Multiple marginalized identities: Multilevel analysis of COVID-19 impacts on youth mental and behavioral health

Objective: The COVID-19 pandemic exacerbated youth mental and behavioral health challenges in the United States, disproportionately impacting minoritized groups. Few studies examine how intersecting social determinants jointly shape these outcomes, particularly in underserved regions. This study applied an intersectional framework to assess pandemic-related changes and identify highest-risk strata. Methods: We applied a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy model to emergency department data (2010–2022) to estimate pre- and post-pandemic prevalence of depression, anxiety, self-harm, and attention-deficit/hyperactivity disorder among youth (ages 5–26) in western North Carolina (WNC) (n = 934,938) and statewide (n = 11,973,484). Intersectional strata were defined by COVID-19 period, sex, race/ethnicity, insurance type, and age. Predicted prevalence identified highest-risk strata for each outcome and region. Results: Lowest-risk strata were consistently pre-COVID, elementary-aged children with self-pay insurance, often male and from minoritized racial/ethnic groups. Highest-risk strata for depression and anxiety were post-COVID, young adult females with insurance across multiple racial/ethnic groups, with prevalence up to 11.9% (depression) and 12.9% (anxiety) in WNC. For self-harm, post-COVID adolescent females with insurance had the highest risk, with slightly higher prevalence in WNC (1.5%) than NC (1.4%). ADHD showed distinct patterns, with highest prevalence among male adolescents with Medicaid (7.1% in WNC, 11.4% statewide). Conclusions: Intersectional analysis revealed both shared and region-specific disparities. WNC showed higher top-risk prevalence for depression, anxiety, and self-harm, while statewide strata showed higher ADHD risk. Findings support regionally tailored prevention strategies, including rural workforce expansion, culturally responsive care, and standardized diagnostic practices.