Variation in public health reimbursement policies of ECT and rTMS across 28 European countries: A call for evidence-based policy reform from the ECNP Neuromodulation Network.

Mental disorders contribute significantly to the disease burden in Europe. Brain stimulation treatments such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are supported by strong evidence and are recommended in clinical guidelines in many countries. However, access to these interventions remains highly inconsistent across Europe. Reimbursement by public health services plays a critical role in enabling equitable access to these therapies. In this study, we examined disparities in national reimbursement policies for ECT and rTMS for the treatment of mental disorders in both inpatient and outpatient settings across 28 European countries, leveraging information from public databases and expertise from a multinational expert group within the ECNP Neuromodulation Network. Our results show that ECT is reimbursed for inpatient care in all 28 studied countries, while outpatient ECT is reimbursed in 15 of 28 countries (53.6%), with a geographic trend toward higher availability in Scandinavian and Western European countries. rTMS reimbursement was reported in 15 of 28 countries (53.6%) for inpatient care and in 8 of 28 countries (28.6%) for outpatient care, with no consistent geographic pattern. Subsequent analyses examining reimbursement policies in relation to the national Human Development Index (HDI), the Gini coefficient, and healthcare infrastructure metrics revealed no statistically significant differences between countries that do and do not reimburse outpatient ECT. Although countries reimbursing outpatient ECT showed numerically fewer hospital beds and slightly higher HDI values, these differences did not reach statistical significance. Similarly, no significant associations were observed between rTMS reimbursement and indicators of socioeconomic development, income inequality, or healthcare infrastructure. These findings highlight a striking disparity in national reimbursement policies across Europe, despite the solid evidence base for ECT and rTMS in treating mental health disorders. The current landscape suggests that many patients in Europe experience limited access to these effective treatments that could alleviate individual suffering and reduce societal disease burden. We call for urgent policy action to align health system reimbursement with clinical evidence for treatment efficacy and to improve access to evidence-based brain stimulation therapies across Europe.