Structural Correlates of Mental Health Support Access among Sexual Minority Youth of Color during COVID-19

Recovery and Response: Responding to Mental Health Needs That Emerged in the Wake of the COVID-19 Pandemic in Chicago Public Schools

BACKGROUND

The COVID-19 pandemic elevated mental health needs among students. As such, in 2022 Chicago Public Schools (CPS) introduced the Comprehensive Mental Health and Suicide Prevention Policy to deliver mental health awareness and services to all pK-12th grade students. While transitioning back to in-person learning, an evaluation was conducted in the 2022-2023 school year to identify current practices and barriers of delivery, and identify lessons learned to support the policy in schools.

METHODS

Interviews were conducted with 30 staff members who delivered mental health services. Interviews were recorded, transcribed, and thematically coded.

RESULTS

Themes identified in the interview highlighted barriers to providing mental health supports included: 1) overwhelming number of mental health cases with limited time and capacity; 2) mental health stigma among families and staff, and 3) the lack of diversity representation among mental health professionals in schools and the communities. Implications for School Health Policy, Practice, and Equity: CPS prioritized and elevated awareness of resources, training sessions and policies guidance through toolkits, newsletters, mandated trainings, and communication about new state mental health laws.

CONCLUSIONS

The pandemic disrupted mental health services and illuminated critical barriers to access. CPS' Office of Student Health and Wellness used these findings to provide additional training and technical assistance for staff, families, and the community.

"My family won't let me." Adolescent-reported barriers to accessing mental health care

Depression is the leading cause of disability among adolescents. Fewer than 50% of youth with depression access mental healthcare services. Leveraging a mixed-methods approach, this pre-registered study characterized youths' self-reported barriers to accessing mental healthcare in a socio-demographically diverse sample of 123 United States adolescents (ages 13-16, identifying as Asian (n = 19), Hispanic (n = 23), Black (n = 7), White (n = 65), or other race (n = 9); man (n = 9), woman (n = 58), or gender minority (n = 56); heterosexual (n = 19) or sexual orientation minority (n = 104)). All participants were experiencing elevated depression symptoms (Patient Health Questionnaire-2 score of ≥2) and endorsed wanting mental health support but being unable to access it. We asked participants an open-ended question gauging perceived barriers to accessing care ("what has kept you from getting support when you wanted it?"), and a binary item gauging perceived current need for mental health support ("right now, do you feel that you need support for emotional or mental health problems?"). Via thematic analysis of responses to the perceived barriers question, we identified a total of 13 categories of barriers. Across all participants, 42.48% (n = 52) endorsed family-related barriers and 31.71% (n = 39) endorsed financerelated concerns. We conducted Chi-square analyses, examining rates of endorsing specific barriers as a function of (a) perceived current support need and (b) demographic variables (e.g. race/ethnicity, gender). In the current study, all adolescents endorsed similar categories of treatment access barriers, regardless of race/ethnicity, gender, sexual orientation, and level of depression. Implications for increasing mental healthcare access for adolescents with elevated depression symptoms are discussed.

COVID-19 Stress and Coping Among Black Youth: The Role of Socio-Emotional Community Mentor Support

This study examined associations between COVID-19 stress and the utilization of engaged and disengaged coping responses among diverse Black youth during the COVID-19 pandemic. In addition, the role of mentor social-emotional support was tested as a moderator of these associations. Participants were 1232 youth ages 11 to 18 year old from the United States who identified as Black/African American. Analyses indicated that COVID-19 stress was positively associated with both engaged and disengaged coping. Results also showed a significant interaction between COVID-19 stress and mentor social-emotional support in the prediction of engaged coping, such that COVID-19 stress positively predicted engaged coping more pronouncedly at lower levels of mentor support than at higher levels of mentor support. Similarly, there was also a significant interaction between COVID-19 stress and mentor social-emotional support in predicting disengaged coping, such that at low levels of mentor support, COVID-19 stress was marginally associated with disengaged coping. At high levels of mentor support, COVID-19 stress was no longer significantly associated with disengaged coping. The current study highlights that the social-emotional support of mentors can attend to the psychosocial strengths of Black youth even in the face of concurrent, ongoing stressors.

Structural Stigma, Racism, and Sexism Studies on Substance Use and Mental Health: A Review of Measures and Designs

PURPOSE

Most research on the structural determinants of substance use and mental health has centered around widely studied factors such as alcohol taxes, tobacco control policies, essential/precursor chemical regulations, neighborhood/city characteristics, and immigration policies. Other structural determinants exist, however, many of which are being identified in the emerging fields of structural stigma, structural racism, and structural sexism. This narrative review surveys the measures and designs used in substance use and mental health studies from these three fields.

SEARCH METHODS

The PubMed, PsycINFO, and Scopus databases were searched on May 11, 2023. A focused search approach used terminology for structural racism, stigma, or sexism combined with terminology for substance use or mental health. Peer-reviewed studies were included if they were written in English and assessed associations between objective structural measures and substance use and mental health outcomes.

SEARCH RESULTS

Of 2,536 studies identified, 2,487 were excluded. Forty-nine studies (30 related to stigma, 16 related to racism, and three related to sexism) met the inclusion criteria. Information was abstracted about the structural measures, outcome measures, research design, sample, and findings of each study.

DISCUSSION AND CONCLUSIONS

The structural determinant measures used in the studies reviewed were diverse. They addressed, for example, community opinions, the gender of legislators, economic vulnerability, financial loan discrimination, college policies, law enforcement, historical trauma, and legislative protections for sexual and gender minorities and for reproductive rights. Most of the structural determinant measures were constructed by combining multiple indicators into indexes or by merging indexes into composite indexes, although some studies relied on single indicators alone. The substance use and mental health outcome measures most frequently examined were related to alcohol and depression, respectively. The studies were conducted in numerous nations and drew samples from an array of groups, including, for example, patients who experienced overdoses from substance use, sexual and gender minorities, racial and ethnic minority groups, women, youth, migrants, and patients subject to involuntary psychiatric hospitalization. Most of the studies used passive-observational (correlational) research designs and, as a result, did not assess whether their structural determinant variables were causally related to substance use and mental health. Nevertheless, the studies reviewed can be used by public health proponents to foster awareness that a wide range of structural determinants correlate with the substance use and mental health of many groups within and across nations.

Transgender-Specific Adolescent Mental Health Provider Availability is Substantially Lower in States with More Restrictive Policies

OBJECTIVE

Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states - especially at the macro-social level - have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states' transgender-specific policy climate.

METHOD

We quantified states' policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states' transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers - identified via Psychology Today - per transgender adolescent in all 50 states and the District of Columbia.

RESULTS

Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio = 0.65, 95% CI [0.52, 0.81], p = .00017), controlling for state-level conservatism, religiosity, and urbanicity. States' transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity.

CONCLUSIONS

Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.

Anti-racism, Heterosexism, and Transphobia: Strategies for Adolescent Health Promotion Post-Coronavirus Disease 2019

Anti-Black racism, heterosexism, and transphobia are significant public health concerns contributing to poor adolescent health outcomes. The authors introduce the health-equity adapted STYLE framework to increase knowledge and awareness of Black and lesbian, gay, bisexual, transgender, non-binary, queer, questioning, asexual, or intersex (LGBTQ) + intersectionality. Guided by case examples, the authors identify key strategies to promote anti-racist, anti-heterosexist, and anti-transphobic practices. Utilization of this framework by adolescent health providers could promote the health and well-being of Black and LGBTQ + adolescents.

Identifying disparities in mental illness and well-being across no-risk, risk, and intersectional groups during the Covid-19 pandemic and the role of sociodemographics in mental health outcomes

OBJECTIVE

Few pandemic studies have explored positive aspects of mental health employing an intersectional perspective. Our intersectional investigation aimed to identify mental illness and well-being differences between groups identified as psychologically vulnerable during the pandemic by the World Health Organization (immigrants, minorities, and people with psychiatric diagnoses) and people without pre-existing risk factors while controlling for sociodemographic variables.

METHODS

This cross-sectional survey included 1,134 participants (76.1% women) aged 18 to 76 years. We used the Depression, Anxiety, and Stress Scales to assess mental disorders and the Satisfaction with Life Scale and the Positive and Negative Affect Schedules to assess well-being.

RESULTS

Through a variable-centered approach, multivariate analysis revealed significant mental health differences between the groups: depression (F2.1131 = 72.7, p < 0.001), anxiety (F2.1131 = 78.0, p < 0.001), stress (F2.1131 = 85.9, p < 0.001), and subjective well-being (F2.1131 = 53.6, p < 0.001). The groups also differed when a person-centered approach was used to analyze the variables jointly through latent profile analysis. We identified six mental profiles consisting of different levels of depression, anxiety, stress, and well-being. The risk and intersectional groups were more likely to be characterized by the generalized suffering (ORrisk = 0.85, ORintersec = 0.93) and profound anguish (ORrisk&intersec = 0.97) profiles. After controlling for demographic variables, mental health disparities were partially attributed to participant risk conditions.

CONCLUSIONS

Based on our results, we emphasize the urgent need for public health policies that consider the specificities and vulnerabilities of minority and risk groups.

Introduction: Student Experiences of COVID-19 Around the Globe: Insights from the Pandemic Journaling Project

The COVID-19 crisis has taken a significant toll on the mental health of many students around the globe. In addition to the traumatic effects of loss of life and livelihood within students' families, students have faced other challenges, including disruptions to learning and work; decreased access to health care services; emotional struggles associated with loneliness and social isolation; and difficulties exercising essential rights, such as rights to civic engagement, housing, and protection from violence. Such disruptions negatively impact students' developmental, emotional, and behavioral health and wellbeing and also become overlaid upon existing inequities to generate intersectional effects. With these findings in mind, this special issue investigates how COVID-19 has affected the mental health and wellbeing of high school and college students in diverse locations around the world, including the United States, Mexico, Brazil, China, and South Africa. The contributions collected here analyze data collected through the Pandemic Journaling Project, a combined research study and online journaling platform that ran on a weekly basis from May 2020 through May 2022, along with complementary projects and using additional research methods, such as semi-structured interviews and autobiographical writing by students. The collection offers a nuanced, comparative window onto the diverse struggles that students and educators experienced at the height of the pandemic and considers potential solutions for addressing the long-term impacts of COVID-19. It also suggests a potential role for journaling in promoting mental wellbeing among youth, particularly in the Global South.

Structural transphobia is associated with psychological distress and suicidality in a large national sample of transgender adults

PURPOSE

Transgender adults face increasingly discriminatory laws/policies and prejudicial attitudes in many regions of the United States (US), yet research has neither quantified state-level transphobia using indicators of both, nor considered their collective association with transgender adults' psychological wellbeing, hindering the identification of this potential social determinant of transgender mental health inequity.

METHODS

We therefore used factor analysis to develop a more comprehensive structural transphobia measure encompassing 29 indicators of transphobic laws/policies and attitudes at the state level, which we linked to individual-level mental health data from a large national sample of 27,279 transgender adults (ages 18-100) residing in 45 US states and the District of Columbia (DC).

RESULTS

Controlling for individual- (i.e., demographics), interpersonal- (i.e., perceived discrimination), and state- (i.e., income inequality, religiosity) level covariates, transgender adults from US states with higher (vs. lower) levels of structural transphobia reported more severe past-month psychological distress and were more likely to endorse past-year and lifetime suicidal thoughts, plans, and attempts.

CONCLUSION

Findings provide novel evidence that state-level transphobic laws/policies and attitudes collectively shape a range of important mental health outcomes among transgender adults in the US. Multilevel intervention strategies, such as affirming mental health treatments, provider-training interventions, and supportive legislation, are needed to address structural transphobia's multifaceted nature and negative mental health consequences.

Crisis as Opportunity, Risk, or Turmoil: Qualitative Study of Youth Narratives About the COVID-19 Pandemic

PURPOSE

The present study employed a narrative approach in order to explore how young people constructed meanings regarding their sense of self in the context of COVID-19 experiences. Adolescents have been identified as a particularly vulnerable group, as the developmental challenges they face are superimposed and amplified by the accidental crisis caused by the pandemic.

METHODS

An in-depth narrative analysis was conducted on written accounts of 13 females aged 17-23 years from Serbia. We selected these narratives from a larger sample of 70 responses (M = 20.1; SD = 2.9; 85.7% female) collected via an online form. We used reflexive thematic analysis as a tool for the selection process of the narratives subjected to in-depth narrative analysis.

RESULTS

Young people told stories that differ significantly in coherence, affective tone, personal agency, and depth of self-exploration. Narrative analysis of the selected accounts identified three distinct types of stories: (1) crisis as an opportunity for personal growth, (2) crisis as a risk for the sense of self, and (3) crisis as inner turmoil.

DISCUSSION

Narrative analysis enabled us to recognize three distinct processes of youth meaning-making related to the sense of self in times of crisis, all reflecting a significant impact on their core developmental task. Personal narratives served different functions; for some, the pandemic was framed as a challenge one could grow from, while others were left devastated or overwhelmed. Narrative coherence reflected youths' capacities for integrating experiences not necessarily connected to their psychological well-being.

Internalizing the COVID-19 pandemic: Gendered differences in youth mental health

We review research on gendered patterns of internalizing behaviors in adolescents and emerging adults during the COVID-19 pandemic. We find that young women reported worse mental health than young men. Transgender and gender-diverse (TGD) youth are underrepresented in mental health research but often report the highest internalizing disorders of any gender group. Finally, we use intersectionality as a lens to acknowledge how gender and other social identities (e.g., race, socioeconomic position) impact mental health. Overall, this review points to gender as a meaningful social construct that is relevant for understanding young people's internalizing symptoms during the pandemic. We call attention to the structural factors underlying gender disparities and the need for intersectionality-informed approaches to work towards mental health equity.

A longitudinal investigation of the effects of the COVID-19 pandemic on 2SLGBTQ+ youth experiencing homelessness

INTRODUCTION

The objective of this study was to examine the impacts of the coronavirus 2019 (COVID-19) pandemic on various dimensions of wellbeing among 2SLGBTQ+ youth experiencing homelessness over a 12-month period during the COVID-19 pandemic.

METHODS

2SLGBTQ+ youth (recruited using a convenience sampling method) participated in three online surveys to assess mental health (depression, anxiety, suicidality), substance and alcohol use, health care access, and violence for 12-months between 2021-2022. Quantitative data analysis included non-parametric one-sample proportion tests, paired t-test and McNemar's test. Longitudinal data collected across all three timepoints were treated as paired data and compared to baseline data using non-parametric exact multinomial tests, and if significant, followed by pairwise post-hoc exact binomial tests. For the purposes of analysis, participants were grouped according to their baseline survey based on pandemic waves and public health restrictions.

RESULTS

2SLGBTQ+ youth experiencing homelessness (n = 87) reported high rates of mental health challenges, including anxiety and depression, over 12-months during the pandemic. Youth participants reported experiencing poor mental health during the early waves of the pandemic, with improvements to their mental health throughout the pandemic; however, results were not statistically significant. Likewise, participants experienced reduced access to mental health care during the early waves of the pandemic but mental health care access increased for youth throughout the pandemic.

CONCLUSION

Study results showed high rates of mental health issues among 2SLGBTQ+ youth, but reduced access to mental health care, due to the COVID-19 pandemic. Findings highlight the need for 2SLGBTQ+ inclusive and affirming mental health care and services to address social and mental health issues that have been exacerbated by the pandemic.

Associations between the Self-Reported Likelihood of Receiving the COVID-19 Vaccine, Likelihood of Contracting COVID-19, Discrimination, and Anxiety/Depression by Sexual Orientation

There is limited evolving literature on COVID-19 vaccine uptake and its barriers among sexual minority populations (lesbian, gay, bisexual, transgender, and queer [LGBTQ]), despite their increased COVID-19 risk factors. We assessed the differences in intention to receive the COVID-19 vaccine by self-reported likelihood of contracting COVID-19, anxiety/depression, discrimination frequency, social distancing stress, and sociodemographic factors across sexual orientation. An online national cross-sectional survey was conducted in the United States between 13 May 2021, and 9 January 2022, among adults aged ≥18 (n = 5404). Sexual minority individuals had a lower intention of receiving the COVID-19 vaccine (65.62%) than heterosexual individuals (67.56%). Disaggregation by sexual orientation, however, showed that gay participants had a higher intention of COVID-19 vaccination (80.41%) and lesbian (62.63%), bisexual (64.08%), and non-heterosexual, non-LGB sexual minority (56.34%) respondents had lower intentions of receiving the COVID-19 vaccine than heterosexual respondents. Sexual orientation significantly moderated the association between the perceived likelihood of receiving the COVID-19 vaccine and the self-reported likelihood of contracting COVID-19, anxiety/depression symptoms, and discrimination. Our findings further underline the importance of improving vaccination efforts and access among sexual minority individuals and other vulnerable groups.

A protocol for applying health equity-informed implementation science models and frameworks to adapt a sleep intervention for adolescents at risk for suicidal thoughts and behaviors

Background

Effective and equitable strategies to prevent youth suicidal thoughts and behaviors (STB) are an urgent public health priority. Adolescent sleep disturbances are robustly linked to STB but are rarely addressed in preventive interventions or among Black and/or Hispanic/Latinx youth for whom STB risk is increasing disproportionately. This paper describes an application of health equity-informed implementation science models and frameworks to adapt and evaluate the evidence-based Transdiagnostic Sleep and Circadian (TSC) intervention for primary care implementation with adolescents of minoritized backgrounds with depression and STB risk.

Methods

This multiphase study protocol uses the Assessment, Decision, Adaptation, Production, Topical Experts-Integration, Training, Testing (ADAPT-ITT) model to adapt and evaluate TSC for primary care implementation with adolescents who are depressed, at risk for STB, and of primarily Black and/or Hispanic/Latinx backgrounds. We integrate the Consolidated Framework for Implementation Research (CFIR) in an initial qualitative inquiry of adolescent, caregiver, and clinician perceptions of TSC. Subsequent ADAPT-ITT phases include systematically and iteratively testing adaptations based on the qualitative inquiry, with ongoing key informant input, and then evaluating the adapted TSC for feasibility, acceptability, and efficacy in a pilot randomized trial.

Anticipated results

Based on youth depression and sleep health disparities research, we expect that TSC adaptations will be needed to enhance intervention content for adolescents with depression, STB risk, and primarily Black and/or Hispanic/Latinx backgrounds. We also anticipate adaptations will be needed to align TSC delivery methods with primary care implementation.

Conclusions

Adapting evidence-based interventions with end-users and contexts in mind can help ensure that intervention strategies and delivery methods are acceptable to, and feasible with, health disparate populations. Although TSC has shown effectiveness for adolescents with sleep disturbances, we expect that additional multiphase research is necessary to optimize TSC for primary care delivery with Black and/or Hispanic/Latinx adolescents with depression and STB risk.

Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis

BACKGROUND

Research indicates that tailored programming for sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, queer) people, compared to non-tailored programming, is effective for reducing the disproportionate health burden SGM people experience relative to the general population. However, the availability of SGM-tailored programming is often over-reported and inconsistent across behavioral health (i.e., substance use and mental health) facilities in the United States (U.S.).

METHODS

Using panel analysis, the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Mental Health Services Survey (N-MHSS), this study examines structural stigma and government funding as two structural determinants affecting the availability of SGM-tailored programming in the U.S.

RESULTS

Results indicated that from 2010 to 2020, reductions in structural stigma (i.e., increases in state-level supportive SGM policies) were positively associated with increases in the proportion of substance use treatment facilities offering SGM-tailored programming. This effect was significant after controlling for over-reporting of SGM-tailored programming and time- and state-specific heterogeneity. On average, the effect of reduced structural stigma resulted in approximately two new SGM-tailored programs in the short term and about 31 new SGM-tailored programs in the long term across U.S. substance use treatment facilities. Structural stigma did not predict the availability of SGM-tailored programming in mental health treatment facilities. Government funding was not significant in either data set. However, without correcting for over-reporting, government funding became a significant predictor of the availability of SGM-tailored programming at substance use treatment facilities.

CONCLUSIONS

Because SGM-tailored programming facilitates access to healthcare and the current study found longitudinal associations between structural stigma and the availability of SGM-tailored programming in substance use treatment facilities, our findings support claims that reducing structural stigma increases access to behavioral health treatment specifically and healthcare generally among SGM people. This study's findings also indicate the importance of correcting for over-reporting of SGM-tailored programming, raising concerns about how respondents perceive the N-SSATS and N-MHSS questions about SGM-tailored programming. Implications for future research using the N-SSATS and N-MHSS data and for public health policy are discussed.

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

COVID-19 and Youth Psychopathological Distress in Umbria, Central Italy: A 2-Year Observational Study in a Real-World Setting

INTRODUCTION

Adolescents and young adults represent a vulnerable population in the context of the Coronavirus disease 2019 (COVID-19) pandemic. The present retrospective study aims to investigate the pandemic's psychological impact on adolescents and young adults by analyzing data from an outpatient mental health service dedicated to youths in Umbria, central Italy.

MATERIALS AND METHODS

The clinical charts of subjects aged 14-24 who first accessed the service in the timeframe between March 1st, 2019, and February 28th, 2021, were reviewed. Subjects were divided into two subgroups according to the period of time when they accessed the service (pre-COVID-19 vs. during- COVID-19 outbreak). Bivariate analyses were performed using the Chi-square test and the Welch's t-test. A secondary analysis was performed considering only subjects suffering from psychiatric disorders. Furthermore, data concerning individuals who were already followed by the service before the pandemic were analyzed by the McNemar's test and the t-paired test to assess changes in treatment features.

RESULTS

The number of new accesses during the pandemic period remained stable. After the emergency onset, youths accessing the service showed a higher prevalence of anxiety disorders (p = 0.022). During the COVID-19 period, services were more frequently delivered by using a digital mental health approach (p = 0.001). Psychopharmacological treatment was more frequently prescribed among subjects that were referred to the service after the pandemic onset (p = 0.033). As for substance use, a highly significant reduction in opioid use was observed (p = 0.003). Family therapy was delivered less frequently in the during-COVID-19 subgroup, especially in the subpopulation of subjects suffering from psychiatric disorders (p = 0.013). When considering subjects referred to the service in the pre-COVID-19 period, the number of interventions provided to this population increased after the pandemic outbreak (p = 0.038).

CONCLUSION

In the context of the COVID-19-related public health crisis, youths represent an at-risk population for which pathways to care should be reinforced, and targeted interventions, including psychosocial treatments, should be implemented.