Structural Context and Lived Experience as Complementary Indicators of Youth Mental Health Risk

Social determinants of health, including youths' lived experiences, shape exposure to stressors and access to resources associated with youth mental health and suicide risk. Although county-level indicators are commonly used to guide prevention efforts, it remains unclear how well they capture the lived experiences of adversity or differentiate mental health risk.

Data are from Project Lift Up, a national survey of adolescents and young adults aged 13-22 years (N=4,800 with residential ZIP code data) collected between 2022 and 2023. County-level social determinants of health indicators from the 2023 County Health Rankings were used to identify latent profiles representing distinct structural contexts. Self-reported social determinants of health included financial instability, food insecurity, poor home conditions, community disorder, barriers to mental health care, discrimination, and adversity. Multivariate regression models examined associations between social determinants of health and depression/anxiety symptoms, lifetime suicidal ideation, lifetime suicide attempt, and perceived likelihood of living to age 35 years. Analyses were conducted in 2026.

Seven county-level social determinants of health profiles characterized distinct structural contexts and showed modest associations with self-reported social determinants of health and mental health. Self-reported social determinants of health were more strongly associated with outcomes than county-level context. The inclusion of self-reported social determinants of health improved model fit for depression/anxiety symptoms (adjusted R²: 0.16-0.42). Food insecurity, discrimination, adversity, and community disorder were consistently associated with higher depression/anxiety symptoms and greater odds of suicide attempt. Mental health care barriers were strongly associated with depression/anxiety and suicidal ideation but not with suicide attempt. County-level profiles showed modest associations that were further attenuated after accounting for self-reported social determinants of health.

County-level social determinants of health identify geographic patterns of risk, but youths' lived experiences more strongly differentiate individual vulnerability. Prevention strategies that rely solely on county-level structural indicators may miss high-risk youth, even in relatively advantaged areas. Integrating geographic targeting with screening for social adversity may improve the identification of youth at risk and inform multilevel mental health prevention planning.