216 - Rural adolescent girls’ unmet mental health need outpaced others’ after the COVID-19 pandemic

Publication Number: 2208.216

Joanna Y. Kim, Kaiser Permanente Bernard J. Tyson School of Medicine, Los Angeles, CA, United States; Abraham Gallegos, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States; Rebecca N. Dudovitz, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Sam Behseta, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States; Paul J. Chung, Kaiser Permanente Bernard J. Tyson School of Medicine, Los Angeles, CA, United States

Background: The prevalence of anxiety and depression among U.S. adolescents has increased during the COVID-19 pandemic, with especially sharp increases among girls. Less is known about how these mental-health trends have unfolded beyond the initial COVID-19 period or if access to care has kept pace, particularly in rural communities where adolescents have been vulnerable to both increased incidence and longstanding shortages that decrease access to mental health services. We used the National Survey of Children's Health (NSCH) to examine changes in adolescent anxiety/depression and mental-health service receipt by sex and urban/rural status.

Objective: Our aim was to evaluate changes in reports of anxiety/depression and mental-health care receipt among U.S. youth, aged 12-17 years old, from 2018 to 2023, and to assess whether rural girls experienced disproportionately greater increases in reports of anxiety/depression after the pandemic versus before.

Design/Methods: For pediatric patients aged 12-17 years old, from years 2018-2023. Primary outcomes were self-reported anxiety/depression and receipt of mental-health care, statistically analyzed using survey-weighted logistic regression. Models included time-period (pre-, during, and post-COVID), sex, and urban/rural status, with three-way interaction terms to estimate subgroup differences. Difference-in-differences tested whether changes in predicted probabilities of outcomes differed for rural girls compared with peers.

Results: Among 74,516 adolescents, anxiety/depression increased over time, with the largest descriptive rise among rural girls (11.6% pre-COVID, 20.4% post-COVID) compared with metro girls (12.9%, 17.2%) and metro boys (8.1%, 10.2%). In adjusted models, the post-COVID × female × rural interaction was significant (aOR 1.68, 95% CI 1.08-2.61, p=0.02), indicating that the pre-to-post change in anxiety/depression for rural girls was greater than for the reference group (metro boys). Difference-in-differences confirmed a +6.9 percentage-point post-COVID relative increase in need for rural girls (p = 0.021) but no relative increase in care (+1.3 pp; p = 0.51).

Conclusion(s): During COVID-19 recovery, rural adolescent girls experienced the steepest rise in anxiety/depression, and although mental-health care use also increased, it did not keep pace with need. These results point to widening post-pandemic gaps between mental-health need and access in rural areas, especially for girls. Increased school- and community-based screening and service capacity may be important to improve rural youth access to needed mental health care.

Table 1. Weighted Sociodemographic Characteristics of Adolescents Aged 12-17 Years, by Study Period


Table 2. Adjusted Odds Ratios for Adolescent Anxiety/Depression and Receipt of Mental-Health Care From Pre-COVID to COVID Recovery
Note. Each model adjusts for age, household FPL, race/ethnicity, insurance, medical home, caregiver education, BMI, and region. * p < 0.05; ** p < 0.01; *** p < 0.001.