In Vienna, where Sigmund Freud once championed the need for free mental healthcare, the city’s outpatient clinics for children and teenagers have become vital in addressing the rising mental health pressures on young people. Freud’s belief in prioritising the poorest remains relevant, with recent data showing a rise in symptoms among those from low-income backgrounds.

by Alexei Korolyov

When, in 2019, the City of Vienna unveiled the second of its six planned outpatient clinics specifically designed for children and young adolescents (the first having opened in 2003), no one could have foreseen that the world was on the brink of a global pandemic, large-scale wars in Europe and the Middle East, and the economic instability that would follow. Yet, by 2023, a study by Vienna’s Psychosocial Services (Psychosoziale Dienste Wien) found that some of the biggest pressures on young people’s mental health were the cost-of-living crisis (59%), Russia’s war in Ukraine (30%) and the aftershocks of the coronavirus pandemic (21%).

The most common mental health issues – though not necessarily linked to these pressures – include ADHD (attention deficit hyperactivity disorder), depression, first-episode psychosis (a mental state where a person may lose touch with reality), anxiety, as well as post-traumatic and personality development disorders. “We are seeing an increasingly similar picture with young people as with adults,” says psychiatrist Katrin Skala, who is set to lead the fifth clinic opening this month in Vienna’s 9th district. All the clinics handle a range of cases – each sees between 600 and 800 patients a year – but each has a specific focus, or ‘Kompetenzzentrum.’ The newest clinic, in the 21st district, specialises in borderline personality disorder, for instance.

Beyond psychiatry

Youth mental health is not just about psychiatry. It also intersects with the world of criminality, particularly when a patient is the victim, or a suspected victim, of domestic violence – such cases are reported to the police. However, matters become more complicated when the patient themselves may be involved in illegal activities, such as drug use or dealing. Under patient-doctor confidentiality, PSD is not permitted to disclose any details to the authorities unless there is an immediate danger to the individual or others. “It’s important to see everything in context,” says Ewald Lochner, Coordinator for Psychiatry, Addiction and Drug Issues for the City of Vienna. “There are ill individuals, there are criminal individuals, and there are people who have become criminal because of their illness – and these should not be mixed up.”

Freud and social class

One of the early advocates for free outpatient psychiatric care was, perhaps unsurprisingly, Sigmund Freud. Speaking two months before the end of the First World War, Freud argued for state-funded facilities that would treat the mind in the same way that surgeries treat the body. “The neuroses threaten public health no less than tuberculosis,” he proclaimed. The comparison may seem outdated – Freud was speaking in 1918, when tuberculosis was still a major public health issue, and the neuroses he described were largely those caused by the war and the political upheaval of the era – but the principle behind his assertion would, in time, underpin the transformation of healthcare systems across Europe. That transformation, marked by the shift from old-fashioned, closed mental asylums to outpatient care that kept patients within reach of their homes and families, gained momentum in the decades following the Second World War, as understanding of mental illness improved. In Vienna, this shift culminated in the 1970s with the founding of PSD in 1979 and its launch of operations the following year.

In his speech, delivered as it happens to a psychoanalysis congress, Freud particularly highlighted the plight of the poorest, who could not afford expensive private care. The new clinics, he argued, should prioritise working-class communities above all. While Lochner stresses that PSD’s clinics for children and adolescents are open to everyone, PSD statistics suggest that Freud’s vision remains strikingly relevant. Although PSD does not ask patients directly about their financial situation, since 2020 the number of symptoms reported by those in the lowest economic third in Vienna has steadily risen (from an average of 3.6 symptoms in 2020 to 6.7 in 2023). Among this group, the most common issues are exhaustion, anxiety, depressive symptoms and sleep disorders.

Here too, the pandemic has played a part. Before it, many patients were young people who were heavy drug users, predominantly from underprivileged backgrounds. In the years following the lockdowns, however, there has been an increase in patients from all social backgrounds.

How do the clinics work?

Children and young adolescents do not need permission or oversight to be treated at PSD facilities. However, until the age of 14, PSD requires contact with parents or caretakers at some stage; after 14, no such contact is necessary. “Of course, very few six-year-olds come on their own, but it’s not impossible,” says Skala. The clinics are primarily intended for people living in Vienna, but no one is turned away, Lochner adds. Patients can simply walk in, though it’s recommended to book an appointment in advance by phone. Clinic teams also carry out home visits.

As outpatient clinics, patients cannot stay overnight, but in principle, they can come every day. However, when more personalised and extensive treatment is required, patients may be referred to a private practitioner outside the PSD system.