Mental disorders affect an estimated 84 million people in Europe, with a lifetime prevalence approaching one in four individuals.1 Yet a marked mismatch persists between the scale of their consequences and the level of investment they receive. Beyond prevalence alone, mental disorders impose a substantial burden in terms of disability, personal suffering, and both direct healthcare and broader social impact. This non-fatal burden is captured through Years Lived with Disability (YLDs). In 2021, mental disorders—excluding substance use disorders and suicide—accounted for 161.2 million YLDs worldwide (17.2% of the total), exceeding cardiovascular, kidney, and chronic respiratory diseases combined.2 They remain among the leading causes of disability globally.
Despite this, resource allocation for mental health remains disproportionately limited. In Europe, direct mental health expenditure represents approximately 5% of total health care spending, falling to 2.5% in Spain.3 Pharmaceutical prioritization has also shifted markedly over recent decades. While leading therapeutic areas increased from 11% of the market in 1995 to 62% in 2020, areas that included mental health declined from 53% to 6%, largely due to generic competition and limited innovation.4 At a time when the societal impact of mental illness has become increasingly visible, its relative position within pharmaceutical development has weakened. The imbalance becomes even more evident when indirect costs are considered. In Europe, indirect costs associated with mental disorders—including informal care and productivity losses—are estimated at around €410 billion annually, more than three times the €127 billion attributed to cardiovascular diseases.5 Added to this are the societal costs of suicide. With approximately 47,000 deaths each year in Europe, estimates based on the OECD's Value of a Statistical Life (VSL) place the associated economic cost between €117 and €235 billion annually.6 These figures represent not only financial losses, but also preventable deaths and enduring social consequences. Taken together, these data reveal a difficult paradox: mental disorders generate one of the greatest societal burdens yet receive comparatively limited investment. When sustained underinvestment coexists with overwhelming burden, the explanation cannot be purely economic. Rather, it reflects a structural imbalance that contributes to persistent stigma in mental health.
Stigma toward mental disorders operates at multiple levels, including public stigma, self-stigma, and stigma within healthcare systems, all of which may limit help-seeking and reduce engagement with care. Occupational stigma also affects mental health professionals, sustained by the perception that psychiatry occupies a marginal position within medicine. This perception may, in turn, be internalized by psychiatrists themselves.7 Within this context, persistent underinvestment acquires broader significance. When systematically stricter standards are applied to funding decisions, what appears economically neutral may in fact reflect a hierarchy of value. We refer to this pattern as economic stigma in mental health.
Economic stigma does not operate through explicit exclusion, but through funding decisions that systematically disadvantage people with mental disorders. It becomes apparent when stricter cost-effectiveness thresholds, heightened administrative requirements, or greater reluctance to support innovation are applied in mental health vs other medical fields. Such patterns convey an implicit message that the suffering associated with mental disorders is assigned lower priority. By contrast, costly interventions in other areas of medicine are often accepted even when prognosis is uncertain, without questioning the legitimacy of providing care.
Furthermore, these dynamics shape clinical practice. Anticipating restrictive funding environments, psychiatrists may reserve innovative treatments for the most severe and treatment-refractory cases. Therapies approved for earlier use are therefore frequently implemented only as a last resort, limiting their potential to support functional recovery and social reintegration. The cumulative result is a form of minimalist medicine, in which lower expectations become normalized despite substantial clinical and social impact. Even treatments supported by solid evidence and regulatory approval often encounter restrictive reimbursement criteria not applied with comparable intensity in other specialties.
Daridorexant for chronic insomnia and intranasal esketamine for treatment-resistant depression (TRD) illustrate this dynamic. In Spain, chronic insomnia is associated with productivity losses exceeding €10.7 billion annually.8 TRD, although affecting only 16.5–18.8% of individuals with depression, accounts for approximately 25.3% of total depression-related costs.9 Both treatments rely on innovative mechanisms and have demonstrated clinical efficacy. Yet access remains constrained. Daridorexant is not publicly funded in Spain, perpetuating reliance on benzodiazepines. By the end of 2025, approximately 8000 patients had received esketamine—just over 5% of the estimated 130,000 individuals living with TRD.9 The gap between clinical need and actual access exemplifies economic stigma in practice. Moreover, an asymmetry is evident in the standards applied to therapeutic innovation. Many psychiatric treatments are introduced only after failure of multiple prior interventions and are therefore evaluated under particularly unfavorable clinical conditions. Yet they are often expected to demonstrate near-universal effectiveness and unequivocal cost-effectiveness—benchmarks rarely demanded with similar rigidity in other areas of medicine.
Variability in treatment response is intrinsic to clinical practice. No intervention achieves universal benefit; value is frequently defined by meaningful improvement within a subgroup of patients. In oncology, immunology, or neurology, therapies offering modest symptomatic relief or survival gains are routinely incorporated into clinical practice, even when annual costs exceed €50,000 per patient. In mental health, however, the same variability is more readily invoked as a justification for restriction. This differential tolerance reflects differences in how therapeutic value is evaluated across conditions. When partial improvement may restore functioning or reduce suicide risk, the threshold for recognizing benefit should not be higher than in other medical domains.
Investing in mental health is, therefore, not only clinically justified but economically rational. When a psychiatric treatment demonstrates benefit after other interventions have failed, this should reinforce—rather than diminish—its value. Denying access based on upfront costs often leads to greater long-term expenditures through hospitalizations, sick leave, productivity losses, and disability benefits. What appears fiscally prudent in the short term may ultimately represent a false economy.
In mental health, delayed or insufficient intervention carries cumulative consequences. Clinical deterioration, comorbidity, functional decline, and social disconnection amplify both human suffering and economic costs. Early and equitable access to effective treatments therefore represents a correction of imbalance rather than an expansion of privilege.
Ultimately, economic stigma in mental health represents a consequential form of exclusion. It operates not through overt denial, but through funding patterns that implicitly signal which conditions are prioritized. While cost considerations are legitimate within health care systems, they should not eclipse the obligation to address suffering proportionately to its scale.
As the Lancet Commission on Ending Stigma and Discrimination in Mental Health emphasizes, stigma and social injustice are deeply intertwined, and reducing one requires confronting the other.10 Recognizing economic stigma is therefore not merely a semantic exercise, but an essential step toward recalibrating institutional priorities. A system that fails to value mental health proportionately to its burden ultimately undermines both its economic sustainability and ethical integrity.
Declaration of generative AI useDuring the preparation of this work, the authors used ChatGPT (OpenAI, San Francisco, CA, USA) to assist with language editing and improvement of clarity in the English version of the manuscript. The authors carefully reviewed and revised all content and take full responsibility for the accuracy and integrity of the published article.
None declared.
