Periods of transition usually generate discomfort and are often turbulent. If that is how it is when one changes jobs or moves to a new city, perhaps it comes as no surprise to expect anything different from adolescence, a phase of intense physical, mental and social changes. At this time in life, one out of every three Brazilian adolescents is already showing signs of some degree of psychological distress, according to the most wide-ranging heath survey ever conducted on the health of young people in Brazil: the Study of Cardiovascular Risks in Adolescents (ERICA) (see report).
The study also used a 12-item questionnaire to assess the occurrence of symptoms of anxiety and depression in 75,000 students from 1,247 public and private schools in 124 cities with more than 100,000 inhabitants. These indications, grouped under the single and comprehensive heading of common mental disorders, were much more frequent in girls than in boys – something already observed in previous studies conducted in Brazil and abroad, but generally involving fewer people and cities.
In the recent survey, on average, 38.4% of girls and 21.6% of boys presented complaints that fit the definition of common mental disorders at the time of the study. Also as expected, the proportion of cases grew as participant age increased: it reached 34.1% among adolescents aged 12-14, and 40.4% among those aged 15-17.
“Other countries have conducted prevalence studies on these groups, but those who work in the field of mental health felt that there was a lack of national data that represented the youth cohort,” says psychiatrist and epidemiologist Claudia de Souza Lopes, a professor at the Institute of Social Medicine of the State University of Rio de Janeiro (UERJ), in charge of the mental health portion of the ERICA. “These data about mental disorders can help guide public policies in health and education,” she says.
Published in February 2016 in the journal Revista de Saúde Pública, the results of the ERICA indicate that, in general, the prevalence of common mental disorders in Brazil showed almost no variation among regions, although there is a significant difference between gender and age group (see table). The rates were particularly high among older adolescents in the North and Central-West regions.
The fact that 30% of the adolescents interviewed presented signs of anxiety and depression raised concern among researchers and other experts, but such data should be interpreted with caution. “The figures revealed in the ERICA could potentially serve as an indicator of psychological distress, but not of mental illness,” explains psychiatrist and epidemiologist Laura Andrade, a professor at the Institute of Psychiatry at the University of São Paulo (IPq-USP).
The purpose of the ERICA was not to make diagnoses or define who has or does not have a psychiatric illness, but rather to identify likely causes of the problem. To this end, the survey used a screening questionnaire that, because it is a more sensitive and less specific tool, can include, among suspected cases, individuals with no mental disorders (false positives). Although it does not allow a diagnosis, screening can indicate early signs of serious disorders that may only later be described fully. “A tool like this indicates which individuals need to be monitored more closely,” adds psychiatrist Wang Yuan Pang, a researcher in Andrade’s group at the Psychiatric Epidemiology Center of the IPq-USP.
Most specialists consulted in this report estimate that a smaller proportion – perhaps one third of the adolescents classified as having common mental disorders, equivalent to 10% of the total – do in fact present some mental health issue that requires medical follow-up and the possible use of medications. The rest could benefit from psychotherapy sessions or even from measures to promote health, such as incentives to engage in sports. Those who think the ERICA numbers are overstated base their belief on the results of previous surveys – which involved fewer participants and used diagnostic tools.
One of them is the 2010-2011 study conducted by researchers from São Paulo, Rio de Janeiro and Rio Grande do Sul in four Brazilian cities that numbered over 50,000 inhabitants and whose development index was similar to the national average – Caeté (MG), Goianira (GO), Itaitinga (CE) and Rio Preto da Eva (AM). Researchers in that survey used a diagnostic questionnaire to assess the mental health of 1,623 children and adolescents between the ages of 6 and 16, and verified that 13.1% of them presented some type of psychiatric disorder at the time of the assessment.
According to that survey and the article published in the journal Revista Brasileira de Psiquiatria in 2015, the most common problems were anxiety disorders marked by excessive fear, dread or apprehension, even when there is no real threat. Researchers in that study also found that one out of every five children that received the diagnosis of a psychiatric problem – and thus a recommendation to pursue medical or psychological treatment – had had access to some mental health specialist, generally a psychologist, during the year that preceded the study.
“The use of diagnostic tools requires more complicated training of interviewers and makes the study very expensive,” explains psychiatrist Isabel Bordin, a professor at the Federal University of São Paulo (Unifesp) and one of the coordinators of the study carried out in the four Brazilian cities. That is why large surveys generally use screening questionnaires.
It has been known for some time that psychiatric disorders, in addition to being chronic and incapacitating, manifest themselves early in life. A study published in 2005 by sociologist Ronald Kessler, an expert in psychiatric epidemiology at Harvard University, showed that half the cases begin before the age of 14, and two-thirds occur by the age of 24.
Genes, environment and hormones
Recently, that finding has helped support the idea, now accepted by both medicine and psychology, that mental disorders are the result of interactions between an individual’s genetic characteristics and the social, economic, cultural and psychological conditions in which he or she lives. Together, they promote the notion that psychiatric disorders arise from changes in brain development.
The transformations that the body goes through once puberty begins can make adolescents more vulnerable to mental disorders. An increase in the production of sex hormones causes the body to mature from the reproductive standpoint and, in some ways, reach peak functioning: reflexes become the fastest they will ever be and memory is sharper than ever. In boys, testosterone increases physical strength and promotes aggressive behaviors, while progesterone causes girls to experience mood swings. It is also in this phase that the brain undergoes a major remodeling: fragile connections between its cells are eliminated and the most robust cells, now strengthened, come to define certain personality traits.
“It is a period of great vulnerability, in which one is more sensitive to environmental stimuli,” says IPq-USP Professor Sandra Scivoletto, psychiatrist who specializes in children and adolescents. The need to interact with friends increases at the same time as one develops the ability to understand the motives behind social relationships. As the so-called social brain matures, adolescents learn that non-verbal signs of communication can reflect emotional state. “Social interactions also become more complex, requiring additional cognitive skills for successful integration with the group,” Scivoletto says. “The need to feel as if they belong to the group and the fear of rejection increases stress, which adds to the stress already caused by the unfamiliar and experimentation, possibly compromising adolescents’ ability to function and characterizing the beginning of a psychiatric disorder.”
What is often manifested in adolescence as a mental health problem, may, at least in part, be a result of events that took place long ago. It is becoming increasingly clear that repeated exposure to maltreatment in the early stages of life increases the risk of developing psychiatric problems. And maltreatment does not necessarily mean extremely intense assaults, such as frequent beatings or sexual abuse. They can be much more subtle occurrences such as neglecting a child’s physical or emotional needs or failing to promote her development. “Just over half of the cases of depression are considered to be the result of abuse during childhood and adolescence,” says psychiatrist Elisa Brietzke, a professor at Unifesp.
The effect of abuse on the brain can be so deep that it alters some of the brain’s structures. In a review article published in 2016 in the Journal of Child Psychology and Psychiatry, neuro-pharmacologist Martin Teicher and psychologist Jacqueline Samson, both researchers at the McLean Hospital in Belmont, Massachusetts, and professors at Harvard University analyzed neuroimaging studies of individuals who have experienced psychiatric problems in recent decades. They concluded that many of the anatomical changes previously attributed to mental disorders may in reality be the result of childhood abuse, a common occurrence all over the world.
Another 2016 review study carried out by researchers at the U.S. Centers for Disease Control and Prevention (CDC) estimate that half of all children and adolescents – nearly one billion people between the ages of 2 and 17 – are victims of violence somewhere in the world. Another group at the CDC had previously concluded that childhood abuse costs the public health system more than do cancer and heart disease. This same team calculated that hypothetical eradication of abuse would prevent half of the cases of depression and two-thirds of the cases of alcoholism, in addition to reducing drug use, domestic violence and the number of suicides.
One piece of good news is that in many cases it is possible to reverse, or at least mitigate the effects of deprivation and abuse. One success story is the Equilibrium Program, a rehabilitation project for abused children and adolescents who once lived on the streets of São Paulo (many of whom were drug abusers), developed by Sandra Scivoletto. In 2007, Scivoletto, in collaboration with her team at USP, non-governmental organizations and the São Paulo city government, set up a multidisciplinary care program – offering medical and psychological care, speech and occupational therapy, psychopedagogical support and social support – at a community athletic center in the city’s downtown area, to help these children and adolescents forge links to the community and improve their self-esteem. Since it began, the program has served just over 600 children and adolescents. Of the 351 young people admitted in the initial stages of the program (58.4% were victims of physical or sexual abuse), two-thirds of them were continuing to participate two years later, and 34% had gone back to living with their families. “The resilience of these children is amazing,” says Scivoletto.
LOPES, C. S. et al. Erica: Prevalence of common mental disorders in Brazilian adolescents. Revista de Saúde Pública. V. 50, p. 1-14s. 2016.
PAULA, C. S. et al. Prevalence of psychiatric disorders among children and adolescents from four Brazilian regions. Revista Brasileira de Psiquiatria. April/June 2015.
TEICHER, M. H. e SAMSON, J. A. Enduring neurobiological effects of childhood abuse and neglect. Journal of Child Psychology and Psychiatry. V. 57 (3), p. 241-66. 2016.
MARQUES, A. et al. Community-based global health program for maltreated children and adolescents in Brazil: The Equilibrium Program. Frontiers in Psychiatry. July 2015.