The verdict ordered the payment of $6 million in damages: $3 million in compensatory damages and $3 million in punitive damages, with 70% of the liability assigned to Meta and 30% to YouTube, which is owned by Google.

Experts view this decision as a potential turning point for the technology industry, one that could pave the way for similar lawsuits. The case has mobilized both legal and technological communities, further fueling scientific debate over the limits of corporate liability in the health sector.

Understanding the case: Meta, YouTube, and adolescent mental health

Social media as a public health risk

The verdict echoes arguments raised in an opinion piece published on April 7 in the journal BMJ by researcher Ilona Kickbusch, director of the Digital Transformations for Health Lab (DTH-Lab) at the University of Geneva, in Switzerland.

In the article, Kickbusch argues that the practices of major digital platforms constitute new health risks, particularly among young people, by influencing behavior, mental well-being, and consumption patterns.

According to the author, the issue calls for an update to regulatory and legal strategies—similar to what occurred decades ago with the tobacco industry. 

Holding tech giants legally accountable for negative health impacts would, in her view, mark a new phase in the relationship between public health, regulation, and corporate power.

An architecture designed to keep users connected

Kickbusch points out that, unlike other industries historically associated with health risks, digital platforms operate in an environment that remains largely unregulated, one in which negative impacts tend to be diffuse, cumulative, and difficult to measure. 

The business model of these companies, based on capturing attention and maximizing screen time, is, according to the researcher, at the core of the problem.

In the case of children and adolescents, this design can amplify preexisting vulnerabilities.

This analysis aligns with data that help quantify the extent of this exposure: adolescents spend, on average, about two and a half hours per day on social media, according to the World Happiness Report produced by the United Nations (UN).

The rise of judicial rulings such as the one in Los Angeles signals a broader paradigm shift.

Digital platforms have already become a permanent feature of the social fabric; however, their impact on public health is no longer treated as an inevitable side effect, but is increasingly recognized as a central issue of regulation, ethics, and corporate responsibility.

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Conducted by consultancy People Insight in partnership with the University & Colleges Employers Association (UCEA), the study exposes striking disparities between the responses of faculty and administrative services staff.

According to the report:

• Only 43% of faculty staff feel they can manage their workload comfortably;
• The situation is also unfavorable when it comes to mental health and institutional support: only 44% say that they receive adequate support from their institutions;
•  48% say they are able to balance their work and personal lives.

The rates are considerably higher among administrative staff: 

• 63% claim to be comfortable with their workloads;
• 61% feel supported in terms of well-being;
• 71% state that they have struck a balance between their personal and professional lives.

Nevertheless, these figures are below the average for other sectors, according to the digital journal Times Higher Education (THE). 

Satisfaction vs. benefits 

Another critical outcome of the study is the low level of satisfaction with benefits packages offered to faculty staff: only 38% of the academics surveyed are satisfied, compared to 54% of administrative professionals, a rate that mirrors the average across other sectors.

The survey warns that different arrangements, with working hours conflicting between departments, limit opportunities for face-to-face interaction. 

Hybrid working agreements, which are likely to vary among departments, may be contributing to this problem, as conflicting working times make for less in-person engagement, which is essential for effective collaboration between different areas of an institution.

Small advances and large gaps 

Among administrative professionals, the perception of their work-life balance has improved slightly since 2021, increasing by three percentage points; this is attributed to greater flexibility for partial remote working. 

However, there has been no progress in respect of academics, highlighting the need for institutional policies more geared toward their specific requirements.

This serves to demonstrate the involvement of academics in their activities, even under adverse conditions.

Practical recommendations: Pathways for transforming the academic environment

Based on the results, the report proposes five key recommendations for higher education institutions. Despite their focus on the British context, they provide practical takeaways for universities from other countries, including Brazil:

1. Enhancing interdepartmental collaboration: incentivizing interdisciplinary projects, inter-team communication channels, and shared events calendars to strengthen collaborative work.

2. Offering effective workload management support: Implementing time management training, regular meetings for task redistribution, and improvements to administrative systems.

3. Strengthening well-being and balance initiatives: generating mental health and active listening programs, and awareness-raising campaigns on making the most of leaves of absence, vacations, and flexibility

4. Improving recognition and rewards systems: establishing clear practices of staff appreciation, with formal acknowledgement, financial rewards, and incentives for the teaching career.

5. Adopting a continuous listening approach: conducting frequent organizational satisfaction surveys, setting up focus groups, and implementing action plans based on employee necessities.

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Since then, more than 2,000 gambling websites have begun operating in Brazil, according to a report in the newspaper O Estado de S. Paulo. Many of these companies are headquartered in tax havens and operate locally through Brazilian partners or contracted representatives. As a result, much of their revenue is exempt from domestic taxation and does not provide any benefit to the public.

The financial impact on the population is enormous. Brazilian consumers are forecast to lose up to R$1.2 trillion on betting by 2030. The global online gambling market is projected to generate around US$700 billion by 2028.

The social costs, however, go far beyond these numbers.

Silent epidemic: addiction, bankruptcy, and family breakdown

Experts have warned of a range of consequences not limited to financial problems. Online gambling addiction increases the risk of suicide, domestic violence, bankruptcy, and the erosion of family relationships. These impacts, as shown by scientific and political reports, can stretch across generations, creating cycles that are difficult to break.

Data from a senate inquiry into gambling show that in 2024 alone, five million recipients of the Bolsa Família welfare program spent R$3 billion on betting websites, leaving them without enough money to buy basic items such as food, clothing, and medicine.

A survey by the Brazilian Society of Retail and Consumption found that 23% of gamblers stopped buying clothes, 19% skipped buying food, and 19% canceled trips because of their habit.

“If we delay, gambling and the harm it causes will become an even more ingrained global phenomenon and much more difficult to tackle,” warns a report in The Lancet Public Health analyzing the global impact of this growing industry.

An expanding global phenomenon

According to the study published in The Lancet, led by Heather Wardle of the University of Glasgow, Scotland, 448.7 million adults worldwide gamble online, 80 million of whom are already addicted.

The research also found that gambling is permitted in more than 80% of countries and has grown disproportionately in vulnerable regions.

Betting sites are designed to encourage rapid, frequent, and repeated gambling, making use of intensive advertising and behavioral design. “Marketing and technology make it easier to start gambling, and harder to stop,” the report notes.

In Brazil, the Locomotiva Institute estimates that 52 million adults have placed bets online and 25 million started doing so in 2024 alone.

Among them, 45% have suffered financial losses and 37% have spent money that would have been used for other priorities.

Understanding risk-taking behavior

Studies show that problem gambling results from a combination of neurological, psychological, and environmental factors. Gamblers’ brains respond to wins with dopamine rushes, similarly to other types of addiction.

Impulsive people or people with low self-control are more susceptible to developing an addiction.

People who participate in more than two forms of gambling or who gamble more than four times a month are at a high risk of suffering some form of loss.

How to regulate and address the problem

In response to the advance of gambling and its side effects, the senate inquiry’s report proposes:

• A ban on 100%-online games, such as “tigrinho,” due to a high risk of manipulation
• The creation of a national gambling audit and monitoring platform
• A national registry of gamblers to track compulsive patterns
• Greater control over advertising and the role of digital influencers
• Rules to prevent gambling from being marketed as a financial solution

The recommendation is clear: the sector requires more robust, transparent, and ethical regulation, with active monitoring and modern controls.

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When embarking upon their graduate studies (aiming at an academic career), many young people come face-to-face with a hostile environment, normally manifesting itself in pressure to publish articles in prominent journals, in the excessive workload, and in over-the-top demands—with the potential for moral harassment (bullying) to develop.

The feeling that one has to “get into the game” and follow the rules (even when not agreeing with many of them) can overwhelm master’s and doctoral students, disenfranchising them in respect of academic and research careers.

It is neither easy nor fair to attempt to tackle a systemic problem individually.

Specialists interviewed for the article allude to the need to occupy spaces, share dissatisfactions, and join forces to build a less competitive and more accommodating academic environment.

Student participation in decision-making

According to the Law of Brazilian National Education Guidelines and Bases (LDB), and the statutes of higher education institutions, the discussion on their academic and management policies should be on the agenda of collegiate bodies with a minimum of 70% faculty staff. Administrative representatives and students can participate, but the maximum collegiate should feature professors in the majority.

Psychologist Filipe Buchmann, of the University of São Paulo’s ECOS program explains that a very relevant determining factor for developing illness at university is indeed the exclusion of students and collaborators from institutional political involvement.

“There is a certain delegitimization of potential contributions from both students and technical-administrative staff,” says Buchmann. “This is a power concentration dynamic that facilitates situations of abuse.”

Democratizing institutional deliberations is of paramount importance in the debate on the mental and physical health of graduate students and early-career researchers, says historian Heribaldo Maia, MA Phil. from the Federal University of Pernambuco (UFPE) and author of the book Neoliberalismo e sofrimento psíquico: o mal-estar nas universidades (Neoliberalism and psychological suffering: Malaise in universities).

“It is essential that professors listen to students’ needs in meetings,” observes Maia. “Another important measure is to enable them to participate in drafting calls for entry for graduate education programs.”

For Maia, actions of this type can enhance the participation of master’s, doctoral, and postdoctoral researchers in decisions that can significantly impact their careers.

It is worth remembering that gender and race disparities in universities also undermine the sense of belonging to the academic community. There is a prevalence of White male professors in Brazilian higher education. They are also a majority in the corridors of power, and the lack of diversity means that key decisions are taken by a group representing only one section of the university population.

Buchmann takes the view that the lethargy of some universities in implementing affirmative policies for Black, Brown, and Indigenous people could be interpreted as indicative of the lack of diversity on the committees of these institutions.

“Ethno-racial and socioeconomic inclusion not only stimulate the entry of more Black, Indigenous, and low-income students into universities, but also widens the diversity of issues, walks of life, and types of mental suffering that the University has to deal with,” the psychologist states.

These people often come from a completely different social reality, and enter into an institution where almost all the faculty staff are White, with practices from a world for which they have never been prepared, continues Buchmann.

This conflicting context, says Buchmann, can lead to considerable suffering and, in many cases, dropouts by students. “Based on psychological therapy with quota students, it is clear that many fall by the wayside because the institution is very hard on them, and there are not always programs to accommodate these groups.”

Public confidence in science

Poor representation of students and researchers in decision-making processes at universities, added to the poor visibility of research work in Brazil, is another factor that can influence the course of academic careers and shake the self-esteem of young researchers.

Academic and scientific careers have long been undervalued—and this is not exclusive to Brazil. An editorial in the journal Nature, published on April 1, warns of the strong trend in brain drain from the United States, motivated by the attacks of Donald Trump’s government on the scientific community in the country. There have been mass job losses and funding cuts across support agencies, the freezing of scholarships, and reprisals against prestigious universities, including Harvard.

Close to 75% of the 1,600 US scientists that answered a questionnaire in Nature said that they are considering leaving the USA due to the very turbulent current climate, with Europe and Canada among the main options for relocation. “A lot of the respondents are thinking about moving to countries where they have collaborators, friends, relatives, or proximity with the language,” the journal reported.

In Brazil, data published in 2024 by the Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES) indicate that undergraduate students’ interest in pursuing an academic career is dwindling.

Between 2019 and 2022, more than 14,000 graduate education vacancies were closed, and 2022 saw the lowest number of graduate education enrollments in almost a decade.

According to CAPES, one factor that goes toward explaining the decline during the period analyzed is the COVID-19 pandemic. However, the agency acknowledges that the successive cuts and reallocations of the public research budget have broadsided the country’s capacity to put people through graduate qualifications.

In addition to the budgetary shrinkage, CAPES lists other aspects responsible for students dropping out of graduate education in recent years:

• Emotional and financial issues;
• Unsatisfactory social relationships with colleagues, professors, and employees;
• A lack of programs contributing to curricular enrichment;
• The need to work or dependence on somebody to fund their studies;
• Distance from home.

This professional derision, added to scientific misinformation and denialism, only serve to compromise public confidence in science, as suggested in a study published by the Center for University, Society, and Science Studies (SoU_Ciência) at the Federal University of São Paulo (UNIFESP).

According to the survey, 36% of the Brazilian population is unaware of what happens in public universities. The survey team interviewed 1,500 people in 2021, revealing that even among young people of potential university age (16–29 years), there is little awareness of what these institutions do (37%).

“As part of the resistance against these attacks, backward steps, and denial of science, communication today is even more pressing, especially among populations with low levels of income and schooling, and also with young people and students, to widen and democratize knowledge and access to programs and activities,” said Soraya Smaili, professor at the UNIFESP São Paulo School of Medicine and overall coordinator of SoU_Ciência.

These and other data on the public perception of science demonstrate that there also needs to be movement among the institutions themselves, to approximate once again to society and rebuild their credibility—not before first taking a look at themselves, evaluating their culture, and making the necessary adjustments.

Uncertainties about professional future

The academic career treads a unique pathway. While in other areas people graduate and then generally enter the formal employment market, academia involves a number of steps until a person is in fact considered a professional.

“This medium- and long-term career plan causes considerable mental stress,” says chemist Juliana Fedoce, a professor at the Federal University of Itajubá (UNIFEI) in Minas Gerais State.

She says that during her graduate program, her father tried to calm her with the advice: “You’re taking one step back to take two steps forward”—but it’s not that simple.

According to the report Masters and Doctors 2024, produced by the Center for Management and Strategic Studies (CGEE), the number of masters and PhDs with formal employment after two years of their postgraduation is falling, revealing a more dramatic drop in the employment rate of recently appointed PhDs.

In the case of doctorate holders, the academic areas with the highest formal employment rates 10 years after receiving their titles (in 2021) were exact and earth sciences (78.9%), with the lowest rate (67.9%) in biological sciences.

It’s very difficult to foresee or plan how or when to take those “two steps forward” mentioned by Fedoce’s father. There are not enough vacancies in public universities for all the PhDs awarded annually in Brazil.

Moreover, with a reduced number of competitive examinations (a consequence of education investment cuts and jeopardizing of higher education), many scientists wishing to become faculty staff end up spending several years on postdoctoral internships—temporary research posts of one or two years’ duration, with a scholarship grant, but no employment bond or employee rights, and with no guarantee whatsoever of being hired.

Physician Olavo Amaral, a professor at the Federal University of Rio de Janeiro (UFRJ), says the most obvious solution would be for people to go out and scour the market for jobs.

“Brazilian graduate education does not prepare young researchers to work in other sectors,” says Amaral.

Scientists find it difficult to seek opportunities outside the university environment when they have no corporate experience or even behavioral (soft) skills, or for being overqualified for certain sectors.

There are reports of postdoctoral researchers hiding stages of their qualification from their résumés in order to get a job.

Furthermore, many graduate students have no contact with other careers during their qualification, and opt for teaching due to the simple lack of information on other professional possibilities. 

The CAPES report from last year suggests that to revert this low absorption of masters and PhDs by industry and the business sector (and the unattractiveness of a scientific career), there is a need for “strategies for both increased investment in research focused on development and stimulating innovation, and increased qualification of human resources for innovation, with closer liaison between the academic and business sectors.”

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In addition to complex interpersonal relationships and the wide range of responsibilities in academia, another obstacle that makes life difficult for many researchers is the pressure to publish scientific articles—especially in high-impact journals with greater international prestige.

In Brazil, when researchers publish a paper in a prestigious journal, they update their profile on the Lattes résumé platform, which hosts some 8 million academic résumés, serving as a credential and a means for earning recognition and rewards in the form of leadership positions, promotions, and funding.

Although alternative indicators for assessing teaching and research quality have been established over the last decade, quantitative metrics like the number of articles published and the number of citations received are still the most-used parameters.

In recent years, a lack of research funding has contributed to a decline in Brazilian scientific output, according to a report published last year by Dutch publisher Elsevier and Brazilian science news agency Agência Bori.

Budget and grant cuts not only limit scientific production, but also the publication of results, especially in internationally prestigious open-access scientific journals, which charge authors high fees.

Publish or perish

The number of articles published in scientific journals does not only influence the professional careers of researchers, but also the score of graduate programs assessed by the Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES), an agency affiliated with Brazil’s Ministry of Education.

International rankings that compare the performance of universities around the world based on various classification models also use quantitative criteria, despite recent efforts to encourage research evaluation systems to adopt more qualitative indicators when analyzing the work of academics.

One initiative seeking to contribute to this mission is the Coalition for Advancing Research Assessment (CoARA), which brings together more than 720 scientific organizations from around the world and is led by the European Science Foundation.

In an article published in September 2024, members of the CoARA Steering Board stated that the initiative seeks to draw attention to the “unreliable and unhealthy over-reliance on narrowly focused publication metrics.”

They also recognized that the overuse of indicators such as the h-index and citation numbers negatively impacts mental health, as well as encouraging ethical misconduct in academia.

Article 207 of Brazil’s Federal Constitution establishes that universities have didactic and scientific autonomy, meaning institutions have the freedom to define their own teaching methods, course topics, research lines, and ways of transmitting knowledge to society.

However, due to the heavy reliance on quantitative metrics by evaluating agencies, the interests of the researchers themselves are now guided by subjects they believe have the greatest potential to result in more articles and more citations.

We need to move past the idea that scientists who do not publish frequently in high-impact journals are unproductive, argues Juliana Fedoce, a chemistry professor at the Federal University of Itajubá (UNIFEI), Minas Gerais.

“Competitiveness has turned us into paper producers instead of scientists,” says Fedoce, founder of Instituto Sua Ciência, a nonprofit organization dedicated to disseminating knowledge and seeking funding sources.

Peter Schulz, a professor at the School of Applied Sciences of the University of Campinas (UNICAMP) who specializes in scientometrics (the investigation of scientific literature based on indicators), believes the over-emphasis on quantitative metrics has made publishing papers an end instead of a means.

“This overshadows the performance of the university’s other objectives, such as teaching and outreach activities,” says Schulz. “Today, science is led by papers, but it should be the other way around.”

According to Filipe Rebelo Buchmann, a psychologist from the ECOS Program at the University of São Paulo (USP), the pressure to publish more and more can encourage a frantic race with no “winners.”

“This logic can foster feelings of doubt and insufficiency, profoundly affecting the mental health of scientists.”

The responsibility of scientific publishers

Scientific publishers are central figures in this debate. For decades, major publishing groups have been achieving high profit margins with the journal subscription system, charging readers through contracts with funding agencies and teaching and research institutions.

In recent years, many publishers have also begun striving to maximize their profits from publishing papers via open access. In this new business model, instead of asking readers to pay fees or subscriptions, the costs are transferred to the authors, who have to pay article processing charges (APC) to publish their work.

Since APCs are often prohibitive, researchers then have to turn to their institutions or the agencies funding their research.

For physician Olavo Amaral, a professor at the Federal University of Rio de Janeiro (UFRJ) who studies the challenges of scientific reproducibility, indiscriminately adopting the number of published articles to measure the quality of a researcher’s work has placed scientific publishers in an unwarranted position of power.

“Not to mention that thousands of dollars are paid in publication fees for journals to send the manuscript to reviewers who work for free,” Amaral points out.

Asymmetries and imbalance

Much of the Brazilian scientific literature is created at public educational institutions and relies on financial support from federal and state bodies.

In addition to the frequently discussed budget cuts, another major problem is the unequal way in which funding is distributed across regions, affecting the performance of researchers based on where they are located.

Federal and state funding agencies work in a similar way: they launch calls for proposals with specific requirements and applicants compete for a certain amount.

However, asymmetries in Brazilian society have led to a historical concentration of research infrastructure and scientific production in the South and Southeast regions, according to the 2024 report by the Center for Management and Strategic Studies (CGEE), linked to the Brazilian Ministry of Science, Technology, and Innovation.

“Scientists with good proposals but who are little known or linked to institutions with little scientific tradition and fewer resources are greatly disadvantaged,” says historian Heribaldo Maia, who has a master’s in philosophy from the Federal University of Pernambuco (UFPE) and wrote a book titled Neoliberalismo e sofrimento psíquico: o mal-estar nas universidades (Neoliberalism and psychological suffering: The malaise at universities).

“We need to establish the conditions for people to become productive,” says Maia, drawing attention to the importance of public policies that focus on decentralizing resources and research activities in Brazil.

In addition to the economic and infrastructure disparities that hinder many academics, there is also a substantial emotional burden created by race and gender inequalities.

Gender imbalance in the academic environment can significantly compromise the mental health of women scientists.

A 2021 survey by members of Parent in Science, an initiative created in 2017 to address the impact of parenting on academic careers, highlighted the need for different evaluation parameters for specific groups.

The survey indicated that in 2020 (the first year of the COVID-19 pandemic), only 47.4% of researchers who are mothers and responded to the questionnaire were able to submit manuscripts for publication in journals. Among male researchers with children, the proportion was 65.3%.

In many cases, the pressure to be productive and the difficulties female researchers face in advancing their careers (the glass ceiling that prevents women from reaching higher positions) are associated with episodes of depression.

In her master’s dissertation, presented at Fluminense Federal University (UFF) in 2023, physiotherapist Sarah Rocha Alves showed that approximately 40% of the scientist mothers interviewed for the survey experienced signs of depression, while the rate among scientist fathers was 22%.

“In the academic community, mothers present more depressive symptoms than non-mothers. For men, we found no differences between fathers and non-fathers,” Alves wrote. Additional factors such as being a primary caregiver, having a child with a disability, being Black, and not having a support network contributed to greater symptoms of depression among mothers.”

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The winner is chosen by a council of more than 600 scientists from all over the world, including Nobel and Abel prize winners.

The honor, awarded to early-career scientists, was given to Fabiana Corsi Zuelli for her studies on the relationship between inflammatory changes and environmental factors in the development of first psychotic episodes.

Zuelli spent her entire academic career in the public system. “I faced the barriers of a shortage of physical and personal resources, but with the desire to experience a quality public higher education.”

In 2009, she passed the entrance exam to study a degree at USP’s Ribeirão Preto School of Nursing. In her first year, she received a research grant from the Brazilian National Council for Scientific and Technological Development (CNPQ).

She also participated in Science without Borders, a government program that operated from 2011 to 2017, giving Brazilian university students foreign exchange opportunities. While still an undergraduate, Zuelli visited the UK, where she took part in research into the impact of stress on the development of mental disorders.

Her time in the UK helped broaden her horizons in research. It also paved the way for the Brazilian to study abroad once more during postgraduate studies at the Ribeirão Preto School of Medicine.

As part of her master’s degree in neuroscience, which she completed in 2019, she spent a sandwich period at King’s College London. She then began a PhD (also in neuroscience) with a grant for a sandwich period at the University of Birmingham, UK. She defended her thesis in 2024, with funding from the São Paulo State Research Foundation (FAPESP).

In her research, Zuelli seeks to integrate two fields of health sciences: psychiatry and immunology. Her motivation, she says, is based on personal experience.

“My late aunt was diagnosed with schizophrenia. I experienced first-hand the suffering caused by this debilitating disorder, which also impacts the lives of those caring for patients. My aunt was taken care of by my mother,” says Zuelli.

For almost ten years, Zuelli dedicated herself to investigating immunological changes and environmental factors in the development of psychosis.

Her work was part of a thematic project (with funding from FAPESP, CNPQ, and the Center for Research in Inflammatory Diseases) and an international consortium known as The European Network of National Schizophrenia Networks Studying Gene-Environment Interactions.

Inflammation and behavior

In her investigations in Ribeirão Preto, located in the interior of São Paulo state, Zuelli and her research team identified 588 cases of psychosis between 2012 and 2015. They collected blood samples for analysis from 166 patients.

“We observed that people experiencing their first psychotic episode had higher concentrations of inflammatory proteins, such as cytokines, in their blood than other individuals in the community,” explains Zuelli.

The research also found that people who suffered childhood abuse may be more susceptible to these inflammatory changes. “Individuals who experienced childhood trauma were more likely to develop diseases with inflammatory causes.”

According to Zuelli, individuals with inflammatory changes were also more vulnerable to the negative effects of daily consumption of marijuana (Cannabis sativa).

“The inflammatory state detected in some of these individuals was associated with exacerbation of the symptoms of the disease and a reduction of the brain structures involved in social and cognitive processes,” explains Zuelli.

One of the merits of the research, she highlights, is its interdisciplinary nature. “For a long time, mental disorders were considered ‘problems’ exclusive to the brain,” she says.

“Today, however, we know that there is an important connection between the brain and the rest of the body, and our results support this by showing that organic changes—inflammation detected in the blood—can influence behavior.”

Identifying inflammatory markers could pave the way for personalized treatments, says Zuelli.

During her sandwich PhD in the UK, she took part in the first clinical trial testing an adjuvant therapy for antipsychotics with a drug that modulates the immune system response, specifically in psychosis patients with inflammatory changes in the blood.

“This is an excellent example of precision medicine, in which therapy is targeted according to the individual’s biological characteristics.”

International recognition

Zuelli has received several international awards over the course of her career, including recognition from entities such as the Schizophrenia International Research Society and the World Federation of Societies of Biological Psychiatry.

At the end of January, she will travel to the University of Oxford, UK, where she will begin postdoctoral research.

“I will continue studying mechanisms related to inflammatory and metabolic changes caused by mental disorders, in order to design new stratified clinical trials,” says Zuelli.

“I believe that in the coming years, the field of immunopsychiatry will move towards increasingly personalized interventions, tailored to individual characteristics, allowing for more effective treatments aligned with the specific needs of each patient.”

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Among patients who seek care at primary care settings, mental health clinics, and psychiatric hospitals, the prevalence is even higher, at 6%, 12%, and 22% respectively.

Despite these figures, BPD has traditionally remained on the edges of the curricula of medicine and psychology courses, making it difficult for health professionals to learn the skills needed for early diagnosis and appropriate treatment.

However, thanks to new research, the situation has been changing in recent years.

To navigate different social environments, deal with challenges at work, and make good decisions, a stable psyche is necessary, which does not occur with BPD. The disorder is characterized by intensely turbulent emotions, thoughts, and behavior.

In its classic presentation, patients suffer significant difficulties regulating their emotions from an early age, which can be exacerbated by adversities in childhood, such as family conflicts and bullying.

In adolescence and adulthood, symptoms include irritability and a marked hypersensitivity to rejection, as well as difficulties developing a stable sense of identity, self-esteem, impulse control, and the ability to reflect on the mental state of oneself and others. Patients report that relatively common stressors, such as a disapproving look, the possibility of a relationship ending, or a low score on a test, can trigger intense negative emotions, such as anguish and anger; suicide attempts; episodes of self-harm; and even dissociation, paranoia, and hallucinations.

Even in the twenty-first century, patients still hear disparaging remarks such as “people who attempt suicide don’t really want to die,” “they’re just looking for attention,” and “it’s all about manipulation.”

Diagnostic criteria

Other psychiatric disorders that occur at similar rates in the population are more studied by and more often taught to medical students due to a range of factors.

A classic example is bipolar disorder, the clinical presentation of which has been established in a way that is more in line with current definitions since the mid-nineteenth century, about which there are at least five times as many published studies, and on which physicians receive much more training.

Borderline personality disorder, meanwhile, was only added to international psychiatric classifications in 1980, when pioneering empirical studies by John Gunderson and the theoretical concepts of Otto Kernberg allowed for a better clarification of the diagnostic criteria.

In addition to having been introduced to science later, BPD has historically been interpreted negatively and personally by professionals, who often see the symptoms—such as uncontrolled anger and swings between idealizing and devaluing other people—through a pejorative lens, rather than a diagnostic one.

In extreme cases, we have seen even well-intentioned professionals reduce BPD to a narrow set of characteristics deemed socially undesirable, due to misinformation.

During case discussions among colleagues about certain patients who meet full criteria for BPD, it is not uncommon to hear things like: “I like this patient, he can’t be borderline.”

There is also a great therapeutic nihilism in the medical field that contaminates patients.

There is also a prevalent belief that in adulthood, personality is immutable. So many psychiatrists, fearful of causing their patients distress, make two mistakes:

• Not diagnosing BPD in adolescence in the hope that it will improve on its own with time, thus delaying treatment
• Not diagnosing BPD in adults, believing that the personality is already set in stone and there is therefore nothing that can be done

Patients often receive alternative diagnoses, such as depression, anxiety, or bipolar disorder, which in these cases are inadequate or explain only part of the problem. They are then frequently overmedicated and referred to psychotherapies that are ineffective against the real problem.

Research and classification

In terms of research, due to the high risk of suicide and self-harm and the fact that psychotherapy is generally more effective than pharmacological treatment, there is less funding for BPD studies.

There has also been criticism of the specificity of personality disorder diagnoses, which are currently being modified and include two parallel classification systems.

However, we know that limited diagnostic accuracy in psychiatry is not exclusive to these disorders and that classification systems are constantly evolving, as is typical of science.

Given how common BPD is and the severity of the functional impairment, it is essential that we combat the ignorance about the condition that still permeates the health system and better prepare professionals to diagnose and treat the disorder.

Fortunately, a number of new strategies based on scientific evidence have been developed for this purpose.

After the diagnosis was officially established in the 1980s, the following two decades were marked by a series of advances.

Marsha Linehan developed dialectical behavioral therapy, the clinical trials of which demonstrated that BPD, previously considered untreatable, improved considerably when treated with specialized psychotherapy.

Later, several other methods proved effective in clinical trials, such as mentalization-based treatment, transference-focused psychotherapy, and schema-focused therapy.

At the same time, Mary Zanarini and other researchers conducted two major longitudinal studies which empirically demonstrated that over years, the symptoms of most patients gradually diminished, to a point where they no longer reached the threshold for diagnosis.

Studies on genetics, neuroimaging, and endocrinological changes highlight the existence of biological and innate components of the disorder, meaning it is not solely a product of the environment, as was previously thought.

Altogether, the findings of these studies reveal that BPD patients are highly sensitive to stress, feeling intense emotions that are not adequately counterbalanced by hormonal mechanisms, impulse control, or proper reflection and decision-making capabilities.

In the twenty-first century, with a better prognosis and more effective psychotherapies available, further research has shown that providing a BPD diagnosis and explaining it openly is generally well received by patients and their families, contrary to previous assumptions. This process itself, known as psychoeducation, helps to reduce symptoms, demonstrating the impact of self-awareness.

Access to treatment

Despite the importance of these advances, there is another barrier that still needs to be overcome: ensuring that the majority of patients have access to quality treatment.

With Good Psychiatric Management for Borderline Personality Disorder, Gunderson and Paul Links showed that generalist, well-structured, and manual-based treatment can be as effective as specialized therapies—which demand a significant investment of time and money to train professionals and provide access to patients.

Furthermore, research has shown that after training in these approaches, clinicians reported less stigma and greater confidence when treating patients with BPD.

Brazil has played a relevant role in the development of compact BPD training methodologies for healthcare professionals.

The Institute of Psychiatry at the School of Medicine of the University of São Paulo took part in an international project led by Lois Choi-Kain of Harvard University and Carla Sharp of the University of Houston, adapting Good Psychiatric Management for adolescents.

In Brazil, the project has been used in the training of professionals who work in the country’s public health system (SUS) and in private healthcare, to promote early detection of BPD and intervention, which can greatly alter the outcome for people with the disorder.

Over the past decade, these efforts have resulted in a situation that would once have been unthinkable: mental health professionals are now competing for spots at training centers for borderline personality disorder, a diagnosis that many clinicians in the past would not have wanted anything to do with.

Our growing knowledge of BPD is one example of how research, training, and clinical care can be orchestrated in a way that benefits the patient, reduces stigma, and increases access to treatment.

Marcelo Brañas is a psychiatrist, co-director and co-founder of the Outpatient Clinic for the Development of Relationships and Emotions (ADRE) at the Institute of Psychiatry, Hospital das Clínicas, USP School of Medicine (IPqHCFMUSP), and an official Good Psychiatric Management trainer, by the Gunderson Personality Disorders Institute at McLean Hospital, Harvard Medical School (USA).

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Considered a key exponent of the so-called “psychedelic rebirth” (the resumption of scientific studies into medicinal use of psychedelic substances), Sidarta Ribeiro advocates that the new wave of research projects on this line constitutes “a scientific revolution with potential for also becoming a clinical revolution.”

Having obtained his PhD at The Rockefeller University, with a postdoctoral placement at Duke, both in the United States, Ribeiro has published articles in noteworthy scientific journals such as Nature Mental Health and PLoS Mental Health, as well as the digital magazine Sumaúma. These works focus on psychedelic science and the therapeutic use of substances traditionally used by Indigenous cultures.

His research covers a range of areas including sleep, dreams, memory, learning, animal behavior, neuronal plasticity, computational psychiatry, cannabis, and psychedelics.

In addition to his scientific accomplishments, Ribeiro gained renown as an author after publication of O oráculo da noite (The Oracle of Night) (2019), which looks at the history and science of dreams. His most recent book, As flores do bem (The flowers of good) (2023), addresses the history and science of cannabis, combining his role as a scientist with that of a multiplier and thinker in scientific evolution.

In an interview with Science Arena, the researcher discusses the evolution of psychedelic science and its therapeutic applications, addressing crucial questions that arise as these insights and practices advance, considering the impacts for researchers, healthcare professionals, regulators, and society as a whole.

Science Arena – What is the current outlook on psychedelic science and its applications in the mental health area?

Sidarta Ribeiro – It’s important to remember that the so-called “psychedelic rebirth,” which started about two decades ago, is, in fact, the third wave. The first has been ongoing for thousands of years, and involves all the discoveries, inventions, and cultural constructions around psychedelic substances by Indigenous peoples—including, for example, peyote in Mexico, ayahuasca in South America, and other substances in Africa and Asia.

The second wave occurred between the 1950s and 1970s in urban environments, with science involved, and documented several interesting aspects until it was interrupted by the “war on drugs.”

The third wave began to gain ground in the first decade of this century, when research pathways opened by the second wave were resumed, with the assistance of more powerful methodologies, more advanced technology, and more robust statistics. Today, the third wave constitutes a scientific revolution with the potential of also becoming a clinical one.

How does Brazil fit into this third wave scenario?

The biomedical psychedelic research field is growing fast, but is still relatively small. Brazil was one of the few countries that started riding the third wave when it was just beginning. Currently, at least 10 independent groups are conducting relevant research in the area, and we are at the forefront of knowledge production on certain substances, such as ayahuasca, which, as well as being used by several Brazilian Indigenous peoples, is cleared for religious use in the country, which incentivizes and facilitates the research.

Which substances and their clinical applications stand out in the research results?

The complex substances used by Amerindian peoples in the form of natural products, such as peyote, ayahuasca, and “magic” mushrooms (which respectively contain the psychedelics mescaline, N,N-Dimethyltryptamine [DMT], and psilocybin), have been validated by academic research for their medicinal properties.

Synthetic substances discovered in laboratory settings in the twentieth century, such as LSD, are also validated. These are the so-called “classic psychedelics”—tryptamines and phenylethylamines.

Other psychedelic substances, such as ibogaine, discovered and used by African first-nation peoples, and MDMA and ketamine, synthesized in the laboratory, also have valuable properties for mental healthcare. Psychedelic-assisted psychotherapy shows much promise for a number of clinical conditions, including extreme cases of trauma, desperation and imminent suicide, depression, treatment of addictions, and improved quality of life for patients under palliative care.

Is there a fundamental property of psychedelics that stands out for its therapeutic potential?

Yes. Psychedelics produce neural plasticity of a particular type—known as metaplasticity—which tends to be more balanced, more homeostatic than the plasticity produced by other substances that induce this type of neurophysiological process.

In respect of application to medicine, this metaplasticity production is also promising for neurological treatments for repair, regeneration, and maintenance of neural tissue health.

Why are psychedelic experiences important?

There are two key points here. The first and most basic is understanding the importance of the setting; the environmental and relational context in which the experiences and therapeutic process occur. This understanding, strongly conveyed through knowledge about psychedelics, also goes for other substances.

For example, experimental results show that the antidepressive medication fluoxetine tends to have the opposite effect, aggravating depression when the setting is hostile or adverse, and we can assume that this applies to a considerable portion of the Brazilian and global population.

So, the idea that mental health is manageable by substances regardless of the context is a misconception. The people and cultures that discovered psychedelics and knew how to use them as a powerful healing resource teach that the interaction of these substances with the setting is a fundamental aspect of their action.

What about the psychedelic experience itself?

What both Indigenous knowledge systems and a considerable number of non-Indigenous people and communities that use psychedelics in different ways—such as medicine, religious sacrament, or a tool for exploring different levels of awareness—tell us is that they provide adventures, and subjective, inner odysseys, fundamental to these processes.

Psychedelic experiences are related to belief systems and the conscious processes undergone by people during and after the effects of the substances. The research outcomes confirm this.

A well-managed psychedelic experience can bring long-term beneficial effects. Thus, therapeutic protocols that include psychedelic experiences do not mandate continual use of the substance, but merely a few sessions combined with psychotherapy.

I believe that as it evolves, the research will demonstrate, with increasing clarity, that the attempt to reduce psychedelics to yet another type of pill not producing any significant introspective or otherness experience leads to a reduction in the potential of these substances.

Is this related to the difficulties in obtaining approval of some of these therapy protocols by regulators such as the Food and Drug Administration (FDA), which governs the use of foods and medications in the United States?

Yes. First and foremost, we must remember that the actual psychedelic rebirth started a short time ago after decades of research invalidation under the “war on drugs” banner. Prejudices against substances which, regrettably, were associated with crime and exaggerated or invented risks, are still widespread.

As with any substance, psychedelics have their risk groups and contraindications, and require knowledge and caution for use with patients; many people can safely use them, however.

In addition to overcoming these prejudices, the challenges for regulators such as the FDA and Brazilian Health Surveillance Agency (ANVISA) have to do with the fact that approval of psychedelic-assisted therapies does not just require safety and efficacy analysis for the medical use of a key ingredient.

As well as the substance itself, each therapeutic model submitted to these agencies has to be assessed. But what may seem like excessive complexity today, may in the future prove to be a necessary step for a fuller, deeper understanding of mental health and ways to promote it.

There’s also the question of “unmasking” the placebo in clinical trials, right?

In the case of psychedelics, it’s easy for clinical trial participants to know when they are taking the substance or a placebo. This also demands a slightly different perspective in evaluating results, and that type of development may be met with resistance by conservative regulatory structures.

You defend the valuing of knowledge systems and recognition of the rights of Indigenous peoples across the various aspects of the psychedelic rebirth. Can you explain what this means?

We need to capitalize on the Nagoya Protocol to ensure fair benefit sharing. Moreover, it’s time to acknowledge that we are in trouble, needing the help of men and women who carry different knowledge and wisdom to ours.

We need to open our eyes and realize that we have a lot to learn from other peoples, cultures, and human experiences, particularly when dealing with medicines that they have presented to us, together with the knowledge systems accumulated and honed over thousands of years.

Failing to understand this, besides constituting predatory appropriation, would be crass ignorance and a waste of the opportunities that we need to wake up to and take advantage of intelligently and fairly. We are in a good position to do so. But we need to do it, and more.

By way of example, as stated by psychiatrist and professor Ricardo Moebus [of the Federal University of Ouro Preto, in Minas Gerais State], among the integrated therapies accepted by the Brazilian National Health System (SUS), there is great diversity of practices coming out of other countries and continents, such as acupuncture, Reiki, and homeopathy, but there is still no quilombola (maroon community) or Indigenous input.

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The study, conducted by researchers based in the UK, Finland, and USA, is just one in a wave of studies that has been examining the effects of climate change on mental health.

According to a report published in the journal Nature in April, climate change is having a negative impact on mental health. Almost a billion people are already affected by mental illness, which is one of the biggest health issues facing the world today.

Scientists have identified several ways that the consequences of global warming affect mental health, from trauma caused by hurricanes, floods, droughts, and wildfires to the phenomenon of ecoanxiety (chronic worrying about environmental damage).

Although further studies are needed on how to help people prevent or deal with these problems, some research suggests that activism and taking action against climate change can be an effective method.

Studies indicate that the most commonly afflicted tend to be those who suffer most from climate injustice—groups that are and will be more affected by climate change.

In addition to the young, other frequently affected people include those already living in poverty or experiencing inequality, and people who already suffer from mental health disorders. “Climate change exacerbates existing economic situations, where it's the poorer people who are feeling even worse,” climate researcher and activist Jennifer Uchendu, founder of an environmental group based in Lagos, Nigeria, told Nature.

This new field of research is examining how awareness of climate change and its impacts can cause people to feel worry and stress (or “ecostress”), which has been given various names, including ecoanxiety, climate grief, and solastalgia—described by Australian philosopher Glenn Albrecht as the feeling that “your endemic sense of place is being violated.” Solastalgia is the feeling of missing home, despite not having left.

Global phenomenon

In a 2018 survey, 72% of people aged 18 to 34 responded that negative news about the environment affects their emotional well-being, causing anxiety, racing thoughts, and trouble sleeping.

Another study, carried out during the pandemic in 2020 and published in The Lancet Planetary Health in 2022, indicated that people aged between 16 and 24 years old felt more stress due to climate change than due to COVID-19.

These eco-emotions have previously been dismissed as a concern solely for people in developed nations. But studies like the one cited at the beginning of this article, which found that Brazilians are among the most concerned about the climate, have challenged this perspective.

Of all respondents from the 10 countries in the survey, more than 45% stated that climate change had an impact on their diet, work, sleep, or other aspects of their daily life.

The most likely to report that it impacted their ability to function normally were people from the Philippines, India, and Nigeria, and the least likely were the USA and the UK, contrary to the idea that such concerns are exclusive to residents of rich countries (see graph).

Treatment options

Scientists emphasize that understanding and treating mental health problems exacerbated by the climate crisis will be an immense challenge in a world where mental healthcare is already subpar.

In low- and middle-income countries, only around 3% of people with depression receive adequate treatment, while in rich countries the figure is 23%. At the same time, many communities are finding their own ways to overcome these obstacles, but the effectiveness of their efforts is little studied and shared.

Some evidence suggests that taking action to address the impacts of climate change can help people deal with eco-anxiety. Another recommendation is to limit the amount of time spent reading negative news about the subject.

Researchers are also starting to take collective action. One of the most ambitious research projects on mental health related to climate change, Connecting Climate Minds, released a series of research and action priorities, such as understanding how climate change is linked to the stress caused by war, violence, and epidemics in sub-Saharan Africa.

The project includes researchers, policymakers, and individuals who are experiencing climate change firsthand. Uchendu, one of the scientists interviewed by Nature, says that one of these individuals recently joined an online meeting held by the group. The room he was calling from had been flooded.

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When it comes to anxiety, the situation is no better. Unfortunately, the data are even more alarming. Brazil is facing an anxiety epidemic, with the highest prevalence in the world. Approximately 18.6 million Brazilians (9.3% of the population) are living with the disorder.

Mental illness generates global economic losses of US$1 trillion per year.

But let’s not focus only on the negatives. Brazil is also the country with the greatest biodiversity in the world. The country is home to more than 116,000 catalogued animal species and 46,000 plant species across six terrestrial biomes and three major marine ecosystems.

Not to mention those we don’t yet know about. And what do these two sets of figures, from seemingly unrelated topics, have to do with each other?

If you’ve ever heard about One Health, you may already have the answer. This year, we began celebrating National One Health Day, which falls on November 3, with the aim of raising awareness of the inseparable relationship between animal, human, and environmental health.

When people feel stressed, they often seek out nature as a way to relax, recover, reenergize, and reinvigorate themselves. This seemingly intuitive urge has been the subject of psychology research since the 1960s, when the biophilia hypothesis was formulated. The theory, popularized by American biologist Edward Wilson (1929–2021) in the 1980s, suggests that human beings have an innate tendency to seek connections with nature because Homo sapiens itself is a part of nature.

Another classic study from the 1980s, published in the journal Science, demonstrated that surgical patients whose rooms offered views of green areas were discharged earlier and required less analgesia compared to those with views of buildings.

The experience is a result of an individual’s perception and/or interactions with elements of the natural world (from potted plants and private gardens to large green public spaces and areas of wilderness, as well as the weather and movements of the sun) through a variety of sensory stimuli (vision, hearing, taste, touch, and smell), in addition to feelings of connection, aesthetic appreciation, and previous, positive experiences in nature.

It has been shown that adults who were more exposed to nature as children have better mental health than those who were not. The psychological wellbeing of a population has been related to factors such as living near green spaces, blue spaces (i.e. aquatic and marine environments), and trees in streets or private gardens.

Contact with nature has been identified as a useful resource for managing attention deficit and hyperactivity disorder (ADHD).

The evidence also suggests that compared to urban experiences, exposure to nature translates into emotional benefits, which in addition to reducing anxiety, depression, and aggression, also alleviates rumination and negative moods, while preserving or increasing positive impacts.

There are also cognitive benefits, such as improved working memory—the type used to carry out day-to-day tasks.

Mental fatigue

A concept known as Attention Restoration Theory explains how nature reduces mental fatigue. This same mental fatigue increases the longer we spend in front of technological screens (which drain our attention and energy).

A person’s undirected sense of attention when walking in nature, for example—which may be drawn to a singing bird, a beautiful flower, or a sweet smell in the air—helps the brain recover from mental exhaustion, reflecting therestorative environment of the natural world.

Being close to nature was a determining factor in improving mental health, reducing stress, and increasing well-being during the COVID-19 pandemic. This contact varied from spending more time in the backyard, as people began making better use of immediately available natural spaces for emotional regulation, to people from urban areas seeking refuge in nature during those difficult times, many of whom decided not to return to the city, even after the pandemic ended.

Oh, and the birds! Birdsong is one of the elements of natural environments most cited in scientific literature as offering significant perceived restorative benefits. An abundance of birds in the area in which a person lives has also been associated with a lower prevalence of depression, anxiety, and stress.

Returning to the numbers, in a country with 1,825 bird species, many of which live in urban areas, any given person has at least 20 species in their neighborhood. It is therefore just a matter of paying attention, listening to them sing, taking a deep breath, and feeling your well-being being nourished by nature.

Opinion articles do not necessarily reflect the views of Science Arena or Einstein Hospital.

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