Municipal spending on school health services is unequally associated with dual-factor mental health profiles: a latent profile study of 63,000 Swedish adolescents, 2006–2024

BACKGROUND: Adolescent mental health has declined internationally, prompting increased investment in school-based services. However, whether such investments benefit all students equally remains unclear. We examined whether municipal spending on school health services is associated with adolescent mental health in Sweden, and whether this association differs across distinct profiles. These profiles, defined using the dual-factor model, separate adolescents' psychiatric symptoms from their school well-being. METHODS: Data were drawn from Stockholmsenkäten (the Stockholm Survey), a biennial population-based survey of 9th-grade students (approximately 15 years) in Region Stockholm, Sweden. The analytic sample comprised 63 190 students across 26 municipalities surveyed between 2006 and 2024. Latent profile analysis identified four mental health profiles based on psychiatric symptoms and school well-being: Complete Mental Health, Troubled (high symptoms, low well-being), Vulnerable (low symptoms, low well-being), and Symptomatic but Content (high symptoms, adequate well-being). Municipal spending on school health services (per student, lagged two years) was decomposed into within-municipality (year-to-year change) and between-municipality (stable differences) components, both entered as predictors in the model. A multilevel multinomial logistic regression (students nested within municipalities) estimated associations between spending and profile membership, controlling for student gender and survey year. RESULTS: Complete Mental Health declined from 55.6% (2006) to 45.4% (2024), while the Troubled profile more than doubled (3.4% to 7.2%). The Vulnerable profile remained stable at approximately 17%. Within-municipality spending increases were associated with 16% lower odds of the Troubled profile (OR = 0.84, 95% CI 0.73-0.95, p = .007) but only a borderline, non-significant association with the Vulnerable profile (OR = 1.08, 95% CI 0.99-1.17, p = .084). Spending was associated with 9% higher odds of the Symptomatic but Content profile (OR = 1.09, 95% CI 1.01-1.17, p = .026), possibly reflecting a compositional shift from the Troubled profile, as students who retain psychiatric symptoms nonetheless regain adequate school well-being. Between-municipality differences in average spending were largely unrelated to profile membership. CONCLUSIONS: Increased municipal spending on school health services was associated with a lower prevalence of the symptomatic Troubled profile, consistent with services reaching students whose distress is visible, but showed no comparable association for the Vulnerable profile, that is, students whose difficulties manifest as low school well-being without psychiatric symptoms. From a precision public health perspective, these findings suggest that school-based services may need to complement their symptom-oriented focus with systematic attention to school well-being in order to reach the Vulnerable subgroup, who comprise roughly one in six adolescents and showed no measurable association with spending in this study.