Introduction

Adolescent depression is a public health concern with a prevalence has been steadily rising among adolescents in the United States since the COVID-19 pandemic [1]. Based on the data gathered from the National Survey of Drug Use and Health (NSDUH) [2], the rate of adolescent depression surged from 8.1% in 2009 to 19.5% in 2022 [1,3]. Although concerns about youth mental health existed prior to the COVID-19 pandemic, the past several years have subjected adolescents to various unprecedented challenges, including prolonged quarantines, school closures, interrupted social interactions, COVID-19 infections, the loss of loved ones, and an overarching sense of uncertainty in their daily lives [4]. Adolescent-onset depression is linked to more severe social and psychological consequences compared to depression that begins in adulthood. Early recognition and interventions are necessary to prevent long-lasting negative educational, health, and social outcomes [5–9]. There has been extensive research focused on the identification and treatment of mental health conditions in adolescents; however, the increased burden of mental disorders and the disruption of mental health services due to the COVID-19 pandemic created new challenges to the equitable delivery of quality services to those in need [10].

Adolescent mental health service utilization is shaped by a range of intersecting factors, including race, gender, geography, and health insurance coverage [11–13]. Historically, adolescents of African American/Black, Asian, and Hispanic descent encounter diminished access to mental health treatment, including prescription medication, consultations with mental health specialists or medical professionals, and outpatient therapy, compared to non-Hispanic White adolescents [11]. In addition, racial and ethnic minority groups faced a higher exposure to morbidity and mortality related to COVID-19 [14–17], increasing the mental tolls on communities of color and potentially contributing to the onset of or exacerbating psychological disorders, including depression [18–21]. Racial/ethnic minority groups are not the only sub-populations to experience a disproportionately high rate of depression. Among adolescents, depression is more prevalent in girls, who are also more likely than boys to receive a diagnosis and undergo treatment [12]. In rural areas, the distinct socio-cultural obstacles that can increase rural adolescents vulnerability to depression and anxiety are compounded by the shortage of mental health providers [13]. Although primary care providers typically manage mild to moderate anxiety and depression, rural areas often lack specialized clinicians to support them in connecting patients to therapy and treatment for more severe or complex mental health disorders [22]. Moreover, rural adolescents encounter greater challenges than their urban peers in their ability to access the technology and reliable internet connectivity essential for telehealth services, despite telehealth becoming increasingly crucial for ensuring effective and equitable mental health care delivery to individuals affected by distance and isolation, particularly during the COVID-19 pandemic [23]. The incidence of suicide among rural adolescents is nearly double that of urban areas, with untreated depression and anxiety identified as major risk factors [13]. Additionally, evidence suggests that uninsured adolescents, particularly those from racial minorities, have lower rates of mental health service utilization [24], highlighting the role of insurance coverage in reducing barriers to accessing necessary mental health care and addressing health disparities. In sum, the convergence of high depression rates with diminished access to care constitutes a medical and public health crisis.

Since the World Health Organization (WHO) and the U.S. Secretary of Health and Human Services declared the end of the global health emergency in May 2023, the number of studies on mental health service utilization and disparities during the COVID-19 pandemic has increased but remains limited, especially in relation to adolescent depression [25]. In an earlier study, Flores and colleagues analyzed the nationally representative 2021 NSDUH data and documented lower adolescent depression treatment rates among racial and ethnic minority groups [25]. Previous studies have highlighted disparities and national patterns in adolescents use of mental health services, influenced by gender, race/ethnicity, geographical area, and health insurance coverage [11,26–29]; however, to our knowledge, existing studies relied on data collected from before 2022 and may not fully capture the potential shifts in utilization patterns influenced by the COVID-19 pandemic. Therefore, updated analyses using more recent data are necessary to better understand current disparities and inform targeted interventions and policy changes. To thoroughly examine adolescent mental health service utilization patterns during the COVID-19 pandemic, we analyzed the National Survey of Drug Use and Health data [2] from 2022 to quantify and contrast mental health service utilization for adolescent depression in relation to race/ethnicity, age, urban/rural residence, and health insurance coverage. Our goal is to generate evidence highlighting inequitable access to mental health services among adolescents with major depressive episode (MDE), as well as the persistent structural disparities shaped by socioeconomic, geographic, and systemic factors. Understanding the inequity in mental health service utilization among adolescents is critical for identifying key areas that require targeted interventions and policies aimed at improving access to mental health services for disadvantaged populations, ultimately leading to better outcomes for those who are most in need.

Methods

Results

Characteristics of U.S. adolescent with Major Depressive Episode (MDE) in the past year

In the 2022 NSDUH sample, 2283 out of 11969 respondents aged 12–17 (19.2%) had MDE in the past year. Using survey weights, the analysis revealed that the majority of the adolescents with MDE were female (71.0%). Self-reported race and ethnicity included 54.2% White, 11.9% Black, 24.9% Hispanic, 5.1% Asian, and 3.8% more than one race or ethnicity, Native American, Hawaiian or Pacific Islander (Table 1). Approximately one-fifth were 12–13 years old (22.6%), 39.6% were 14–15, and 37.8% were 16–17. Over half (58.1%) of the sample lived in large metropolitan areas, and more than half (59.7%) had a total household income of more than twice the federal poverty level. Only 2.7% had no insurance, 50.2% were privately insured, and 40.1% were publicly insured.

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Table 1. Descriptive characteristics of adolescents with major depressive episode (MDE) in the past year.

https://doi.org/10.1371/journal.pmen.0000388.t001

Mental health service types by respondent characteristics

After applying analytic weights, 47.5% of the adolescents with MDE in the past year had received any treatment, 39.1% received specialist clinician treatment, 30.5% received school-based services, and 25.0% received prescription services (Table 2). Moreover, 34.5% of adolescents utilized telehealth services for mental health with MDE. The proportion of adolescents receiving any form of mental health treatment did not differ significantly across area types. Among all racial and ethnic categories, non-Hispanic White adolescents had the highest rates of treatment: 62.8% received any treatment, 62.1% received specialist clinician care, 64.5% utilized telehealth services, and 67.3% were prescribed medication (P < 0.001). The differences in receiving school-based services across racial groups were not statistically significant. In terms of gender, there was no statistically significant difference between male and female adolescents in utilizing any kind of mental health treatment. As for age, adolescents with MDE in the 14–15 age category utilized the highest percentage of telehealth services (39.6%; P < 0.01) compared to the 16–17 (30.8%) and 12–13 (29.6%) age categories. The proportion of adolescents with MDE utilizing other mental health services was not statistically significant across ages. The adolescents with MDE in the household income > 200% federal poverty level category utilized the highest percentage of telehealth services (67.8%; P < 0.01) compared to the 100% to 200% (18.4%) and <100% (13.8%) categories. As for health insurance status, adolescents with private insurance had the highest percentage of utilization of telehealth services (56%), followed by public insurance (36.4%), and those with more than one type of insurance (5.9%; P < 0.01). Similarly, private insurance holders had the highest proportion of using prescription medication (55.4% vs. public 37.7%: vs. none 1.0%: vs. more than 1 type 5.6%%; P < 0.05).

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Table 2. Types of mental health service utilized during the past year by adolescents with major depressive episode (MDE)’s characteristics.

https://doi.org/10.1371/journal.pmen.0000388.t002

Logistic regression analysis of mental health service utilization

Logistic regression showed that adolescents in non-metropolitan areas had lower odds of specialist clinician treatment (AOR 0.65; 95% CI 0.44-0.96) and telehealth services (AOR 0.65; 95% CI 0.43-0.98) compared to adolescents in large metropolitan areas (Table 3). No differences in school-based services and prescription medication utilization were observed across area types. Black adolescents were less likely to utilize school-based services (AOR 0.31; 95% CI 0.17-0.55) and less likely to receive specialist clinician treatment (AOR 0.41; 95% CI 0.24-0.69) than White adolescents. No statistically significant differences were observed among other racial/ethnic groups in the regression model. Black and Hispanic adolescents had lower odds of receiving prescription medication than non-Hispanic White adolescents, with AOR of 0.26 (95% CI 0.14-0.48) and 0.53 (95% CI 0.35-0.80), respectively. As a whole, Asian (AOR 0.30; 95% CI 0.13-0.70), Black (AOR 0.37; 95% CI 0.22-0.62), and Hispanic (AOR 0.62; 95% CI 0.41-0.96) adolescents had lower odds of receiving any mental health treatment than non-Hispanic White adolescents, but not Others adolescents (AOR 0.54; 95% CI 0.28-1.06).

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Table 3. Logistic regression of mental health service utilization during the past year among adolescents with major depressive episode (MDE).

https://doi.org/10.1371/journal.pmen.0000388.t003

Compared to male adolescents, female adolescents were more likely to receive any mental health (AOR 1.57; 95% CI 1.11-2.21), specialist clinician treatment (AOR 1.52; 95% CI 1.02-2.26), and prescription medication (AOR 1.50; 95% CI 1.02-2.21), but not school-based services and telehealth services, compared to male adolescents. Relative to adolescents aged 12–13, adolescents in the 16–17 age group were less likely to utilize school-based services (AOR 0.52; 95% CI 0.38-0.71). The regression model revealed no statistically significant differences in the utilization of other mental health services across age groups. As for healthcare insurance status, compared to adolescents without insurance, adolescents with public insurance (AOR 3.36; 95% CI 1.26-8.93), private insurance (AOR 3.31; 95% CI 1.22-8.98), and more than 1 type of insurance (AOR 3.68; 95% CI 1.08-12.57) had higher odds of utilizing telehealth services; adolescence with private insurance had greater odds of receiving prescription medication (AOR 3.40; 95% CI 1.01-11.44); adolescents with “Others” insurance had higher odds of utilizing any treatment (AOR 1.17; 95% CI 2.62-5.22); no significant difference was found across the utilization of specialist clinician treatment and school-based services. There was no statistical difference between the odds of utilization of mental health services and household income with reference to the federal poverty level.

Discussion

In analyzing the nationally representative data from the NSDUH, this study highlighted the patterns and disparities of mental health service utilization among adolescents who experienced MDE in 2022. We found that among adolescent populations with MDE, less than half received any type of mental health treatment during the pandemic. Moreover, there were notable disparities in treatment by rurality, race/ethnicity, gender, and health insurance that may have profound medical and public health implications.

Our findings build upon previous work establishing the long-standing rural/urban gap in mental health service utilization by illustrating this disparity persisted amidst the COVID-19 pandemic [29,32,33]. Unsurprisingly, adolescents in rural areas utilized fewer specialist clinician treatment and telehealth services than in large metropolitan areas, emphasizing the need for rural-specific service providers and increasing the availability of specialized mental healthcare for rural adolescents [34–37]. It has been emphasized that bridging the digital divide is essential for overcoming disparities in rural mental health services, particularly due to the uneven adoption of telehealth in these areas [34]. Data from the U.S. Census Bureau’s American Community Survey indicate that over 75% of households in urban counties have broadband subscriptions, compared to about 65% in predominantly rural counties [38]. Moreover, rural residents often experience lower broadband speed and pay as much as $25 more per month compared to their urban counterparts [39]. Rural adolescents are also less likely compared to urban/suburban peers to own smartphones and rely on shared computers [40]. Improved broadband coverage could make telehealth a viable solution for enhancing access to care and addressing mental health and healthcare disparities in rural areas [41]. A study conducted in rural Pennsylvania analyzing the emergence of telehealth for rural mental health service delivery during the pandemic revealed positive outcomes such as service continuation, decreased no-show rates, increased parental involvement, and ease of transportation difficulties [34]. However, existing literature points out that many telehealth platforms are not well-suited for clinicians and young people, particularly for individuals with disabilities or those who have difficulty focusing [42]. Looking ahead, emerging and innovative technologies, like smartphone apps, online programs, and potentially virtual reality, could significantly improve the quality and accessibility of mental health services for young people [43]. For those who either dislike telehealth or do not have the resources to effectively engage in telehealth care, other modes of delivery for mental health care must be implemented.

The findings of this study underscore the enduring racial disparities in healthcare that continued throughout the COVID-19 pandemic. Consistent with Flores et al. (2023) [25], Asian, Black, and Hispanic adolescents were less likely to receive outpatient services, prescriptive medication, or specialty services compared to their White counterparts. In addition, an increased rate of depression can be attributed in part to the emotional trauma caused by the COVID-19 pandemic. This impact was felt by all adolescents but especially pronounced in racial and minority groups who faced disproportionate rates of COVID-19-related morbidity and mortality [25]. Indeed, Black and Hispanic youth were up to 4.5 times higher than White youth to have a parent or grandparent die due to COVID-19 [44]. In addition, the murder of George Floyd in 2020 and the rise in anti-Asian hatred during the COVID-19 pandemic have increased anxiety, depression, and mistrust in health service systems among Asian Americans and Black Americans [45,46]. The gap in service utilization may be attributed to residential segregation, unequal distribution of health resources, cultural stigma surrounding mental health, and misbeliefs about psychological and pharmaceutical treatment for mental health [47,48]. Moreover, parental perceptions play a crucial role in whether minority adolescents pursue mental health services. Parents’ attitudes toward mental health, their ability to identify issues in their children, and their beliefs about seeking help can significantly impact their children’s access to care, either as barriers or facilitators [49]. This finding highlights the need for a deeper understanding of the considerations related to adolescent mental health treatment among diverse cultural groups. By doing so, culturally competent strategies can be developed to effectively engage racial and ethnic minority youth and their parents in treatment.

We found that female adolescents had higher odds of utilizing mental health services, which aligns with previous literature highlighting the disproportionately lower utilization of mental health services among males compared to female adolescents [50]. This trend is influenced by several factors, including societal norms that frame emotional expression and vulnerability as a weakness and contradict the traditional notion of masculinity that adolescent males often seek to uphold [51]. This stigma can prevent them from openly discussing their feelings, acknowledging their mental health struggles, or seeking help [51]. Consistent with previous studies, this finding stresses the importance of mental health literacy to dispel misconceptions and destigmatize mental health service-seeking among male adolescents [52].

A surprising finding is that compared to adolescents with health insurance, adolescents without any type of insurance coverage had a significantly lower utilization of telehealth services and prescription medication, but not the other types of mental health treatment. The correlation between health insurance gaps and prescription-related issues is well-documented [53]. However, even though previous findings suggest that having health insurance coverage for mental or behavioral health needs had lower odds of experiencing perceived difficulties obtaining care [32], we speculate that communities most critically affected by the loss of employment and health insurance coverage may be turning to safety-net settings like community health centers and federally qualified health centers for mental health treatment. Indeed, federally funded health centers have reported increased pediatric mental health patients during the pandemic but continue to face barriers to telehealth use due to cost, reimbursements, and technical issues [54,55].

Schools can potentially improve accessibility to mental health services, as adolescents spend most of their day in the academic setting. To that end, we found no significant differences in school-based mental health service utilization based on gender, rural-urban areas, and health insurance status. Moreover, only Black adolescents had significantly lower odds of receiving school-based services as compared to non-Hispanic White adolescents, as there was no statistical difference in odds of school-based mental health service utilization between Asian, Hispanic, non-Hispanic White, and adolescents of “Other” racial groups. During the 2021 and 2022 school years, 96% of public schools reported providing mental health services for their students; nevertheless, the most common limitations identified were a shortage of mental health professionals to handle the schools’ caseloads, limited access to licensed mental health professionals, and inadequate funding [56]. Intervention programs with a school-based approach have correlated with a greater utilization rate and lower stigma, specifically within minority groups [57]. These school-based approaches must have the requisite resources to meet the needs of their student body such that they can meet the needs of students from diverse backgrounds. If successful, school-based clinics could bridge the accessibility gap, providing primary and preventative health services to young people living in underserved communities [58]. However, this intervention may not fully address Black youth’s needs, further emphasizing the crucial role of culturally competent approaches to enhance their engagement with school-based services.

Our findings should be considered amid several limitations. First, the NSDUH is a cross-sectional design, which prevents causal inferences. Second, the data relies on adolescents’ self-reporting, making it susceptible to recall and social-desirability biases. Third, the NSDUH data reported major depressive episodes (MDE) within the past year without distinguishing between current and past MDE status or the severity of depression. This limitation hinders the ability to differentiate between ongoing and resolved cases of depression, as well as to assess the severity of depression among adolescents. Fourth, the dataset dichotomized gender as male and female, omitting analysis of mental health service utilization among non-binary and transgender adolescents, who are at a higher risk for mental health issues and encounter greater barriers to treatment [59]. Fifth, the exclusion criteria for the NSDUH sample further limit the generalizability of the findings, as it did not include the individuals who are homeless, incarcerated, or in residential treatment. Consequently, our estimates may be optimistic as these groups are more likely to experience higher levels of depression and face more challenges in accessing mental health treatment. Sixth, due to sample size, we grouped Native American and Alaska Native adolescents as a single race/ethnicity category to ensure sufficient data points for analysis. Lastly, the 2022 NSDUH survey used web-based and in-person self-interview methods to enhance response accuracy, restricting comparisons of mental health utilization patterns and disparities to pre-pandemic years.

Conclusion

The findings of this national cross-sectional study build upon existing foundational literature [29,32,33], illustrating the persistence of disparities in mental health service utilization, particularly among adolescents from racial and ethnic minority groups, during the third year of the COVID-19 pandemic. Moving forward, policy and clinical initiatives should be informed by further research into how cultural and systemic factors influence the utilization of mental health services and help-seeking behaviors in race/ethnic minority populations. Additionally, gaps in telehealth service utilization indicate that adolescents without health insurance and those from rural areas require increased support to access mental health services available through telecommunications technology effectively. This study also suggested leveraging and expanding school-based mental health services to address access barriers related to gender, race/ethnicity, rurality, and health insurance coverage. In sum, addressing the disparities in mental health treatment revealed by this study is crucial for ensuring a more inclusive and equitable mental health support system for all adolescents.

Supporting information

Acknowledgments

The authors would like to express sincere gratitude to Dr. Samantha Ehrlich for her guidance and invaluable feedback on the development and analysis of this study.