The EU committed EUR 1.23 billion to mental health — but without binding targets, implementation varies widely across member states
In June 2023, the European Commission adopted what it described as a landmark shift in EU health policy. The Communication on a Comprehensive Approach to Mental Health — formally COM(2023) 298 — signalled, for the first time, that the Union intended to treat mental health on equal footing with physical health. The document is substantial: 20 flagship initiatives, a combined financing envelope of approximately EUR 1.23 billion, and a framework explicitly acknowledging that mental health cuts across employment, education, climate, digitalisation, and urban planning. What the Communication does not contain, and what critics have not allowed Brussels to forget, is a set of binding targets with measurable timelines.
The gap between political ambition and operational accountability has defined the reception of the strategy among health researchers, civil society organisations, and parliamentary observers. The Commission’s framing is one of systemic transformation; the critique from organisations including Mental Health Europe and the European Economic and Social Committee is that transformation without enforcement mechanisms tends to produce variation — between member states that already invest in mental health infrastructure and those that do not. That tension runs through every dimension of the strategy’s implementation landscape.
The Scale of the Problem
The Commission’s case for action rests on a body of epidemiological and economic evidence that is not seriously contested. According to OECD estimates cited in the strategy, more than one in six people across EU countries — approximately 84 million people — have a mental health condition. The economic burden is substantial: the OECD’s Health at a Glance: Europe 2018 report estimated the total costs of mental ill-health at more than 4 percent of GDP across the EU-28, equivalent to over EUR 600 billion annually. That figure comprises direct health expenditure of around EUR 190 billion, social protection spending of approximately EUR 170 billion, and indirect costs from reduced employment and productivity of roughly EUR 240 billion.
Those costs were already accumulating before the pandemic. The COVID-19 crisis added a further layer of deterioration. The Commission’s own data indicate that the share of young people reporting symptoms of depression in several EU countries more than doubled during the pandemic. Almost one in two young Europeans report unmet needs for mental health care — a figure that frames the youth-focused flagship initiatives as addressing a genuine and measurable crisis rather than a policy preference. Post-COVID mental health effects have also been documented among health and care workers, whose elevated rates of burnout, anxiety, and depression represent both a workforce challenge and a systemic risk to health systems that are already under strain.
Stigma compounds access barriers across all demographics. Public attitudes toward mental health conditions vary significantly across EU member states, and in several countries, seeking mental health support carries social costs that deter help-seeking behaviour. The strategy acknowledges this dimension explicitly, framing destigmatisation as a precondition for improved care uptake rather than a supplementary communication objective. Whether awareness campaigns at EU level can shift deeply embedded cultural attitudes in 27 heterogeneous societies is a question the Communication raises without fully resolving.
Twenty Flagships, Three Priorities
The 20 flagship initiatives are organised around three broad priorities, each addressing a distinct dimension of the mental health challenge. The first is prevention, with particular emphasis on children and young people, and on workplace mental health. The second is access to care — reducing the structural and financial barriers that leave a significant share of people with mental health conditions without adequate support. The third is what the Commission describes as mental health in crisis contexts, encompassing post-COVID recovery, support for Ukrainian refugees, and humanitarian settings more broadly.
The prevention agenda for children and young people is among the most politically visible elements of the strategy. The Commission has committed to developing an evidence-based framework for school-based mental health programmes and to supporting member states in integrating mental health literacy into educational curricula. These commitments are, at this stage, process-oriented: they describe what the Commission intends to develop rather than what coverage levels or outcome indicators member states are expected to achieve.
Workplace mental health represents a separate and contentious strand of the strategy. The European Trade Union Confederation had been calling for a binding EU directive on psychosocial risks at work for several years before the 2023 Communication was adopted. The Commission’s response — referencing a “possible future EU initiative on psychosocial risks at work” — was characterised by Eurocadres, the council of European professional and managerial staff, as inadequate given the evidence that existing voluntary frameworks had not delivered measurable results. The 2004 Autonomous Framework Agreement on Work-Related Stress, implemented by social partners, has seen uneven application across member states, and calls for legislative underpinning have intensified with the post-pandemic rise in documented workplace burnout. The strategy does not include a directive; it includes a signalled intention to consider one.
The access pillar addresses the structural deficit in mental health services directly. The Commission’s flagship on access to care focuses on reducing waiting times, expanding community-based care models, and improving the integration of mental health support into primary care pathways. These are priorities that a number of Europe’s Beating Cancer Plan implementation reviews have also flagged as structural weaknesses in EU health systems more broadly: the challenge of driving service transformation in health systems organised as national competences, funded differently, and staffed at widely varying ratios.
Workforce Gaps and Regional Disparities
The mental health workforce shortage is one of the most significant structural barriers to implementing the EU strategy, and it is also the dimension over which Brussels has the least direct leverage. The WHO’s Mental Health Atlas documents wide variation in the density of psychiatrists, psychologists, and mental health nurses across European countries — variation that correlates broadly with economic development but is also shaped by historical policy choices about institutional care versus community-based models.
Portugal provides a useful illustration of the challenge. The country has made meaningful investments in community mental health reform since 2007, when the National Mental Health Plan established a framework for deinstitutionalisation and community care expansion. But a shortage of psychologists — documented in national health data and acknowledged by the Portuguese Ministry of Health — has constrained delivery. Geographic disparities within the country mean that access to mental health services in rural regions differs substantially from what is available in Lisbon and Porto. Recovery and Resilience Plan funding has been allocated to address the workforce gap, but institutional capacity takes years to build.
Belgium’s trajectory offers a contrasting model that has attracted policy attention from the Commission’s health directorate. Belgium undertook a systemic reform of its mental health care architecture over the past decade, establishing 32 regional mental health networks and removing the requirement for a medical prescription as a prerequisite for accessing reimbursed psychological sessions. The reform effectively lowered the financial and administrative barriers to mental health care access simultaneously — a double-barrier reduction that health economists have cited as a driver of improved uptake. The Belgian model has been referenced as a best practice in the EU’s joint action on mental health, though scaling its specific features to 27 member states with different health system architectures is not straightforward.
The broader workforce challenge connects to the strategy’s most structurally difficult element: EU health policy cannot compel member states to train more psychiatrists, expand psychology reimbursement, or restructure how primary care physicians handle mental health presentations. The Commission can identify best practices, fund knowledge exchange, and set aspirational benchmarks. It cannot prescribe national workforce planning or guarantee that EUR 1.23 billion in financing — distributed across multiple EU instruments, available to member states, regions, and NGOs — translates into coherent national action.
The Monitoring Gap
The most substantive critique of the 2023 Communication concerns not its content but its accountability architecture. The European Economic and Social Committee, in its assessment of the strategy, called for time-bound targets, defined responsibilities, and measurable progress indicators embedded in the European Semester process. The Mental Health Europe briefing on the Communication noted that the flagship initiatives lack the operational specificity needed to drive consistent implementation — there are no coverage targets for school-based programmes equivalent to the 90 percent HPV vaccination coverage target in Europe’s Beating Cancer Plan, no waiting time benchmarks for outpatient psychiatric care, and no minimum workforce ratio standards for EU member states.
The Commission’s 2023 Communication acknowledged that monitoring capacity required strengthening. It committed to expanding the European Health Interview Survey from 2025 onwards to include additional mental health indicators, which would provide improved cross-national data on prevalence, service access, and unmet need. That commitment is meaningful — the current EHIS coverage of mental health is limited, and better data would make the strategy’s outcomes more assessable. But data collection and target-setting are not equivalent: improved surveillance can measure divergence without creating incentives for convergence.
The Renew Europe group’s December 2023 parliamentary report on mental health called explicitly for the Communication to be upgraded into a formal EU strategy with binding elements. The European Parliament’s October 2024 analysis similarly noted that while the 2023 approach represented significant progress over the previous absence of any EU-level mental health framework, its voluntary character meant that implementation would reflect member state willingness and capacity rather than EU-wide standards. That observation is not a criticism unique to mental health — it applies to many areas of EU health policy where competence remains primarily national. But in a domain where the consequences of inadequate provision include suicide, long-term disability, and workforce loss, the gap between aspirational frameworks and enforceable standards carries particular weight.
The Commission’s approach to digital mental health tools adds a further layer of complexity to the monitoring question. Several of the flagship initiatives reference digital interventions — apps, online therapy platforms, AI-assisted triage — as components of expanded access strategies. The evidence base for these tools varies considerably by modality and condition, and the regulatory framework for digital health products in the EU, while advancing under the Medical Device Regulation, has not kept pace with the commercial deployment of consumer mental health applications. Whether digital tools genuinely expand access or primarily serve populations already capable of navigating the formal health system is a question the strategy raises without providing a framework for answering.
What the EU’s Comprehensive Approach to Mental Health represents is a substantive first step that also reveals the limits of what Commission communications can accomplish without legislative backing. The EUR 1.23 billion financing envelope is real money, distributed across instruments that will support research, awareness, capacity-building, and service development. The 20 flagship initiatives address the right dimensions of a complex problem. The post-COVID political moment that propelled mental health onto the Commission’s priority agenda has created an opening that did not exist five years earlier. The question that the strategy’s critics — and its designers — will have to answer in the implementation years ahead is whether that opening can be converted into measurable, equitable improvements in mental health across all 27 member states, or whether it produces the familiar pattern of EU health policy: strong in ambition, variable in delivery.
