Health Care Setting and Minimally Adequate Depression Treatment Among Publicly Insured Children

The prevalence of depression among children and adolescents has increased, yet many do not receive adequate treatment. The rise of telemental health care highlights the need to examine how delivery setting changes are associated with depression care.

To estimate the association between service delivery setting (telehealth vs clinic-only care) and the receipt of mental health treatment among publicly insured children and adolescents with depression.

This cross-sectional study of publicly insured children and adolescents (ages 3-17 years) with an index depression diagnosis used multistate claims data from 41 states and Washington, District of Columbia, to examine the association between health service setting and minimally adequate depression care in 2016 to 2019 (before COVID-19) and 2020. Data were analyzed from June 14, 2022, to March 15, 2024.

Mental health service setting categories included most mental health services via telehealth (>50%), some mental health services via telehealth (≤50%), any in-home visits (no telehealth), any in-school visits (no telehealth or in-home visits), and clinic-only visits (reference group).

Outcomes of interest were dichotomous measures of at least 4 mental health visits within 12 weeks of index diagnosis, minimally adequate pharmacotherapy (≥84 days of antidepressant medication fills within 144 days of index diagnosis), and minimally adequate treatment (≥4 visits or minimally adequate pharmacotherapy). Multiple logistic regressions controlled for individual- and contextual-level covariates, state, and year of index diagnosis (2016-2019 vs 2020).

Among 799 452 publicly insured children with an index depression diagnosis from 2016 to 2020, most were aged 12 to 17 years (640 738 [80.1%]) and female (469 014 [58.7%]). The percentage with any telemental health visit increased from 4.5% before the COVID-19 pandemic to 49.8% in 2020, while clinic-only care declined from 76.8% before COVID-19 to 43.1% in 2020. In 2020, children receiving some or most mental health services via telehealth were more likely to receive minimally adequate depression treatment than those receiving clinic-only services (some telehealth: 50.9%; mostly telehealth: 54.5%; clinic-only: 32.1%; P < .001 for both comparisons). Differences remained significant in regressions (some telehealth: marginal effect [ME], 16.1 [95% CI, 14.6-17.6] percentage points; mostly telehealth: ME, 19.8 [95% CI, 18.2-21.5] percentage points).

In this cross-sectional study of publicly insured children and adolescents, receipt of telemental health services in 2020 was positively associated with minimally adequate depression care. These findings underscore the importance of continued telemental health coverage use by state Medicaid programs and Children's Health Insurance Programs to facilitate access and minimize barriers to mental health care.