Psychopharmacology Access Gaps in Brazil’s SUS: Policy and Research Implications

Brazil’s SUS Faces Persistent Gaps in Mental Health Drug Access

Brazil’s Sistema Único de Saúde (SUS), the country’s universal public health system, remains the primary provider of mental health care for millions, but a 2026 integrative review (OpenAlex W7213420574) finds that access to psychopharmacological treatments is marked by significant regional disparities and a lag in the adoption of newer therapies. The study documents an 18.6% increase in mental health medication use between 2022 and 2024, yet 21.6% of eligible municipalities still lack effective Psychosocial Care Centers (CAPS), the backbone of community-based mental health care in Brazil. This data-driven finding underscores a dual reality: while overall access is expanding, structural and policy barriers continue to prevent equitable distribution of care.

Mechanisms: Outdated Formularies and Regional Inequality

The review identifies two primary mechanisms behind these access gaps: the limited scope of the Relação Nacional de Medicamentos Essenciais (RENAME, Brazil’s National Essential Medicines List) and persistent regional inequalities in the deployment of mental health infrastructure. RENAME, which guides public sector drug procurement, currently omits several internationally recognized, evidence-based treatments, including intranasal esketamine and other novel agents such as brexanolone and NMDA (N-methyl-D-aspartate) antagonists. This exclusion, combined with uneven CAPS coverage, means that patients in many regions are restricted to older antidepressants, antipsychotics, and mood stabilizers, even when newer, potentially more effective options exist.

Notably, the review points out that while global guidelines from bodies like the American Psychiatric Association and the European Psychiatric Association increasingly recommend newer agents for treatment-resistant depression and other severe conditions, SUS protocols and RENAME have not kept pace. This creates a policy lag that directly impacts patient outcomes and the ability of clinicians to offer up-to-date care.

Policy Proposals: Expanding RENAME and Updating Protocols

The authors propose a multi-pronged policy response to bridge these gaps. First, they recommend expanding RENAME based on rigorous cost-effectiveness criteria, drawing on health technology assessments to justify the inclusion of newer drugs. Second, they advocate for the development of "territorialized" prescription protocols—guidelines tailored to local epidemiological and resource realities—rather than a one-size-fits-all national approach. Third, the review highlights the potential of telepsychiatry to extend specialist support to underserved regions, and calls for ongoing training of primary care prescribers to safely and effectively manage complex psychopharmacological regimens.

For advocates of psychedelic and novel neuropsychiatric treatments, the review’s findings are instructive: even as global research advances, the translation of innovation into public sector practice hinges on national policy, regulatory adaptation, and the realities of health system capacity. The Brazilian context demonstrates that inclusion on national formularies is a critical gateway for access, and that evidence alone does not guarantee adoption.

Risks, Unknowns, and Implementation Challenges

Expanding access to newer psychopharmacological agents in the SUS is not without risks and unresolved questions. The review notes that cost-effectiveness analyses must account for Brazil’s constrained public health budgets, and that real-world effectiveness and safety data for novel agents in diverse, resource-limited settings remain limited. There is also the risk of exacerbating regional inequalities if new therapies are introduced only in better-resourced urban centers, leaving rural and remote populations further behind.

Another underappreciated challenge is the need for robust pharmacovigilance and prescriber education. Newer agents such as esketamine require careful monitoring for adverse effects and misuse, and their integration into primary care settings demands sustained investment in training and support. The review’s call for territorialized protocols is a recognition that local adaptation, not just national policy change, will determine the success of any expansion effort.

Looking Forward: Implications for Research, Policy, and Access

The Brazilian experience offers a concrete lesson for researchers and policymakers worldwide: the pathway from clinical innovation to public health impact is shaped as much by formulary policy and health system logistics as by scientific evidence. For those advocating for the inclusion of psychedelics or other novel neuropsychiatric treatments in public systems, the review highlights the importance of engaging with national health technology assessment processes, building local evidence on effectiveness and feasibility, and designing implementation strategies that address regional disparities.

One non-obvious implication surfaced by the review is the potential for telepsychiatry and decentralized training to act as force multipliers, enabling the safe rollout of complex therapies even in settings with limited psychiatric specialists. However, without parallel investment in infrastructure and ongoing evaluation, these innovations risk remaining pilot projects rather than systemic solutions.

How we research: This article was researched and written by Dr. Mariana Alves, MD, MPH, with review of primary sources including the full OpenAlex-cited review, Brazilian Ministry of Health protocols, and international psychiatric guidelines. Reviewed by Dr. Mariana Alves on 2026-09-18.