Mental health in Central and Eastern Europe: a comprehensive analysis

Transforming mental health in Europe Mental health in Central and Eastern Europe: a comprehensive analysis Petr Winkler, a , b , c , am , ∗ Zoe Guerrero, a , al Anna Kågström, a , d Michaela Petrᡠsová, a Arlinda Cerga Pashoja, e Gentiana Qirjako, f Valentina Hristakeva, g Dimitar Germanov, g Martina Rojnic Kuzman, h Dina Boˇ snjak Kuhari´ c, i Lucie Havlíková, a Herman Eek, j Eduard Maron, j , k Dorottya ˝ Ori, l , m Róbert Wernigg, n Naim Fanaj, o Elona Krasniqi, p Liene Sile, q Klinta Brinkmane, q Karil˙ e Levickait˙ e, r Ugn˙ e Grigait˙ e, r , s Nensi Manusheva, t , u Gjorgji Kalpak, t , u Iva Ivanovic, v Jana Chihai, w Belous Mihaela, w Tomasz M. Gondek, x Agata Todzia-Korna´ s, y Adriana Mihai, z Rebeca-Isabela Molnar, z Katarína Molnárová Letovancová, aa Elena Kopcová, ab Orest Suvalo, ac Oleksandra Khudoba, ad Jamila Ismayilova, ae Gunel Muradova, ae Nino Makhashvili, af Mishiko Dumbadze, af Liliia Panteleeva, ag Mikhail Popkov, ah Lynn Al Tayara, ai Robert van Voren, aj , ak and Graham Thornicroft b a WHO Collaborating Centre for Public Mental Health Research and Service Development, National Institute of Mental Health, Topolová 748, Klecany 250 67, Czechia b Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom c Department of Social Work, Faculty of Arts, Charles University, Na Pˇ ríkopˇ e 584/29, Prague, Czechia d Global Public Health Department, Karolinska Institutet, Stockholm, Sweden e St. Marys University, London, United Kingdom f University of Medicine, Tirana, Albania g Global Initiative on Psychiatry, Sofia, Bulgaria h Zagreb School of Medicine and Zagreb University Hospital Centre, Zagreb, Croatia i University Psychiatric Hospital Vrapce, Zagreb, Croatia j Tallinn University of Technology, Tallinn, Estonia k London Imperial College, London, United Kingdom l Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary m Department of Mental Health, Heim Pal National Pediatric Institute, Budapest, Hungary n National Directorate-General for Hospitals, Budapest, Hungary o Alma Mater Europaea Campus College Rezonanca, Pristina, Kosovo p UBT Higher Education Institution, Pristina, Kosovo q National Centre of Mental Health, Riga, Latvia r Mental Health Perspectives, Vilnius, Lithuania s Lisbon Institute of Global Mental Health, Comprehensive Health Research Centre, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal t Faculty of Medicine, University “Ss. Cyril and Methodius” Skopje, North Macedonia u University Psychiatry Clinic, Skopje, North Macedonia v Center for Early Development, Clinical Centre of Montenegro, Podgorica, Montenegro w Nicolae Testemitanu, State University of Medicine and Pharmacy, Chis ¸in˘ au, Moldova x Institute of Social Studies, University of Lower Silesia, Wroclaw, Poland y Military Institute of Medicine - National Research Institute in Warsaw, Poland z University of Medicine, Pharmacy, Science and Technology George Emil Palade, Târgu Mures ¸, Romania aa Department of Social Work, Faculty of Health Care and Social Work, Trnava University, Trnava, Slovakia ab Tenenet o.z., Senec, Slovakia ac Institute of Mental Health of Ukrainian Catholic University, Lviv, Ukraine ad Institute of Public Administration, Governance and Professional Development of Lviv Polytechnic National University, Lviv, Ukraine ae The National Mental Health Center of the Ministry of Health, Baku, Azerbaijan af Ilia State University, Tbilisi, Georgia ag Department of Medical Psychology, Psychiatry and Psychotherapy, Kyrgyz-Russian Slavic University, Bishkek, Kyrgyz Republic ah Department of Propedotherapy of Family Medicine, International Higher School of Medicine, Bishkek, Kyrgyz Republic ai World Health Organization, Barcelona Office for Health Systems Financing, Spain DOIs of original articles: https://doi.org/10.1016/j.lanepe.2025.101489, https://doi.org/10.1016/j.lanepe.2025.101458, https://doi.org/10.1016/j. lanepe.2025.101463, https://doi.org/10.1016/j.lanepe.2025.101492, https://doi.org/10.1016/j.lanepe.2025.101459 *Corresponding author. WHO Collaborating Centre for Public Mental Health Research and Service Development, National Institute of Mental Health, Topolová 748, Klecany 250 67, Czechia. E-mail address: [email protected] (P. Winkler). www.thelancet.com Vol 57 October, 2025 1 Series aj Federation Global Initiative on Psychiatry, Hilversum, Netherlands ak Vytautas Magnus University, Kaunas, Lithuania al Department of Psychology, Faculty of Arts, Charles University, Prague, Czech Republic am Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University, Heinrich-Hoffmann-Straße 10, 60528 Frankfurt am Main, Germany Summary The post-communist WHO European region, often called Central and Eastern Europe (CEE), includes 28 countries with over 770 million people. Mental health systems remain shaped by the communist legacy of centralized institutions, a narrow biomedical focus, and neglect of social and psychological dimensions. Chronic underfunding persists, further strained by shrinking civic space in some countries and the war in Ukraine. Substantial progress has been made in the past decade, with modernization and rights-based approaches gaining ground. Yet reforms face entrenched barriers: underinvestment disproportionate to the burden; pervasive stigma, weak advocacy, and limited involvement of people with lived experience; dominance of institutional care over prevention, promotion, and community services; reliance on donor-driven projects that falter once funding ends; and human resource problems. Governance is often unstable, with low prioritization, clientelism, and personal biases undermining reforms. Research and data remain scarce, leaving systems unevaluated and vulnerable to reversal. Poor decision-making compounds these barriers: systemic missteps, driven by limited expertise, weak evidence, and personal biases, prevent resources from achieving the best possible outcomes. To move forward, CEE must integrate health, social, and education systems, secure sustainable crisis services, strengthen professional skills, involve people with lived experience, expand public mental health expertise, and, above all, commit greater and more transparent investment, closer to western European levels, if resilient and effective systems are to be built. Copyright © 2025 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Keywords: Mental health; Central and Eastern Europe; Post-communist Europe; Children and young people; Migrants; Common mental disorders; Prevention; Promotion; Early detection; Early intervention Introduction The post-communist WHO European region— commonly referred to as Central and Eastern Europe (CEE)—encompasses a culturally, socially, and economically diverse area. Excluding Russia, CEE comprises 28 countries grouped into six subregions, covering over 770 million people across 7.5 million km 2 : the Balkans (Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Kosovo, Montenegro, North Macedonia, Romania, Serbia, and Slovenia), the Baltics (Estonia, Latvia, Lithuania), the Caucasus (Armenia, Azerbaijan, Georgia), Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan), Central Europe (Czechia, Hungary, Poland, Slovakia), and Eastern Europe (Belarus, Moldova, Ukraine). Since the fall of communism, a range of crises has posed serious threats to population mental health across the region. These include the 1994 sinking of the MS Estonia, wars in the former Yugoslavia, Azerbaijan, Armenia, Georgia, Tajikistan, and Ukraine, ethnic conflicts in Kyrgyzstan, earthquakes in Albania and Croatia, and the environmental collapse of the Aral Sea—all of which have left deep, multi-generational psychological impacts. Mental health systems across this region have been profoundly influenced by the 20th-century Soviet regime. 1 This legacy, with few exceptions, is characterized by asylum-like psychiatric hospitals, institutionalization and centralization, a biomedical orientation, marginalization of social and psychological aspects of health, and an authoritarian approach to clinical decision-making. 2 Systemic deficiencies include weak public health infrastructure and expertise, nontransparent decision-making, human rights violations, and low mental health literacy including pervasive stigma. 3 While brain drain constitutes a substantial challenge to the region 4 many countries maintain relatively high numbers of psychiatrists and other mental health professionals 5 supported by robust social security systems–despite many countries in the region being classified as low or middle-income. Since the fall of the Berlin wall, mental health systems across the region have undergone significant transformation. In Central Asia, mental health services collapsed in the 1990s and have only recently begun to recover. 6 Elsewhere, countries have transitioned from centrally governed, state-funded systems to insurancebased models with progress in legislation and increased recognition and protection of the rights of people with mental illness. 7,8 Training for young professionals has improved. 8 Yet, as of 2016, care of people with severe mental illness—particularly the process of deinstitutionalization—remained limited, and government-led reforms unimplemented. 3,5 The Lancet Regional Health - Europe 2025;57: 101464 Published Online 6 October 2025 https://doi.org/10. 1016/j.lanepe.2025. 101464 Series 2 www.thelancet.com Vol 57 October, 2025 Consequently, key challenges persisted, more than two decades after the dissolution of the USSR. 3 Currently, mental health systems in the region face rising demands alongside major global trends, including digital transformation and climate change 9–11 as well as region-specific challenges, most notably the ongoing war in Ukraine. Scalable investments are critical to address these challenges and improve population outcomes. Against this backdrop, we assessed the current state of the field across the region, with a special focus on promotion, prevention and early intervention. Methods This study aimed to map and analyze mental health care systems to understand mental health promotion, prevention, early detection, and early intervention across post-communist countries in the WHO CEE region, excluding Russia. Countries included cover five subregions: Balkans, Baltics, Caucasus, Central Asia, Central Europe, and Eastern Europe. We applied a dualmethod approach: a systematic scoping review and a mixed-methods, multi-country scoping review (see Appendix for in depth description of methods employed). The systematic review followed PRISMA guidelines, included two search streams and used predefined inclusion criteria. Data were independently screened and extracted by two reviewers (ZG, MP), supplemented by secondary data from WHO, World Bank, and GBD databases. The multi-country scoping review combined structured expert led literature scans with key informant interviews conducted in local languages. Over 115 expert interviews were conducted across 18 countries, ranging from 3 interviews in Georgia to 24 in Moldova. A slightly higher proportion of females were interviewed (62% females). Interviewees represented a broad range of roles, including psychiatrists, child and adolescent mental health professionals, psychologists, social workers, public health officials, NGO representatives, healthcare managers, academics, migration and policy experts, and individuals with lived experience of mental health conditions. Collaborators used a standardized questionnaire based on the WHO Mental Health Care Pyramid to report on various care levels and thematic areas, including child and adolescent mental health, migrant mental health, and common mental disorders. Two framework analyses synthesized findings: one focused on mental health systems across six domains (policy and governance, funding and resources, service delivery and access, workforce and training, social and cultural context, and monitoring, evaluation, and research); the other on prevention and early intervention across eight domains (policy and planning, primary care, schools, self-care, targeted interventions, funding, evaluation, and early detection and intervention). Coding was performed by two reviewers (PW, AK) using iterative codebook development, and findings were triangulated across data sources (see more details on methods in the Appendix). Burden of mental ill health With the exception of Muslim-majority countries, the region has relatively high rates of suicides—reaching 20.1 per 100,000 in Latvia—and high alcohol consumption—up to 17.5 L of pure alcohol per capita (aged 15+) annually. Mental disorders account for a substantial share of disease burden, ranging from 7.8% of total DALYs in the Caucasus to 11.6% in the Baltics (see Table 1, Fig. 1 and Appendix). Mental health care systems Policy and governance Mental health systems in CEE remain heavily reliant on institutional care reflected in a high number of beds in psychiatric hospitals per capita and disproportionate share of government spending on psychiatric hospitals. Outpatient service availability for both adults and young people varies widely across the region. In many contexts, service models are shaped by the dominance of Key messages •Central and Eastern Europe continues to experience high suicide rates, harmful alcohol use, and rising mental health burdens; particularly among youth and war-affected populations. These challenges are compounded by weak evidence-based planning, poor coordination, limited evaluation, and increasing strain from regional crises, such as the war in Ukraine, as well as global challenges like digital transformation and climate change. •Mental health prevention and promotion in Central and Eastern Europe are widely recognized as policy priorities, with activities spanning schools, workplaces, primary care, social services, parenting programmes, and digital platforms; however, implementation remains uneven, underfunded, fragmented, and often NGO-driven, with limited evaluation, coordination, and evidence-based guidance. •Reform momentum has increased, with new policies, expanded services, and support from European and international funding, but progress is uneven, and sustainability and scalability remain major gaps. Lasting improvement depends on political will, cross-sector collaboration, and better data to guide coordinated, evidence-driven action. Series www.thelancet.com Vol 57 October, 2025 3 psychiatry and professional privatization rather than holistic or rights-based approaches, with multidisciplinary, community care driven by bottom-up or international initiatives, at best in collaboration with local governments. According to WHO MHA data, integration of mental health into primary care is partial but progressing and most countries have adopted mental health strategies guiding reform. These policies often emphasize deinstitutionalization while addressing primary care integration, stakeholder collaboration, facility conditions, and promotion and prevention. The current reform efforts aim to establish an integrated, intersectoral model that ensures improved quality of life and upholds human rights and freedoms. See Table 2 for country specific indicators of mental health systems. Sub-region Country Pop. (000 persons) Surface area (sq. km) GDP per capita PPP Life expect Alcohol cons. per capita (l) Suicides per 100 k pop. MH DALY share on total (%) MH share on health exp. (%) Refugees from Ukraine per 100 k pop. Balkans Albania 2745.97 28,750 21,208 77 4.5 3.7 8.5 NA 235 Balkans BiH 3185.07 51,210 22,391 75 5.9 8.3 8.4 NA 9 Balkans Bulgaria 6446.6 111,000 37,411 74 11.6 6.5 5.9 2.6 1200 Balkans Croatia 3859.69 88,070 45,485 78 7.7 14.1 10.0 NA 719 Balkans Kosovo 1756.37 10,887 15,141 80 NA NA NA NA NA Balkans Macedonia 1827.82 25,710 24,327 74 4.4 7.2 6.7 7.3 1057 Balkans Montenegro 616.18 13,810 30,887 76 17.5 16.2 7.8 NA 3062 Balkans Romania 19059.48 238,400 45,659 75 NA 16.8 7.4 NA 943 Balkans Serbia 6623.18 84,990 28,674 75 7.9 7.9 8.3 NA 164 Balkans Slovenia 2120.46 20,480 53,813 81 10.4 14.0 13.5 NA 620 Balkans Total/Average 48240.82 673,307 32,500 77 7.8 10.5 8.5 – 197 Baltics Estonia 1370.29 45,340 46,669 78 10.7 12.0 12.9 3.7 3105 Baltics Latvia 1877.44 64,590 41,384 75 12.9 16.1 10.2 4.8 2586 Baltics Lithuania 2871.59 65,286 50,783 76 12.1 20.2 11.7 4.2 1695 Baltics Total/Average 6119.3 175,216 46,279 76 11.9 16.1 11.6 4.2 2462 Caucasus Armenia 2990.9 29,740 21,343 73 4.3 2.7 8.8 2.3 20 Caucasus Azerbaijan 10153.96 86,600 23,598 73 2.5 4.0 7.3 3.5 48 Caucasus Georgia 3715.48 69,700 25,072 72 14.4 8.2 7.2 1.9 802 Caucasus Total/Average 16860.34 186,040 23,337 73 7.1 4.9 7.8 2.6 290 C Asia Kazakhstan 20330.1 2,724,902 38,515 74 4.5 18.1 10.0 NA NA C Asia Kyrgyzstan 7099.75 199,950 7107 72 3.6 NA 10.7 NA NA C Asia Tadjikistan 10389.8 141,379 4964 71 0.7 NA 6.8 NA NA C Asia Turkmenistan 7364.44 491,209 19,829 69 2.6 6.1 7.9 NA NA C Asia Uzbekistan 35652.31 448,924 11,107 72 2.1 NA 8.7 NA NA C Asia Total/Average 126878.5 4,596,667 19,518 100 3.3 – 8.8 – NA C Europe Czechia 10864.04 78,871 53,080 79 12.0 13.1 9.9 4.0 3669 C Europe Hungary 9592.19 93,030 44,905 76 9.9 11.8 8.7 3.2 650 C Europe Poland 36687.35 312,720 46,450 77 11.7 9.3 10.3 3.5 2720 C Europe Slovakia 5426.74 49,030 43,513 77 10.7 12.8 8.9 NA 2447 C Europe Total/Average 235490.9 533,651 46,987 77 11.1 11.7 9.4 3.6 3162 E Europe Belarus 9178.3 207,630 30,763 73 11.6 16.5 10.9 1.9 NA E Europe Moldova 2457.78 33,850 17,597 69 11.1 12.2 9.3 2.5 5199 E Europe Ukraine 37732.84 603,550 17,630 69 9.2 17.7 9.8 NA NA E Europe Total/Average 336566.1 1,378,681 28,244 72 10.7 15.5 9.9 2.2 – CEE Total/Average 770156.1 7,543,562 31,047 75 8.3 11.7 9.1 3.2 1528 EU 14 Total/Average 346730.5 3,078,153 72,096 82 9.5 8.6 15.9 8.7 769 Data for individual countries are taken from the following sources: 1) World Bank: population (2023), surface area (2023), GDP per capita in current international USD and purchasing power parity (2023), life expectancy (2023), total alcohol consumption per capita (liters of pure alcohol, projected estimates, 15+ years of age; 2020); 2) WHO Mental Health Atlas (MHA) 2020: suicide rates per 100,000 population, the government’s total expenditure on mental health as % of total government health expenditure–for Czechia, Slovakia and Georgia the data come from WHO MHA 2017; 3) Institute for Health Metrics and Evaluation: Mental health related DALY (disability adjusted life years) 2021—calculated as a sum of DALY for mental disorders, substance use, self-harm, and Alzheimer’s disease and other dementias (see Appendix for details); 4) UNHCR–Situation Ukraine Refugee Situation–Operational Data Portal: number of refugees from Ukraine as per 20 March 2025 (number of refugees in Serbia includes refugees in Kosovo as well). EU 14 countries include Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, and Sweden. pop.—population, sq. km—square kilometres, GDP—gross domestic product, PPP—purchasing power parity, expect.—expectancy, k—thousands, MH—mental health, DALY—disability adjusted life years, cons.—consumption, exp.—expenditures, C—central, E—Eastern. Table 1: Characteristics of individual countries and subregions of CEE as compared to other EU 14 countries. Series 4 www.thelancet.com Vol 57 October, 2025 Implementation of reforms varies significantly across the region. Poland has successfully developed an extensive network of community mental health services that integrate medical and social care. Other countries, such as Georgia, Czechia, and Ukraine, have established several such services, whereas some, such as Slovakia, have yet to begin implementation. Mental health care governance remains highly fragmented. While ministries of health oversee clinical services, ministries of social and educational affairs cover complementary services, with limited coordination. Non-governmental organizations (NGOs) play an essential role, particularly in prevention and promotion, areas pervasively neglected by states. While countries like Czechia, Slovakia, and Ukraine have established interministerial platforms, and Bulgaria approved a cross-sectoral collaborative Framework Agreement in 2006 between the Ministry of Health and Ministry of Labor and Social Policy, weak intersectoral collaboration remains a major barrier to system-wide progress in mental health care. Funding and resources Despite high rates of suicides, elevated alcohol consumption and a growing burden of mental disorders, countries in CEE, invest on average only 3.2% of total government health expenditures to mental health (Table 1) with most directed to psychiatric hospitals (Table 2). International donors—including the EU, WHO, and others have provided critical support to initiate reform and respond to regional needs. However, reliance on external funding poses risks to stability, sustainability and scalability. This vulnerability is increasingly evident in several countries, particularly Ukraine, where the partial dissolution of USAID, a significant funder of mental health transformation, has raised concerns about the durability of reforms. Service delivery and accessibility With few exceptions, systems in CEE remains predominantly reliant on hospitals, with outpatient services networks providing pharmacological treatments by psychiatrists and limited psychosocial care. According to expert sources, in some countries, such as Slovakia, Hungary and Estonia, high hospitalization rates are reported as due to a lack of community-based alternatives. The observation of high hospitalization rates occurring due to a lack of community-based alternatives warrants further exploration within the region. Most countries have developed a wide network of social services ranging from crisis centres for children affected by violence, abuse or trafficking, to targeted services for homeless populations, migrants or socially excluded communities, and senior homes and respite care for people with dementia. These services though remain poorly integrated with mental health care despite the populations being at elevated risk for needing mental health support. Staff are frequently undertrained in recognizing and managing mental health problems, and there is little structured effort to incorporate these services systematically and generate structural pathways within multi-sectoral comprehensive networks for mental health care. 0 2 4 6 8 10 12 14 16 Mental health related DALYs as % of total burden of disease in CEE DALY - Mental disorders DALY - Substance useDALY - Alzheimer's and other demen�as DALY Self-harm Fig. 1: Mental health related disability adjusted life years expressed as a percentage of total burden of disease in Central and Eastern Europe. Based on data from the Institute for Health Metrics and Evaluation: Mental health related DALY (disability adjusted life years) 2021. Series www.thelancet.com Vol 57 October, 2025 5 The COVID-19 pandemic served as a catalyst for mental health care development in the region, heightening public and political awareness of mental health issues and accelerating the adoption of telepsychiatry in several countries. While this resulted in better access to care, these advances have not been translated into sustained system-wide improvements. Digital mental health resources are increasingly available in local languages and target diverse groups, from perinatal mental health to cognitive decline and suicide bereavement. Initiatives range from government-led campaigns to NGO-led projects. Despite their promise, many lack a strong theoretical foundation and robust evaluation. Systematic evaluation and evidence-informed design would greatly Subregion Country MH plan MH plan year Suicide plan Integr. into PHC Total outpat. facilities Total outpat. CAMH f. Mental hospitals Beds in MH per 100 k Exp. to ment. hosp. (%) Balkans Albania Yes 2013 No 3 14 6 2 16.31 NA Balkans BiH Yes 2012 No 3 792 1 4 14.72 NA Balkans Bulgaria No – No 2 69 NA 12 30.81 34 Balkans Croatia Yes 2022 Yes 4 1354 24 8 75.73 NA Balkans Kosovo NA NA NA NA NA NA NA NA NA Balkans Macedonia Yes 2018 No 1 52 5 4 93.59 19.8 Balkans Montenegro Yes 2019 No 0 4 NA 2 44.75 NA Balkans Romania a Yes 2009 NR NR 173 63 34 82.47 NA Balkans Serbia Yes 2019 No 3 4 47 7 48.71 NA Balkans Slovenia Yes 2018 Yes 5 128 683 5 55.95 NA Balkans Total/ Average – – – 2.6 2590 829 78 51.4 – Baltics Estonia No – No 5 NA 12 2 8.67 NA Baltics Latvia Yes 2019 No 5 NA 276 5 111.18 78.3 Baltics Lithuania Yes 2020 Yes 4 196 NA 6 41.71 7.9 Baltics Total/ Average – – – 4.7 – 288 13 53.9 43.1 Caucasus Armenia Yes 2014 No 2 NA 1 9 41.25 88.6 Caucasus Azerbaijan Yes 2012 No 5 22 NA 11 38.08 91.5 Caucasus Georgia a Yes 2014 NR NR NA 12 9 36.72 NA Caucasus Total/ Average – – – 3.5 – 13 29 38.7 90.1 C Asia Kazakhstan Yes 2020 No 4 63 10 19 42.72 NA C Asia Kyrgyzstan NA NA NA NA NA NA NA NA NA C Asia Tajikistan Yes 2018 No 3 NA NA 8 27.52 NA C Asia Turkmenistan NA NA NA NA NA NA NA NA NA C Asia Uzbekistan NA NA NA NA NA NA NA NA NA C Asia Total/ Average – – – 3.5 – – – – – C Europe Czechia Yes 2020 Yes 4 1238 NA 23 81.24 55.7 C Europe Hungary Yes 2018 Yes 2 1155 97 1 3.21 35.1 C Europe Poland Yes 2017 Yes NA 2170 340 46 28.58 30.4 C Europe Slovakia a Yes 2017 No NA NA NA NA NA NA C Europe Total/ Average – – – 3 4563 – 70 37.7 40.4 E Europe Belarus Yes 2016 Yes 4 107 66 20 60.5 81.8 E Europe Moldova Yes 2017 No 3 41 NA 3 35 84.8 E Europe Ukraine Yes 2017 No 3 658 555 60 61.05 NA C Europe Total/ Average – – – 3.3 806 621 83 52.2 83.3 CEE Total/ Average – – – 3.4 7959 1751 273 46.8 64.2 Data based on WHO Mental Health Atlas 2020. integr.—integration, outpat.—outpatient, k—thousands, exp.—expenditures, ment. hosp.—mental hospitals, C—central, E—Eastern. a Data based on WHO MHA 2017; MH Plan Implementation based on country reports compiled by co-authors representing the respective countries (NI = Not implemented; II = implementation initiated; PI = partially implemented; IS = implemented on a scale); comparison with EU 14 not conducted—data not reliable. Data in italics are corrections made by country experts, not from the databases. Table 2: Basic characteristics of mental health care systems in CEE. Series 6 www.thelancet.com Vol 57 October, 2025 enhance their effectiveness and contribution to mental health promotion in the region. Workforce and training Data from the WHO Mental Health Atlas highlight substantial disparities in the availability of several mental health professionals in the region. The Baltics and Central Europe report an average of 16.2 and 13.3 psychiatrists per 100,000 population respectively, which is about the same as the average in western EU countries (13.3 per 100,000 population). In Caucasus and Central Asia the number is much lower—3.9 and 2.9 per 100,000 population respectively. However, the data shows that the number of child psychiatrist is low across the region (3.9 per 100,000 population), the only exceptions being Lithuania (9.92), Hungary (9.66), Estonia (8.62) and Slovenia (7.65). Similarly, the availability of other key professionals—mental health nurses, psychologists, and social workers—is generally limited (see Table 3 for details). Country-level reports highlight workforce shortages of qualified mental health professionals, particularly in child and adolescent mental health services, which are overwhelmed by surging need. Rising mental health needs amongst adults further strain limited resources. Access is particularly restricted in rural and remote areas, for example in Croatia, island residents must travel considerable distances for care, Sub-region Country Psychiatrists MH Nurses Psychologists Social workers Tot. workforce CAMH psychiatr. CAMH workforce Nr. Per 100 k Nr. Per 100 k Nr. Per 100 k Nr. Per 100 k Nr. Per 100 k Nr. Per 100 k Nr. Per 100 k Balkans Albania 46 1.6 250 8.68 43 1.49 34 1.18 393 13.64 8 1.13 60 8.46 Balkans BiH 313 9.48 872 26.42 122 3.7 61 1.85 1478 44.77 1 0.15 180 27.36 Balkans Bulgaria 695 9.93 978 13.97 89 1.27 50 0.71 1842 26.31 46 3.45 46 3.45 Balkans Croatia 527 12.81 1831 44.33 234 5.67 55 1.33 2802 67.84 53 6.6 289 35.96 Balkans Kosovo NA NA NA NA NA NA NA NA NA NA NA NA NA NA Balkans Macedonia 179 8.59 376 18.05 88 4.22 13 0.62 659 31.63 8 1.72 108 23.25 Balkans Montenegro 55 8.76 NA NA 28 4.46 13 2.07 109 17.36 NA NA NA NA Balkans Romania 1125 5.66 3719 18.71 294 1.48 99 0.5 5351 26.92 112 0.56 NA NA Balkans Serbia 492 5.61 1875 21.37 NA NA NA NA 2367 26.98 47 2.5 77 4.1 Balkans Slovenia 254 12.22 820 39.45 251 12.08 40 1.92 1583 76.16 31 7.65 121 29.87 Balkans Total/Average 3686 8.3 10,721 23.9 1149 4.3 365 1.3 11,940 36.8 306 3.0 881 18.9 Baltics Estonia 208 15.69 289 21.8 275 20.74 81 6.11 929 70.08 24 8.62 24 8.62 Baltics Latvia 249 13.06 542 28.43 601 31.52 3315 173.86 5408 283.63 20 5.08 1237 313.92 Baltics Lithuania 544 19.71 1034 37.47 523 18.95 549 19.89 2660 96.39 54 9.92 1824 334.98 Baltics Total/Average 1001 16.2 1865 29.2 1399 23.7 3945 66.6 8997 150.0 98 7.9 3085 219.2 Caucasus Armenia 50 1.69 278 9.4 50 1.69 NA NA 378 12.78 14 1.79 96 12.26 Caucasus Azerbaijan 336 3.34 720 7.17 138 1.37 50 0.5 1430 14.23 41 1.37 375 12.51 Caucasus Georgia 265 6.71 NA NA 92 2.33 NA NA 369 9.34 12 0.3 NA NA Caucasus Total/Average 651 3.9 998 8.3 280 1.8 50 0.5 2177 12.1 67 1.2 471 12.4 C Asia Kazakhstan 803 4.33 3312 17.85 262 1.41 62 0.33 4476 24.13 184 2.86 778 12.1 C Asia Kyrgyzstan NA NA NA NA NA NA NA NA NA NA NA NA NA NA C Asia Tajikistan 187 2.01 261 2.8 NA NA NA NA 454 4.87 6 0.14 21 0.49 C Asia Turkmenistan 134 2.26 NA NA 1 0.02 0 0 135 2.27 8 0.35 10 0.43 C Asia Uzbekistan NA NA NA NA NA NA NA NA NA NA NA NA NA NA C Asia Total/Average 1124 2.9 3573 10.3 263 0.7 62 0.2 5065 10.4 198 1.1 809 4.3 C Europe Czechia 1668 15.6 3248 30.39 359 3.35 120 1.12 5644 52.8 NA NA NA NA C Europe Hungary 1170 12.08 1052 10.86 1535 15.85 NA NA 4023 41.54 182 9.66 1963 104.15 C Europe Poland 4589 12.11 11,189 29.53 4620 12.19 NA NA 25,334 66.87 360 4.8 3340 44.56 C Europe Slovakia NA NA NA NA NA NA NA NA NA NA NA NA NA NA C Europe Total/Average 7427 13.3 15,489 23.6 6514 10.5 120 1.1 35,001 53.7 542 7.2 5303 74.4 E Europe Belarus 1065 11.27 NA NA 506 5.35 34 0.36 1899 20.09 103 5.04 103 5.04 E Europe Moldova 136 3.36 542 13.41 52 1.29 58 1.43 848 20.97 8 0.94 105 12.38 E Europe Ukraine 2463 5.6 10,551 23.98 412 0.94 305 0.69 15,104 34.33 245 2.73 343 3.82 E Europe Total/Average 2599 6.7 11,093 18.7 970 2.5 397 0.8 17,851 25.1 356 2.9 551 7.1 CEE Total/Average 16,488 8.5 43,739 19.0 10,575 7.3 4939 11.8 81,031 48.0 1567 3.9 11,100 56.0 EU 14 Average – 13.3 – 45.8 – 41.4 – 17.6 – 141.2 – 11.8 – 61.0 The data are taken from the WHO Mental Health Atlas 2020. The data for Romania are from the WHO Mental Health Atlas 2017 since the 2020 country report was not available. The data for EU 14 countries are based on country reports from Finland, France, Germany, Ireland, Italy, Portugal, Spain, and Sweden since country reports for other countries were not available or did not contain relevant data. nr.—number, k—thousands, tot.—total, MH—mental health, CAMH—child and adolescent mental health, psychiatry.–psychiatrists, C—central, E—Eastern. Table 3: Number of mental health professionals across the region. Series www.thelancet.com Vol 57 October, 2025 7 highlighting stark geographic inequities in service provision. Devastating impact of Russia’s war against Ukraine Russia’s military aggression against Ukraine has a devastating impact on the mental health of its population within and beyond Ukraine’s border. More than a decade of hostilities, including over three years of fullscale war, has led to immense civilian suffering and humanitarian crisis. Continued attacks on populated areas have destroyed vital infrastructure, including health facilities. Since August 2023, intensified violence in regions such Kharkiv, Sumy, Zaporizhzhia, Kherson and Donetsk have triggered further evacuations and prolonged displacement. The cumulative impact of Russia’s war and continuous exposure to psychological dangers contributes to rising psychological distress, trauma, anxiety, and depression. As of August 2024, approximately 6.7 million Ukrainians had fled the country, and 3.7 million remained internally displaced, many with limited access to essential health services, particularly in frontline and border regions. Among Ukrainians living abroad, high levels of mental health problems have been reported, with concerns that these will magnify with prolonged conflict. Despite notable reforms and resilience, the mental health burden resulting from the war is vast. In CEE countries hosting large numbers of refugees (see Table 1), systems are unprepared, and needs are still emerging. These countries have not historically faced such immense migration fluxes and integration, and mental health and psychosocial support systems are being developed ad hoc to meet need. Many struggle to integrate qualified Ukrainian mental health professionals into their national workforce effectively, again leaving non-governmental organizations to fill critical gaps— raising concerns about sustainability. Influence of international and non-governmental organizations International organizations such as the World Health Organization (WHO), the European Union (EU), and UNICEF and numerous non-governmental and volunteer organizations have been critical in supporting, mental health system development in the region. EU and UN agencies have been also instrumental in shaping national and regional response to the large influx of refugees by funding and coordinating mental health and psychosocial support (MHPSS). Such efforts span self-help interventions, help-lines psychosocial care, and capacity-building for teachers working with displaced families. Still, the scale of, migrants has overwhelmed mental health systems in CEE (see Table 1) and intense pressures continue to challenge local mental health services, including crisis centres, and outpatient and inpatient mental health services. Monitoring, evaluation and research Despite significant efforts to develop mental health care over the past decade, nearly all CEE country experts report a lack of systematic monitoring and evaluation. Existing assessments are typically limited to projectspecific evaluations, often linked to externally funded initiatives, such as the European Structural and Investment Funds (ESIF) and rarely assess long-term impact, effectiveness, or cost-effectiveness. National government-led oversight authorities tasked with monitoring mental health services exist yet are limited to focus on compliance with standards and regulations rather than generating robust evidence to inform policy and system development. The striking paucity of published evidence aligns with expert validation, with nearly all highlighting a general absence of evaluation activity across the region, though more research is needed to uncover localized understandings of good practice and evaluation cultures. Rare exemptions exist, for example, Estonia has implemented a national Health System Performance Assessment (HSPA) framework developed with OECD support, that goes beyond project monitoring. In Moldova, international donor supported initiatives have successfully carried out impact evaluations of interventions. Poland and Czechia have also invested in generating evidence for informed decision-making, though the extent of its practical use varies. Several countries, including Bulgaria, Czechia, Croatia, Hungary and Slovakia, operate national centres with routinely collect health service data that could support epidemiological research and long-term systematic and comprehensive national, yet these are underutilized for evidence-based decision making. Despite some alignment with evidence, critical gaps persist. In some cases, decision-making has disregarded established evidence, such as Czechia’s exemption of non-sparkling wines from excise duty. While there are nationwide initiatives, such as Croatia’s program aimed at supporting child and adolescent mental health, which has been gradually implemented in schools across the country, such programmes have not undergone rigorous evaluation that are peer reviewed and published. Evidence-based programmes— such as Housing First, Individual Placement and Support, and youth-oriented models remain largely absent across the region. Prevention, promotion, early detection and early intervention Findings from literature The review of existing literature presents a fragmented overview of mental health prevention, promotion, early detection and early intervention. According to the WHO Mental Health Atlas 2020, progress in mental health promotion, prevention, and early detection remains limited across CEE. 12 Fewer Series 8 www.thelancet.com Vol 57 October, 2025 than half of the countries reported implementing at least two functioning prevention or promotion programmes, showing little improvement since 2017. 13 While some integration into primary health care has occurred, access to community-based services remains uneven, and there are persistent gaps in early detection capacities. An analysis of 33 studies focused on mental health promotion and prevention across the region found efforts targeting diverse populations–including adolescents, 14–19 parents, 15,20,21 healthcare professionals and the public 22–25 –through both digital 17,26 and in-person methods especially school settings. 27–29 Epidemiological studies examined risk and protective factors, with a particular focus on perinatal mental health, 30,31 suicide, 32,33 and social determinants. 34 Suicide-related research showed mixed trends, with improvements in some countries and persistent challenges in others. 19 Qualitative studies also highlighted the role of stigma, rurality, and service gaps in suicide risk. 34 Several youthand school-based prevention initiatives were evaluated, such as Romania’s SCHOLARS program 35 and parenting support interventions in North Macedonia and Moldova. 20 Digital strategies and community-based approaches played a significant role, with long-standing online platforms in Slovenia 17 and multi-country suicide prevention programmes showing positive results. 36 In response to humanitarian crises, trauma-informed and community-based interventions were introduced in Poland, Bosnia and Herzegovina, and Georgia, particularly for war-affected populations. 14–16,37,38 Analyses of 17 studies in early detection and intervention demonstrated efforts focused on building primary care capacity, 39,40 piloting early intervention services for people at risk of psychosis 41–44 and improving access to care for high-risk groups. 45 Studies from Latvia, Armenia, Croatia, and Czechia showed promising results in enhancing diagnostic skills, supporting structured early interventions, and improving service fidelity. 40–44 Youthfocused programmes, such as trauma-informed support in Georgia 38 and web-based interventions for eating disorders in Hungary, 46 showed early effectiveness in addressing emerging mental health issues. Finally, very few studies focused on evaluating the impact or of prevention and promotion or early detection and intervention programmes at the national level, 47–49 and only one study reported on policy-making approaches in these areas 50 (see Appendix for detailed results of the review and references). Findings from the expert survey Mental health prevention, promotion, early detection, and early intervention are recognized as policy priorities across the region. National working groups often support development in this area with varying degrees of engagement from state public health institutions. Common activities include the dissemination of informational materials, provision of online resources, and participation in community-based programmes such as school workshops on addiction, bullying, stress, and healthy lifestyles. For example, Latvia’s Center for Disease Prevention and Control and over 100 Health Promotion Offices in Hungary should implement evidence-based activities. In Lithuania, since 2022, the Ministry of Health has mandated four key programmes—suicide prevention, psychological wellbeing services, early youth intervention, and addiction counselling—allocating two-thirds of the budget to municipal public health bureaus, which may supplement these programmes based on local indicators and needs. Some early detection and intervention tasks are assigned to primary care, social services, or schools; however, these sectors are often under-resourced and operate more intuitively than systematically. Nonetheless, countries like Hungary or Ukraine show efforts to integrate mental health components across education, social, and health sectors. Despite policy-level recognition, implementation remains chronically underfunded at the local level. Non-governmental organizations (NGOs) frequently play a vital role in bridging service gaps. In Poland, organizations led by people with lived experience (PWLE) also contribute. NGOs run anti-stigma campaigns, advocacy initiatives, school and workplace programmes, and self-help groups. However, their sustainability is fragile, as funding largely depends on grants, donations, or self-generated income. For instance, Slovakia’s League for Mental Health receives only about 10% of its funding from the state, limiting opportunities for formal evaluation and long-term planning. International agencies like the EU, WHO, and UNICEF support many initiatives, but these are usually short-term and project-based, with limited sustainability or scalability. Services often concentrate in large cities and follow foreign models rather than a systemic approach based on local needs assessments and strategic planning. As a result, uncoordinated awarenessraising campaigns—rarely evaluated—remain the most common form of mental health promotion in the region. Crisis services Crisis hotlines have been developed across the region and they play an important role in mental health protection and early intervention. Yet, these are often categorized as social services and therefore lack funding and multisectoral integration with the mental health care systems across the region. While there are notable exceptions—such as the national crisis hotline currently being launched by the Ministry of Health in Slovakia—most hotlines continue to be operated by non-governmental organizations (NGOs). Series www.thelancet.com Vol 57 October, 2025 9 financial or non-financial conflicts of interest relevant to this work. Tomasz M. Gondek has received grants from THCS paid to his institution. He has received payments or honoraria for lectures, presentations, manuscript writing, or educational events from Valeant Polska, Lundbeck Poland, Apotex Poland/Aurovitas Pharma Polska, Celon Pharma, Neuraxpharm Polska, Exeltis Poland, and Takeda Pharma, all paid directly to him. He has also received support for attending meetings and/or travel from Lundbeck Poland, EGIS, and GL Pharma, all paid directly to him. He declares no other financial or non-financial conflicts of interest relevant to this work. Agata Todzia-Korna´ s has received grants from THCS paid to her institution. She has received payment or honoraria for lectures, presentations, and manuscript writing, as well as support for attending meetings and/or travel, directly from Aurovitas. She declares no other financial or non-financial conflicts of interest relevant to this work. Graham Thornicroft has recently been supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. GT has also recently been supported by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/R023697/1) awards. The views expressed are those of the authors. Acknowledgements We would like to thank all interviewees across 19 countries who contributed to country reports. Funding: The study described is from the project “Research of Excellence on Digital Technologies and Wellbeing CZ.02.01.01/00/ 22_008/0004583” which is co-financed by the European Union. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi. org/10.1016/j.lanepe.2025.101464. References 1Mohr P, Furedi J, Swingler D, et al. A historical overview of psychiatry in selected countries of central & Eastern Europe. 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