Differential Patterns of Service Use for Depression Among Diverse Medicaid-Insured Children and Youth

Differential Patterns of Service Use for Depression Among Diverse Medicaid-Insured Children and Youth | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Differential Patterns of Service Use for Depression Among Diverse Medicaid-Insured Children and Youth Molly Finnerty, Qingxian Chen, Shuo Chen, Amy Ehntholt, Junghye Jeong, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7643217/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study explored differences in service use by race/ethnicity across the full continuum of care for Medicaid-enrolled youth diagnosed with depression, using a hybrid cross-sectional and longitudinal cohort design of children (0–17 years) in New York City (N = 865,281) with new episodes of depression in 2021 (n = 11,093). Measures included clinical setting on initial presentation and over the six months that followed; hospitalization on initial diagnosis; receipt of any follow-up care, any outpatient service, minimally adequate outpatient care, or any antidepressant; and ER/inpatient services received during six-month follow-up. Compared to White children, Black children were more likely to initially present in an emergency room setting (AOR = 1.44, 95%CI:1.12–1.85) and were more likely to be hospitalized on initial diagnosis (AOR = 1.52, 95%CI:1.02–2.26); Black and Hispanic/Latinx children were less likely to use private practice for initial treatment (AOR = 0.37, 95%CI:0.29–0.47 and AOR = 0.44 95%CI:0.36–0.55, respectively) or for follow-up treatment (AOR = 0.56, 95%CI:0.44–0.72 and AOR = 0.76, 95%CI:0.61–0.94, respectively). Overall, 58% of children received any follow-up treatment after diagnosis; two-thirds of those received four or more outpatient services. Black children had the lowest receipt of any treatment after diagnosis (AOR = 0.80, 95%CI:0.67–0.96), and, when they did receive outpatient treatment, the lowest completion of at least four visits (AOR = 0.62, 95%CI:0.47–0.81), lowest receipt of any antidepressant (AOR = 0.60, 95%CI:0.47–0.75), and higher rates of ER/inpatient admissions during the six months of the episode (AOR = 1.38, 95%CI:1.10–1.73). Gaps in depression care exist for all children, but these gaps are greater for Black children. These barriers warrant both research and public policy attention. race and ethnicity disparities youth psychiatric epidemiology Figures Figure 1 Figure 2 INTRODUCTION In 2021 the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health, citing the dual stressors of the COVID-19 pandemic and ongoing racial inequity (American Academy of Pediatrics 2021 ). The pandemic amplified existing racial and ethnic disparities in mental health (Parenteau et al. 2023 ) et al., 2023) and was accompanied by increases in the prevalence of depression (Racine et al. 2021 ), suicidality (Jones et al. 2022 ), and mental health emergency department presentations among youth (Overhage et al. 2023 ). Improving mental health care and outcomes for children and adolescents with depression requires understanding patterns of service use and variations in those patterns over time, including different trajectories by demographic factors, such as race and ethnicity. Such an examination within a large system is particularly critical in light of the racial and ethnic disparities previously described. The first line treatment for depression in children and adolescents is psychotherapy (Birmaher et al. 2007 ; Walter et al. 2023 ). Delivery of this recommended practice requires a series of steps: (1) the child presents to a health care provider and the treating clinician diagnoses depression; (2) depending upon the setting, a referral or follow-up appointment is made and the child attends; and (3) the child receives a course of psychotherapy over a series of sessions. Several studies have identified disparities by race and ethnicity in one or more of these steps (Cummings et al. 2019 ; Lu 2019 ; Lui et al. 2022 ; Rodgers et al. 2022 ; Substance Abuse and Mental Health Services Administration 2023). In one analysis of data from the Medical Expenditure Panel Survey (MEPS), White youth were roughly twice as likely to initiate mental health care compared to their Black and Hispanic/Latinx peers (Cook et al. 2013 ). In a later analysis of data on adolescents from the National Survey on Drug Use and Health (2011 to 2016), compared to White teens with depression, Hispanic/Latinx, Black, and Asian teens with depression were less likely to report seeing or talking with a doctor or other professional about their symptoms (Lu 2019 ). Similar disparities by race and ethnicity have been documented in utilization of outpatient mental health care (Marrast et al. 2016 ) as well as higher psychotropic use among White youth compared to Black and Hispanic/Latinx youth (Fontanella et al. 2025 ; Rodgers et al. 2022 ). However, there is a dearth of more comprehensive studies of patterns of service use for youth with depression—from clinical setting of initial diagnosis for a new episode of depression (e.g., primary care, emergency department), to follow-up treatment setting and delivery of care, including measurement of care adequacy and use of acute care services by race and ethnicity. Such analyses are critical for understanding differences in treatment trajectories, and for informing policy and program interventions aimed at achieving more equitable care in public mental health services. This study focuses on a socioeconomically disadvantaged and diverse population of Medicaid-insured children and adolescents living in New York City in 2021. It builds upon previous epidemiological research by examining racial and ethnic differences for new episode depression treatment for children aged 0–17. The service types include diagnosis, initial and follow-up treatment settings, filling of antidepressant prescriptions, and service utilization through the first six months after diagnosis. These analyses aim to explore whether patterns of service use for depression are similar or different for children/youth of diverse racial and ethnic backgrounds. These analyses provide new information on differences in treatment patterns among children and youth from low-income families in a large metropolitan area. Examining a single city with a large defined services environment may identify differences that might be masked in a larger geographic sample. METHODS Study Design This study used New York State (NYS) Medicaid data to examine patterns of service use by race and ethnicity among children and adolescents living in New York City with a new episode of depression in 2021 at initial diagnosis (cross-sectional design) and at six-month follow-up (longitudinal cohort design). The study was reviewed by the Nathan Kline Research Institute Institutional Review Board and received a determination of not human subjects research. Data Source and Study Population Data for the study population were extracted from the NYS Medicaid data warehouse (MDW), including enrollment, eligibility, demographic characteristics, and claims and encounter data from 1/1/2020-7/1/2022 for all Medicaid-enrolled children (ages 0–17) residing in New York City as of December 31, 2021 (N = 1,130,745). The study cohort was restricted to children with one or more health services in 2021 (n = 1,093,538). The index date was defined for each child as the first date of service in 2021 with a depression diagnosis or, if no depression diagnosis in 2021, then the first date of any clinical service during the year, including medical and other behavioral health service. A depression diagnosis was defined as having a clinical service claim or encounter in 2021 with an ICD-10 diagnosis code for depression (single episode F32.X, or recurrent F33.X excluding those in remission: F32.5, F33.40 and F33.42). New episodes of depression care were defined as those where there was no diagnosis or treatment for depression in the 12 months prior to the index date (including those with a first depression diagnosis in 2021, and individuals with previous episodes of depression care ending more than 12 months ago). The period of observation for each child was the 12 months prior and six months after their index date, to determine whether the depression diagnosis represented a new episode of care, and to allow for six months of follow-up. Continuous Medicaid eligibility (maximum allowable gap of 45 days) was required in 2021 and for the period of observation for each child (n = 865,299). Children who were dual eligible for Medicare were excluded since services paid by Medicare may not be visible in the Medicaid data, for a final Medicaid study cohort of N = 865,281. (n = 17,613). Children and adolescents with diagnoses of schizophrenia or bipolar disorder (ICD-10: F2X, or F30-F31 on two dates of service) were excluded using a hierarchical assignment to more severe mental illness (n = 783), yielding a prevalent depression cohort of n = 16,830. The new episode of depression care cohort included those children who had no evidence of a depression diagnosis in the 12 months prior to their depression index date (n = 11,093, Supplemental Figure S1 available online). Covariates and Measures Race, ethnicity, and other demographic variables were drawn from Medicaid eligibility files. Age was defined as of December 31, 2021, and categorized into four groups (< 6 years, 6–11 years, 12–14 years, 15–17 years). Seven mutually exclusive race and ethnicity groups were constructed: Hispanic/Latinx (all races and referred to as “Hispanic” for brevity), and non-Hispanic groups referred to as White, Black, Asian, American Indian/Pacific Islander (AI/PI), Multiracial (more than one race identified), and Unknown race. Unknown race was included in model testing to examine differences between racial group and missingness. Clinical treatment settings were grouped into six categories: (1) specialty behavioral health program (outpatient specialty mental health or substance use disorder treatment programs, including specialty clinics, Assertive Community Treatment, psychosocial rehabilitation programs, and other behavioral health programs licensed or designated by the NYS Office of Mental Health or the NYS Office of Addiction Services and Supports); (2) medical clinic (outpatient licensed medical clinic programs and urgent care); (3) private practitioner (outpatient individual or group practices of any type); (4) emergency room (ER); (5) inpatient treatment; and (6) other settings, based on invoice type, state rate codes, diagnosis and procedure codes. To capture all crisis services, some analyses combined inpatient hospitalization or emergency room (ER/inpatient) presentation with or without subsequent inpatient admission. The initial or index treatment setting was the clinical setting on the index diagnosis date for children with a new episode of depression. When there was more than one treatment setting on the index date a hierarchical assignment was used to identify the single most likely sequence for initial presentation (e.g., outpatient before acute care, and primary care before specialty behavioral health services), specifically, medical outpatient clinic was prioritized, followed by private practitioner, specialty behavioral health outpatient, and ER/inpatient. Only children presenting directly to ER/inpatient were assigned to this category of initial treatment setting (no outpatient services on the index diagnosis day). Follow-up outpatient treatment settings included all outpatient clinical services with a primary diagnosis of depression. ER/inpatient use on the day of a new diagnosis of depression was assessed (whether preceded by an outpatient visit or not), and ER/inpatient treatment during the first six months of the episode was examined. Two additional dichotomous measures of any treatment were examined separately: (1) any outpatient clinical service with a primary diagnosis of depression, and (2) any antidepressant medication filled. “Any follow-up treatment” in the six months after the new episode index date was defined as either having received any clinical outpatient service with a primary diagnosis of depression or having filled any antidepressant medication prescription. Minimally adequate treatment was adapted from previous studies (Cummings et al. 2019 ; Stein et al. 2013 ) and defined as four or more outpatient services for depression (primary diagnosis of depression on the claim or encounter) on separate dates of service in the six months following the index date for a new episode of depression. We did not restrict to services with psychotherapy codes due to inconsistent use of these codes in some treatment settings (e.g., foster care mental health programs). Data Analysis Logistic regression was used to examine differences in depression incidence by demographic characteristics. Course of treatment measures were described (number of children receiving treatment in each setting for new episodes of depression and for the first six months that followed, divided by the number of children with a depression diagnosis). Logistic regression models examined differences in treatment measures by race and ethnicity, adjusted for sex and age group. Adjusted odds ratios (AORs) were estimated with 95% confidence intervals (CIs). Given the existing evidence of increased access to quality mental healthcare among White children receiving mental health services (Rodgers et al. 2022 ), the White group was used as the reference category to allow for assessment of racial disparities. All statistical analyses were conducted using SAS enterprise guide 8.2. RESULTS The demographic characteristics of children and adolescents in the New York City Medicaid study population (N = 865,281) are summarized in Table 1 . The largest race and ethnicity group was Hispanic (28.9%, n = 249,715), followed by Multiracial (24.3%, n = 210,484), Black (17.5%, n = 150,996), White (12%, n = 103,466), Asian (11.8%, n = 102,343), Unknown (5.2%, n = 44,937) and AI/PI children (0.4%, n = 3,340). The incidence of new treatment episodes of depression was 1.28% overall (n = 11,093) and varied by age, sex, and race (Table 1 ). Incidence was higher for females than for males (1.84% vs 0.75%, AOR = 2.54, 95% CI: 2.43–2.64), and increased with age from 0.03% for < 6 years (AOR = 0.009, 95% CI: 0.007–0.012), to 3.69% for 15–17 years (AOR = 1.39, 95% CI: 1.34–1.45), compared to middle school aged children 12–14 years (2.68%, referent). Compared to the White group (prevalence 0.65%, referent), all other race and ethnicity groups except Asian (0.75%) had significantly higher incidence of new treatment episodes of depression. New treatment episodes were highest for the Hispanic group (1.85%, AOR = 2.49, 95% CI: 2.29–2.70), followed by the Multiracial (1.27%, AOR = 1.70, 95% CI: 1.56–1.85), Black (1.26%, AOR = 1.67, 95% CI: 1.53–1.83), and AI/PI (1.11%, AOR = 1.48, 95% CI: 1.06–2.08) groups after adjusting for age and sex. Differences by race and ethnicity were observed for all age groups, beginning with very young children, where Hispanic preschool children were over four times more likely to have a new diagnosis of depression than White children (0.052% vs 0.012%; AOR = 4.39, 95% CI:1.56–12.39). Treatment Setting on Initial Presentation and for Follow-up Care Overall, new episodes of depression were most commonly diagnosed in an outpatient medical clinic (41.8%, n = 4,634), followed by outpatient specialty behavioral health programs (27.9%, n = 3,092), ER or inpatient settings (16.2%, n = 1,792), private practices (13.3%, n = 1,472), and other settings (0.9%, n = 103). Figure 1 summarizes the variation in clinical treatment settings on initial presentation of a new episode of depression by race and ethnicity (n = 10,641; AI/PI and Unknown were excluded due to small cohort sizes). Private practice treatment settings were more common for White (21.7%, referent) and Asian children (28.5%, AOR = 1.49, 95% CI: 1.17–1.90), compared to other race and ethnicity groups, with the lowest adjusted odds for Black children (9.16%, AOR: 0.37, 95% CI 0.29–0.47), followed by Hispanic (10.82%, AOR: 0.44, 95% CI 0.36–0.55), and Multiracial groups (13.96%, AOR: 0.60, 95% CI 0.48–0.74). Only Black children were more likely to have an initial diagnosis in an ER/inpatient setting compared to the White referent group (18.27% vs 13.47%, AOR: 1.44, 95% CI 1.12–1.85) (Table 2 ). Initial practice setting of index diagnosis is mutually exclusive. Medical Clinic = outpatient licensed medical clinic programs and urgent care; Private Practitioner = outpatient individual or group practices of any type; Specialty BH (behavioral health) program = outpatient specialty mental health or substance use disorder treatment programs licensed or designated by the Office of Mental Health or the Office of Addiction Services and Supports; Emergency Room = Inpatient hospitalization or emergency room presentation with or without subsequent inpatient admission. *Indicates significantly different odds compared to White referent group, adjusted for age and gender (See Table 2 for adjusted odds ratios and 95% confidence intervals). Follow-up treatment settings also varied by race and ethnicity during the first six months after initial diagnosis (Table 2 ). Overall, the most common treatment setting was specialty behavioral health programs (32.6%), followed by private practice (14.7%), and medical clinics (12.3%). Receiving depression treatment in a medical clinic was more common for Hispanic (13.0%, AOR: 1.45, 95% CI 1.10–1.92) and Multiracial children (13.1%, AOR: 1.44, 95% CI 1.08–1.92) than for White children (9.1%, referent). Private practice was more common for White (17.5%, referent) and Asian children (22.4%, AOR: 1.36, 95% CI 1.05–1.77), and was lowest for Black (10.9%, AOR: 0.56, 95% CI 0.44–0.72) and Hispanic children (14.0%, AOR: 0.76, 95% CI 0.61–0.94). Follow-up Outpatient Treatment After a diagnosis of a new episode of depression, receipt of any follow-up treatment, and of minimally adequate treatment varied by race and ethnicity. Overall, 58% of children and adolescents aged 0–17 had any follow-up treatment (outpatient service or antidepressant medication) during the six-month follow-up period (n = 6,433 of 11,093), with just over half having one or more outpatient clinical services for depression (52.9%, n = 5,870) and 17.5% an antidepressant medication. Of those with any outpatient service for depression, approximately two-thirds (65.3%, n = 3,832) received minimally adequate treatment (four or more services). Figure 2 illustrates the disparities in the first six months of treatment by race and ethnicity. The Black group was less likely than the White referent group to receive any treatment (54.9% vs 59.9%, AOR: 0.80, 95% CI 0.67–0.96). Antidepressant medication was more likely among White (21.3%, referent) and Asian children (27.4%, AOR: 1.35, 95% CI 1.05–1.72) than among other race and ethnicity groups, with Black children being the least likely to receive any antidepressant medication (14.1%, AOR: 0.60, 95% CI 0.47–0.75), followed by Hispanic (17.1%, AOR: 0.76, 95% CI 0.62–0.93), and Multiracial children (17.4%, AOR: 0.77, 95% CI 0.62–0.95). Among children who did receive any outpatient services for depression, only the Black group was less likely than the White referent group to receive minimally adequate care (60.8% vs 70.9%, AOR: 0.62, 95% CI 0.47–0.81). Inpatient and Emergency Room Services Hospitalization on the first day of a new episode of depression treatment was experienced by approximately 5% of children with a new diagnosis of depression (4.94%, n = 548). Black children (7.11%, AOR = 1.52, 95% CI: 1.02–2.26) were more likely than their White peers (4.79%, referent) to be hospitalized on the day of their initial presentation, with no differences observed for other groups (Table 3 ). Over 20% of children experienced inpatient or ER services during the first six months of new episode of depression (20.9%, n = 2,321 of 11,093). Black (22.4%, AOR: 1.38, 95% CI 1.10–1.73) and Multiracial children (22.1%, AOR: 1.35, 95% CI 1.08–1.68) were more likely to experience an inpatient and/or ER visit than White children (17.2%) (Table 3 ). DISCUSSION In this study of Medicaid-insured children and adolescents with new episodes of depression care in New York City, disparities by race and ethnicity were found for initial diagnosis and follow-up treatment settings, adequacy of care, and types of services received. Compared to White children, Black children were more likely to receive an initial diagnosis in a hospital emergency service, but less likely to receive any follow-up treatment, and those who did receive services were less likely to receive minimally adequate care. These findings build on earlier reports of disparities in depression care for Black and Hispanic youth(Cummings et al. 2019 ; Fontanella et al. 2025 ; Lu 2019 ; Rodgers et al. 2022 ) and contribute new information on racial inequities in depression treatment while also suggesting the persistence of greater barriers to care for racially minoritized children. Of note, White youth had significantly lower odds of new episodes of depression compared to all other race and ethnicity groups. Hispanic youth had the highest odds, roughly two and a half times that of White youth. This finding aligns with other survey research indicating that Hispanic youth have a higher prevalence of depressive symptoms compared to their non-Hispanic peers, including recent reports from the CDC’s Youth Risk Behavior Survey (Roche et al. 2024 ). Alarmingly, diagnoses of depression among Black, Hispanic, and Multiracial children are accompanied by evidence of inequitable care, in a system that appears already inadequate for the population overall. Similar findings of inadequacy of care have previously been seen.Lu ( 2019 ) found White teens with depression were more likely to discuss their symptoms with a doctor or other health professional compared to their Hispanic, Black, or Asian peers with depression. A nine-state study of depression among Medicaid-enrolled children found Black and Hispanic children with depression in 2008 to 2011 were more likely to receive no treatment, and less likely to receive adequate care if they did receive treatment (Cummings et al. 2019 ). Such studies are important because they identify disparities in public mental health services and systems that are tasked with providing equitable care. Results of the current study suggest that over ten years later, achieving equitable care remains an elusive goal for the treatment of child and adolescent depression. Differences in service utilization by treatment setting suggest differential access issues for Black and Hispanic youth, as seen, for example, in this study’s finding of lower use of private practice for both of those demographic groups, as well as the increased emergency room and inpatient services among Black youth compared to their White peers. These differences in treatment settings may influence whether children receive any or adequate follow-up care. Emergency room presentation for initial depression diagnosis is a particularly concerning indicator of poor access. Use of emergency services may be due to level of severity of illness at the time of initial presentation, suggesting decreased access to prevention or earlier intervention in less acute settings. Alternatively, emergency room presentations for an initial assessment of depression in a child may also indicate that families are using the emergency room as their point of access for health care, indicating lack of access to routine outpatient services. Family preferences for accessing health care also need to be better understood. A study of lower acuity emergency room patients presenting for any reason found that Black adults were twice as likely as White patients to identify the emergency room as their preferred treatment setting for accessing health care, independent of insurance (Brown et al. 2012 ). The differences identified in our analyses could be driven by a constellation of factors: discordance in race and ethnicity of providers and youth presenting for treatment; provider bias; perceived expectations or utility of treatment, perhaps driven by historical mistreatment; social determinants of health such as income level, transportation, availability, systemic racism; and cultural beliefs and stigma about depression (Stewart et al. 2012 ). Future studies should examine how these factors impact treatment preferences, access to treatment, and outcomes for families and children with new episodes of depression. The greater likelihood of hospital emergency and inpatient services among Black youth highlights the need for more tailored interventions for historically marginalized and underserved communities. This finding is consistent with studies of adult populations, which have found evidence of increased severity of depression among Black adults(Vyas et al., 2020 ). Further, it is consistent with reported increases in the rate of suicidality among Black youth (Lindsey et al. 2019 ; Price and Khubchandani 2019 ; The American Academy of Child and Adolescent Psychiatry 2022). An important area for future study is to examine the relationship between course of treatment for depression for children and adolescents with suicidality by race and ethnicity. Higher severity of depressive symptoms in the face of lower receipt of minimally adequate care underscores the need for immediate intervention. The higher incidence of new episodes of diagnosed depression among Black children compared to White children was a novel and unexpected finding. Earlier studies have suggested that Black Americans may be less likely to experience depression than their White peers, despite greater exposure overall to known stressors tied to poorer mental health (Keyes 2009 ; Merikangas et al. 2010 ; Substance Abuse and Mental Health Services Administration 2022a ). At the same time, conflicting evidence indicates that Black, Hispanic, and Asian individuals may in fact experience more symptoms of depression than their White counterparts (Adkins et al. 2009 ; Brown et al. 2007; Mcleod and Owens 2004 ). While it is not possible to equate findings within a treated population to estimates of prevalence across the population at large, the higher odds among Hispanic and Black children remains noteworthy. Policies impacting the delivery of children and adolescent healthcare services vary by region and demographics (Hoagwood et al. 2017 ; Sultan et al. 2018 ). Marked regional variations in population demographics and mental health services infrastructure present challenges to understanding the impact of race and ethnicity on prevalence, service utilization patterns, and outcomes. Examining a single city with a large defined services environment may have elucidated differences that would be masked in a larger geographic sample; however, clearly further study is warranted. For example, a recent study in Los Angeles identified disparities in access to evidence-based mental health care for AI/PI children, while White, Black, and Hispanic children were not significantly different (Lui et al. 2022 ). As states and localities try to identify and address disparities in mental health care access for youth, methods and scope matter, and may impact ability to observe critical differences in needs and access. The 2021 Declaration of a National Mental Health Emergency for Children and Adolescents by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association (AAP-AACAP-CHA) called for national, state, and local interventions to address critical gaps in access to mental health care (American Academy of Pediatrics, 2021 ). Congress launched the national 988 Suicide Crisis Lifeline in 2022, acknowledged as a key strategy for improving crisis response services for children and families, (Substance Abuse and Mental Health Services Administration 2022b ) and 26 states enacted legislation to support funding and implementation within the following year (National Academy for State Health Policy 2023). The Council of State Governments identified mental health as one of the top five priorities for states in 2023, and reports that collectively states enacted over 100 laws in the prior three years to support school-based mental health (The Council of State Governments 2023), a key strategy called for in the AAP-AACAP-CHA declaration. In New York State, Governor Hochul developed a billion dollar mental health plan that included expansion of children’s mental health services including school-based mental health services, suicide prevention for high-risk youth, eating disorder treatment, early childhood development services, and in-home Crisis Intervention, among many other services (Ferré-Sadurní and Newman 2023). As national, state, and local interventions are implemented to improve access for all children, it will be important to monitor potential differences in service use by race to see whether mental health equity is also being enhanced. This study has several limitations. First, these findings on Medicaid-insured children and adolescents living in New York City may not be generalizable to rural or other populations, including other states whose Medicaid policies may not mirror those of New York. Second, we defined depression through the use of claims and encounter data, which only identify diagnosed depression, and yields lower estimates than self-report or other methods. Unidentified and untreated depression will be missed, as will any treatment paid out of pocket or received free of charge. We also defined depression as a single date of service during the year with a qualifying diagnosis, rather than requiring two dates of service with a diagnosis as is often used in services research to increase validity. This choice allowed us to study individuals with a single index visit, rather than exclude them from the study population, but this approach increases the noise in estimates. Third, we defined minimally adequate care as four or more outpatient services for depression in the first six months, but we do not know about the content or quality of these sessions. Fourth, although depression typically has onset in older children, we examined all children in the Medicaid population < 18 years of age. This approach yields lower estimates of prevalence and incidence for the total population, due to inclusion of younger children, but allowed us to examine disparities by race and ethnicity within different age groups, including very young children. Finally, this analysis did not include measures that might elucidate underlying mechanisms or driving forces explaining the findings. Future research should explore, among other factors, the role of provider bias in referral habits, symptom severity, and geographic and cultural differences. CONCLUSION Disparities in access to quality mental health services have long been a concern as well as a prioritized area of focus. However, profound differences persist in access to and use of depression care services. To redress racial and ethnic disparities in the treatment of diagnosed depression for Black, Hispanic, and Multiracial children, concerted attention should be paid to understanding the drivers of inequitable access, including social and structural determinants of health, and to making this a priority for research and public policy attention. Declarations Author Contribution All co-authors contributed to the design of the study, interpretation of results, critical review, editing, and approval of the manuscript. MTF, KEH, KK, and NM led the development of the study design, interpretation of results, and manuscript development. QC, SC, and JJ ran the analyses, with oversight by ELW. MTF, DL, AE, ELW, QC, SC, and JJ drafted the manuscript. Acknowledgement Thank you to Carol Barth Lanzara and Jonathan Plasencia for all of their manuscript support. The data included in the manuscript have not previously been published and are not currently being considered for publication elsewhere, either in full or in part. Data Availability The NYS Medicaid data is proprietary. Access and use of the data are contingent on completing a data-use agreement and purchasing the required license. Requests for data access, code, or analysis should be directed to the corresponding author. The corresponding author will assist with reasonable replication attempts for two years following publication using non-proprietary data. References Adkins, D. E., Wang, V., Dupre, M. E., van den Oord, E. J. C. G., & Elder, G. H. (2009). Structure and stress: Trajectories of depressive symptoms across adolescence and young adulthood. Social Forces , 88 (1), 31–60. https://doi.org/10.1353/sof.0.0238 American Academy of Pediatrics (2021). 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(2016). Racial and ethnic disparities in mental health care for children and young adults. International Journal of Health Services , 46 (4), 810–824. https://doi.org/10.1177/0020731416662736 Mcleod, J. D., & Owens, T. J. (2004). Psychological well-being in the early life course: Variations by socioeconomic status, gender, and race/ethnicity. Social Psychology Quarterly , 67 (3), 257–278. https://doi.org/10.1177/019027250406700303 Merikangas, K. R., He, J. P., Brody, D., Fisher, P., Bourdon, K., & Koretz, D. S. (2010). Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics , 125 (1), 75–81. https://doi.org/10.1542/peds.2008-2598 National Academy for State Health Policy (2023, June 6). State legislation to fund and implement the 988 suicide and crisis lifeline. https://nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/ . Accessed 26 September 2023. Overhage, L., Hailu, R., Busch, A. 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JAMA Pediatrics , 175 (11), 1142–1150. https://doi.org/10.1001/jamapediatrics.2021.2482 Roche, K. M., Ehrlich, K. B., Vaquera, E., & Little, T. D. (2024). Mental health during early adolescence and later cardiometabolic risk: A prospective study of US Latinx youth. Journal of Adolescent Health , 74 (1), 71–77. https://doi.org/10.1016/j.jadohealth.2023.08.026 Rodgers, C. R. R., Flores, M. W., Bassey, O., Augenblick, J. M., & Cook, B. L. (2022). Racial/ethnic disparity trends in children’s mental health care access and expenditures from 2010–2017: Disparities remain despite sweeping policy reform. Journal of the American Academy of Child and Adolescent Psychiatry , 61 (7), 915–925. https://doi.org/10.1016/j.jaac.2021.09.420 Stein, B. D., Sorbero, M. J., Dalton, E., Ayers, A. M., Farmer, C., Kogan, J. N., & Goswami, U. (2013). Predictors of adequate depression treatment among Medicaid-enrolled youth. Social Psychiatry and Psychiatric Epidemiology , 48 , 757–765. https://doi.org/10.1007/s00127-012-0593-7 Stewart, S. M., Simmons, A., & Habibpour, E. (2012). Treatment of culturally diverse children and adolescents with depression. Journal of Child and Adolescent Psychopharmacology , 22 (1), 72–79. https://doi.org/10.1089/cap.2011.0051 Substance Abuse and Mental Health Services Administration (2022a). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health . https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report . Accessed 20 September 2023. Substance Abuse and Mental Health Services Administration (2022b). National guidelines for child and youth behavioral health crisis care. Publication No. PEP22-01-02-001 . Rockville, MD. https://library.samhsa.gov/product/national-guidelines-child-and-youth-behavioral-health-crisis-care/pep22-01-02-001 . Accessed 13 March 2025. Substance Abuse and Mental Health Services Administration (2023, January 4). 2021 NSDUH detailed tables. National Survey on Drug Use and Health . https://www.samhsa.gov/data/report/2021-nsduh-detailed-tables . Accessed 7 March 2023. Sultan, R. S., Correll, C. U., Schoenbaum, M., King, M., Walkup, J. T., & Olfson, M. (2018). National patterns of commonly prescribed psychotropic medications to young people. Journal of Child and Adolescent Psychopharmacology , 28 (3), 158–165. https://doi.org/10.1089/cap.2017.0077 The American Academy of Child and Adolescent Psychiatry (2022, March). AACAP policy statement on increased suicide among Black youth in the U.S. https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx . Accessed 24 September 2023. The Council of State Governments (2023, March 8). Mental health among top policy priorities for the states. https://www.csg.org/2023/03/08/mental-health-among-top-policy-priorities-for-the-states/ . Accessed 26 September 2023. Vyas, C. M., Donneyong, M., Mischoulon, D., Chang, G., Gibson, H., Cook, N. R., et al. (2020). Association of race and ethnicity with late-life depression severity, symptom burden, and care. JAMA Network Open , 3 (3), e201606. https://doi.org/10.1001/jamanetworkopen.2020.1606 Walter, H. J., Abright, A. R., Bukstein, O. G., Diamond, J., Keable, H., Ripperger-Suhler, J., & Rockhill, C. (2023). Clinical practice guideline for the assessment and treatment of children and adolescents with major and persistent depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry , 62 (5), 479–502. https://doi.org/10.1016/j.jaac.2022.10.001 Additional Declarations No competing interests reported. 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19:06:36","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147672,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/717d137f68900576a20c4d04.html"},{"id":94223092,"identity":"42b438c3-9873-48dd-961c-55640598f616","added_by":"auto","created_at":"2025-10-23 19:06:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129506,"visible":true,"origin":"","legend":"\u003cp\u003ePractice setting for initial diagnosis of a new episode of depression among Medicaid-insured children by race and ethnicity (0 – 17 years)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: \u003c/em\u003eData source is New York State Medicaid. Race and Ethnicity groups are mutually exclusive: White Non-Hispanic (n=668), Black Non-Hispanic (n=1,899), Hispanic (any race) (n=4,631), Asian Non-Hispanic (n=771), Multiracial Non-Hispanic (n=2,672).\u003c/p\u003e\n\u003cp\u003eInitial practice setting of index diagnosis is mutually exclusive. \u003cstrong\u003eMedical Clinic\u003c/strong\u003e= outpatient licensed medical clinic programs and urgent care; \u003cstrong\u003ePrivate Practitioner\u003c/strong\u003e= outpatient individual or group practices of any type; \u003cstrong\u003eSpecialty BH (behavioral health) program\u003c/strong\u003e= outpatient specialty mental health or substance use disorder treatment programs licensed or designated by the Office of Mental Health or the Office of Addiction Services and Supports; \u003cstrong\u003eEmergency Room\u003c/strong\u003e = Inpatient hospitalization or emergency room presentation with or without subsequent inpatient admission.\u003c/p\u003e\n\u003cp\u003e*Indicates significantly different odds compared to White referent group, adjusted for age and gender(See Table 2 for adjusted odds ratios and 95% confidence intervals).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/aa13144b9be65ff199714883.png"},{"id":94223101,"identity":"5ba8c34f-2c7d-4158-b11f-55ec8d353e4f","added_by":"auto","created_at":"2025-10-23 19:06:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97708,"visible":true,"origin":"","legend":"\u003cp\u003eDepression Incidence and Course of Treatment for Medicaid-insured Children and Adolescents by Race and Ethnicity\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e \u003cstrong\u003eIncidence\u003c/strong\u003e= Any new episode depression diagnosis (from any diagnosis field on the claim) for individuals receiving services between January 1 – December 31, 2021. \u003cstrong\u003eAny Treatment \u003c/strong\u003e= Any outpatient depression service or filled antidepressant medication prescription. \u003cstrong\u003eAny OP\u003c/strong\u003e = any outpatient clinical service with a primary depression diagnosis. \u003cstrong\u003eAny AD\u003c/strong\u003e = any filled prescription for an antidepressant medication. \u003cstrong\u003e4+OP\u003c/strong\u003e = adequate outpatient treatment measure with 4+ clinical outpatient services with a primary diagnosis of depression among those with 1 or more follow-up visit.\u003c/p\u003e\n\u003cp\u003e* Indicates significant difference in adjusted odds for racial groups compared to the White Non-Hispanic reference group.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/50997fc13bec71cd23a8bb37.png"},{"id":94224015,"identity":"083d4f94-b806-49b0-b654-4641b02bf207","added_by":"auto","created_at":"2025-10-23 19:14:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":762958,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/937f6c6d-e8cf-4230-8b61-029abf46dc50.pdf"},{"id":94224014,"identity":"d28cd844-c44a-40f8-b10b-bf4c9dbc5396","added_by":"auto","created_at":"2025-10-23 19:14:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28457,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/a3f65a450b050aa1d46304d6.docx"},{"id":94223090,"identity":"54cd97f5-9d26-4fcb-98ee-473215e4031e","added_by":"auto","created_at":"2025-10-23 19:06:36","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30191,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643217/v1/af23fb8776411aae1a7af960.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDifferential Patterns of Service Use for Depression Among Diverse Medicaid-Insured Children and Youth\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn 2021 the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children\u0026rsquo;s Hospital Association declared a national emergency in child and adolescent mental health, citing the dual stressors of the COVID-19 pandemic and ongoing racial inequity (American Academy of Pediatrics \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The pandemic amplified existing racial and ethnic disparities in mental health (Parenteau et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) et al., 2023) and was accompanied by increases in the prevalence of depression (Racine et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), suicidality (Jones et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and mental health emergency department presentations among youth (Overhage et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Improving mental health care and outcomes for children and adolescents with depression requires understanding patterns of service use and variations in those patterns over time, including different trajectories by demographic factors, such as race and ethnicity. Such an examination within a large system is particularly critical in light of the racial and ethnic disparities previously described.\u003c/p\u003e\u003cp\u003eThe first line treatment for depression in children and adolescents is psychotherapy (Birmaher et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Walter et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Delivery of this recommended practice requires a series of steps: (1) the child presents to a health care provider and the treating clinician diagnoses depression; (2) depending upon the setting, a referral or follow-up appointment is made and the child attends; and (3) the child receives a course of psychotherapy over a series of sessions. Several studies have identified disparities by race and ethnicity in one or more of these steps (Cummings et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Lu \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Lui et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Rodgers et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Substance Abuse and Mental Health Services Administration 2023). In one analysis of data from the Medical Expenditure Panel Survey (MEPS), White youth were roughly twice as likely to initiate mental health care compared to their Black and Hispanic/Latinx peers (Cook et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In a later analysis of data on adolescents from the National Survey on Drug Use and Health (2011 to 2016), compared to White teens with depression, Hispanic/Latinx, Black, and Asian teens with depression were less likely to report seeing or talking with a doctor or other professional about their symptoms (Lu \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Similar disparities by race and ethnicity have been documented in utilization of outpatient mental health care (Marrast et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) as well as higher psychotropic use among White youth compared to Black and Hispanic/Latinx youth (Fontanella et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Rodgers et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, there is a dearth of more comprehensive studies of patterns of service use for youth with depression\u0026mdash;from clinical setting of initial diagnosis for a new episode of depression (e.g., primary care, emergency department), to follow-up treatment setting and delivery of care, including measurement of care adequacy and use of acute care services by race and ethnicity. Such analyses are critical for understanding differences in treatment trajectories, and for informing policy and program interventions aimed at achieving more equitable care in public mental health services.\u003c/p\u003e\u003cp\u003eThis study focuses on a socioeconomically disadvantaged and diverse population of Medicaid-insured children and adolescents living in New York City in 2021. It builds upon previous epidemiological research by examining racial and ethnic differences for new episode depression treatment for children aged 0\u0026ndash;17. The service types include diagnosis, initial and follow-up treatment settings, filling of antidepressant prescriptions, and service utilization through the first six months after diagnosis. These analyses aim to explore whether patterns of service use for depression are similar or different for children/youth of diverse racial and ethnic backgrounds. These analyses provide new information on differences in treatment patterns among children and youth from low-income families in a large metropolitan area. Examining a single city with a large defined services environment may identify differences that might be masked in a larger geographic sample.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study used New York State (NYS) Medicaid data to examine patterns of service use by race and ethnicity among children and adolescents living in New York City with a new episode of depression in 2021 at initial diagnosis (cross-sectional design) and at six-month follow-up (longitudinal cohort design). The study was reviewed by the Nathan Kline Research Institute Institutional Review Board and received a determination of not human subjects research.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Source and Study Population\u003c/h3\u003e\n\u003cp\u003eData for the study population were extracted from the NYS Medicaid data warehouse (MDW), including enrollment, eligibility, demographic characteristics, and claims and encounter data from 1/1/2020-7/1/2022 for all Medicaid-enrolled children (ages 0\u0026ndash;17) residing in New York City as of December 31, 2021 (N\u0026thinsp;=\u0026thinsp;1,130,745). The study cohort was restricted to children with one or more health services in 2021 (n\u0026thinsp;=\u0026thinsp;1,093,538). The index date was defined for each child as the first date of service in 2021 with a depression diagnosis or, if no depression diagnosis in 2021, then the first date of any clinical service during the year, including medical and other behavioral health service. A depression diagnosis was defined as having a clinical service claim or encounter in 2021 with an ICD-10 diagnosis code for depression (single episode F32.X, or recurrent F33.X excluding those in remission: F32.5, F33.40 and F33.42). New episodes of depression care were defined as those where there was no diagnosis or treatment for depression in the 12 months prior to the index date (including those with a first depression diagnosis in 2021, and individuals with previous episodes of depression care ending more than 12 months ago). The period of observation for each child was the 12 months prior and six months after their index date, to determine whether the depression diagnosis represented a new episode of care, and to allow for six months of follow-up. Continuous Medicaid eligibility (maximum allowable gap of 45 days) was required in 2021 and for the period of observation for each child (n\u0026thinsp;=\u0026thinsp;865,299). Children who were dual eligible for Medicare were excluded since services paid by Medicare may not be visible in the Medicaid data, for a final Medicaid study cohort of N\u0026thinsp;=\u0026thinsp;865,281. (n\u0026thinsp;=\u0026thinsp;17,613). Children and adolescents with diagnoses of schizophrenia or bipolar disorder (ICD-10: F2X, or F30-F31 on two dates of service) were excluded using a hierarchical assignment to more severe mental illness (n\u0026thinsp;=\u0026thinsp;783), yielding a prevalent depression cohort of n\u0026thinsp;=\u0026thinsp;16,830. The new episode of depression care cohort included those children who had no evidence of a depression diagnosis in the 12 months prior to their depression index date (n\u0026thinsp;=\u0026thinsp;11,093, Supplemental Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e available online).\u003c/p\u003e\n\u003ch3\u003eCovariates and Measures\u003c/h3\u003e\n\u003cp\u003eRace, ethnicity, and other demographic variables were drawn from Medicaid eligibility files. Age was defined as of December 31, 2021, and categorized into four groups (\u0026lt;\u0026thinsp;6 years, 6\u0026ndash;11 years, 12\u0026ndash;14 years, 15\u0026ndash;17 years). Seven mutually exclusive race and ethnicity groups were constructed: Hispanic/Latinx (all races and referred to as \u0026ldquo;Hispanic\u0026rdquo; for brevity), and non-Hispanic groups referred to as White, Black, Asian, American Indian/Pacific Islander (AI/PI), Multiracial (more than one race identified), and Unknown race. Unknown race was included in model testing to examine differences between racial group and missingness.\u003c/p\u003e\u003cp\u003eClinical treatment settings were grouped into six categories: (1) specialty behavioral health program (outpatient specialty mental health or substance use disorder treatment programs, including specialty clinics, Assertive Community Treatment, psychosocial rehabilitation programs, and other behavioral health programs licensed or designated by the NYS Office of Mental Health or the NYS Office of Addiction Services and Supports); (2) medical clinic (outpatient licensed medical clinic programs and urgent care); (3) private practitioner (outpatient individual or group practices of any type); (4) emergency room (ER); (5) inpatient treatment; and (6) other settings, based on invoice type, state rate codes, diagnosis and procedure codes. To capture all crisis services, some analyses combined inpatient hospitalization or emergency room (ER/inpatient) presentation with or without subsequent inpatient admission.\u003c/p\u003e\u003cp\u003eThe initial or index treatment setting was the clinical setting on the index diagnosis date for children with a new episode of depression. When there was more than one treatment setting on the index date a hierarchical assignment was used to identify the single most likely sequence for initial presentation (e.g., outpatient before acute care, and primary care before specialty behavioral health services), specifically, medical outpatient clinic was prioritized, followed by private practitioner, specialty behavioral health outpatient, and ER/inpatient. Only children presenting directly to ER/inpatient were assigned to this category of initial treatment setting (no outpatient services on the index diagnosis day). Follow-up outpatient treatment settings included all outpatient clinical services with a primary diagnosis of depression. ER/inpatient use on the day of a new diagnosis of depression was assessed (whether preceded by an outpatient visit or not), and ER/inpatient treatment during the first six months of the episode was examined.\u003c/p\u003e\u003cp\u003eTwo additional dichotomous measures of any treatment were examined separately: (1) any outpatient clinical service with a primary diagnosis of depression, and (2) any antidepressant medication filled. \u0026ldquo;Any follow-up treatment\u0026rdquo; in the six months after the new episode index date was defined as either having received any clinical outpatient service with a primary diagnosis of depression or having filled any antidepressant medication prescription. Minimally adequate treatment was adapted from previous studies (Cummings et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Stein et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) and defined as four or more outpatient services for depression (primary diagnosis of depression on the claim or encounter) on separate dates of service in the six months following the index date for a new episode of depression. We did not restrict to services with psychotherapy codes due to inconsistent use of these codes in some treatment settings (e.g., foster care mental health programs).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eLogistic regression was used to examine differences in depression incidence by demographic characteristics. Course of treatment measures were described (number of children receiving treatment in each setting for new episodes of depression and for the first six months that followed, divided by the number of children with a depression diagnosis). Logistic regression models examined differences in treatment measures by race and ethnicity, adjusted for sex and age group. Adjusted odds ratios (AORs) were estimated with 95% confidence intervals (CIs). Given the existing evidence of increased access to quality mental healthcare among White children receiving mental health services (Rodgers et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), the White group was used as the reference category to allow for assessment of racial disparities. All statistical analyses were conducted using SAS enterprise guide 8.2.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe demographic characteristics of children and adolescents in the New York City Medicaid study population (N\u0026thinsp;=\u0026thinsp;865,281) are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The largest race and ethnicity group was Hispanic (28.9%, n\u0026thinsp;=\u0026thinsp;249,715), followed by Multiracial (24.3%, n\u0026thinsp;=\u0026thinsp;210,484), Black (17.5%, n\u0026thinsp;=\u0026thinsp;150,996), White (12%, n\u0026thinsp;=\u0026thinsp;103,466), Asian (11.8%, n\u0026thinsp;=\u0026thinsp;102,343), Unknown (5.2%, n\u0026thinsp;=\u0026thinsp;44,937) and AI/PI children (0.4%, n\u0026thinsp;=\u0026thinsp;3,340).\u003c/p\u003e\n\u003cp\u003eThe incidence of new treatment episodes of depression was 1.28% overall (n\u0026thinsp;=\u0026thinsp;11,093) and varied by age, sex, and race (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Incidence was higher for females than for males (1.84% vs 0.75%, AOR\u0026thinsp;=\u0026thinsp;2.54, 95% CI: 2.43\u0026ndash;2.64), and increased with age from 0.03% for \u0026lt;\u0026thinsp;6 years (AOR\u0026thinsp;=\u0026thinsp;0.009, 95% CI: 0.007\u0026ndash;0.012), to 3.69% for 15\u0026ndash;17 years (AOR\u0026thinsp;=\u0026thinsp;1.39, 95% CI: 1.34\u0026ndash;1.45), compared to middle school aged children 12\u0026ndash;14 years (2.68%, referent). Compared to the White group (prevalence 0.65%, referent), all other race and ethnicity groups except Asian (0.75%) had significantly higher incidence of new treatment episodes of depression. New treatment episodes were highest for the Hispanic group (1.85%, AOR\u0026thinsp;=\u0026thinsp;2.49, 95% CI: 2.29\u0026ndash;2.70), followed by the Multiracial (1.27%, AOR\u0026thinsp;=\u0026thinsp;1.70, 95% CI: 1.56\u0026ndash;1.85), Black (1.26%, AOR\u0026thinsp;=\u0026thinsp;1.67, 95% CI: 1.53\u0026ndash;1.83), and AI/PI (1.11%, AOR\u0026thinsp;=\u0026thinsp;1.48, 95% CI: 1.06\u0026ndash;2.08) groups after adjusting for age and sex. Differences by race and ethnicity were observed for all age groups, beginning with very young children, where Hispanic preschool children were over four times more likely to have a new diagnosis of depression than White children (0.052% vs 0.012%; AOR\u0026thinsp;=\u0026thinsp;4.39, 95% CI:1.56\u0026ndash;12.39).\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTreatment Setting on Initial Presentation and for Follow-up Care\u003c/h2\u003e\n \u003cp\u003eOverall, new episodes of depression were most commonly diagnosed in an outpatient medical clinic (41.8%, n\u0026thinsp;=\u0026thinsp;4,634), followed by outpatient specialty behavioral health programs (27.9%, n\u0026thinsp;=\u0026thinsp;3,092), ER or inpatient settings (16.2%, n\u0026thinsp;=\u0026thinsp;1,792), private practices (13.3%, n\u0026thinsp;=\u0026thinsp;1,472), and other settings (0.9%, n\u0026thinsp;=\u0026thinsp;103). Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the variation in clinical treatment settings on initial presentation of a new episode of depression by race and ethnicity (n\u0026thinsp;=\u0026thinsp;10,641; AI/PI and Unknown were excluded due to small cohort sizes). Private practice treatment settings were more common for White (21.7%, referent) and Asian children (28.5%, AOR\u0026thinsp;=\u0026thinsp;1.49, 95% CI: 1.17\u0026ndash;1.90), compared to other race and ethnicity groups, with the lowest adjusted odds for Black children (9.16%, AOR: 0.37, 95% CI 0.29\u0026ndash;0.47), followed by Hispanic (10.82%, AOR: 0.44, 95% CI 0.36\u0026ndash;0.55), and Multiracial groups (13.96%, AOR: 0.60, 95% CI 0.48\u0026ndash;0.74). Only Black children were more likely to have an initial diagnosis in an ER/inpatient setting compared to the White referent group (18.27% vs 13.47%, AOR: 1.44, 95% CI 1.12\u0026ndash;1.85) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eInitial practice setting of index diagnosis is mutually exclusive. \u003cstrong\u003eMedical Clinic\u003c/strong\u003e\u0026thinsp;=\u0026thinsp;outpatient licensed medical clinic programs and urgent care; \u003cstrong\u003ePrivate Practitioner\u003c/strong\u003e\u0026thinsp;=\u0026thinsp;outpatient individual or group practices of any type; \u003cstrong\u003eSpecialty BH (behavioral health) program\u003c/strong\u003e\u0026thinsp;=\u0026thinsp;outpatient specialty mental health or substance use disorder treatment programs licensed or designated by the Office of Mental Health or the Office of Addiction Services and Supports; \u003cstrong\u003eEmergency Room\u003c/strong\u003e\u0026thinsp;=\u0026thinsp;Inpatient hospitalization or emergency room presentation with or without subsequent inpatient admission.\u003c/p\u003e\n \u003cp\u003e*Indicates significantly different odds compared to White referent group, adjusted for age and gender (See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e for adjusted odds ratios and 95% confidence intervals).\u003c/p\u003e\n \u003cp\u003eFollow-up treatment settings also varied by race and ethnicity during the first six months after initial diagnosis (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, the most common treatment setting was specialty behavioral health programs (32.6%), followed by private practice (14.7%), and medical clinics (12.3%). Receiving depression treatment in a medical clinic was more common for Hispanic (13.0%, AOR: 1.45, 95% CI 1.10\u0026ndash;1.92) and Multiracial children (13.1%, AOR: 1.44, 95% CI 1.08\u0026ndash;1.92) than for White children (9.1%, referent). Private practice was more common for White (17.5%, referent) and Asian children (22.4%, AOR: 1.36, 95% CI 1.05\u0026ndash;1.77), and was lowest for Black (10.9%, AOR: 0.56, 95% CI 0.44\u0026ndash;0.72) and Hispanic children (14.0%, AOR: 0.76, 95% CI 0.61\u0026ndash;0.94).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eFollow-up Outpatient Treatment\u003c/h3\u003e\n\u003cp\u003eAfter a diagnosis of a new episode of depression, receipt of any follow-up treatment, and of minimally adequate treatment varied by race and ethnicity. Overall, 58% of children and adolescents aged 0\u0026ndash;17 had any follow-up treatment (outpatient service or antidepressant medication) during the six-month follow-up period (n\u0026thinsp;=\u0026thinsp;6,433 of 11,093), with just over half having one or more outpatient clinical services for depression (52.9%, n\u0026thinsp;=\u0026thinsp;5,870) and 17.5% an antidepressant medication. Of those with any outpatient service for depression, approximately two-thirds (65.3%, n\u0026thinsp;=\u0026thinsp;3,832) received minimally adequate treatment (four or more services). Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the disparities in the first six months of treatment by race and ethnicity. The Black group was less likely than the White referent group to receive any treatment (54.9% vs 59.9%, AOR: 0.80, 95% CI 0.67\u0026ndash;0.96). Antidepressant medication was more likely among White (21.3%, referent) and Asian children (27.4%, AOR: 1.35, 95% CI 1.05\u0026ndash;1.72) than among other race and ethnicity groups, with Black children being the least likely to receive any antidepressant medication (14.1%, AOR: 0.60, 95% CI 0.47\u0026ndash;0.75), followed by Hispanic (17.1%, AOR: 0.76, 95% CI 0.62\u0026ndash;0.93), and Multiracial children (17.4%, AOR: 0.77, 95% CI 0.62\u0026ndash;0.95). Among children who did receive any outpatient services for depression, only the Black group was less likely than the White referent group to receive minimally adequate care (60.8% vs 70.9%, AOR: 0.62, 95% CI 0.47\u0026ndash;0.81).\u003c/p\u003e\n\u003ch3\u003eInpatient and Emergency Room Services\u003c/h3\u003e\n\u003cp\u003eHospitalization on the first day of a new episode of depression treatment was experienced by approximately 5% of children with a new diagnosis of depression (4.94%, n\u0026thinsp;=\u0026thinsp;548). Black children (7.11%, AOR\u0026thinsp;=\u0026thinsp;1.52, 95% CI: 1.02\u0026ndash;2.26) were more likely than their White peers (4.79%, referent) to be hospitalized on the day of their initial presentation, with no differences observed for other groups (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOver 20% of children experienced inpatient or ER services during the first six months of new episode of depression (20.9%, n\u0026thinsp;=\u0026thinsp;2,321 of 11,093). Black (22.4%, AOR: 1.38, 95% CI 1.10\u0026ndash;1.73) and Multiracial children (22.1%, AOR: 1.35, 95% CI 1.08\u0026ndash;1.68) were more likely to experience an inpatient and/or ER visit than White children (17.2%) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study of Medicaid-insured children and adolescents with new episodes of depression care in New York City, disparities by race and ethnicity were found for initial diagnosis and follow-up treatment settings, adequacy of care, and types of services received. Compared to White children, Black children were more likely to receive an initial diagnosis in a hospital emergency service, but less likely to receive any follow-up treatment, and those who did receive services were less likely to receive minimally adequate care. These findings build on earlier reports of disparities in depression care for Black and Hispanic youth(Cummings et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Fontanella et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lu \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Rodgers et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and contribute new information on racial inequities in depression treatment while also suggesting the persistence of greater barriers to care for racially minoritized children.\u003c/p\u003e\u003cp\u003eOf note, White youth had significantly lower odds of new episodes of depression compared to all other race and ethnicity groups. Hispanic youth had the highest odds, roughly two and a half times that of White youth. This finding aligns with other survey research indicating that Hispanic youth have a higher prevalence of depressive symptoms compared to their non-Hispanic peers, including recent reports from the CDC\u0026rsquo;s Youth Risk Behavior Survey (Roche et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Alarmingly, diagnoses of depression among Black, Hispanic, and Multiracial children are accompanied by evidence of inequitable care, in a system that appears already inadequate for the population overall. Similar findings of inadequacy of care have previously been seen.Lu (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) found White teens with depression were more likely to discuss their symptoms with a doctor or other health professional compared to their Hispanic, Black, or Asian peers with depression. A nine-state study of depression among Medicaid-enrolled children found Black and Hispanic children with depression in 2008 to 2011 were more likely to receive no treatment, and less likely to receive adequate care if they did receive treatment (Cummings et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such studies are important because they identify disparities in public mental health services and systems that are tasked with providing equitable care. Results of the current study suggest that over ten years later, achieving equitable care remains an elusive goal for the treatment of child and adolescent depression.\u003c/p\u003e\u003cp\u003eDifferences in service utilization by treatment setting suggest differential access issues for Black and Hispanic youth, as seen, for example, in this study\u0026rsquo;s finding of lower use of private practice for both of those demographic groups, as well as the increased emergency room and inpatient services among Black youth compared to their White peers. These differences in treatment settings may influence whether children receive any or adequate follow-up care. Emergency room presentation for initial depression diagnosis is a particularly concerning indicator of poor access. Use of emergency services may be due to level of severity of illness at the time of initial presentation, suggesting decreased access to prevention or earlier intervention in less acute settings. Alternatively, emergency room presentations for an initial assessment of depression in a child may also indicate that families are using the emergency room as their point of access for health care, indicating lack of access to routine outpatient services. Family preferences for accessing health care also need to be better understood. A study of lower acuity emergency room patients presenting for any reason found that Black adults were twice as likely as White patients to identify the emergency room as their preferred treatment setting for accessing health care, independent of insurance (Brown et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe differences identified in our analyses could be driven by a constellation of factors: discordance in race and ethnicity of providers and youth presenting for treatment; provider bias; perceived expectations or utility of treatment, perhaps driven by historical mistreatment; social determinants of health such as income level, transportation, availability, systemic racism; and cultural beliefs and stigma about depression (Stewart et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Future studies should examine how these factors impact treatment preferences, access to treatment, and outcomes for families and children with new episodes of depression.\u003c/p\u003e\u003cp\u003eThe greater likelihood of hospital emergency and inpatient services among Black youth highlights the need for more tailored interventions for historically marginalized and underserved communities. This finding is consistent with studies of adult populations, which have found evidence of increased severity of depression among Black adults(Vyas et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Further, it is consistent with reported increases in the rate of suicidality among Black youth (Lindsey et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Price and Khubchandani \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; The American Academy of Child and Adolescent Psychiatry 2022). An important area for future study is to examine the relationship between course of treatment for depression for children and adolescents with suicidality by race and ethnicity. Higher severity of depressive symptoms in the face of lower receipt of minimally adequate care underscores the need for immediate intervention.\u003c/p\u003e\u003cp\u003eThe higher incidence of new episodes of diagnosed depression among Black children compared to White children was a novel and unexpected finding. Earlier studies have suggested that Black Americans may be less likely to experience depression than their White peers, despite greater exposure overall to known stressors tied to poorer mental health (Keyes \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Merikangas et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Substance Abuse and Mental Health Services Administration \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022a\u003c/span\u003e). At the same time, conflicting evidence indicates that Black, Hispanic, and Asian individuals may in fact experience more symptoms of depression than their White counterparts (Adkins et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Brown et al. 2007; Mcleod and Owens \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). While it is not possible to equate findings within a treated population to estimates of prevalence across the population at large, the higher odds among Hispanic and Black children remains noteworthy. Policies impacting the delivery of children and adolescent healthcare services vary by region and demographics (Hoagwood et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Sultan et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Marked regional variations in population demographics and mental health services infrastructure present challenges to understanding the impact of race and ethnicity on prevalence, service utilization patterns, and outcomes. Examining a single city with a large defined services environment may have elucidated differences that would be masked in a larger geographic sample; however, clearly further study is warranted. For example, a recent study in Los Angeles identified disparities in access to evidence-based mental health care for AI/PI children, while White, Black, and Hispanic children were not significantly different (Lui et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As states and localities try to identify and address disparities in mental health care access for youth, methods and scope matter, and may impact ability to observe critical differences in needs and access.\u003c/p\u003e\u003cp\u003eThe 2021 Declaration of a National Mental Health Emergency for Children and Adolescents by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children\u0026rsquo;s Hospital Association (AAP-AACAP-CHA) called for national, state, and local interventions to address critical gaps in access to mental health care (American Academy of Pediatrics, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Congress launched the national 988 Suicide Crisis Lifeline in 2022, acknowledged as a key strategy for improving crisis response services for children and families, (Substance Abuse and Mental Health Services Administration \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022b\u003c/span\u003e) and 26 states enacted legislation to support funding and implementation within the following year (National Academy for State Health Policy 2023). The Council of State Governments identified mental health as one of the top five priorities for states in 2023, and reports that collectively states enacted over 100 laws in the prior three years to support school-based mental health (The Council of State Governments 2023), a key strategy called for in the AAP-AACAP-CHA declaration. In New York State, Governor Hochul developed a billion dollar mental health plan that included expansion of children\u0026rsquo;s mental health services including school-based mental health services, suicide prevention for high-risk youth, eating disorder treatment, early childhood development services, and in-home Crisis Intervention, among many other services (Ferr\u0026eacute;-Sadurn\u0026iacute; and Newman 2023). As national, state, and local interventions are implemented to improve access for all children, it will be important to monitor potential differences in service use by race to see whether mental health equity is also being enhanced.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, these findings on Medicaid-insured children and adolescents living in New York City may not be generalizable to rural or other populations, including other states whose Medicaid policies may not mirror those of New York. Second, we defined depression through the use of claims and encounter data, which only identify diagnosed depression, and yields lower estimates than self-report or other methods. Unidentified and untreated depression will be missed, as will any treatment paid out of pocket or received free of charge. We also defined depression as a single date of service during the year with a qualifying diagnosis, rather than requiring two dates of service with a diagnosis as is often used in services research to increase validity. This choice allowed us to study individuals with a single index visit, rather than exclude them from the study population, but this approach increases the noise in estimates. Third, we defined minimally adequate care as four or more outpatient services for depression in the first six months, but we do not know about the content or quality of these sessions. Fourth, although depression typically has onset in older children, we examined all children in the Medicaid population\u0026thinsp;\u0026lt;\u0026thinsp;18 years of age. This approach yields lower estimates of prevalence and incidence for the total population, due to inclusion of younger children, but allowed us to examine disparities by race and ethnicity within different age groups, including very young children. Finally, this analysis did not include measures that might elucidate underlying mechanisms or driving forces explaining the findings. Future research should explore, among other factors, the role of provider bias in referral habits, symptom severity, and geographic and cultural differences.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDisparities in access to quality mental health services have long been a concern as well as a prioritized area of focus. However, profound differences persist in access to and use of depression care services. To redress racial and ethnic disparities in the treatment of diagnosed depression for Black, Hispanic, and Multiracial children, concerted attention should be paid to understanding the drivers of inequitable access, including social and structural determinants of health, and to making this a priority for research and public policy attention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll co-authors contributed to the design of the study, interpretation of results, critical review, editing, and approval of the manuscript. MTF, KEH, KK, and NM led the development of the study design, interpretation of results, and manuscript development. QC, SC, and JJ ran the analyses, with oversight by ELW. MTF, DL, AE, ELW, QC, SC, and JJ drafted the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThank you to Carol Barth Lanzara and Jonathan Plasencia for all of their manuscript support. The data included in the manuscript have not previously been published and are not currently being considered for publication elsewhere, either in full or in part.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe NYS Medicaid data is proprietary. Access and use of the data are contingent on completing a data-use agreement and purchasing the required license. Requests for data access, code, or analysis should be directed to the corresponding author. The corresponding author will assist with reasonable replication attempts for two years following publication using non-proprietary data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdkins, D. E., Wang, V., Dupre, M. E., van den Oord, E. J. C. G., \u0026amp; Elder, G. H. (2009). 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AACAP policy statement on increased suicide among Black youth in the U.S. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx\u003c/span\u003e\u003cspan address=\"https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 September 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Council of State Governments (2023, March 8). 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Association of race and ethnicity with late-life depression severity, symptom burden, and care. \u003cem\u003eJAMA Network Open\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(3), e201606. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamanetworkopen.2020.1606\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2020.1606\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalter, H. J., Abright, A. R., Bukstein, O. G., Diamond, J., Keable, H., Ripperger-Suhler, J., \u0026amp; Rockhill, C. (2023). Clinical practice guideline for the assessment and treatment of children and adolescents with major and persistent depressive disorders. \u003cem\u003eJournal of the American Academy of Child and Adolescent Psychiatry\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(5), 479\u0026ndash;502. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2022.10.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2022.10.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"race and ethnicity, disparities, youth, psychiatric epidemiology","lastPublishedDoi":"10.21203/rs.3.rs-7643217/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7643217/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study explored differences in service use by race/ethnicity across the full continuum of care for Medicaid-enrolled youth diagnosed with depression, using a hybrid cross-sectional and longitudinal cohort design of children (0\u0026ndash;17 years) in New York City (N\u0026thinsp;=\u0026thinsp;865,281) with new episodes of depression in 2021 (n\u0026thinsp;=\u0026thinsp;11,093). Measures included clinical setting on initial presentation and over the six months that followed; hospitalization on initial diagnosis; receipt of any follow-up care, any outpatient service, minimally adequate outpatient care, or any antidepressant; and ER/inpatient services received during six-month follow-up. Compared to White children, Black children were more likely to initially present in an emergency room setting (AOR\u0026thinsp;=\u0026thinsp;1.44, 95%CI:1.12\u0026ndash;1.85) and were more likely to be hospitalized on initial diagnosis (AOR\u0026thinsp;=\u0026thinsp;1.52, 95%CI:1.02\u0026ndash;2.26); Black and Hispanic/Latinx children were less likely to use private practice for initial treatment (AOR\u0026thinsp;=\u0026thinsp;0.37, 95%CI:0.29\u0026ndash;0.47 and AOR\u0026thinsp;=\u0026thinsp;0.44 95%CI:0.36\u0026ndash;0.55, respectively) or for follow-up treatment (AOR\u0026thinsp;=\u0026thinsp;0.56, 95%CI:0.44\u0026ndash;0.72 and AOR\u0026thinsp;=\u0026thinsp;0.76, 95%CI:0.61\u0026ndash;0.94, respectively). Overall, 58% of children received any follow-up treatment after diagnosis; two-thirds of those received four or more outpatient services. Black children had the lowest receipt of any treatment after diagnosis (AOR\u0026thinsp;=\u0026thinsp;0.80, 95%CI:0.67\u0026ndash;0.96), and, when they did receive outpatient treatment, the lowest completion of at least four visits (AOR\u0026thinsp;=\u0026thinsp;0.62, 95%CI:0.47\u0026ndash;0.81), lowest receipt of any antidepressant (AOR\u0026thinsp;=\u0026thinsp;0.60, 95%CI:0.47\u0026ndash;0.75), and higher rates of ER/inpatient admissions during the six months of the episode (AOR\u0026thinsp;=\u0026thinsp;1.38, 95%CI:1.10\u0026ndash;1.73). Gaps in depression care exist for all children, but these gaps are greater for Black children. These barriers warrant both research and public policy attention.\u003c/p\u003e","manuscriptTitle":"Differential Patterns of Service Use for Depression Among Diverse Medicaid-Insured Children and Youth","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 19:06:31","doi":"10.21203/rs.3.rs-7643217/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c49eb816-8a5e-47ba-81bb-2eae43d6d3ee","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T02:09:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 19:06:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7643217","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7643217","identity":"rs-7643217","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}