Access to mental healthcare in Europe: methodology
The investigation began in May 2019 and has lasted for many months. It was carried out by Ángela Bernardo and María Álvarez del Vayo (reporting and data); Carmen Torrecillas and Antonio Hernández (data visualization); Eva Belmonte (coordination and editing); Miguel Ángel Gavilanes and David Cabo (data); Olalla Tuñas (interviews); Aspasia Daskalopoulou, Monica Georgescu, and Lucas Laursen contributed to this work.
The sources
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 EDJNet. 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 / 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.
Going more in detail,
1. The prevalence data for mental health problems come from the 2019 Global Burden of Disease, published by the Institute for Health Metrics and Evaluation. We have taken into account the prevalence, that is, the number of individuals with mental health problems at a given moment in relation to the total population during that period of time. We used anxiety disorders and depressive disorders data since they are the most common mental health problems.
2. The Health at a Glance reports of 2018 and 2020 of the Organization for Economic Cooperation and Development (OECD), the World Mental Health Survey, the European Health Information Gateway and the Mental Health Atlas (in their different editions, the latest from 2017) of the WHO, the European Quality of Life Survey (2016) of Eurofound and the European Core Health Indicators (ECHI), the EU Compass for Action on Mental Health and Well-being (2016), the EuroPoPP-MH (2013) report, the Joint Action on Mental Health and Well-being — Depression, suicide prevention and e-health (2017) report, the report on psychologists and related professionals in the European Union (2015) and the EC’s 2014 Eurobarometer dedicated to mental health. In addition, we consulted research related to suicides, differences in access to healthcare and anxiety disorders, burden of disease, psychological care in primary care (PsicAP trial), a review of the state of the mental health care in Central and Eastern Europe, studies on the cost of mental health problems and on mental health care reforms in several European countries, as well as a report by various scientific societies on depression, among others.
3. We sent an initial questionnaire on access to mental healthcare to the national professional organisations of psychology and psychiatry of all countries belonging to the European Union before Brexit, to mental health experts, to non-profit organisations related to mental health, and to journalists from the European Data Journalism Network (EDJNet). The objective was to understand the situation of mental health care in each of the countries, such as whether or not their public healthcare systems covered psychological treatment and the principal barriers and limitations. We sent the same questionnaire by email to health ministry press offices of all EU countries. France, Hungary, Poland, and Portugal did not respond. In the case of Spain, we made a public information request for the 2018 report on psychological care from the General Secretariat of Health condition on which the 2020 recommendations of the Ombudsman on access to psychologists in the national health system were based.
Here’s why we excluded some European countries or ruled out that they offered access to psychological treatment:
Luxembourg: as confirmed by the Ministry of Social Security and the Société Luxembourgeoise de Psychologie, public health insurance (CNS) does not currently cover access to psychological treatments, but they are negotiating a new regulation planned to enter into force during the first semester of 2021, according to the Government.
Cyprus: the health insurance system (GESY) has just been recently reformed, as confirmed by a government spokesperson and the national association of psychologists, to include access to psychologists for the first time, so we lack up-to-date and realistic data on the barriers and limitations.
Latvia: the health ministry confirmed that the psychotherapist is not paid by the State, unless he or she works in hospital care as a member of the multi-professional team, so we recorded that there is no routine public access.
Bulgaria: a spokesman for the health ministry explained to us that psychologists are not covered by health insurance. They are paid out of pocket in outpatient cases or with the budget of the respective hospital where they work.
France: despite not receiving a response from the health ministry, we learned from the national association of psychologists that access to psychology is not covered by the national public healthcare system, although there are several regional pilot projects dating to 2018 for treating mild anxiety and depression in patients between 18 and 60 years old and mental health problems in young people up to 21 years in order to reduce suicide rates. The experimental pilot programs are located in Toulouse, Marseille or Brittany, among others.
Although Belgium is included, there is also a pilot programme to bring access to psychological treatment closer to primary care, or first-line provision. In this specific case, according to Sarah Morsink, an expert in this mental health reform at the Belgian Health ministry, the service provides up to 8 sessions per year, for a co-payment of 11.20 euros per session (which can be reduced to 4 euros for people with financial problems), with average waiting times of 10 days and a maximum of one month, and with access to 750 professionals all over the country. We do not take this data into account in the visualisation since it does not apply to the whole country.
4. We have taken into account that there are two main types of healthcare systems. The Spanish health ministry outlines the differences between the Bismarck and Beveridge systems in this 2019 report.
5. We obtained co-payment data from various sources, including official sources, reports, and interviews with experts. Austria data comes from the social affairs ministry, a 2018 WHO report, information from the Austrian Health Insurance Fund, and from a 2020 scientific article. In the case of Belgium, it comes from the National Institute for Health and Disability Insurance (RIZIV). Denmark data is from the National Association of Psychologists and the National Association of Psychiatrists (DPBO). Estonia data is from a 2018 WHO report and information provided by the National Associations of Psychiatrists and Psychologists. Finland data is from a response of the National Association of Psychologists and that published by the Finnish Social Security (KELA). Germany data is from a 2019 report by the Federal Chamber of Psychotherapists (BPTK). Greece data is from a 2017 WHO report and interviews with a dozen official sources and experts by journalist Aspasia Daskalopoulou. Hungary data is from a 2018 report from the EC on inequalities in access to healthcare. In Ireland, the information is on the official website of the national health system. In the case of Italy, the health ministry establishes a national rate for the co-payment of certain health benefits, as is the case with individual psychotherapy, although in some regions, such as Friuli-Venezia Giulia, Tuscany, the Autonomous Province of Trento, Umbria, Valle d’Aosta and Veneto, the co-payment is slightly higher. Our Lithuania data source is the health ministry. Malta data comes from the National Association of Psychologists. In the Netherlands, we consulted the official information. Portugal data is from a 2016 EC report. In the case of Spain, our sources are the official information from the health ministry regarding mental health care and the list of specialised care services. UK data is from the National Health System (England) related to IAPT therapies. We do not have specific data for Scotland, Wales and Northern Ireland.
We could not confirm co-payment data for Poland, Czechia, Romania, Slovakia, Slovenia, or Sweden.
6. Information on the number of available sessions in psychological care comes from various sources. Austria data comes from the social affairs ministry and a 2018 WHO report. Belgium data is from Sarah Morsink, expert on mental health care reform at the health ministry. Denmark data is from Anne Mette Brandt-Christensen, an expert in mental health care. Estonia data is from the National Association of Psychiatrists. Finland data is from the National Association of Psychologists and the official KELA website. In Germany, the information comes from the health ministry, from a 2019 report by the Federal Chamber of Psychotherapists (BPTK), from Julia Scharnhorst, spokesperson for the EFPA standing committee on Health and Psychology, from the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology e. V. (DGPPN), from some guides to accessing psychological therapy and from two local journalists (Robert Meyer, from Spiegel Data, and Kira Schacht, from Deutsche Welle). We consulted the official website of the Irish health system. We contacted the health ministry and the Lithuanian National Association of Psychiatrists to confirm the limited number of sessions. Netherlands data is from a health ministry spokesperson, who indicated that there was a limitation, but without specifying the specific figure. The Slovakian health ministry told us that there were session limitations, without specifying the number, which we obtained from the expert Barbora Vaseckova. The Spanish national association of clinical and resident psychologists (ANPIR) confirmed to us that there is no limited number of sessions in the public sphere. In Sweden there is no limit, either, per a health ministry spokesperson. In the United Kingdom, we referred to data from the national health system (England), based on the stepped care model (individual cognitive-behavioural therapy), according to the NICE guidelines. We do not have specific data for Scotland, Wales and Northern Ireland.
We did not find specific information for Croatia, Czech Republic, Greece, Hungary, Italy, Malta, Portugal, Poland, Romania, and Slovenia.
In addition, we assumed an hour per psychological session to convert and graph the data for Austria, established at 40 hours, which we have made equivalent to 40 sessions, for comparison to the other national data.
7. We requested by email the number of psychologists in the national healthcare system per 100,000 inhabitants from the following authorities: National Register of Health Care Providers, Croatian Institute of Public Health (Croatia, 2019 data), Sundhedsdatastyrelsen — Authority Health and Medicines (Denmark, 2018 data), Health Ministry (Greece, 2019 data), Institute of Hygiene — Lietuvos Respublikos, Sveikatos Apsaugos Ministerija (Lithuania, 2019 data), National Health Fund data — Health ministry (Poland, 2019 data), National Health Information Centre (NHIC) and Slovak Psychological Association — Health Minister (Slovakia, 2020 data), Register of health care providers and health care workers — National Institute of Public Health — Minister Za Zdravje (Slovenia, 2020 data), Health ministry (Northern Ireland, UK, 2020 data). In other cases, we obtained the information from reports and official statistics: National Institute for Health Development (Estonia, 2019 data), Irish Government — Health Service Employment Report October 2020 (Ireland, 2020 data), Report Il personale of the Italian health system — Anno 2017 (Italy, 2017 data), Relátorio CNS — Conselho Nacional de Saúde (Portugal, 2019 data), Socialstyrelsen — Statistical Database, Health Care Practitioners (Sweden, 2018 data), NHS Workforce Statistics (England, United Kingdom, 2020 data), Stats Wales (Wales, United Kingdom, 2020 data), NHS Scotland (Scotland, United Kingdom, 2020 data). In the case of Spain, we made a public information request to the General Secretariat of Health, to obtain the 2018 report on the situation of clinical psychology in the national health system on which the 2020 recommendation of the Ombudsman was based. It contains 2018 data.
It was not possible to obtain data from the rest of the countries of the European Union, despite multiple requests to the respective Ministries of Health and, in some cases, to other official health care or statistical research entities.
The recommendation to have 20 psychologists for every 100,000 inhabitants or, in other words, 1 psychologist for every 5,000 inhabitants, comes from a report published in 2012 by clinical psychologists Michael Byrne (Principal Psychology Manager, Health Service Executive of Ireland) and Andrea Branley (National University of Ireland). This ratio is very similar to one previously proposed by the British Psychological Society. We tried to contact the authors of the report, without receiving a response at the close of this article. We checked the recommendation with Dr. Javier Prado, from ANPIR, who told us that it is an excellent proportion, which in Spain would offer an “excellent degree of assistance, not only limited to mental health as now, but in primary care, oncology, neurology, bariatric surgery, childhood and adolescence in various formats.”
We have not used the data from the WHO 2017 Mental Health Atlas, although it provides information on the number of psychologists per 100,000 inhabitants in some European countries. The reason is that the data are inconsistent with information provided to Civio by the official authorities of each country, there are significant inconsistencies with data from previous atlases, and the WHO does not explain their methodology or publish their raw data. We asked the WHO about the origin of the information and their explanations did not include their methodology or the national data by countries, so we ruled out publishing it.
We also relied on a 2015 EC report on regulated professions. Regarding the differentiation between psychologists, psychotherapists and similar definitions, we note that certification and regulation differs. Not all countries regulate access or the specific training that is needed for the exercise of the profession of psychologists. Some countries distinguish between clinical psychologists and health psychologists while others do not make any type of differentiation or require any type of specific training. Some have mandatory requirements (for example, in Spain, it is necessary to do a specific master’s degree to work as a general health psychologist — the previous qualification consisted of an accreditation of 400-hour training, with at least 100 hours of internships; while, in the case of clinical psychologists, it is necessary to pass the corresponding exam of the Specialised Health Training, the PIR). In those countries where there are both psychologists and psychotherapists working in the national health system, we have included both types of professionals because according to an EU report, psychologists are specifically included in the ISCO classification (International Standard Classification of Occupations), produced by the International Labor Organization. In particular, the one used for psychotherapists falls within the 2634 category, although they do not always have the same training or professional requirements. This decision is also supported by the fact that, to date, there is no complete harmonisation of the profession of psychology at European level, despite the EuroPsy initiative, promoted by the European Federation of Psychologists’ Associations (EFPA), which was not sufficiently successful, given that the certification of these professionals today is not the same in all EU countries.
8. Information about waiting lists comes from various official sources, studies and analyses, depending on the country. In the main visualisation, we consider only the information related to the average wait times. The waiting range in Germany comes from a 2018 report and a 2019 analysis published by the Federal Chamber of Psychotherapists. In Portugal, the national health system publishes detailed data on waiting times per service, including psychology, in the country’s hospitals, so we have calculated the average. The UK data for England, Wales and Scotland comes from the OECD analysis. Official data from the websites of the National Health Service (England), National Health Service (Scotland) and National Health Service (Wales) were also checked. No information was found for Northern Ireland.
In the case of Spain, we made a public information request to the General Secretariat of Health, to obtain the 2018 report on the situation of clinical psychology in the national health system on which the recommendation of the Ombudsman is based.
In other cases, although they are not specified in the visualisation, but are specified in the text, we have found maximum waiting times or general comments about waiting lists in mental health. In the case of Austria, the problems about waiting times were discussed by journalist Stefanie Braunisch, from Quo Vadis Veritas, and mentioned in a 2019 scientific article on access to healthcare; the specific data come from a 2015 report on psychotherapy that was published by the OECD. In Belgium, waiting lists are one of the most important barriers in access to mental health: this 2020 report mentions wait times between months and years, without providing specific data. In the Czech Republic, we know that there are long waiting lists, according to information provided by Pavel Bartusek, Czech journalist at VoxEurop. In Denmark, the information comes from a 2020 OECD analysis of mental health services, without explicitly referring to psychology, which numbers 94% of patients who were seen by mental health services in less than 30 days. This same document mentions waiting data for Finland of around 90 days (which can be extended to 6 months in less urgent cases). In the case of Ireland, the analysis of the psychological care programme in 2018 indicated that the majority of the participants (76–80%) waited a period of up to four months. Waiting times in the Netherlands and Poland also come from the 2020 OECD mental health care report. Our Sweden data comes from the same OECD report, whose original source is the country’s national health system, which lists maximum time limits to be seen by a specialist, without specifically mentioning psychological care. For Lithuania, data on waiting times broken down by centre comes from this official source, which lists care by “medical psychologists”. For Slovenia, we know that there is a long waiting list, as confirmed by the National Association of Psychologists, but we have not been able to specify a specific amount of time. For Italy, we have information about long waiting lists (as explained here). Waiting times depend on the urgency to visit the specialist and can range from: urgent priority (as soon as possible or within 72 hours), short-term priority (within 10 days), deferred priority (within a 30-day period for exams), programmable priority (to be done within 120 days). An example of waiting times in an Italian region, which assumes a period of time of several weeks, can be found here. As Roberto Ferretti, former president of the Italian Society of Psychology of Hospital and Territorial Services (SIPSOT), explains in this interview, Italian patients are usually treated within weeks.
We have not found specific information on this indicator in relation to Croatia, Estonia, Greece, Hungary, Malta, Romania and Slovakia.
9. The data on prices for private consultations come from estimates requested from national associations of professional psychologists. We asked for an indicative range per individual session in private consultation with a psychologist in their country. The following entities answered: Berufsverband Österreichischer PsychologInnen (Austria), Vlaamse Vereniging van Klinisch Psychologen (Belgium), Дружеството на психолозите в Република България (Bulgaria), Hrvatsko psihološko društvo (Croatia), Czech-Moravian Psychological Society (Czechia), Eesti Psühholoogide Liit (Estonia), Suomen Psykologiliitto (Finland), Fédération Française des Psychologues et de Psychologie (France), EFPA standing committee on Health and Psychology an the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology e. V. (DGPPN) (Germany), Magyar Pszichológiai Társaság (Hungary), Italian Network of Psychologists’ Association (Italy), Lietuvos psichologų sąjunga (Lituania), Société Luxembourgeoise de Psychologie(Luxembourg), Malta Chamber of Psychologists (Malta), Ordem dos psicólogos (Portugal), Colegiul Psihologilor din Romania (Romania), Drustvo psihologov Slovenije (Slovenia) and Sveriges Psykologförbund (Sweden). In the case of Spain, we contacted the General Council of Psychology and all the official colleges (provincial and autonomous) of psychologists, without receiving a satisfactory answer. Only the press office of the Official Colexio de Psicoloxía de Galicia and the National Association of Clinical and Resident Psychologists (ANPIR) gave us approximate estimates of the price of private consultation. We also checked the Spanish estimate by doing a random search in several Spanish cities using the Doctoralia application. In other cases, the figures are estimates made by non-profit organisations dedicated to mental health: Mental Health Ireland (Ireland) and Liga za duševné zdravie SR (Slovakia); or by renowned experts in mental health: Anne Mette Brandt-Christensen (Denmark) and Mattia Indi Gerin (United Kingdom). Finally, the information on Greece has been obtained by the freelance scientific journalist Aspasia Daskalopoulou, after consulting the following sources: Georgios Moussas, Director of the Psychiatry Department of the Thoracic Diseases General Hospital “Sotiria” and Professor of Psychiatry at the National and Kapodistrian University of Athens; Dimitris Georgakopoulos, Head of the Department of Community Public Health Services at the Ministry of Health; Kostas Bousoulas, psychologist-psychotherapist at a Mental Health Centre in the centre of Athens, where he is providing adult community mental health services; Dimitris Kyriazis, private psychiatrist; Marilena Komi, (private psychotherapist; Chrysanthi Kantziou, head of the Independent Department for the Supervision of the Development and Function of the National Organization for Healthcare Services Provision (EOPYY), health ministry; Areti Antonoudi, from the Department of Strategic Development, National Organization for Healthcare Services Provision (EOPYY); Kostas Moschovakis, Director, Department of Mental Health, Ministry of Health. Journalist Danuta Pawlowska from Biqdata-Gazeta Wyborcza/Agora, collected our Poland data, after consulting the Polskie Towarzystwo Psychologiczne. Journalist László Arató, verified Hungarian price ranges for private consultations with psychologists in Budapest and rural areas of the country.
We do not have available data on prices for private consultations in Cyprus, Latvia and the Netherlands.
In addition, in the cases of the Czech Republic, Denmark, Sweden and the United Kingdom, our raw data was in the respective national currencies, so we applied the exchange rate of the European Central Bank corresponding to December 17; in the case of Hungary and Poland, we used the December 18, 2020, rate, since we got that information later.
10. In order to obtain the hours necessary to pay the co-payment in each country and the private consultation of a psychologist, we used the minimum interprofessional salary per country for the last semester of 2020, published by Eurostat. In those countries that do not have a minimum wage (Austria, Denmark, Finland, Italy and Sweden), there is a minimum wage established for certain jobs by collective agreements. In these five cases, a Eurofound analysis published the collective bargaining wages of the ten lowest paid sectors and estimated an average with the lowest three figures, which has been used in our calculation. Based on these figures, we calculated the daily salary per worker in all countries, taking into account a maximum limit of annual hours of 1,720 hours / year for all, since it is the limit the European Commission uses to calculate working hours for scholarships and grants in the Horizon 2020 programme. The reason for using this limit is that there is no annual limit on working hours by law, but there is a weekly limit dictated by Convention 132 of the International Labor Organization (ILO) and Directive 2003/88/CE of the European Parliament and of the Council, dated November 4, 2003, as explained to us by Dr. Cristóbal Molina, professor of Labor Law at the University of Jaén and Dr. Ignasi Beltrán, associate professor of Labor Law at the Open University of Catalonia.
11. Together with the people and organisations mentioned above, we want to thank Robert Meyer (Spiegel Data), Kira Schacht (Deutsche Welle), Stefanie Braunisch (Quo Vadis Veritas), Laszlo Arato (Index.hu), Danuta Pawlowska (Biqdata-Gazeta Wyborcza/Agora), Leonard Wallentin (J ++), Rita Marques Costa (Público.pt), Anze Bostic (Pod crto), Ivana Peric (H-Alter) , Rossen Bossev (Capital), Emanuela Barbiroglio (freelance), Bartosz Chyż (Gazeta Wyborcza), Andreas Vou (VoxEurop), Giuseppe Rizzo (Internazionale), Alexandra Spanu (VoxEurop), Pavel Bartusek (VoxEurop), Anna Udre (freelance), Massimiliano Sfregola (31mag.nl), Andreas Vou (VoxEurop), Orlane Jézéquélou, Catherine Andre and Laurent Jeanneau (Alternatives Economiques), Irene Caselli (freelance), Mariangela Maturi (freelance), Lorenzo Ferrari, Chiara Sighele, Federico Caruso (OBCT / CCI) and Gian-Paolo Accardo (VoxEurop).
