A study presented at the European Psychiatric Association Congress 2025 reveals deep socioeconomic inequalities in reported need for mental health care across the European Union. The research highlights how financial barriers disproportionately affect lower-income individuals, with significant disparities also linked to education level, whether the person lives in a city or in the countryside, and geographic location.
Led by Dr. João Vasco Santos, a public health physician, health economist, and professor at the University of Porto, the cross-sectional analysis used data from the 2019 European Health Interview Survey (EHIS), covering 26 EU member states. The survey among others asked participants whether they had gone without needed mental health care in the previous 12 months due to financial constraints.
Measuring Unmet Needs: A Financial Lens
The EHIS captures self-reported experiences, focusing specifically on financial reasons as a barrier including to accessing mental health services.
Across the EU, the proportion of self-reported unmet needs for mental health care varied widely — from as low as 1.1% in Romania to as high as 27.8% in Portugal, with a median of 3.6%.
Dr. Santos emphasized that while many European countries have moved toward mixed health systems — blending elements of Beveridge- and Bismarck-style models — financial protection remains inconsistent. Even in countries with universal coverage, out-of-pocket costs for medications, therapy, diagnostic testing, or medical devices can create substantial barriers.
“This is not just about whether care is public or private,” explained Dr. Santos. “Even in systems that are largely public, co-payments can be a burden. And sometimes, vulnerable groups—like migrants or asylum seekers—are excluded altogether.”
Cultural Perceptions Shape Reporting
One of the most striking findings was the stark contrast between Romania and Portugal. Dr. Santos cautioned against interpreting these figures at face value.
“It’s not just about the availability of services — it’s also about awareness and cultural perception,” he said. He noted that in Portugal, “we’re increasingly open about mental health and the mental health service.”
Portugal has been one of the countries that is spearheading the new perception of mental health care. “The UN Convention on the Rights of Persons with Disabilities laid the foundation for the much-needed paradigm shift in mental health. From an exclusively medical approach to one based on the respect of the human rights of persons with mental health conditions and psychosocial disabilities,” Ms Marta Temido, Minister of Health of Portugal told during a United Nations consultation meeting in 2021.
Ms Marta Temido stressed that “In Portugal, we have been making significant efforts to align our laws, policies and practice with human rights.”
She specifically pointed out that “We have clearly made an option for community-based mental health services instead of institutionalization. We have been improving access to outreach care, through the launching of community teams for adults and for children and adolescents.”
In countries like Romania, stigma remains high, and is influenced by a long history of institutionalized care that fails to meet basic human standards. It should be obvious that if the psychiatric system hasn’t evolved much beyond large psychiatric institutions with reported human rights violations, one might think twice before reporting need of help.
Dr. Santos noted that in countries where mental illness is stigmatized or misunderstood, individuals may avoid reporting symptoms altogether. In some cases, people may not perceive a need for care because of limited exposure to mental health education or fear of discrimination.
Education and Inequality
The study also revealed a strong correlation between educational attainment and unmet needs. In 15 out of 26 countries analyzed, individuals with only primary education were significantly more likely to report going without mental health care than those with tertiary education.
“In Bulgaria, Greece, Romania, and Slovakia, this disparity is especially pronounced,” Dr. Santos noted. The pictures across the European countries however is quite complex, as exemplified with France where the opposite is the case. In France people with tertiary education showed a higher unmet need of mental health care. This indicate that further studies may be needed which could look at adjusting for income and other factors. The study conducted only considered the educational related inequalities.
Pandemic Impact and Future Trends
Although the study drew on pre-pandemic data (from 2019), Dr. Santos warned that the pandemic likely exacerbated existing inequalities.
“We know that mental health deteriorated during the pandemic — there was increased violence, isolation, and trauma,” he said. “At the same time, access to care was disrupted. I suspect the next wave of data will show a rise in unmet needs, particularly among lower-income and marginalized groups.”
However, he stressed that longitudinal comparisons must be made carefully, noting that changes in survey design over time can affect results.
“The goal must be to leave no one behind,” Dr. João Vasco Santos
Policy Recommendations addressing socioeconomic inequalities
To address these systemic challenges, Dr. Santos outlined a series of priorities that require coordinated action at both national and regional levels.
First, he emphasized the importance of expanding universal coverage to ensure that all individuals — including migrants and asylum seekers — have access to essential mental health services without facing financial hardship. He called for reforms that would exempt low-income and chronically ill populations from co-payments, even in systems where care is otherwise publicly funded.
Second, he advocated for a shift toward community-based care models, which improve accessibility, reduce stigma, and foster integrated, person-centered treatment approaches.
Third, Dr. Santos underscored the need for national and regional mental health strategies that incorporate public education campaigns aimed at improving health literacy.
“The goal must be to leave no one behind,” he concluded. “Health is an investment — not just in individuals, but in the resilience and equity of society as a whole.”
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First published in this link of The European Times.
