“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.
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 (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.
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.
Why we exclude some European countries or rule out that they offer 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.
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 and member of EDJNet. 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 in the methodology, 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 Gianpaolo Accardo (VoxEurop).
12) The visualisations are embeddable in multiple languages and are written in D3.js, ai2html.js and scrollama.js.