Enhancing the capacity of the Brazilian health system to support the mental health of young people

Mental health problems affect a significant proportion of young people in Brazil, and can have long-lasting negative consequences, leading to poor school achievement, troubled family relationships, difficulties in keeping stable jobs and involvement with crime and drugs. Mental health problems affect more young people in low- and middle-income countries (LAMICs), than in the high-income ones. LAMICs such as Brazil; however, have fewer resources to provide young people with the effective mental health care they need. Additionally, health professionals working in primary care settings, where most people with mental health problems could be treated, often don't have access to proper training and/or technical resources to deliver treatment to young people with mental health problems.

We are developing a research project which aims to enhance the capacity of the Brazilian health system to support the mental health of young people. Our project comprises three activities: in the first activity, we will estimate the number of young people in Brazil who need mental health care through analysis of existing data collected from all five regions in Brazil. We will, then, estimate the economic impact of child and adolescent mental health problems, and how much the country would save by delivering effective treatment for young people with mental health problems, considering that improved mental health should lead to improvement in education achievement and employment prospects, and reduction in the use of drugs and contact with criminal justice.

In the second activity, we will generate evidence on effective and affordable interventions that can be implemented in the Brazilian health system to support young people with mental health problems through a systematic review of existing scientific literature. We will focus our review on interventions for prevention and treatment which have been proven cost-effective in Brazil or similar countries and that are, therefore, suitable for the Brazilian context.

In the third activity, we will use evidence generated through activities one and two to develop a practical toolkit and training material to support health professionals and policymakers to adapt and implement mental health treatment that is suited to the local reality. It will help them estimate how much it will cost to provide these services and what the long term costs and benefits will be.

To ensure that our results will be translated into public health policymaking, and the applicability of our toolkit in different regional contexts, we have assembled a multi-professional team of researchers from the London School of Economics and Political Sciences (LSE), in the UK, and from three Brazilian universities - the State University of Mato Grosso do Sul (UEMS) in the Central-West region, Federal University of Alagoas (UFAL), in the Northeast, and Federal University of Minas Gerais (UFMG), in the Southeast. These three regions (Northeast, Central-West and Southeast) comprise 48% of Brazil's territory and 77% of the country's population. Our research team will work with a Stakeholder Impact Advisory Group (SIAG), which will comprise policymakers from Brazil's five regions and administrative levels (municipality, state and federal), public health practitioners, and representatives from service-user organizations. The SIAG's feedback and advice will be fundamental to the tailoring of our toolkit and training package according to different reginal reality and needs.

One important outcome of our project will be the capacity building of researchers in each university. This will facilitate future research and links between researchers and stakeholder groups after the three-year timeframe of the project we are submitting to the UK Medical Research Council and Brazil's Council of State Research Foundations.

Our research plan proposes to address health system challenges using three main activities. The first will involve generating new evidence through analysis of existing youth mental health service use data collected from all regions of Brazil to estimate the economic impact of youth mental health problems. We will use existing datasets to project regional mental health needs, services and treatments required to meet those needs and associated costs and impacts in the short and long-term. The second part will involve performing a systematic review of existing evidence for effective/cost-effective interventions for prevention and treatment of youth mental health problems. We will identify interventions which have evidence for effectiveness in Brazil or similar countries. The third part will involve synthesising the newly developed evidence from parts one and two into a practical toolkit for health and education professionals and policymakers and planners. The return on investment tool in the toolkit will expand on modelling evidence from work packages 1 and 2 on cost effectiveness. The toolkit will be built using Excel for ease of access and it will compare the costs of delivering interventions with the net potential future health and other resource costs that could be averted as a result of effective treatment or prevention of mental health problems among young people. It could also consider the value of additional positive benefits to society, e.g. increased employment participation. Following consultation with stakeholders, it will also be possible to vary estimates of selected parameters in the tool, for instance on the effectiveness, unit costs, level of uptake /use and future benefits of various interventions. We have previously used this modelling approach to estimate the case for investment and aid local and national policy making for mental health in a UK context. https://www.gov.uk/government/publications/mental-health-services-cost-effective-commissioning

Impact summary

This would be the first study to use population data from Brazil to estimate the long-term economic impacts of a range of mental health problems experienced by children and young people. Through ongoing collaborations we will have access to rich and unique datasets allowing us to make robust estimates on the cost of psychiatric disorders in young people for each region in Brazil from childhood into young adulthood. Our team of researchers have excellent links and experience in using these data and we will work together to generate the research evidence and policy tools needed to support "evidence-based policy-making". This will help us to achieve our overarching objective to "enhance the current limited capacity of the Brazilian health system to prevent psychiatric disorder and treat young people with mental health problems."

Each of the collaborating research centres, in Brazil and in the UK, includes both junior and senior researchers. Training of early career researchers to develop expertise in this field, where there is currently a paucity of researchers, will also help to facilitate continuation of work in this important area. In addition to the toolkit deliverable, development of the methodology and identification of the costs associated with health service use, education, criminal justice, employment benefits for each of the cohort members and synthesising these data with both the national epidemiological dataset and SUS dataset (data on Brazilian public health services) will require a substantial amount of effort. In addition to informing the specific toolkit aims; however, we believe this will lay the groundwork for additional insightful mental health economic and policy research, for example examining the economic impact of other risk factors or for specific population subgroups. Moreover, there will also be broader benefits and learning to other areas of focus in the health system, particularly because of what we know about the high levels of comorbidities between mental and physical health problems. Thus, capacity building in these methods and in using these datasets to apply in future research will be another important outcome of this project.

Our project network will span broadly beyond just academic researchers. Through our network, we will also facilitate partnerships between academics from interdisciplinary background and with strong track records in research on child adolescent mental health, economics and policy research in Brazil and internationally, in addition to policy-makers and healthcare practitioners. Although we will focus on enhancing the capacity of the health system, we will also include relevant stakeholders from the educational system given they represent a key sector which can support identification and referral and potentially delivering interventions to children and adolescents with mental health problems. Thus, establishing more effective links and communication between sectors should support more efficient and effective delivery of mental health care and better outcomes for young people.

On completion, all the tools and research developed as part of this project will be made publicly available. All project research and policy tools will be designed so that they are easy to update and adapt, and they can continue to be useful well after the end of the project, both by the local researchers, policymakers and practitioners involved in this project, but also by other relevant stakeholders. Our findings should also lead to local recommendations which can support strengthening of child and adolescent mental health care across Brazil.