA, Setzer E, Cicero MX, Auerbach M. Changes in pediatric emergency department visits for mental health during the COVID-19 pandemic: a cross-sectional study. Clin Child Psychol Psychiatry. 2021 Jan;26(1):33–38	Cross-sectional; youth presenting to emergency department for a mental health diagnosis (defined as chief complaint of “psychiatric evaluation”); comparisons pre- and post-pandemic were made	March 10, 2020 to May 20, 2020	148 youth; Connecticut (Yale)	23.6% Black	Compared to White children, Black children were 0.55 less likely to present to the emergency department with a mental health condition in the post-pandemic study period (p = 0.002; 95% CI 0.36–0.85)
Campos-Castillo C, Laestadius LI. Mental healthcare utilization, modalities, and disruptions during spring 2021 of the COVID-19 pandemic among U.S. adolescents. J Adolesc Health. 2022 Jun 28:S1054-139X(22)00,507–9	Cross-sectional online survey; self-reported mental healthcare utilization, if that care had been disrupted due to COVID-19, and whether losing care was due to preferring in-person visits	March to May 2021	540 youth (ages 13–17 years); USA	15.2% Black	42.5% (n = 226) identified as receiving mental healthcare; of those who lost care during the pandemic, Black youth preferred in person care odds ratio 7.28 (1.32–22.56; p < 0.05); if receiving telehealth, Black youth preferred text/chat (vs video/phone) odds ratio 7.84 (1.78–34.51; p < 0.01)

Discussion

This is the only narrative review of Black youth utilization of mental health services during the COVID-19 pandemic. One important finding from our review highlighted that Black youth had less frequent utilization of emergency departments for mental health concerns. Future studies are needed to understand this trend, particularly if it means that Black youth are not receiving appropriate emergency mental health care in the setting of acute psychiatric illness or suicidal ideations.

The study by Campos-Castillo offers unique insights into potential interventions as the authors were able to analyze youth who lost access to mental health during the pandemic and ask them what services were preferred. These authors reported that Black youth who participated in the study preferred in person to telehealth visits and if telehealth was offered, preferred chat/text over video. These differences in preferred service modality should be explored and incorporated into clinical programs striving to reduce barriers to care for Black youth.

One important limitation of our review is that there were very few studies that offered service utilization data specifically for Black youth. Additionally, two of the studies were conducted in very limited geographic locations, so results are not generalizable.

Conclusion

The COVID-19 pandemic has disproportionately affected Black youth and prioritizing mental health services for this population is imperative. This narrative review sought to evaluate literature on the utilization of mental health services by Black youth pre and during COVID-19. While there were a number of studies that offered insight into the prevalence of specific mental health conditions and rates of screening during the pandemic, there were few that specifically called attention to changes in mental health utilization, specifically among Black youth.

More research is needed to explore innovative ways to reach Black youth, understand which mental health conditions are most impactful due to the changes of the pandemic, and how to revise or create services that will meet the needs of Black adolescents.

Data Availability

The authors declare that the data supporting the findings of this study are available within the article.

Declarations

Conflict of Interest

Dr. Douglas’s time was funded by the NIH/NICHD Child Health Equity Research Program for Post-doctoral Trainees, T32HD101397, the funder/sponsor did not participate in the work. Dr. Evans is a guest co-editor on the Current Pediatric Reports for Springer and received a small honorarium for participation as a guest editor. Dr. Richardson has no conflicts of interest or financial disclosures.