Telemedicine-Based Provision of Adolescent Gender-Affirming Medical Care to Promote Equitable Access.

Purpose: To explore transgender and nonbinary (TNB) young adults' (1) interest in receiving gender-affirming medications through telemedicine before age 18 years and (2) willingness to initiate this care with primary care providers (PCPs). Methods: Data were from a survey of TNB young adults who had not received gender-affirming medications before age 18 years. Chi-square and Wald tests identified demographic differences in telemedicine interest and willingness to initiate medications with their PCP as minors. Results: Among 280 respondents, 82.5% indicated interest in telemedicine and 42.0% were willing to initiate medications with their PCP. Black/African American respondents were more likely to indicate interest in telemedicine than White and multiracial respondents. Respondents from rural areas were more likely to indicate willingness to initiate medications with their PCP than those from urban areas. Conclusions: Telemedicine expansion and further support for PCPs may represent critical opportunities to promote equitable access to adolescent gender-affirming care.

Child Health Needs and the Adolescent Medicine Workforce Supply: 2020-2040.

Adolescent medicine (AM) subspecialists provide primary, subspecialty, and consultative care to adolescents and young adults (AYAs). Given insufficient numbers of AM subspecialists to care for all AYAs, the workforce supports AYAs health care capacity through education, research, advocacy, and the development of policies and programs sensitive to their unique needs. A modeling project funded by the American Board of Pediatrics Foundation was developed to forecast the pediatric subspecialty workforce in the United States from 2020 to 2040 on the basis of current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios, and reports results in headcount and headcount adjusted for percentage of time spent in clinical care, termed "clinical workforce equivalent." For the AM subspecialty, several scenarios were considered that modified the number of fellows and/or clinical time. The baseline model predicted low growth nationally (27% and 13% increase in total AM subspecialists and AM subspecialists per 100 000 children, respectively) and declines in AM workforce relative to population growth in census divisions with existing geographic workforce disparities. In the alternative scenarios, fellow number and clinical time changes did not significantly change predictions relative to the baseline model, but a 12.5% decrease in fellows predicted a 40% reduction in the workforce from baseline with a widening of geographic workforce disparities. On the basis of the expansive clinical and nonclinical roles of AM subspecialists and these forecasted workforce challenges, significant educational, practice, and policy changes will be necessary to bolster the supply of well-trained clinicians addressing the dynamic health care needs of AYAs.

Demographic Differences in Gender Dysphoria Diagnosis and Access to Gender-Affirming Care Among Adolescents.

Purpose: The goal of this article was to identify demographic differences in receipt of gender dysphoria (GD) diagnosis and access to gender-affirming care (GAC) among adolescents whose gender identity and/or pronouns differed from their sex assigned at birth. Methods: Data were from 2444 patients who were 13-17 years old and had a documented gender identity and/or pronouns that differed from their sex assigned at birth in the electronic health record. Adjusted logistic regression models explored associations between demographic characteristics (sex assigned at birth, gender identity, race and ethnicity, language, insurance type, rural status) and presence of GD diagnosis and having accessed GAC. Results: The average predicted probability (Pr) of having received a GD diagnosis was 0.62 (95% confidence interval [CI] = 0.60-0.63) and of having accessed GAC was 0.48 (95% CI = 0.46-0.50). Various significant demographic differences emerged. Notably, Black/African American youth were the least likely to have received a GD diagnosis (Pr = 0.43, 95% CI = 0.33-0.54) and accessed GAC (Pr = 0.32, 95% CI = 0.22-0.43). Although there were no significant differences in GD diagnosis by insurance type, youth using Medicaid, other government insurance, or self-pay/charity care were less likely to have accessed GAC compared with youth using commercial/private insurance. Conclusion: Results indicate significant differences in both receipt of GD diagnosis and accessing GAC by various demographic characteristics, particularly among Black/African American youth. Identification of these differences provides an opportunity to further understand potential barriers and promote more equitable access to GAC among adolescents who desire this care.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. METHODS: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. RESULTS: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. CONCLUSIONS: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Sexual attraction and experiences in the primary care setting: Examining disparities in satisfaction with provider and health self-efficacy.

INTRODUCTION: To test whether sexual minority males and females report lower satisfaction with primary care providers and lower health self-efficacy relative to heterosexual males and females. METHODS: Data from 535 adolescents who participated in one of two randomized clinical trials conducted in a primary care setting were analyzed. Multiple linear regressions controlling for demographic characteristics and treatment condition were used to examine sexual attraction differences in indicators of satisfaction with provider and health self-efficacy. RESULTS: Sexual minority and heterosexual youth both endorsed high satisfaction with providers. Relative to heterosexual males, sexual minority males reported lower self-efficacy in reaching their health goals. Relative to heterosexual females, sexual minority females reported lower confidence in positively impacting their own health, and lower self-efficacy in setting goals and working actively to improve their health. CONCLUSIONS: Sexual minority youth may benefit from additional support from health care providers to enhance their health self-efficacy and reach their health goals.

Hospital-Based Quality Measures for Pediatric Mental Health Care.

BACKGROUND AND OBJECTIVES: Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS: We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS: Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS: These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

The Costs and Cost-effectiveness of Collaborative Care for Adolescents With Depression in Primary Care Settings: A Randomized Clinical Trial.

Importance: Depression is one of the most common adolescent chronic health conditions and can lead to increased health care use. Collaborative care models have been shown to be effective in improving adolescent depressive symptoms, but there are few data on the effect of such a model on costs. Objective: To evaluate the costs and cost-effectiveness of a collaborative care model for treatment of adolescent major depressive disorder in primary care settings. Design, Setting, and Participants: This randomized clinical trial was conducted between April 1, 2010, and April 30, 2013, at 9 primary care clinics in the Group Health system in Washington State. Participants were adolescents (age range, 13-17 years) with depression who participated in the Reaching Out to Adolescents in Distress (ROAD) collaborative care intervention trial. Interventions: A 12-month collaborative care intervention included an initial in-person engagement session, delivery of evidence-based treatments, and regular follow-up by master's level clinicians. Youth in the usual care control condition received depression screening results and could access mental health services and obtain medications through Group Health. Main Outcomes and Measures: Cost outcomes included intervention costs and per capita health plan costs, calculated from the payer perspective using administrative records. The primary effectiveness outcome was the difference in quality-adjusted life-years (QALYs) between groups from baseline to 12 months. The QALYs were calculated using Child Depression Rating Scale-Revised scores measured during the clinical trial. Cost and QALYs were used to calculate an incremental cost-effectiveness ratio. Results: Of those screened, 105 youths met criteria for entry into the study, and 101 were randomized to the intervention (n = 50) and usual care (n = 51) groups. Overall health plan costs were not significantly different between the intervention ($5161; 95% CI, $3564-$7070) and usual care ($5752; 95% CI, $3814-$7952) groups. Intervention delivery cost an additional $1475 (95% CI, $1230-$1695) per person. The intervention group had a mean daily utility value of 0.78 (95% CI, 0.75-0.80) vs 0.73 (95% CI, 0.71-0.76) for the usual care group. The net mean difference in effectiveness was 0.04 (95% CI, 0.02-0.09) QALY at $883 above usual care. The mean incremental cost-effectiveness ratio was $18 239 (95% CI, dominant to $24 408) per QALY gained, with dominant indicating that the intervention resulted in both a net cost savings and a net increase in QALYs. Conclusions and Relevance: Collaborative care for adolescent depression appears to be cost-effective, with 95% CIs far below the strictest willingness-to-pay thresholds. These findings support the use of collaborative care interventions to treat depression among adolescent youth. Trial Registration: clinicaltrials.gov Identifier: NCT01140464.

Association of Adolescent Depressive Symptoms With Health Care Utilization and Payer-Incurred Expenditures.

OBJECTIVE: Screening adolescents for depression is recommended by the US Preventive Services Task Force. We sought to evaluate the impact of positive depression screens in an adolescent population on health care utilization and costs from a payer perspective. METHODS: We conducted depression screening among 13- to 17-year-old adolescents enrolled in a large integrated care system using the 2- and 9-item Patient Health Questionnaires (PHQ). Health care utilization and cost data were obtained from administrative records. Chi-square, Wilcoxon rank sum, and t tests were used to test for statistical differences in outcomes between adolescents on the basis of screening status. RESULTS: Of the 4010 adolescents who completed depression screening, 3707 (92.4%) screened negative (PHQ-2 <2 or PHQ-9 <10), 186 (3.9%) screened positive for mild depression (PHQ-9 10-14), and 95 (2.4%) screened positive for moderate to severe depression (PHQ-9 ≥15). In the 12 months after screening, screen-positive adolescents were more likely than screen-negative adolescents to receive any emergency department visit or inpatient hospitalization, and they had significantly higher utilization of outpatient medical (mean ± SD, 8.3 ± 1.5 vs 3.5 ± 5.1) and mental health (3.8 ± 9.3 vs 0.7 ± 3.5) visits. Total health care system costs for screen-positive adolescents ($5083 ± $10,489) were more than twice as high as those of screen-negative adolescents ($2357 ± $7621). CONCLUSIONS: Adolescent depressive symptoms, even when mild, are associated with increased health care utilization and costs. Only a minority of the increased costs is attributable to mental health care. Implementing depression screening and evidence-based mental health services may help to better control health care costs among screen-positive adolescents.

Common and costly hospitalizations for pediatric mental health disorders.

BACKGROUND AND OBJECTIVES: Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children's hospitals. METHODS: We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids' Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children's hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modification-defined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges). RESULTS: Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children's hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions; $1.33 billion), bipolar disorder (18.1%; $702 million), and psychosis (12.1%; $540 million). CONCLUSIONS: We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.

Trends in the prescription of opioids for adolescents with non-cancer pain.

OBJECTIVES: Opioids are among the most commonly abused drugs among adolescents, and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations. METHODS: We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions and types of medications given, as well as clinical and demographic features of adolescents receiving opioids. RESULTS: In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short-acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition. DISCUSSION: Prescription of opioids among adolescents with NCP is common, and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.

Surveying adolescents enrolled in a regional health care delivery organization: mail and phone follow-up--what works at what cost?

PURPOSE: To describe the differential completion rates and cost of sequential methods for a survey of adolescents enrolled in a regional health care delivery organization. METHODS: Four thousand randomly selected enrollees were invited to complete a mailed health survey. Techniques used to boost response included (1) a follow-up mailing, (2) varying the appearance of the survey, (3) reminder calls, and (4) phone calls to obtain parent and child consent and to administer the survey. We evaluated the outcome and costs of these methods. RESULTS: Seven hundred eighty-three enrollees (20%) completed the first mailed survey and 521 completed the second, increasing the overall response rate to 33%. Completion was significantly higher among respondents who received only the plain survey than those receiving only the color survey (P < .001). Reminder calls boosted response by 8%. Switching to administration of the survey by phone boosted response by 20% to 61%. The cost per completed survey was $29 for the first mailing, $26 after both mailings, $42 for mailings and reminder calls, and $48 for adding phone surveys. CONCLUSION: The response to mailings and reminder calls was low and the cost was high, with decreasing yield at each step, although some low-cost techniques were helpful. Results suggest phone surveys may be most effective among similar samples of adolescents.

Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents.

OBJECTIVE: To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents. METHODS: After completing a brief depression screen, 499 youth (aged 13-17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment. RESULTS: A PHQ-2 score of > or =3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75-0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of > or =3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3. CONCLUSIONS: The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma.

OBJECTIVE: To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone. METHODS: A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs. RESULTS: Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures. CONCLUSIONS: Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

Identifying high-risk asthma with utilization data: a revised HEDIS definition.

OBJECTIVE: To develop a definition of high-risk asthma that more precisely identifies patients needing case management than the 2006 Healthcare Effectiveness Data and Information Set (HEDIS) definition. STUDY DESIGN: Two-year claims-based study, with cross-sectional phone survey data, for a sample of 769 youths (age 11-17 years) with asthma. METHODS: The 2006 HEDIS measure defines high-risk asthma as meeting any of the following criteria: >1 emergency department (ED) visits, > or =1 hospitalizations for asthma, > or =4 asthma medication prescriptions, or > or =4 ambulatory visits for asthma with > or =2 prescriptions for asthma medication in 1 year. We created a revised definition (> or =1 ED visits or > or =1 hospitalizations for asthma or > or =1 oral steroid prescriptions for asthma) and identified patients with high-risk asthma in year 1 according to each definition. We compared the 2 groups on demographic and clinical characteristics, and healthcare utilization and costs in years 1 and 2. RESULTS: The revised definition identified 29% of the sample as having high-risk asthma, whereas the 2006 definition identified 67%. Compared with the 2006 definition, the revised definition identified patients with significantly greater asthma-related physical health problems and higher medical costs in year 1. In year 2, youths classified as high risk by the revised definition made more ED visits and were more likely to use oral steroids than those classified as high risk by the 2006 definition. CONCLUSION: The revised high-risk asthma definition identifies half as many individuals and is better able to identify patients with poorly controlled asthma in the subsequent year.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms.

OBJECTIVE: The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma. METHODS: We conducted a telephone survey of 767 youth with asthma (aged 11-17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity. RESULTS: After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with > or = 1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire. CONCLUSIONS: The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Quality of care for medicaid-covered youth treated with antidepressant therapy.

BACKGROUND: Although antidepressant use has increased in pediatric populations, few studies have addressed the quality of follow-up care or duration of treatment for depressed youth. OBJECTIVE: To evaluate the quality of care for antidepressant-treated youth, using the Health Plan Employer Data and Information Set guidelines (>or=3 visits in the 3 months after a new antidepressant prescription fill and continuation of antidepressant use at 3 and 6 months) as a benchmark. DESIGN: Administrative records were examined for 1205 Medicaid-covered youth (aged 5-18 years) who presented with a "new episode" of depression in 1998. Statistics were generated to describe the number of follow-up visits and duration of treatment within 6 months of first prescription fill. RESULTS: A total of 507 (42.1%) youth with new episodes of depression were treated with antidepressants. Selective serotonin reuptake inhibitors accounted for 80.9% of prescriptions. Twenty-eight percent (28.1%) of youth with an antidepressant fill had 3 or more follow-up visits in the subsequent 3 months; however, an additional 29.2% had no further provider visits. Selective serotonin reuptake inhibitors were continued by 46.6% of treated youth at 3 months and by 26.3% at 6 months. CONCLUSIONS: Many antidepressant-treated youth do not receive adequate follow-up or duration of treatment. Future studies should address reasons for poor follow-up and methods to improve monitoring for these youth.

Depression in Medicaid-covered youth: differences by race and ethnicity.

BACKGROUND: Racial disparities have previously been noted in antidepressant use among Medicaid-covered youth. OBJECTIVE: To determine if racial and ethnic differences are due to dissimilarity in the prevalence of diagnosed depression or disparate treatment patterns. METHODS: Claims were examined for 192 441 youth (5-18 years old) who had been continuously enrolled in Medicaid from July 1, 1997, to December 31, 1998. Diagnosed depression was defined as having been assigned an International Classification of Diseases, Ninth Revision code for a depressive disorder in a medical claim. Logistic regression methods were used to evaluate the association between race/ethnicity and (1) depression diagnosis and (2) depression treatment in the 6 months following a new episode of diagnosed depression. All analyses were controlled for age, sex, and rural or urban residence. RESULTS: Two percent of the total sample had a depression diagnosis, 25% of which were new episodes of depression. Compared with white youth, Hispanic (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.46-0.57), Asian/Pacific Islander (OR, 0.16; 95% CI, 0.12-0.21), and black (OR, 0.31; 95% CI, 0.26-0.37) youth were less likely to have a depression diagnosis. Following a new diagnosis, Native American (OR, 0.29; 95% CI, 0.18-0.46) and Hispanic (OR, 0.42; 95% CI, 0.30-0.61) youth were less likely than white youth to have received an antidepressant or a mental health specialty visit. CONCLUSIONS: Racial and ethnic disparities exist in both the prevalence and treatment of diagnosed depression. Future studies should examine underlying reasons for these disparities and how they affect the quality of care for depressed Medicaid-covered youth.