Structural Context and Lived Experience as Complementary Indicators of Youth Mental Health Risk.
Abstract
INTRODUCTION Social and structural determinants of health (SDoH), 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 lived experiences of adversity or differentiate mental health risk.
Methods
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 SDoH indicators from the 2023 County Health Rankings were used to identify latent profiles representing distinct structural contexts. Self-reported SDoH included financial instability, food insecurity, poor home conditions, community disorder, barriers to mental health care, discrimination, and adversity. Multivariate regression models examined associations with depression/anxiety symptoms, lifetime suicidal ideation, suicide attempt, and perceived likelihood of living to age 35. Analyses were conducted in 2026.
Results
Seven county-level SDoH profiles characterized distinct structural contexts and showed modest associations with self-reported SDoH and mental health. Self-reported SDoH were more strongly associated with outcomes than county-level context. Inclusion of self-reported SDoH improved model fit for depression/anxiety symptoms (adjusted R²: 0.16 to 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 suicide attempt. County-level profiles showed modest associations that were further attenuated after accounting for self-reported SDoH.
Conclusions
County-level SDoH identify geographic patterns of risk, but youths' lived experiences more strongly differentiate individual vulnerability. Prevention strategies relying 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 identification of youth at risk and inform multilevel mental health prevention planning.