When schools closed in the spring of 2020 at the onset of the COVID-19 pandemic, the number of children and adolescents receiving mental health treatment in the United States fell by more than half. By 2022, that number had not only rebounded, it exceeded pre-pandemic levels, according to a new national study by researchers from Penn State College of Medicine.
In an analysis of 13 million health records of children and adolescents, available online now ahead of publication in the Journal of the American Academy of Child and Adolescent Psychiatry Open, the researchers found the rise in pediatric mental health treatment patterns was driven largely by new patients versus existing patients seeking more care. Rates of first-time prescriptions for psychiatric medication increased by 35%, outpacing the rise of both first-time psychiatric diagnoses and psychotherapy courses - 24% and 26%, respectively - compared with the years before the pandemic.
The steepest increases were among girls. Antidepressant prescriptions rose 137% among girls ages six to 12 years and 65% among girls ages 13 to 18 years.
"Youth mental health was already worsening before the pandemic, which further accelerated these trends," said Raman Baweja, professor of psychiatry and behavioral health and of public health sciences at Penn State College of Medicine and the first author on the study. This suggests that the rise in psychiatric treatment for mental health not only followed the pandemic but also a decade-long rise of heightened emotional distress among young people, documented by the Centers for Disease Control and Prevention's (CDC) Youth Risk Behavior Survey. "But it didn't hit everyone the same. Some groups, girls especially, were affected more."
According to Baweja, existing research had focused on pediatric mental health trends during 2020. However, much less was known about what happened after schools reopened and daily life returned to normal, or whether increases in mental health treatment reflected more children entering care for the first time or more intensive treatment for those already receiving services.
To parse the two, the researchers tracked cases from October 2018 to December 2022 using the TriNetX U.S. Collaborative Network, which provided a research database of pooled de-identified records from 72 U.S. health systems. Geographically, the sample spanned participating health systems in all four U.S. census regions with roughly 40% of pediatric patients from the South and the rest spread across the Northeast, Midwest and West.
The team analyzed the dataset through two complementary lenses, isolating new patients - children and adolescents receiving a first diagnosis, prescription or therapy after at least a year without a diagnosis or respective treatment - and treatment-engaged patients, defined as those with at least two behavioral health visits within one of the three 17-month phases in the study: pre-pandemic, from October 2018 through February 2020; pandemic, from March 2020 through July 2021; and post-pandemic, from August 2021 through December 2022.
"We evaluated data from patients new to care and those who were already in care, and both showed that adolescent females and antidepressant prescriptions were the driving force of the increase in psychiatric care," Baweja said. Scaling their sample to reflect the national population size, the researchers estimated roughly 40,000 additional girls began antidepressant treatment after the pandemic.
Among all pediatric patients in the "treatment-engaged" group, most measures of medication use changed only slightly between 2018 and 2022, with antidepressant climbing from 32% to 36% among adolescent girls.
Medications for attention-deficit/hyperactivity disorder (ADHD) showed smaller increases than antidepressants, with a notable exception among the youngest children in the study. Among those ages three to five years, prescriptions for stimulant medications used to treat new ADHD cases rose 147%, although this group started from a lower baseline and remained far below rates in older children.
The CDC recommends parent training in behavior management as the first-line treatment for children with ADHD under the age of six before trying medication, but pandemic-era disruptions may have left families few alternatives, according to Baweja.
He added that the findings reflect patterns of documented diagnoses and treatment among children and adolescents who received care within the healthcare system, rather than the overall prevalence of mental health conditions among youth.
"Many children experiencing mental health challenges never receive a formal diagnosis or treatment," Baweja said. "Our study captures those who entered the healthcare system, so these trends reflect changes in healthcare utilization as much as changes in mental health needs."
The study also found that longstanding racial and ethnic disparities in mental healthcare persisted throughout the pandemic and recovery period. Although telehealth expanded access for many families, it did not eliminate inequities in care, according to Baweja.
"There was hope that telehealth would narrow longstanding gaps in access, particularly for underserved communities," Baweja said. "Access is not the same for everyone. It is influenced by many factors, including internet connectivity, transportation, family resources, cultural beliefs about mental health, and trust in the healthcare system. Continued efforts are needed to ensure that every child has equitable access to timely, evidence-based care versus simply assuming technology creates access for all."
The study is one step toward understanding changes in pediatric mental health care among children and adolescents who receive treatment, he added. It fits into a larger line of inquiry from the research team examining how mental health is changing not only for children and adolescents but for adults as well.
"Our ongoing research is examining treatment patterns among both children and adults, including how recent changes - such as medication shortages and evolving clinical practices - have influenced treatment patterns, which groups are more or less likely to receive care and whether disparities in access to evidence-based treatment persist," Baweja said.
Other Penn State College of Medicine authors include senior author James Waxmonsky, professor of psychiatry and behavioral health and University Chair in child psychiatry; Daniel Waschbusch, professor of psychiatry and behavioral health and vice chair for research; Felix Padilla, assistant professor of psychiatry and behavioral health; and Richard Mattison, staff physician in psychiatry.
This study was funded by the National Center for Advancing Translational Sciences, part of the National Institutes of Health.
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