The Dual Burden of Depression Severity and Barriers to Care: Findings From the 2019–2023 National Health Interview Survey

Abstract Low-income adults experience a disproportionate burden of depression and greater need for mental health services, yet face disparities in access to timely and adequate care. This cross-sectional study analyzed 2019–2023 National Health Interview Survey data among low-income adults with household income < 200% of the federal poverty level (N = 16,406; weighted to 140,227,433). Depressive symptom severity was classified using the Patient Health Questionnaire − 8 as none/minimal (reference group), mild, moderate, or severe. Survey-weighted logistic regression models estimated adjusted odds ratios (aORs) for financial and non-financial barriers to care, adjusting for demographic characteristics, anxiety, and other comorbid health conditions. Approximately one quarter of low-income adults reported depressive symptoms, including 16.5% with mild, 6.7% with moderate, and 5.2% with severe symptoms. Greater depressive symptom severity was associated with progressively greater barriers to care. Compared with the reference group, those with severe symptoms had substantially higher odds of needing but being unable to afford mental health services (aOR, 16.66 [95% CI, 12.70–21.86]) and experiencing cost-related delays in mental healthcare (aOR, 16.13 [95% CI, 12.18–21.37]). Similar patterns were observed for non-financial barriers, particularly limited provider availability (aOR, 8.65 [95% CI, 6.06–12.33]) and lack of transportation (aOR, 5.24 [95% CI, 3.76–7.32]). Overall, these findings suggest a “dual burden” wherein low-income adults with the greatest depressive symptom severity, who may also have the greatest need for treatment, experience greater financial and non-financial barriers to accessing care. Addressing these barriers will require multifaceted interventions, including expanding insurance coverage, provider networks, transportation access, and mental health treatment infrastructure.