The prevalence of clinical depression in older teenagers doubled nationally from 2019 to 2022, according to a report that sheds new insights into the youth mental health crisis.
The report from the Blue Cross Blue Shield Association analyzed commercial medical claims data from its member insurers, including Independence Blue Cross, the largest health insurer in the Philadelphia region. It shows the clinical depression rate among commercially insured teens, ages 15-17, rose from 3% to 6% during that stretch.
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"We imagine that there were more kids suffering from depression over that time period," said Dr. K. Ryan Connolly, behavioral health medical director at IBX. "But the other part of it is, more kids are getting diagnosed. So, some of the increase is better diagnosis and some of the increase is more burden of illness."
The clinical depression rate among older teens insured by IBX was 9.7% in 2022, according to IBX claims data. That was higher than the national rate, but the increase among IBX members was not as sharp. It only rose 1.5 times from 2019.
Connolly said there was a decrease in underdiagnosed depression during the COVID-19 pandemic, because more people were seeking treatment.
The rise of telemedicine was "not a thing particularly for young people before the pandemic," he said. "But as everybody sort of pivoted to that, we saw people getting into evaluation and treatment a little bit more easily or more often during that time."
Nationally, the clinical depression rate among adolescents ages 11-14 also increased, but not as sharply. It rose from 1.9% in 2019 to 2.6% in 2022. So, why is the rate higher among older teens?
"That's the age where the pressure really begins to rear its head," Connolly said. "When it does, it's because it is part of the regular mental and neurobehavioral development. We tend to see depression for people that are sensitive to it start in the late adolescent to early 20s range now."
The COVID-19 pandemic also had an effect. One of the biggest triggers for depression in older teens is social stress.
"So, isolation caused by being home, away from school, away from peers, uncertainty about the future, difficulty with school — all the things that we remember pretty well from that period had to contribute to other things, too," Connolly said. "At the same time, there was lots of social unrest. For different demographics, that might have been an issue."
The BCBSA report shows the clinical depression rate of Black and Hispanic youth is 30% lower than white youth, and the rate among Asian and Pacific Islander youth is 50% lower. But these teens aren't less likely to develop depression than their white peers – they're just less likely to get medical attention for it, Connolly said.
"We see fewer people in minority groups are getting diagnosed," Connolly said. "One of the things we've been looking at locally is disparities in depression screening. We've been trying very hard to do things like reimburse providers for depression screening, which is a way that under-resourced providers, family docs and pediatricians in underserved areas can feel more supported in doing a better job of that."
The most socially vulnerable youth are 40% more likely to be diagnosed with clinical depression during a crisis event than the least socially vulnerable youth, the BCBSA report shows. Black youth are 50% more likely to be diagnosed during a crisis than white youth; Hispanic youth are 25% more likely.
"The crisis event means that the first diagnosis was in an emergency room or a crisis center," Connolly said. "The first time they get the diagnosis is when things have gotten so bad they happen in an emergency room — that's what we want to avoid."
IBX has been working to improve access to early diagnosis and treatments to avoid having children diagnosed amid a crisis.
"We're starting to see that our outpatient use of behavioral health services has been growing quite a bit and reassuringly we're seeing less ER and inpatient behavioral health utilization as a result," Connolly said. "The more outpatient treatment you get, the less people have crises."
Telemedicine is a huge part, particularly for socially disadvantaged youth.
The BCBSA report shows, nationwide, primary care physicians account for 41% of initial depression diagnoses among youth. IBX claims data show similar rates, but also an increasing trend of initial diagnoses by behavioral health providers.
Connolly said a huge amount of this diagnosis and behavioral health treatment burden is on primary care doctors, pediatricians and family doctors.
"They're doing a great job, the best they can, but they're really not specialists," Connolly said. "But they're being asked to take care of a specialty issue. What we want to do is figure out ways that we can support them in doing a good job, not feeling burnt out about it and having them feel like they can get good results.
"One of the things we saw on the BCBS report that was a little reassuring was that while diagnosis rates are going up, we do see rates of psychotherapy and medication treatment going up, as well," he added. "So, that means kids are not just getting diagnosed, they're actually getting treatment."
How parents can get help for their kids
What can parents do to help their children? Specifically, how can they recognize when a teenager is experiencing more than the moodiness or sadness typical for the age?
Parents should look for more persistent changes in behavior and physical appearance, Connolly said.
"Changes in sleep or eating usually are a good tip-off that things are going on," he said. "Really big differences in function—grades falling off a cliff, changes in social activity and not seeing friends as much anymore."
Over the last few years, IBX realized that one of the reasons people don't seek mental health treatment, or get evaluated, is that it is too hard to find a provider, Connolly said.
"Waiting six months to get an appointment with someone — and you'd have to take the day off of work — was kind of where we were before," he said. "Now if you call us, we can have a telemedicine appointment within five days with your kids. We'd like to tell parents that treatment and evaluations are a whole lot more available and they're not as hard to do."
