Youth mental health services: the right time for a global reach

Young people have been regarded as a predominantly healthy population group, possibly because of the relatively low prevalence of physical illnesses in this age range. This, however, is in stark contrast with the evidence concerning mental health problems: at no other time point in the lifespan do mental disorders constitute a larger share of disease‐related burden than in the second and third decades. In fact, the early incidence and non‐negligible persistence of these conditions have led experts to describe mental illnesses as “chronic diseases of the young” ¹ .

Despite the epidemiological evidence of early onset, mental disorders are typically detected only at later stages in life. To some extent, this delay is being addressed in recent years through innovative systems of youth mental health care. This set of services and strategies recognizes the needs and opportunities for prevention and clinical care from a developmentally informed perspective. As elegantly reviewed by McGorry et al ² , the case for when to act has been largely addressed in the literature: there are unequivocal benefits of investing in early intervention.

Equally relevant is the question of where action is most urgently required. Youths comprise up to one quarter of the world's population, but the geographical distribution of adolescents and emerging adults is not uniform across the globe. The vast majority of young people live in low‐ and middle‐income countries (LMICs), where they constitute larger proportions of the population in comparison to high‐income countries (HICs). In fact, even if we were able to eradicate 100% of mental disorders among 10 to 24 year‐olds from HICs, this would translate into a decrease of only 15% in the overall global burden of mental disorders in this age range ³ .

There is also the matter of how. Beyond the recognizedly similar needs of youth across the globe, there is an urgent call to enable tailored systems of care for youth mental health, which should move beyond a one‐size‐fits‐all approach to more culturally and locally appropriated services. As a case in point, we here discuss challenges and potential opportunities of putting these strategies into practice in Brazil, a middle‐income country that is home to more than 50 million youths.

Over the past three decades, Brazil has implemented one of the largest universal health care systems in the world. The publicly funded Sistema Único de Saúde (SUS) upscaled service coverage throughout the country, with an emphasis on the expansion of primary care. Despite remaining challenges in terms of disparities and coverage, tremendous progress has been achieved in improving the overall health of the Brazilian population ⁴ .

As a consequence of multiple actions focusing on early childhood, Brazil surpassed the global targets of infant and child mortality reduction, being among the small number of nations to meet Millennium Development Goal 4. Importantly, this has been achieved while decreasing the inequalities among regions in the country. However, a similar advance in regard to the mental health of young people has not been achieved.

Evidence suggests that adolescents in Brazil do not frequently recognize primary care as a source of support for mental health problems, but rather rely on their own or on peer support ⁵ . Since physical health does not usually constitute a reason to have a regular relationship with primary care for the vast majority of young people, services are not typically designed or prepared to engage this age group. The majority of low‐intensity primary care settings lack the resources required to address the developmental needs of young people, focusing mostly on younger children or older individuals. This represents an important challenge in terms of translating high‐quality evidence‐based models from HICs into real‐world practice in LMIC environments.

For individuals with more severe clinical presentations, the SUS has implemented community‐based centres (CAPS) for psychiatric treatment and psychosocial support/rehabilitation ⁶ . Distinct CAPS formats are still organized following a paediatric vs. adult model: paediatric services predominantly address the needs of younger children, while adult services focus on adult needs, without recognition of adolescence and emerging adulthood as relevant developmental periods and usually not addressing the domain of early intervention.

This in fact reflects a further challenge: a difficulty of the public health care system to recognize and articulate the continuum of need – from non‐clinical, community‐ and school‐based up to specialist services. Especially for the low‐intensity end of the spectrum, youth‐focused provision of mental health care could be integrated into youth‐centered initiatives, such as education and welfare programs.

An additional gain of focusing on youth mental health and mental well‐being would be the opportunity to ignite a much needed debate about mental health in the broader community, displaying the importance of this issue beyond the fields of psychiatry and psychology, with the active engagement of youths, families and the wider society. Action should therefore include not only the implementation of developmentally appropriate youth services, but integration with other stakeholders to deal with challenges such as recent actions from the federal government to inhibit discussions on diversity, gender identity, as well as sexual and reproductive health in educational and health care settings.

Across government and society (involving for example the educational system and non‐governmental organizations), advocacy is essential to raise awareness, while structural measures provide material support for change — one noteworthy example being wide‐scale antipoverty actions such as Bolsa Familia, which has operated for several years in Brazil. This conditional cash transfer program has been associated with intersectoral improvements such as increased access to food, education and primary health care, as well as reduction in child mortality and lower suicide rates ⁷ . Recent cash‐transfer strategies implemented in the context of the COVID‐19 crisis may also mitigate the negative impacts of the pandemic, as the proportion of young people not engaged in education, employment or training has been increasing in Brazil over recent years and peaked in late 2020, reaching more than one quarter of this age group ⁸ .

It is somewhat paradoxical that, although the majority of innovative experiences to protect and promote the mental health of young people have been implemented in HICs, the largest contingent of youths live in LMICs. The creation of the SUS in Brazil paved the way for many observable achievements in a relatively short period, attesting that change in such contexts is indeed possible. Furthermore, youth leadership has played a pivotal role in building resilience in disprivileged communities during times of crisis ⁹ .

Now is the time to acknowledge the importance of mental health needs at the point at life in which they are disproportionately burdensome, and to take advantage of many existing initiatives that can support the establishment of local youth support. With the largest cohort of young people in its history, Brazil – as many other LMICs – now faces its biggest window of opportunity to reduce the negative impacts of mental ill‐health and promote the mental wealth of the next generations.