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Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies

Part of: Self Harm and Suicide: A Global Priority

Published online by Cambridge University Press:  27 February 2026

Abir Aldhalimi Open the ORCID record for Abir Aldhalimi [Opens in a new window]
Abir Aldhalimi*
Affiliation:
School of Medicine, Yale University, USA
*
Corresponding author: Abir Aldhalimi; Email: Abir.aldhalimi@yale.edu
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Abstract

Suicide is the third leading cause of death among children and youth aged 10–24, and nearly three-quarters of suicides occur in low- and middle-income countries (LMICs). Despite global efforts, children and youth mental health and suicide prevention remain underprioritized in national policy and are often deployed separately in LMICs. Governments should develop standalone, multisectoral mental health policies for children and youth that integrate suicide prevention strategies and that address social determinants of suicide risk. This commentary aims to inform national policymakers, global health and international development actors, and researchers engaged in the mental health and suicide prevention of children and youth in LMICs.

Keywords

suicidechildyouthmental healthchildren and youth mental healthpolicy

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Type
Perspective
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Cambridge Prisms: Global Mental Health , Volume 13 , 2026 , e53
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Impact Statement

Suicide is the third leading cause of death among people aged 10–24, and nearly three-quarters of suicides occur in low- and middle-income countries (LMICs). Structural and social factors, including poverty, violence, marginalization, unemployment, unregulated social media use and digital harm, increase distress and vulnerability to suicide. Yet, despite recognition by the Lancet Commission on Adolescent Health and Wellbeing (2025) and the World Health Organization (2025a), national children and youth mental health and suicide prevention policies remain scarce, fragmented, underfunded, often deployed separately, and do not address social factors (Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018). This commentary argues that governments should develop standalone, multisectorial children and youth mental health policies that embed suicide prevention efforts, are rights-based, and address the social determinants that increase suicide risk (Pirkis et al., Reference Pirkis, Dandona, Silverman, Khan and Hawton2024). These efforts require collaboration across national governments, global health and international development actors, and researchers.

Introduction

Children and youth aged 10–24 account for a substantial share of the mental health burden in low- and middle-income countries (LMICs; Gore et al., Reference Gore, Bloem, Patton, Ferguson, Joseph, Coffey, Sawyer and Mathers2011; World Health Organization, 2022). Suicide is the third leading cause of death among this age group, and nearly three-quarters of suicides occur in LMICs (World Health Organization, 2025a). This commentary, consistent with global health policy frameworks, including those developed by the World Health Organization (2021) and the Lancet Commission on Adolescent Health and Wellbeing (2025), focuses on children and youth within this age range.

Children and youth differ developmentally, socially, and psychologically from adults and face distinct mental health and suicide risks and barriers to care. For example, children and youth are more likely to experience violence, bullying, and harm associated with social media use. Further, children and youth may encounter obstacles to health care access related to consent, privacy, and confidentiality, especially when seeking services without a parent or caregiver. Their unique experiences underscore the need for standalone mental health policies.

The crisis of children and youth suicide in LMICs is a policy emergency as much as a public and mental health emergency, and governments play an important role in addressing these challenges. Children and youth mental health policies and suicide prevention efforts are rare in LMICs. When governments do employ them, they are often executed separately. This siloed approach undermines the sustainability of these well-intentioned efforts. Suicide is complex, and prevention efforts are more likely to be effective and sustainable when they are embedded within mental health policies that are multisectoral. Consistent with the World Health Organization’s Guidance on Mental Health Policy and Strategic Action Plan (2025b), these policies should also address social determinants, use a rights-based perspective, and deploy a whole-of-government approach supported by sustainable funding.

Prior studies have found that suicide in LMICs is associated with structural, social, and economic stressors (Iemmi et al., Reference Iemmi, Bantjes, Coast, Channer, Leone, McDaid, Palfreyman, Stephens and Lund2016; Knipe et al., Reference Knipe, Williams, Hannam-Swain, Upton, Brown, Bandara, S-S and Kapur2019), especially when mental health care is limited. These stressors include exposure to violence and war, civil unrest, potentially traumatic experiences, poverty, marginalization, and discrimination based on identity, loneliness, and the use of social media (Barry et al., Reference Barry, Clarke, Jenkins and Patel2013; United Nations Children’s Fund, 2021; Kirkbride et al., Reference Kirkbride, Anglin, Colman, Dykxhoorn, Jones, Patalay, Pitman, Soneson, Steare, Wright and Griffiths2024). This points to the fact that mental health policies and prevention strategies must go beyond the health sector and be situated in economic, education, democracy, and human rights sectors.

Policy gap

Children and youth mental health is underprioritized in national policies, despite calls by major actors in the global mental health space, including the Lancet Commission call for large-scale investment (Lancet Commission on Adolescent Health and Wellbeing, 2025; Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018). While the World Health Organization’s Mental Health Atlas (2024) reported that nearly half of the surveyed countries had a children and youth mental health policy or plan, it does not distinguish between standalone policies and plans that are integrated into adult mental health initiatives, making it difficult to assess progress in standalone children and youth policies. Even where policies exist, implementation is limited by scarce human and financial resources.

Suicide prevention efforts are even less developed. Only 6% of low-income countries (as defined by the World Bank’s income classification system) that responded to the World Health Organization’s data call reported having an existing suicide prevention strategy, and none had programs in active implementation (World Health Organization, 2024). In lower-middle-income countries, 37% of the respondents noted having a national plan, and 36% reported an actively implemented program. While an improvement, this average is still well below that of upper-middle-income countries (51% have a strategy, and 49% have a plan) and high-income countries (67% have a strategy, and 73% have a plan; World Health Organization, 2024). In other words, the countries with the highest rates of children and youth suicide have yet to prioritize suicide prevention. Moreover, few LMICs tailor their suicide prevention efforts for young people.

These findings highlight that mental health policies or plans are often established separately from suicide prevention strategies in LMICs. Suicide is often recognized as a public health crisis, and efforts to address suicide are often led by either non-governmental organizations or governmental health departments (Vijayakumar and Phillips, Reference Vijayakumar, Phillips, O’Connor and Pirkis2016; Pirkis et al., Reference Pirkis, Dandona, Silverman, Khan and Hawton2024). While there are benefits to departments of health leading such efforts, including having dedicated funding, designating one sector as the sole leader of a suicide prevention program risks a lack of integration into broader, more sustainable mental health systems.

Further, children and youth most often interact with professionals outside the health sector, such as those in schools and communities. Therefore, a comprehensive approach to mental health care should include efforts to strengthen peer support and peer educators, train teachers and community mental health workers, and increase access to evidence-based digital mental health services (Galagali and Brooks, Reference Galagali and Brooks2020).

Policy examples

Sri Lanka was able to decrease the suicide rate by 70% between the 1990s and 2010s by restricting access to pesticides (Knipe et al., Reference Knipe, Gunnell and Eddleston2017). Although this approach has been successful, it does not address the factors that increase suicide risk, such as economic and social hardships, or create mental health systems for early detection or continuity of care. Recent reporting by the World Health Organization (2025c) documents youth in Sri Lanka continuing to struggle with suicide in high numbers, with 15% of youth having considered attempting suicide in the last year. Further, 1 in 10 reported attempting suicide, according to self-reported survey results. The World Health Organization’s reporting highlights the complex social, health, and economic challenges youth face in the country. Further, Sri Lankan mental health services are underfunded nationally, especially for young people, which may impact mental health workforce development (Vijayakumar and Phillips, Reference Vijayakumar, Phillips, O’Connor and Pirkis2016). While the government has been attempting to introduce a more modern, rights-based mental health law since 2005, mental health policy reform has not been successful. The country’s current mental health law focuses largely on detention or involuntary hospitalization of those with mental illness rather than community-based care (Hapangama et al., Reference Hapangama, Mendis and Kuruppuarachchi2023).

Sri Lanka’s approach presents possibilities and limitations of national suicide prevention strategies centered on means restriction. While pesticide control is one of the most effective population-level suicide prevention strategies, emerging evidence suggests that comprehensive suicide strategies require a multisectoral approach. According to the World Health Organization’s Live Life framework (2021), national suicide prevention strategies for children and youth need a layered approach that includes responsible media reporting, promotion of socio-emotional life skills, and early identification, assessment, management, and follow-up. These interventions are strengthened by the policy framework outlined in the World Health Organization’s mental health policy guidance (2025b). The success of national suicide prevention strategies will depend on effective governance, robust financing, workforce development, multisectoral interventions, and rights-based service delivery.

In contrast, Australia’s standalone children and youth mental health policy may serve as a helpful model. Australia’s policy includes strong legal protections, age-appropriate and rights-based care, early detection, workforce development, and clear accountability across government branches. It works alongside their National Mental Health and Suicide Prevention Plan (2025–2035). In this plan, Australia not only establishes a holistic, system-wide approach to suicide prevention, but it also addresses social and structural factors that increase suicide risk, including financial hardship, housing, and social inclusion (Australian Government National Mental Health Commission, 2025). The approach is based on human rights principles and employs education-sector policies, child-protection frameworks, school-based and community programs, and clinical services (Hung et al., Reference Hung, Choi, Liao, Bowden, Ong, Hwang, Kakimoto, Ni, Nishio, Garcia-Quiroga, Wong, Lu and Chang2025).

Policy considerations

Governments should formally recognize the intertwined nature of children and youth mental health, suicide prevention, and social and economic factors. This recognition can begin with the establishment of standalone, multisectoral, rights-based mental health policies designed specifically for children and youth. Standalone policies would strengthen governance while operating within national mental health systems and working across sectors. Taking recommendations from the Lancet Commission on Adolescent Health and Wellbeing (2025), the World Health Organization (2025b), and the United Nations Children’s Fund (2021), policies should prioritize early detection, prevention, continuity of care, and rights-based service delivery.

Comprehensive suicide prevention can be embedded within these policies, with interventions that include public education, restricting access to means of suicide (e.g., pesticides), and the decriminalization of suicide attempts (World Health Organization, 2021). Interventions should also include crisis intervention services, community-based care models, and clear referral pathways to specialized mental health providers (World Health Organization, 2013; Vijayakumar and Phillips, Reference Vijayakumar, Phillips, O’Connor and Pirkis2016). In line with the World Health Organization’s Guidance on Mental Health Policy and Strategic Action (2025b), dedicated budgets and long-term financing plans must back these policies (Zhou et al., Reference Zhou, Ouyang, Nergui, Bangura, Acheampong, Massey and Xiao2020; World Health Organization, 2021) and be designed and implemented across various government sectors. Progress should be tracked through quantifiable performance indicators with clear accountability plans (United Nations Children’s Fund, 2021).

These broad policies should also address social determinants, especially those related to economic hardship and poverty, such as minimum wage and unemployment, to reduce the financial burdens that contribute to mental health distress and suicide risk. Policies that reduce discrimination and protect human rights, strengthen social cohesion and reduce loneliness, foster social support, and implement school-based and workplace wellness initiatives are also vital to reducing the risk of mental health distress and suicide (Kirkbride et al., Reference Kirkbride, Anglin, Colman, Dykxhoorn, Jones, Patalay, Pitman, Soneson, Steare, Wright and Griffiths2024; Pirkis et al., Reference Pirkis, Dandona, Silverman, Khan and Hawton2024).

To ensure policies reflect the realities and needs of communities, the policy development process needs to include meaningful engagement with children, youth, and families. Children and youth should be engaged at all stages of the policy development process to ensure solutions reflect their lived experience and foster trust in mental health systems (Lancet Commission on Adolescent Health and Wellbeing, 2025; Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018). The design of these policies must involve diverse stakeholders from the community, non-government, and private sectors, engaged in youth mental health and suicide prevention efforts, ensuring a comprehensive societal approach (Vijayakumar and Phillips, Reference Vijayakumar, Phillips, O’Connor and Pirkis2016).

It is well established in the literature that there is a workforce shortage of specialists in children and youth mental health and in suicide response. Mental health policies should therefore prioritize training and expanding this workforce. Efforts might include creating pathways for professional specialization and training non-specialist providers, such as teachers, community health workers, and primary care staff, to deliver basic psychosocial support and to identify early signs of distress (World Health Organization, 2013; Zhou et al., Reference Zhou, Ouyang, Nergui, Bangura, Acheampong, Massey and Xiao2020).

Lastly, digital technology can be an accessible and low-cost intervention to provide mental health services for this age group. Research shows that phone or mobile programs can increase access to mental health care by limiting barriers, such as transportation and stigma. Specific to suicide prevention, digital tools can assist with early detection through screening, provide psychoeducation, offer crisis support by connecting children and youth with helplines or chat services, and provide referral to care (Galagali and Brooks, Reference Galagali and Brooks2020).

The role of global actors

National governments and global development actors should cooperate to close the gap in this critical policy area. International development actors, including the World Health Organization, United Nations Children’s Fund, and the World Bank, as well as implementation science researchers, are positioned to provide effective support to governments. There is a critical shortage of technical assistance and research on mental health policy frameworks and their implementation, especially on mental health policies that include comprehensive suicide prevention initiatives. Global actors are positioned well to strengthen support for national policy development by offering technical guidance to governments, creating strategies to shore up workforce development, elevating youth voices in governance, and building the capacity of mental health ministries and departments, and local non-governmental organizations (NGOs) that advocate for youth mental health and suicide prevention (Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018; United Nations Children’s Fund, 2021).

Zhou et al. (Reference Zhou, Ouyang, Nergui, Bangura, Acheampong, Massey and Xiao2020) conducted a systematic review of youth mental health policies in LMICs and found that limited public awareness of the importance of youth mental health was associated with limited political will among governments to prioritize this issue. Competing priorities, including other public health challenges, place youth mental health at a severe disadvantage. For example, governments have spent approximately 2% of their health budgets on mental health globally (World Health Organization, 2024).

Global actors can move beyond advocacy and position children and youth mental health and suicide prevention as a foundational pillar for human capital development and economic growth. Untreated mental health conditions impede productivity and long-term development (World Health Organization, 2016). In fact, scaling up mental health care, especially for depression and anxiety, results in a fourfold return on investment due to improved productivity and health outcomes (Chisholm et al., Reference Chisholm, Sweeny, Sheehan, Rasmussen, Smit, Cuijpers and Saxena2016). Global actors can increase local government support by leveraging economic data to mobilize funding and to prioritize these issues.

Finally, effective policy development requires collaboration among researchers, international development actors, local NGOs, and governments. Aligning technical assistance with evidence-based policy frameworks, financing mechanisms, and community engagement is vital for effectively translating policy to real progress in children and youth mental health and suicide prevention.

Conclusion

Mental health and suicide prevention in children and youth are public health and policy emergencies. Evidence shows that suicide in LMICs is often associated with social and economic strain, exposure to violence and marginalization, and limited access to mental health care. As such, suicide prevention strategies are most effective when embedded in broad mental health policies that extend beyond clinical care, adopt cross-sectoral, human rights, and community-based approaches, and address social determinants that contribute to suicide risk. Governments can be supported by international development actors, donors, and researchers through technical assistance, evidence-based children- and youth-specific frameworks, community consultations and partnerships, and sustained financing.

In addition to policy commitment, this area is ripe for research. Future research should examine how standalone children and youth mental health policies can be effectively designed and implemented in LMICs. Strengthening these efforts can help inform policy, reduce suicide risk, and improve the mental health of children and youth in LMICs.

Open peer review

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10168.

Data availability statement

No new data were generated or analyzed in support of this research.

Author contribution

Abir Aldhalimi, PhD, developed and wrote the manuscript.

Financial support

This work received no funding.

Competing interests

The author declares no conflicts of interest.

Ethics statement

Ethical approval was not required for this article, as it presents a perspective based on previously published literature.

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Author comment: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR1

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr1 [Opens in a new window]
Abir Aldhalimi [Opens in a new window] Department of Psychology, Yale University School of Medicine, United States
Revision round: 0
Role: author

Comments

Dear Editor,

I am pleased to submit my Perspective article, “Closing the Policy Gap in Child and Youth Suicide in Low- and Middle-Income Countries: The Case for Mental Health Policies,” for consideration in Global Mental Health’s Special Issue on suicide. I am submitting this article as a Perspective.

This article highlights the need for child and youth-focused mental health policies in LMICs that embed suicide prevention, address social determinants, expand the workforce, and prioritize youth participation. Drawing on global evidence and my own experience, I argue for a whole-of-government and whole-of-society approach to make suicide prevention sustainable and effective.

My perspective is shaped by over a decade in policy design and implementation. I have worked in international development, including serving as Senior Advisor on Mental Health at USAID, leading policy work in nearly 20 LMICs. In this role, I worked closely with governments, NGOs, and multilateral organizations to translate evidence into policy and implementation plans. I also served as a mental health advisor in a U.S. Senator’s office, contributing to federal mental health policy initiatives and drafting mental health legislation now signed into law.

I believe that Global Mental Health, particularly this special issue on suicide, is a great fit for this article. Suicide policies and programs must account for the unique needs of vulnerable populations, especially of children and youth. It is difficult to discuss suicide without considering vulnerable and marginalized populations, human rights, and financial and economic disadvantages. I hope that my article contributes to the journal’s mission of advancing solution-oriented research by highlighting the importance of policy development as in global mental health.

I confirm that this manuscript has not been published elsewhere and is not under consideration by any other journal. Thank you for considering this submission. I look forward to contributing to the global dialogue on closing the policy gap in youth suicide prevention.

Thank you for considering this submission.

Sincerely,

Abir Aldhalimi, PhD

Department of Psychology

Yale University School of Medicine

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR2

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr2 [Opens in a new window]
Rachel Jenkins [Opens in a new window] King’s College London, United Kingdom of Great Britain and Northern Ireland
Date of review:  24 October 2025
Revision round: 0
Role: reviewer
Recommendation/decision: minor-revision

Conflict of interest statement

Reviewer declares none.

Comments

This is a timely and well argued paper. There are one or two grammatical glitches.

I would suggest somewhat modifying the call for stand alone youth mental health policies that include suicide prevention so that it is clear that such stand alone policies will also need to be integrated into each of the relevant sector policies eg general health, social welfare, education, criminal justice, employment etc. Otherwise stand alone mental health policies tend not to be well implemented!

I suggest including a box that gives all the usual components of a national suicide prevention strategy, referencing UN/WHO guidance.

I somewhat disagree with the distinction the authors make about suicide in LMIC being more associated with social risk factors and less with mental illness than in HIC. In the studies I am familiar with, both psychiatric disorders and social risk factors are equally relevant in all countries.

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR3

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr3 [Opens in a new window]
Reviewer_2
Date of review:  02 November 2025
Revision round: 0
Role: reviewer
Recommendation/decision: minor-revision

Conflict of interest statement

Reviewer declares none.

Comments

This perspective focuses on how child and youth suicide is inadequately addressed by governmental bodies and national policies in LMIC and suggests, in broad strokes, some reforms that could lead to improved youth suicide prevention in these countries. The author urges LMIC governments, international development partners, and researchers to create dedicated, “whole of-government” mental health policies that address child and youth suicide prevention directly, expand the care workforce, involve young people, and secure sustainable funding and technical support. Overall, the perspective is well-considered and identifies key policy gaps.

I hope the below points will be useful to the author if they would like to refine the perspective.

I suggest clarifying who is the primary audience for this perspective (paper).

The perspective should explicitly state the age group it addresses. Although the manuscript sometimes refers to “children” and at other times to “youth,” it is unclear whether the intended scope includes all individuals under 18, under 24, or the narrower 10‑24 year range mentioned in instances. Clarifying this point would help readers understand whether the perspective applies to the entire child/youth population or solely to the “youth” age range typically recognized by many governments and intergovernmental bodies. That typical youth age range excludes younger children (5‑9 years), who face a non‑zero risk of suicide and could benefit from targeted policy reforms.

Regarding the case‑study section, policymakers unfamiliar with suicide prevention need a clear takeaway. While the examples illustrate successful pesticide‑control campaigns in LMIC, emerging evidence also supports a variety of other preventive approaches—clinical interventions, school‑based education, and community programs. The concluding paragraph of Section 2.2 would be more informative if it summarized the available intervention modalities or levels that might constitute a comprehensive set for a national strategy.

The case studies are limited to two Asian countries, yet LMIC outside of Asia have national strategies. Focusing exclusively on geographically adjacent Asian examples narrows the perspective’s global relevance and may give the impression that those examples and the overall perspective are not more broadly applicable.

Finally, given the rapid expansion of digital technologies and mental‑health applications worldwide, the policy considerations would benefit from a discussion of the potential of digitally based preventive interventions. What is the authors view on how national strategies might leverage technology and digital media for child/youth suicide prevention? If such integration is deemed inappropriate, what is the rationale?

The conclusion claims there is a “clear roadmap” for guiding LMIC toward “integrated, sustainable, youth focused systems.” While the perspective highlights LMIC successes—such as pesticide control initiatives—and outlines useful policy considerations, labeling these examples as a roadmap (i.e., a detailed plan) overstates the extent of the guidance that can be offered, particularly in regions where evidence, money, and political will are most lacking.

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR4

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr4 [Opens in a new window]
Reviewer_1
Date of review:  04 November 2025
Revision round: 0
Role: reviewer
Recommendation/decision: major-revision

Conflict of interest statement

None.

Comments

Thank you for the opportunity to review this important manuscript. This manuscript highlights an issue of central importance for mental health and for adolescent development and wellbeing. The author’s argument is that stand-alone suicide prevention policies are needed specifically for children and adolescents. Additional points raised are the importance of youth involvement and the finding that many youth suicides occur outside the context of experiencing a mental health condition.

The piece could be strengthened in a number of ways. First, the central argument is the need for standalone policies for children and adolescents that focus on suicide prevention and related issues. As a reader, I am left with the question of why standalone policies have greater likelihood of being successful? It would help to describe in more detail what countries have standalone policies. The author cites that more than half of countries worldwide have child and adolescent mental health policies. What are the benefits that have been observed in these countries vs. the other half of the world’s countries that lack such policies? Have the countries with such policies shown greater suicide reduction compared to those without policies? Or are there other indicators, such as those governments with standalone policies have a) greater funding for mental health; b) more child and adolescent mental health providers; or c) some other indicator? It would help to do an analysis of items in the WHO Atlas comparing those countries who do and do not have standalone policies. Overall, on a superficial level, the argument for standalone policies makes sense, but the commentary should go deeper to actually demonstrate that there are some types of positive results of such policies.

Another issue is that the case studies are very brief and not particularly helpful in making the author’s point. From the case studies, it sounds like India has a policy but Sri Lanka does not? Yes, in Sri Lanka, greater reductions were seen because of the pesticide control measures. The author makes the case that pesticide measures are insufficient to generate benefit. However, if one were to compare countries with and without pesticide measures, I am guessing that there would be substantial differences in reduction of suicide rates. Therefore, making the case that standalone policies are the most important step may not hold up if all countries adopted pesticide control measures comparable to Sri Lanka and other countries.

The author raises a very interesting point that suicides often occur outside the context of mental health conditions. There are a number of studies that support this. However, this seems at odds with the demand for stand alone child and adolescent mental health policies. If many of the deaths occur outside the context of mental health conditions, then would an emphasis on mental health policies be insufficient to tackle key causes and factors. The author addresses this by calling for more approaches to social determinants. This seems logical, but outside the purview of an exclusive mental health policy.

Finally, the language used in the commentary is inconsistent with the evidence. The use of ‘must’ in many sentences comes across as demanding something that may still require further exploration. The ‘must’ language is also at odds with some of the statements about youth-led and youth-collaborative approaches—youth may decide that other approaches are needed than standalone policies. The repeated ‘must’ language also comes across as potentially patronizing and colonial from an American institution author directed at the global community.

In summary, this is an extremely important topic. The advocacy for standalone policies is definitely worth exploring. However, considerable more detail about why standalone policies are currently working and would be more successful than other approaches is lacking. Additionally, softening the tone to be something that is more collaborative and in dialogues with governments and youth communities worldwide would be more constructive.

Thank you again for the opportunity to read this important piece.

Recommendation: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR5

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr5 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Date of review:  23 December 2025
Revision round: 0
Role: Handling Editor
Recommendation/decision: major-revision

Comments

Dear Abir, thanks for submitting this perspective for the special issue on self-harm and suicide.

We asked three external reviewers to comment on your manuscript and all agree that the issue is highly relevant but that more nuance and clarity would strengthen this piece.

I hope you’re willing to address their comments as this would be a great addition to our special issue!

Best, Jer

Decision: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R0/PR6

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr6 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Revision round: 0
Role: Editor in Chief
Recommendation/decision: major-revision

Comments

No accompanying comment.

Author comment: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR7

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr7 [Opens in a new window]
Abir Aldhalimi [Opens in a new window] Department of Psychology, Yale University School of Medicine, United States
Revision round: 1
Role: author

Comments

Dear Dr. Galea,

Happy New Year! Thank you for your consideration in publishing my commentary. I’m resubmitting my manuscript: “Closing the Policy Gap in Child and Youth Suicide in Low- and Middle-Income Countries: The Case for Mental Health Policies.” I appreciate the editorial guidance and constructive feedback from the three reviewers. I have made substantial edits and revised the manuscripts in response to the comments. I want to thank you, the team, and the reviewers for the time invested in making this piece stronger. Below, I have responded to each revieweFr’s point.

Response to Reviewer 1

I want to thank Reviewer 1 for the positive assessment of the commentary and for their constructive suggestions.

1. Integration of standalone policies across sectors

I completely agree that standalone child and youth mental health policies must be embedded within a broader, whole-of-government framework to be effective. I have edited the manuscript to state that more clearly. I have included clear language in the intro and in section 2 that explicitly calls for integrating children and youth mental health policies across relevant sectors, including health, education, social welfare, justice, and employment. This clarification has also been incorporated into the policy recommendations section.

2. Inclusion of core components of national suicide prevention strategies

In response to the suggestion to include a summary of evidence-based components of national suicide prevention strategies, I have added language to the manuscript outlining WHO and UN guidance, including the LIVE LIFE framework. I have tied this guidance to the language in the manuscript and emphasized that these components are most effective when implemented as part of comprehensive, youth-centered mental health policies rather than as isolated interventions, as recommended by the UN’s guidance.

3. Clarification regarding psychiatric versus social risk factors

I completely agree that both mental health disorders and social risk factors are relevant contributors to suicide risk in LMICs as well. My intent was not to minimize the role of mental health conditions in LMICs, but to highlight that suicide prevention in these contexts needs to address social and structural stressors alongside clinical care, as suggested by other prevalent articles, which I have cited. I think the call for attending to human rights and ensuring we use a human rights lens when developing mental health policies, as outlined by the UN’s new guidance on mental health policy, showcases that societal factor, including poverty, unemployment, discrimination, and marginalization, are important factors in mental health wellbeing and suicide. It’s incredibly hard to address mental health distress related to marginalization with mental health care alone. I have revised the Introduction to clearly state that mental health and social risk factors co-occur globally.

Response to Reviewer 2

I want to thank Reviewer 2 for investing time in reviewing this commentary and for their detailed, policy-oriented suggestions.

1. Clarification of the primary audience

Thank you for this suggestion. I have revised the Introduction to state that the primary audience for this perspective includes national policymakers in LMICs, international development partners, and global mental health researchers engaged in policy design, implementation, and evaluation. Ultimately, I want policymakers to move the needle on this policy initiative, but global actors play a critical role.

2. Clarification of age group

I appreciate the reviewer’s suggestion to clarify the population of interest. This one is tricky because youth is defined differently in different countries. However, I have referenced a few global health policy frameworks (e.g., the WHO and the Lancet Commission on Adolescent Health and Well-Being). I have aligned the commentary to speak to children and youth aged 10-24.

3. Strengthening the case study takeaway

Thank you for the feedback on the case studies. Your comment helped me think through my use of the term case study. This commentary is too short for me to dive into case studies, but I do want to keep the content on policy examples. I have also edited the section to remove India and to include Australia’s standalone child and youth policy, providing a comparison of a comprehensive approach. Further, in policy considerations, I address a broader set of policy and programming interventions.

4. Geographic scope of case studies

I do agree with you, and I have removed India’s case study and used Australia’s approach as a point of comparison because Australia’s standalone policy and its new suicide prevention strategy are good examples of what I write about in this commentary. It serves as a stark contrast to relying solely on pesticide control.

5. Role of digital and technology-based interventions

I have added a discussion of the potential role of digital technologies in access to mental health services and suicide prevention.

6. Use of the term “roadmap”

I agree that ending the commentary with a clear roadmap in fragmented spaces like global mental health and suicide prevention is an overstatement. I have revised the conclusion to include more measured language, ending it on a note for future research.

Response to Reviewer 3

I want to thank the Reviewer for their thoughtful feedback.

1. Strengthening the rationale for standalone policies

I completely agree that the commentary needed a more justification for standalone programming, and I have made edits to reflect this, including Australia’s model. I also really appreciate the suggestion for future research. I want to acknowledge the current limitations in comparative evidence and clarify that my argument is based on policy development and implementation principles and emerging global practice. Global frameworks are calling for standalone policies to achieve greater visibility, accountability, dedicated funding, and workforce development. There are significant research gaps in this area, but calling for a comprehensive, whole-of-government approach will help move the needle toward ensuring children and youth receive care and establish the conditions for future policy analysis. Further, I do find that even the Mental Health Atlas data collection/indicators can be improved. For example, it isn’t clear in the Atlas whether child and youth mental health policies are standalone or integrated into adult policies.

2. Interpretation of the case studies

I do agree that pesticide control needs to be effective; however, this intervention alone is outside the recommended suicide prevention frameworks, which require a more multifaceted approach. In the case of Sri Lanka, while the data shows improvement, new reporting by WHO showcases high suicide ideation and attempt by youth and points to social and structural factors that may be impacting youth mental health. They also haven’t updated their mental health policies, and their current policy promotes initialization. I have revised that section to include this and reference the WHO’s suicide frameworks.

3. Suicide outside the context of mental health conditions

Thank you for this feedback. I have revised the manuscript to clarify that mental health policies addressing youth suicide must extend beyond clinical care to incorporate social determinants, structural stressors, and multisectoral action. I have revised the context to state that child and youth mental health policies clearly must include cross-sector coordination.

4. Tone and language

I have taken the feedback about the tone seriously. I wanted to convey the urgency of child and youth suicide when using the word must. I have revised the commentary to use more collaborative language.

Thank you again for your time and consideration.

Best,

Dr. Aldhalimi

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR8

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr8 [Opens in a new window]
Reviewer_2
Date of review:  08 January 2026
Revision round: 1
Role: reviewer
Recommendation/decision: accept

Conflict of interest statement

Reviewer declares none.

Comments

I thank the author for their time in preparing the revision and addressing my comments and suggestions. Good work.

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR9

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr9 [Opens in a new window]
Rachel Jenkins [Opens in a new window] King’s College London, United Kingdom of Great Britain and Northern Ireland
Date of review:  21 January 2026
Revision round: 1
Role: reviewer
Recommendation/decision: minor-revision

Conflict of interest statement

Reviewer declares none.

Comments

I am content with the author’s response to the reviewer comments.

I have spotted these glitches in the text .

Abstract

Line 25 Insert missing word here “these policies need to XXXXX structural and social factors””

Intro Line 52 ? insert “when they are embedded WITHIN mental health policies that are multisectoral”

Review: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR10

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr10 [Opens in a new window]
Reviewer_1
Date of review:  24 January 2026
Revision round: 1
Role: reviewer
Recommendation/decision: accept

Conflict of interest statement

None.

Comments

The author adequately my concerns and added helpful illustrative examples.

Recommendation: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR11

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr11 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Date of review:  10 February 2026
Revision round: 1
Role: Handling Editor
Recommendation/decision: minor-revision

Comments

R2 has a few minor/technical errors that should be resolved before accepting.

Decision: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R1/PR12

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr12 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Revision round: 1
Role: Editor in Chief
Recommendation/decision: minor-revision

Comments

No accompanying comment.

Author comment: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R2/PR13

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr13 [Opens in a new window]
Abir Aldhalimi [Opens in a new window] Department of Psychology, Yale University School of Medicine, United States
Revision round: 2
Role: author

Comments

Dear Dr. Galea,

Thank you for your feedback and for the great news on the acceptance of this article. I am pleased to resubmit my manuscript, “Closing the Policy Gap in Child and Youth Suicide in Low- and Middle-Income Countries: The Case for Mental Health Policies.”

I would also like to thank the reviewers again for their time and thoughtful feedback. In this resubmission, I have addressed Reviewer 2’s comments, made non-substantive light revisions for clarity and flow, and updated several references. I attempted to differentiate between the WHO’s references by placing a, b, and c to align the content with the appropriate references. Those three references were in 2025.

Thank you again to you and the team for working with me on this piece.

Best regards,

Dr. Aldhalimi

Recommendation: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R2/PR14

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr14 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Date of review:  18 February 2026
Revision round: 2
Role: Handling Editor
Recommendation/decision: accept

Comments

I have reviewed the most recent edits made to the manuscript and verified that the author has addressed the pending issues.

Decision: Closing the policy gap in children and youth suicide in low- and middle-income countries: The case for mental health policies — R2/PR15

Published online by Cambridge University Press:  27 February 2026
DOI: https://doi.org/10.1017/gmh.2026.10168.pr15 [Opens in a new window]
Jerome Galea [Opens in a new window] Social Work, University of South Florida, United States
Revision round: 2
Role: Editor in Chief
Recommendation/decision: accept

Comments

No accompanying comment.