Opportunity and challenge: the situation of child and adolescent mental health in Brazil

EDITORIAL

Opportunity and challenge: the situation of child and adolescent mental health in Brazil

Christian Kieling^I; Myron Belfer^II

^IDepartment of Psychiatry, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

^IIDepartment of Psychiatry, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA

The field of child and adolescent mental health is relatively new among other medical specialties. The growth that the discipline underwent over the last decades, however, has not occurred uniformly across geographical regions. Progress has certainly been made in terms of describing emotional, behavioral and intellectual problems among young people. Diagnostic classifications (ICD-10 and DSM-IV) have proved to be useful constructs for the identification of individuals with mental health problems - although recent discussions in the context of revisions has demonstrated weaknesses in capturing the complexity of disorders and some have suggested more emphasis on dimensional approaches, especially for child and adolescent disorders. The development of interventions to treat children and adolescents with mental disorders has flourished, with psychosocial, psychopharmacological and combined interventions now described for most disorders, but now the challenge is to improve the evidence base for accepted interventions. The more recent adoption of a developmental perspective underscores the need for early identification of at-risk individuals and the design of preventive strategies to reduce the burden of mental disorders not only in childhood and adolescence, but also across the life cycle. The greatest challenge remains that the vast majority of the 2.2 billion children and adolescents across the globe, especially in low- and middle-income countries, cannot access appropriate diagnosis and care.

Mental health problems are now recognized as accounting for a significant proportion of the global burden of disease. Among children and adolescents, a diagnosable mental disorder is present in at least one out of ten individuals,¹ representing a leading cause of health-related burden worldwide: among young people aged 10-24 years, neuropsychiatric disorders account for 45% of disability-adjusted life years.² At the same time, a growing body of evidence has demonstrated that a substantial proportion of psychiatric diagnoses identified in adults have their roots in childhood and adolescence.³ Even though a proportion of mental health problems remit after childhood and adolescence, a large number of individuals will continue to present similar (homotypic continuity) or new (heterotypic continuity) disorders after entering adulthood. In this sense, one can argue that much of the burden imposed by mental, neurological and substance use disorders across the globe is attributable to the incidence early in life of these disorders and to their persistence into adulthood and old age.

This issue of Revista Brasileira de Psiquiatria brings two articles that emphasize the relevance of improving the care for children and adolescents with mental health problems. As part of the World Health Organization - World Mental Health Survey Consortium, the São Paulo Mental Health Survey estimated a lifetime prevalence of 44.8% for individuals above 18 years, providing data with methods comparable to surveys conducted across the globe. The study by Viana and Andrade⁴ not only brings valuable information to the field of adult mental health epidemiology by conducting a survey in the largest metropolitan area in Latin America, but it also confirms the fact that mental disorders start early in life: half of all diagnoses identified in the survey were reported to be already present in childhood and adolescence; one quarter, before 9 years of age. Half of all cases of anxiety disorders reported an age-of-onset prior to 13 years. Impulse control disorders also exhibited a very early onset, with 75% of the individuals reporting an onset earlier than 18 years of age. For mood disorders, 25% of cases started before age 23.

In a special article, Cristiane Paula and colleagues present and discuss the Brazilian scenario of child and adolescent mental health.⁵ The scarcity of services devoted to the promotion of mental health for children and adolescents - especially in the public sector - is evident. Although the creation of Psychosocial Care Centers for Children and Adolescents (CAPSi) was a welcome initiative from the public sector, the reduced number of units across the country and the focus on more severe cases still leaves the vast majority of youth with mental health problems unassisted. The authors also discuss disparities in terms of human resources. It is evident that the 300 child and adolescent psychiatrists in the country (unevenly distributed among geographical regions) will have to collaborate with other professionals trained to deal with child and adolescent mental health problems. Further development of both primary care and specialized (beyond the CAPSi model) services is urgently required. As different levels of care should be able to collaborate, a joint expansion can leverage opportunities of partnership within and outside the health sector. Brazil is in a unique position globally with an unparalleled continuum of service models and policy. The presence of the Guardianship Councils, CAPSi, ESF and NASF provide much of the necessary framework for the expansion of responsive, quality care for children and adolescents with mental disorders. The challenge for Brazil is to find common ground for advocacy and the political will to allocate the needed resources to see that needed services are provided equitably across the country.

References

1. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, Rohde LA, Srinath S, Ulkuer N, Rahman A. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011;378(9801):1515-25.

2. Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V, Coffey C, Sawyer SM, Mathers CD. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet. 2011;377(9783):2093-102.

3. Kessler RC, Angermeyer M, Anthony JC, DE Graaf R, Demyttenaere K, Gasquet I, DE Girolamo G, Gluzman S, Gureje O, Haro JM, Kawakami N, Karam A, Levinson D, Medina Mora ME, Oakley Browne MA, Posada-Villa J, Stein DJ, Adley Tsang CH, Aguilar-Gaxiola S, Alonso J, Lee S, Heeringa S, Pennell BE, Berglund P, Gruber MJ, Petukhova M, Chatterji S, Ustün TB. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry. 2007;6(3):168-76.

4. Viana MC, Andrade L. Lifetime prevalence, age and gender distribution and age of onset of psychiatric disorders in the São Paulo metropolitan area, Brazil: results from the São Paulo Megacity Mental Health Survey. Rev Bras Psiquiatr. 2012;34:[ePub ahead of print].

5. Paula C, Ribeiro E, Wissow L, Lawrence, Bordin I, Evans-Lacko S. How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector. Rev Bras Psiquiatr. 2012;34:[ePub ahead of print].

Publication Dates

• Publication in this collection
  14 Nov 2012
• Date of issue
  Oct 2012