26 - The Behavioral Healthcare “Service Cliff” for Adolescents and Young Adults with Common Behavioral Health Conditions

Publication Number: 3023.26

Lauren E. Wisk, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Kristen Choi, UCLA Joe C. Wen School of Nursing, Los Angeles, CA, United States; Arseniy Vasilyev, UCLA Department of Medicine Statistics Core, Los Angeles, CA, United States; Susan Ettner, University of California, Los Angeles David Geffen School of Medicine, Culver City, CA, United States; Bonnie Zima, Child Psychiatry, UCLA-Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States

Background: Adolescents and young adults (AYA, ages 12-26) are doubly jeopardized for poor access to behavioral health (BH) care given 1 out of 3 report a BH condition, have the lowest treatment rates, and must navigate the abrupt change in health systems when transitioning to adulthood.

Objective: This study describes the magnitude of this “service cliff” among AYA by specific BH diagnoses and evaluate predictors of poor access.

Design/Methods: Data are from the 2000-2019 Medical Expenditure Panel Survey, a nationally representative survey. We used the Child and Adolescent Mental Health Disorders Classification System (CAMHD) to classify pediatric BH disorders using ICD-9/10 diagnostic codes that span mental, behavioral and developmental health conditions. We include 19,508 person-years of data, covering 10,996 unique individuals with a BH diagnosis, with up to two years of utilization data per individual. Analyses reflect the multi-stage probability-based sampling design of the MEPS.

Results: Across all ages, 9.1% of AYA with a BH diagnosis (AYA+BH) had no healthcare utilization in a given year, ranging from 5.9% among ages 12-14 to 11.6% among ages 21-23. 16.1% of AYA+BH had no access to ambulatory care and 74.9% had no access to psychotherapy/mental health counseling (hereafter ‘behavioral healthcare’). Among those with serious mental illness, 60.5% of 12-year-olds used behavioral healthcare, dropping below 50% after age 18. 41.4% of 12-year-olds with depression used behavioral healthcare, dropping below 30% after age 18; similar patterns were observed for those with anxiety. Approximately 30% of those with ADHD used behavioral healthcare prior to 18 and although this declined to a low of 16.1% at age 21, service use rebounded to ~28% by the mid-20s; similar patterns were observed for those with developmental/intellectual disabilities or autism. Of all conditions assessed, only trauma-related disorders did not see at least a partial rebound in access to behavioral healthcare after the initial service cliff. Adjusted regression analyses revealed substantial disparities in use of behavioral healthcare by sex, age, insurance, education, ethnicity, race, region, and year.

Conclusion(s): Using 20 (pre-pandemic) years of nationally representative data, we found that access to BH care sharply and disproportionately declines after age 18, particularly among minoritized youth and those with serious mental illness, depression, and anxiety. Future research is needed to examine the association of BH policies with continuity of care to illuminate policy levers to remove administrative barriers.

Sample descriptive statistics and Regression predicting access to behavioral health care
HCT-Table 1.pdfTable shows the distribution of sample demographic characteristics (Total column) and regression results for a multivariable model predicting any (vs no) access to behavioral health care

Prevalence of Access to Behavioral Health Care by Age and Condition
HCT-Figure.pdfFigure shows the prevalence of access to behavioral health care (%, y-axis) among adolescent/young adults with a behavioral health diagnosis (overall) by age (years, x-axis) and by specific conditions (including depression, attention-deficit/hyperactivity disorder, anxiety, trauma, serious mental illness, intellectual/developmental disability and Autism spectrum disorder).