Behavioral Healthcare Treatment Access Patterns in Adolescents with Substance Use Disorders

Importance: Despite 2 million adolescents (aged 12-17) in the United States having a substance use disorder (SUD), little is known regarding where they seek behavioral healthcare (e.g., mental health treatment, substance use treatment, or both). Adolescents have higher rates of co-occurring major depressive episodes (MDEs) than adults with SUDs, which may increase their use of mental health services. Understanding where adolescents with SUDs enter behavioral treatment is crucial to ensure adequate workforce preparedness to care for them where they seek help.Objective: To determine where adolescents with SUDs, with or without co-occurring MDE, present to behavioral health treatment. Design: This was a secondary data analysis of a cross-sectional nationally representative survey.Setting: The National Survey on Drug Use and Health for adolescents (2022-2023). Data were analyzed between October 2025 and December 2025.Participants: A sample of 24,541 adolescents between the ages of 12-17 from the United States of America. Exposures: Treatment setting, SUD diagnosis, past year substance use, MDE diagnosis, adolescent age, biological sex, race and ethnicity, insurance status, household income, and study year. Main Outcome(s) and Measure(s): Behavioral health treatment setting (i.e., mental health treatment, substance use treatment, both, or none) among adolescents with a SUD. Results: Adolescents with a SUD were significantly more likely to engage in mental health (34.7% [95% CI: 30.9-38.8%]) than SU treatment (18.6% [95% CI: 15.8-21.8%], F1,50=62.2, p<.001). Similarly, adolescents with co-occurring SUD and MDE were significantly more likely to engage in mental health (70.7% [95% CI: 65.6-75.3%]) than SU treatment (21.2% [95% CI: 17.5-25.5%], F1,50=43.7, p<.001). Minoritized adolescents with a SUD (aPR = 0.82 [95% CI: 0.71-0.94], p = .007) were less likely, while female respondents with a SUD (aPR = 1.22 [95% CI: 1.07-1.40], p=.006) were more likely to receive any treatment. Conclusions and Relevance: This study found that adolescents with a SUD were twice as likely, and adolescents with co-occurring SUD and MDE over three times more likely, to engage in mental health compared to substance use treatment. Clinically, these results suggest mental health treatment may serve as a critically important touchpoint to treat adolescents with SUDs.