In Reply: We thank Dr. Hovens and Dr. van der Ploeg for their interesting and valuable remarks regarding barriers to mental health care in the Netherlands. The points that they highlight are extremely valid; structural barriers will likely increase significantly if access to mental health treatment becomes even more difficult for financial reasons. Even though attitudinal barriers emerged in our study as the more prevalent barrier, we would like to emphasize again that structural barriers may further impede mental health treatment once attitudinal barriers are overcome. It is of great concern that people seeking treatment for mental illness in the Netherlands are being discriminated against and further marginalized.

Fiscal austerity measures across Europe, and more globally, only serve to widen the treatment gap, which in low- and middle-income countries is now 70% for people with schizophrenia (that is, only 30% of those with schizophrenia receive treatment) and 98% for mood disorders (1). The World Health Organization's analysis of mental health services found a distinct positive relationship between treated prevalence rates for mental disorders and country-level income—a pattern evident across low-, middle-, and high-income countries (1). Another finding was the striking disparity in spending on mental health services in low- and middle-income countries—only 3 cents per capita in low- and middle-income settings and 70 times higher in high-income countries. Furthermore, the vast majority of spending on mental health services was found to occur in psychiatric hospitals, leaving community mental health services seriously underresourced.

Consistent with the concerns that Dr. Hovens and Dr. van der Ploeg raise about the negative impact of affordability on accessibility of mental health care is the paradoxical finding that emerges from these cross-national analyses: where there is more poverty, people are more likely to pay for mental health care out of their own pockets. On the African continent more than 50% of countries do not have social insurance schemes. To illustrate this more concretely: both antipsychotic and antidepressant medications are more expensive in lower- and middle-income countries than in upper-middle-income countries.

Very recently, a consortium of clinicians, researchers, and advocates embarked on a research prioritization exercise to identify global grand challenges in addressing the scourge of mental disorders in order to improve the lives of people with mental illness (2). One of the top 25 challenges they identified is the need to “create parity between mental and physical illness by investing in treatment, prevention, research and training.” Realizing this goal will require a substantial shift in thinking and commitment to equitable funding for mental health services by health ministries around the world.