Global Mental Health and Pharmacology: The Case of Attention Deficit and Hyperactivity Disorders in Brazil

Abstract

Global Mental Health (GMH) is the field of study, research, and intervention, which aims at improving access to mental health worldwide. It is based on the global burden of disease research program and on the existence of a large “treatment gap” between the need and availability of mental health services, displaying individual and social costs of undiagnosed and untreated mental disorders, especially in low- and middle-income countries (LMIC). Few academic publications in Brazil dialogue directly with the field of GMH, although several issues drawn from its agenda have been the subject of mental health policies in the country. Brazil can be classified as a middle-income country with a well-structured national health system. This system is oriented toward primary health care, which integrates both community mental health services and the broader health care network. The debate between GMH advocates and critics has unearthed old controversies in psychiatry such as universality or cultural specificity of mental disorders, their expressions, and their relationship with social and economic factors. We intend to examine how these controversies reverberate in the Brazilian mental health scenario, taking as an illustration the debates around Attention Deficit Hyperactivity Disorder (ADHD) in the country. ADHD discussions oppose those who argue that the condition is underdiagnosed and undertreated, and those who claim that there is overdiagnosis and overtreatment and thus, medicalization of childhood. This article presents the current status of the Brazilian mental health literature on ADHD, with emphasis on tensions around diagnosis, prevalence and interventions. Our aim is to highlight how the differential in discourse shapes the debate on ADHD in Brazil and how this may contribute to the GMH agenda. This goal will be undertaken in three steps. First, we will briefly examine studies around GMH and ADHD. Secondly, we address Brazilian studies on this theme, considering the specificities regarding the constitution of the mental health field. Finally, we will examine the debate of treatment gap vs. medicalization in the country in order to underscore the potentials and limitations of each perspective.

A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries

“…In Brazil, for example, which ranked 7th among the major importers of methylphenidate, this medication is no longer included in the Ministry of Health's list of essential medicines and doctors are required to fill a "controlled-drug form" to prescribe it. As a result, in many parts of the country the medication is not easily available in public health services [132].…”

Needs Assessment for behavioral parent training for ADHD in Brazil

“…In Brazil, the most readily available treatment is pharmacotherapy; however, the published research indicates that less than 20% of children with ADHD are prescribed medication for symptom management (Maia et al, 2015). Little information is available regarding access to and use of empirically supported non-pharmacological interventions for ADHD (Ortega & Müller, 2020).…”

“…Strategies include communicating with children in ways to increase behavioral compliance, and when and how to reward children for desired behavior in order to increase the likelihood of it being repeated (Zarakoviti et al, 2021). To the best of our knowledge, access to BPT in Brazil is currently very limited, with the most commonly available non-pharmacological intervention being psychoanalysis, especially in public health services (Ortega & Müller, 2020). It is also unclear whether Brazilian parents would be motivated to take part in BPT if available.…”

Características das prescrições de metilfenidato em ambulatório de neuropediatria

“…O TDAH é a causa mais frequente para prescrição de metilfenidato. No Brasil, das 19,9% das pessoas com o transtorno, 16,2% são tratadas com metilfenidato 27 . Com tal característica, fundamentando-se nos determinantes sociais da saúde, a dificuldade em diagnosticar TDAH gera dúvida se há subdiagnóstico ou excesso de prescrições [27][28][29] .…”

“…No Brasil, das 19,9% das pessoas com o transtorno, 16,2% são tratadas com metilfenidato 27 . Com tal característica, fundamentando-se nos determinantes sociais da saúde, a dificuldade em diagnosticar TDAH gera dúvida se há subdiagnóstico ou excesso de prescrições [27][28][29] . O consumo de metilfenidato em crianças e adolescentes necessita de mais estudos sobre diagnósticos e prevalência de TDAH, bem como sobre a eficácia e repercussões socioeconômicas do metilfenidato 30 .…”