Pay up or put it off: how Europe treats depression and anxiety
In many European countries, the availability of psychological treatment in the public healthcare system is inadequate or even non-existent. Barriers such as long waiting lists, co-payments and inadequate resources push people with anxiety or depression – those who can afford it – to the private system.
“Mental health is like the dentist. In most countries of the European Union, everything that happens to you physically is covered, but to go to the dentist you have to pay extra and it’s the same for taking care of your mental health,” says Marcin Rodzinka, spokesperson for Mental Health Europe .
This article is part of EDJNet’s large investigation on mental healthcare in Europe. We’ve also covered the impact of Covid-19 on mental healthcare, the persistence of psychiatric institutions, and the record-high use of antidepressants.
Depression and anxiety are the most common mental health conditions diagnosed in the European Union. Four out of every 100 people have been diagnosed with depression, five out of every 100 with anxiety. The conditions should not be underestimated, as is often the case, says Javier Prado, spokesperson for the National Association of Clinical and Resident Psychologists in Spain (ANPIR ): “If they are not treated on time and the right way, they end up generating a very significant disability.”
Yet national public healthcare systems do not always include treatment for these problems, despite the fact that in some EU countries, such as Portugal, the Netherlands or Ireland, anxiety exceeds seven cases per 100 people. Greece is the country with the highest prevalence of depression, followed by Spain and Portugal. Nel Zapico, president of the Spain Mental Health Confederation , explains the importance of these high rates, especially the number of people with depression: “It is a scourge, because it also has a sometimes quite dramatic exit and that has a lot to do with suicide”.
When depression ends in suicide
“It is very important to talk about mental health. It is very important to talk about suicides. To get rid of the taboo. I have tried to commit suicide. I am a suicide survivor,” says Andrés Colao, spokesperson for AFESA , an association of family members and people with mental illness. A 2017 European Commission-funded report noted that a lack of proper diagnosis and treatment of depression may be one of the main causes of high suicide rates in Europe. Lithuania has one of the highest rates of depressive disorders, and the highest number of suicides, with 25.8 deaths for every 100,000 people in 2016, according to Eurostat . Suicide has a lot to do with mental health, but other things contribute. “It is a multifactorial issue,” Prado says. Among the main factors determining the situation in Lithuania are the country’s traumatic history, social taboos, high rates of alcohol consumption and underdeveloped prevention programs, according to a 2017 analysis .
However, these figures are incomplete. Not all people who need treatment for anxiety or depression receive it or are even diagnosed. This gap in treatment may be due to several factors and is bigger in Eastern Europe. “In the case of Poland, the data show a very limited number of people with mental health problems, but it is because the majority do not go to consultation, so they are not diagnosed. It is not that there are no people with mental health problems, it is that stigma prevents access to treatment,” Rodzinka says. Poland and Romania have the lowest reported prevalence of anxiety and depression across Europe.
“The stigma is related to the idea that mental health problems are dark things, related to psychiatry, with the madman who hears voices but, in reality, that confuses things and hides the most common problems,” Prado says. Stigma is the main obstacle to getting care for people with mental disorders, according to a 2013 European Commission-funded study .
“There is a lot of shame and fear associated with the idea of going to a psychiatrist. No one talks about it openly in Romania, so no one knows what to expect from an appointment with the psychiatrist. I think most have a negative mental image because no one wants to be labelled as crazy. However, I believe that the idea of going to psychological therapy is increasingly accepted in this country,” says Maria, a Romanian user of psychological therapy who prefers not to reveal her real name.
However, even when people overcome stigma, other obstacles can prevent them from receiving the ideal treatment free of charge in the shortest possible time. They can prevent people with common – but significant – mental health problems from accessing proper diagnosis and treatment. A high number of people with depressive symptoms do not seek treatment because they believe that treatment will not help or that there is no solution or that their symptoms are normal after a traumatic life event.
Others consult a doctor about physical symptoms such as insomnia or fatigue and get medication for these ailments but do not get sufficient psychological treatment to detect the origin of the problem, according to a 2017 European Commission-funded report . “Evidence shows that access to mental health care can be unsatisfactory even in high-income countries with universal health care coverage and well-developed community care systems,” according to a 2016 European analysis .
However, none of these figures show all the people who suffer from mental health ailments but lack diagnoses. Similarly, while most European countries’ public healthcare systems claim to provide access to mental health treatment, many fail to reach users in practice.
“To be honest, I don’t even know if public healthcare covers psychotherapy in Romania. I went directly to a private one that a friend recommended to me,” Maria says. Not all countries of the European Union grant access to a psychologist in the national health system. Bulgaria and Latvia only cover psychiatry, for example. France does not include psychologists in its health system, although in 2018 it began a pilot program for them in some regions. Luxembourg is now negotiating the entry of psychologists into the health system.
Even countries that on paper cover access to psychologists have gaps. For example, in countries where healthcare operates through mutual insurance companies, there are groups of uninsured people who therefore lack access to any type of healthcare coverage. In Estonia many people go without health insurance part of the time. In both Romania and Slovenia, the majority of Roma or homeless people, among others, do not have health insurance and therefore lack mental healthcare, according to a 2020 Health Policy study .
In other cases, insurance companies prioritise minor, easier to treat problems over more serious disorders, as in the Netherlands. Regardless of the healthcare model, the obstacles are repeated in every EU country with public psychological coverage. “There are three main problems: stigma, waiting times and user fees in some countries,” Rodzinka says. Most European countries with publicly funded access to psychologists also limit the number of consultations and suffer insufficient human and financial resources.
A solution that arrives late
“Mental health services have to be agile, accessible and fast. When a person seeks help because they are ill, they need a response as quickly as possible,” says Marta Poll, psychologist and director of the Catalan Mental Health Federation . Long waiting lists for therapy continue to be one of the main problems in countries where publicly funded psychologists are available. In at least seven EU countries, people have to wait more than a month for an appointment with a psychologist.
“When a person is in a state of need or sometimes in a state of emergency, there must be a way to give them an agile response because in some cases, such as depression, they can end in suicide. And in other cases, preventable problems can become chronic,” says the president of the Spain Mental Health Confederation .
One solution may be to impose waiting maximums . This happens, for example, in the UK and Germany. In Germany, if the waiting time exceeds a limit, people can obtain reimbursements for treatment by a private psychologist. But every law has a loophole: a BBC investigation revealed that the United Kingdom only applied the reimbursements to the first appointment with the specialist. Wait times exceeded the limit for subsequent appointments.
The Italian region of Trieste, in contrast, opted for an open-door system, where anyone can access treatment directly without an appointment, according to Roberto Mezzina , a psychiatrist and former director of the ASUI Trieste Department of Mental Health.
In at least nine EU countries, people must pay additional fees to access a psychologist in the public healthcare system. The price varies between countries and even between regions, such as in Italy, but it can be one of the biggest obstacles to accessing treatment. In addition, some countries limit the number of sessions. For example, the Slovak Ministry of Health says: “The number of sessions, the insufficient number of psychologists or psychotherapists or the lack of community treatment” are some of the problems in the country, although not the only ones.
Psychology is not a priority branch within European public healthcare systems , neither in resources nor in personnel, nor is the related field of psychiatry . “There are very good professionals, the problem is the precarity of the system,” says Montse Aguilera, a member of an association for the rights of people who, like her, have a mental health problem. Countries such as Spain, Italy, Portugal, Greece and Croatia have fewer than the 20 psychologists per 100,000 people , recommended in 2012 by psychologists writing in The Irish Psychologist. Sweden and Denmark, in contrast, have more than 50 psychologists per 100,000 people. Although the ratios in these countries are much higher than the European average, some experts say it is still too low.
You can treat it if you can afford it
“It is difficult to compare the situations between countries, but we know what the limitations and barriers are. There are many, but the most obvious is the fact that mental health is not covered by the state or the health insurer in many of the countries, so you have to pay for it out of your own pocket,” Rodzinka says.
In Romania, a worker on the minimum wage would have to work, on average, almost four days to pay for a single session with a private psychologist. In Slovakia, Estonia and Croatia this figure exceeds two days. At the other extreme is France, where although its public healthcare system does not cover psychological treatment, a private consultation costs less than one days’ wage. “The private sector helps a lot to bridge the gap, but it is not accessible to everyone. It can be useful for people with high incomes, with jobs or for people who are aware that they have a psychological problem, need help and can pay for it,” Rodzinka says. That leaves out the neediest.
Discover the differences in access to mental health in Europe, and the sources we’ve used.
This is the result of an investigation that began in May 2019 and has lasted for many months. Aspasia Daskalopoulou and Monica Georgescu contributed to this work.
We started the investigation by soaking up the subject: we interviewed experts and read reports, papers and previous research on the subject. We discovered that there was no data on the reality of access to mental health, and that the official data did not fully reflect the problem. They were superficial.
So, we decided to create our own database from scratch. We sent a questionnaire on access to psychological treatment in the national health systems of all the countries of the European Union (including the United Kingdom, since the research was carried out prior to Brexit). We sent the questions to professional organisations of psychiatrists and psychologists in all EU countries, to various mental health non-profit organisations, to mental health experts and to journalists from the European Data Journalism Network. We also sent them to the press offices of all EU health ministries, with the exception of Spain, where we made a public information request.
In order to create our database and make it as up-to-date and rigorous as possible, we also asked all EU health ministries for the most recent data on psychologists per capita in their national health systems. Finally, we asked national organisations of psychology professionals to give us an estimate of the price ranges in private practices in their respective countries.
In parallel, we consulted numerous official reports and statistical sources, from the Organization for Economic Cooperation and Development (OECD ), the World Health Organization (WHO ), the European Commission (EC), the Institute for Health Metrics and Evaluation (IHME ), Eurofound , among others. The objective was to verify the information we had and to collect new data to put in context or explain all these barriers to access.
Once we had a first draft of the database, which was refined over the course of several edits by our team members and grew during the reporting phase, we interviewed mental health experts, psychiatrists, psychologists, activists, people with mental health conditions, and their relatives, to gather first person testimonies.
In the estimates of co-payments and prices for private consultations, we used minimum wages as of the last semester of 2020, from Eurostat , except in the case of Austria, Denmark, Finland, Italy and Sweden, where we used extrapolations based on collective bargaining agreements from a Eurofound report , given that they do not have a general minimum wage. Furthermore, as there is no maximum limit on annual working hours, we calculated these data with an estimate of 1,720 hours per year for all countries, the figure used by the EC to calculate annual working hours for scholarships and grants in the Horizon 2020 programme .
The visualisations are embeddable in multiple languages and have been developed with D3.js, ai2html.js and scrollama.js.
Click here to read the detailed methodology.
Eva Belmonte, David Cabo, Miguel Ángel Gavilanes and Olalla Tuñas contributed to this investigation.