People with lower incomes have worse outcomes of mental health treatment

Two hands holding over each other
Two hands holding over each other

Low-income patients improve less with the first specialist mental health treatment compared with those with higher incomes, according to a study by researchers from Erasmus MC and Erasmus School of Economics. This indicates that inequality by income persists throughout the treatment process.

A study, published in The Lancet Psychiatry, reveals that compared with high-income patients, low-income patients have higher disease severity at the start of specialist mental health treatment. They are also less likely to experience improvement, even when accounting for the differences in diagnosis and initial severity of mental disorders. Of patients in the highest income group, 43 percent show measurable improvement after the initial course of treatment, compared with 26 percent among patients in the lowest income group.

Francisca Vargas Lopes smiling at the camera
Michelle Muus

Francisca Vargas Lopes

The study was led by PhD candidate Francisca Vargas Lopes, who is affiliated with the Erasmus MC and the Erasmus Centre for Health Economics Rotterdam (EScHER), and part of Erasmus Initiative Smarter Choices for Better Health.

Data on all 950,000 patients

Together with applied economists of Erasmus School of Economics Prof. Tom van Ourti, Dr Bastian Ravesteijn and Dr Carlos Riumallo-Herl, Francisca analysed data on all 950,000 patients who started treatment in Dutch specialist mental health care between 2011 and 2016, linked to data from tax records on income.

Tom van Ourti smiling with a closed smile
Tom van Ourti
Bastian Ravesteijn, researcher at ESE.
Bastian Ravesteijn
Carlos Riumallo with a closed smile
Carlos Riumallo-Herl

The findings from the study

The study also demonstrates that patients with incomes in the bottom fifth of the Dutch population receive slightly less fewer treatment minutes than patients with comparable diagnosis and disease severity in the rest of the income distribution. Finally, low-income patients are more likely to receive additional treatment after finishing the initial one, but the differences to high-income patients are small.

The findings indicate that policy concerns about differences in mental health by income should not be limited to ensuring access to care, say the researchers. ‘We already knew that most countries have inequalities in access to mental health care, but now we demonstrate for the first time that differences related to income persists during treatment, even when we account for differences in diagnosis and initial disease severity. Policies that solely focus on reducing barriers to access will not address these disparities during treatment. This is a discussion we want to initiate’, says Vargas Lopes.

The causes of the differences by income

Based on this study, Francisca Vargas Lopes cannot determine the causes of the differences by income. ‘It is likely related to the interaction between the patient, the social environment and the mental health care system. One can suppose that low-income individuals may be less likely to adhere to treatment, have a less favourable home environment for recovery or may be less likely to advocate for the appropriate kind and intensity of care. There may also be more often a mismatch between the mental healthcare professional and patients in certain vulnerable groups with low income, which hampers the results of the treatment.’

Vargas Lopes stresses that these are just hypotheses that should be investigated further. She hopes that the study will increase awareness around differential mental health treatment and outcomes, and motivate additional research. Her recommendation is that future research should also collect qualitative data, for example on interviews with patients and healthcare providers, to identify possible causes behind the differences along the treatment trajectory.

With this additional information we would be able to make recommendations for policymakers and practitioners on how to maximize the role of treatment in closing the mental health gap between the rich and poor.’

More information

For more information, please contact Ronald de Groot, Media & Public Relations Officer at Erasmus School of Economics:, +31 6 53 641 846.

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