Rebecka Persson

Background
Adolescent mental health has declined internationally, prompting increased investment in school-based services. However, whether such investments benefit all students equally remains unclear. We examined whether municipal spending on school mental health services is differentially associated with dual-factor mental health profiles, which distinguish psychiatric symptoms from subjective well-being, among Swedish adolescents.

Methods
Data were drawn from Stockholmsenkäten (the Stockholm Survey), a biennial population-based survey of 9th-grade students (approximately 15 years) in Region Stockholm, Sweden. The analytic sample comprised 63 190 students across 26 municipalities surveyed between 2006 and 2024. Latent profile analysis identified four mental health profiles based on psychiatric symptoms and school well-being: Complete Mental Health, Troubled (high symptoms, low well-being), Vulnerable (low symptoms, low well-being), and Symptomatic but Content (high symptoms, adequate well-being). Municipal spending on school health services (per student, lagged two years) was decomposed into within-municipality (year-to-year change) and between-municipality (stable differences) components. Multilevel multinomial logistic regression estimated associations between spending and profile membership, controlling for gender and secular trends.

Results
Complete Mental Health declined from 55.6% (2006) to 45.4% (2024), while the Troubled profile more than doubled (3.4% to 7.2%). The Vulnerable profile remained stable at approximately 17%. Within-municipality spending increases were associated with 16% lower odds of the Troubled profile (OR = 0.84, 95% CI 0.73–0.95, p = .007) but showed no significant association with the Vulnerable profile (OR = 1.08, 95% CI 0.99–1.17, p = .084). Spending was associated with 9% higher odds of the Symptomatic but Content profile (OR = 1.09, 95% CI 1.01–1.17, p = .026), possibly reflecting transitions from Troubled to Symptomatic.

Conclusions
Increased investment in school mental health services appears protective for students with visible psychiatric symptoms but does not reach those whose struggles manifest as low well-being without psychiatric symptoms. From a precision public health perspective, current service models may require reorientation to identify and support the Vulnerable subgroup, who comprise one in six adolescents and remain unaffected by spending increases.