In the past few decades, the mental healthcare system in the European Union (EU) has been facing several challenges and transformations. Findings of high rates of mental disorders prompted changes in management and provision of care throughout the EU, moving from large, isolated institutions, which rely on custodial care and social exclusion, to a community-based model of care that emphasizes the integration between health and social services and the fostering of social inclusion. This process was fueled by a different attitude of society towards mental disorders and disability, and growing evidence that a system based on hospital services provisions is insufficient to ensure access to mental health care and to offer continuity of follow-up for people with severe and persistent disability [1]. The balanced care model has been formulated as a conceptual framework for providing the full range of services, including inpatient care, at community level [2].

The EU officially endorsed a policy based on deinstitutionalization [3]. The milestones in the development and reform of mental health policies in Europe were the Mental Health Declaration for Europe, and the Mental Health Action Plan for Europe in 2005 [4,5]. The European health ministers committed themselves to the development of community-based mental health services, thereby downgrading large mental health institutions [6]. Around 83% of European countries now have a mental health policy in place, and 95% have a mental health legislation [7]. However, the implementation of a community-based system has been encountering many barriers, with different countries showing different levels and extent of implementation.

Here, following the conceptual scheme of service accessibility and coverage outlined by Barbato et al., [8] (Figure 1), we aim to describe the status of the development of community-based services by giving an overview of current population needs, service accessibility and coverage in the EU with the most recent data taken from the World Health Organization Mental Health Atlas (WHO-MHA) [9]. However, although we rely primarily on WHO-MHA, we will consider other sources of data as well, such as OECD [10] and Eurostat [11]. With the term “EU” we will refer to the EU27 together with Switzerland, the United Kingdom, Iceland, and Norway.

Mental health problems affect tens of millions of Europeans every year. In 2016, about 84 million (one out of six people) of people living across EU countries were suffering from a mental disorder, representing 17.3% of the general population. Considering the single diagnostic categories, prevalence of anxiety disorders was estimated at 5.4%, depressive disorders at 4.5%, substance abuse disorders at 2.4%, bipolar disorders at 1%, schizophrenia at 0.3%, and other disorders at 3.7% [12]. However, the use of categorical psychiatric diagnoses as a measure of need in epidemiological surveys has been challenged for a number of reasons. First, careful examinations of diagnostic assessment tools reveal high levels of inconsistency, limiting the reliability and reproducibility of diagnoses, especially for common mental disorders [13]. This could partly explain the difference in rates found between epidemiological estimates at European level and data provided by studies conducted in single countries, such as NEMESIS [14] and ESEMED [15]. Moreover, beyond the concerns about validity, the widespread comorbidity of mental disorders can lead to overestimated rates and in many cases common mental disorders are transient, self-limited, not associated with disability or not requiring care from mental health services [16,17].

Therefore, conclusions on population care needs must consider the severity level and the related disability to ensure a targeted and efficient allocation and use of resources. Whereas severe and moderate cases reflect a need of more intensive and integrated treatment, disorders of mild severity might benefit from informal care, adherence to healthy lifestyles and low intensity interventions [18,19]. WHO Mental Health surveys presented data on prevalence by severity of mental disorders in some EU countries, identifying high, moderate, and mild severity [20]. If we consider that moderate and high severity are associated to a need for treatment, we could assume that a rate around 10% represents the prevalence of mental disorders severe enough to benefit from treatment [8]. More accurate data on the public health impact of mental disorders have been provided by the Global Burden of Disease Study. Considering prevalence, severity, disability and comorbidity, age-standardized rates of 2002/100,000 population Disability Adjusted Life Years due to mental disorders were estimated for Western Europe [21].

The COVID-19 pandemic widely impacted population, by heightening the risk factors for mental disorders and weakening the protective factors, especially among young people, women, and people with low socio-economic status [22]. The prevalence of symptoms of depression during the first year of the pandemic doubled in adults in several European countries, and even showed a four-fold increase among young people [22]. Such numbers suggest a worrisome situation and give new urgency in addressing the challenges of adapting the EU mental health systems to population care needs.

In European countries, primary care is the main entry point to the healthcare system for more than 50% of people seeking help for mental disorders [20]. Early identification of mental disorders, management of people with stabilized disorders, treatment of physical illness in mentally ill persons, referral to specialist services and direct treatment of common mental disorders are important functions of primary care services. However, few data are available to assess the performance of primary care practitioners in those areas [8]. Some models have been developed to foster the integration between physical and mental care, but their implementation is relatively limited. The best examples in this field are the collaborative and stepped care approach for depression first developed in United Kingdom [23].

Looking at specialist mental health services, at the top of the pyramid, a distinction should be made between the traditional mental hospitals and the community-based services delivering the full range of treatments at community level: inpatient care in general hospital psychiatric units and community residential facilities, outpatient and home care provided by community mental health centers, outpatient clinics and day care centers [9]. It is worth noting that available data refer to care provided by public services or by private services paid by public funds or compulsory insurance schemes. No large epidemiological survey in Europe assessed the treatments delivered in office-based private practice by psychiatrists and psychologists, although sparse indications suggest that, at least in some important countries such as Germany, private practice can play a role in care pathways [24]. Private practice remains to a large extent an uncharted territory for mental health services research.

The country profiles derived from the WHO survey questionnaires presented information about services, gathered within the framework of the WHO-MHA, which was developed as a worldwide data repository on mental health policy, legislation, resources, services availability, and utilization to track progress in implementing the WHO's Comprehensive Mental Health Action Plan 2013-2030 [9]. Data presented in Table 1, Table 2, Table 3 were gathered from the WHO-MHA country profiles [25]. Specifically, the services offered by category are shown in Table 1, indicators of access to care in Table 2 and mental health workforce in Table 3. Supplementary Table 1 shows a comparison of hospital beds data taken from different sources, namely WHO-MHA [25], Eurostat [11], and OECD [10].

There are a consistent lack of data and huge variations across countries in almost all indicators. Bed rates in mental hospitals are the most widely available indicator, as 28 out of the 31 countries provided information (Table 1). 23 out of 31 countries gave information on outpatient facilities and general hospital psychiatric beds, and only 20 on community residential facilities. A median of 31 beds in mental hospitals per 100,000 population has been reported across the EU, with large differences among countries, ranging from the lowest (Italy, 0) to the highest rate (Belgium, 119). The number of beds in mental hospitals can be used as a proxy of the shift towards community-based care. Italy is the only country which has moved away from institutionalization, whereas Belgium heavily relies on psychiatric hospitals. Low bed rates do not necessarily mean that the country is shifting towards community care, but at least in some countries it might also suggest a lack of investment and resources.

However, it is worth noting that in most countries reporting data about both mental hospitals and community services the offer of community care is coupled with the presence of a sizeable institutional care sector. Some countries, such as Germany, show a top level of community resources alongside with a top level of mental hospital beds (Table 1). It is not surprising that figures of mental hospital beds consistently reported, given the easier accessibility of data. Mental hospitals, being more consolidated as providers of mental healthcare, have more harmonized information systems compared to general hospitals and community residential facilities. The latter indicators yield less data, reflecting the recent history of these types of facilities in many countries, and maybe a lack of consideration of a component of the services [26].

Data about service use (Table 2) confirm and strengthen the findings about service availability. Although the comparison across countries is plagued by even higher rates of missing data, a few countries providing full data still show huge differences in services utilization. Considering the admissions to any inpatient setting as a whole, five-fold differences or more in admission rates can be observed. The situation is even more striking for outpatient contacts, raising serious concerns about the quality of data collection. Although it looks like many countries heavily rely on inpatient admission as an answer to mental health problems, it is worth noting that, considering both mental hospitals and general hospitals, data found in WHO Mental Health Atlas are not consistent with those presented by both OECD and Eurostat (Supplementary Table 1) [10,11]. Unfortunately, both OECD and Eurostat, unlike WHO, add up the number of beds in both mental and general hospitals, making it challenging to clarify the reasons for such striking disparities.

Mental health workforce data can provide information about the investments in mental health care. In line with the data on mental hospitals, the most consistent reports are those about number of psychiatrists, whereas the least information is found in social workers’ rates (Table 3). The consistent reporting of data on psychiatrists exemplifies a greater attention towards their role in mental health services and supports the assumption that the education and training of mental health personnel is leaning towards a medical approach, rather than a psychosocial one. The latter would better fit the nature of mental health conditions and of the services providing care. Therefore, besides a general increase of health professionals, a greater presence of professionals trained in psychosocial interventions is needed.

To address the health workforce crisis that the EU is facing [27], viable strategies to optimize the use of available resources should require reallocating mental health professionals from mental institutions to community services, while also involving peer support and third-sector workers. According to the 2014 WHO-MHA, in the WHO European region, 80% of the mental health workforce were engaged in inpatient services, with only 20% in outpatient services [28]. However, there is a lack of detailed data on personnel distribution across specific services, as a number of staff members could work across both inpatient and outpatient settings. No data are available on this issue. Similarly, there is inadequate reporting on mental health professionals in the private sector, and no comprehensive mapping of service provision outside the healthcare [9]. Nonetheless, the shift from mental institutions to community-based care encompasses a change of roles, expertise, and responsibilities of staff to move from custody and coercion to care and treatment [7,29]. While the traditional psychiatric treatments are based on standardized diagnostics and treatment tools, there is growing consensus among experts that a personalized and flexible approach to mental health is better fitting the interindividual differences in mental disorders and is linked to better outcomes [30,31]. Therefore, the role of the various healthcare professionals must adapt to this change by increasing flexibility in their duties and approaches. This could be achieved by increasing training capacity and invest in community mental health training programs at universities and colleges.

Albeit the urgency of addressing population needs has been a focus of concrete action plans, there is a conspicuous lack of data which makes the transition towards community-based services difficult to assess. The indicators of mental health services availability and access could be a resourceful proxy of the actual healthcare utilization, but interpretation is challenging due to factors such as missing data, low quality of data and different service definitions. For instance, more information on mental workforce should be provided, such as distribution, geographical accessibility, qualifications, and specific services offered by the health professionals to have a better indication of the relative investments and shift towards community-based care. The optimal balance and rate of mental health professionals in community-based care is not defined, and benchmarking systems should be developed to make cross-country comparisons possible.

Including mental health in the priorities of public health agenda has been recognized since 2005 and several attempts to collect, exchange and assess information on national policies and activities in mental health have been carried out in Europe. The issues of incomplete data and the lack of comparable data on mental health systems was highlighted long ago [32]. Moreover, the consensus paper on access to mental care in Europe, presented on behalf of the EU within the framework of the EU Compass for Action on Mental Health and Wellbeing, issued as its first key recommendations the establishment of a consensus on clear operational definitions of any meaningful mental health indicator, mental health service and patters of care to be used in routine data collection, as well as the commitment to member states to improve the quality of mental health-related data reporting [8]. However, as time goes by, it looks like few steps have been taken in this direction and no reasonable explanation is available to clarify the roots of this problem and to design strategies to address it.

The WHO-MHA is considered to be the most accurate and complete information on mental health service provision available [33], but some countries failed to report pieces of information, and sometimes whole country reports were missing. Moreover, as previously said, the WHO-MHA data are not consistent with data coming from other sources. The discrepancy could arise if the WHO-MHA questionnaires are distributed to different national ministries departments, where respondents may have different understanding of the services. Although a guide and an explanation of definitions were provided, those were often unclear, leading to a collection of data not in the manner requested by the questionnaires [34]. Quality control was not ensured, leading to a poor quality of the information, thereby limiting research, the possibility of a comprehensive overview, and the development of firmly evidence-based policies [35]. A serious problem affecting the quality of information is the lack of international consensus on the classification and description of the services, which may lead to different definitions. Recent initiatives to reach an agreement on terms and definitions concerning mental health care provision and financing in Europe have been proposed but not yet fully accepted [36]. To develop effective policies, reliable data are essential. When discrepancies exist among various sources, determining the most accurate estimates becomes challenging. One solution to address conflicting data is to establish a common repository of data to be sent to international organizations (such as OECD, Eurostat, WHO) along with a standardized glossary of terms describing both hospital-based and community-based services. Therefore, advocating for an international consensus is crucial in this regard.