ECAP Journal, September 2013

The economic crisis in Spain and its impact on the mental health of children and adolescents

Article from the ECAP Journal, Eur Child Adolesc Psychiatry (2013) 22:583-586 DOI 10.1007/s00787-013-0465-z. Presented here with the kind permission of the publisher.

ECAP Journal title/logoIntroduction
The international economic crisis that started in 2007 has had
deleterious effects in Spain. Spanish debt grew from 12 %of
the gross domestic product (GDP) in 2009 to over 90 % of
the GDP in 2013. The number of individuals who are
unemployed increased from 1,856,000 in 2007 to 6,202,700
in April 2013. This current report represents an unemployment
rate of 27.16 % of the total active population and
57.2 % of individuals under the age of 25 [9]. The impact of
this economic crisis on Spanish society is global, but children
and the elderly are the most vulnerable groups [2].

Impact of the economic crisis on society
The main immediate effects of the current economic crisis
include unemployment, the impoverishment of the population
and emigration [2].
The request for social aid has significantly increased. A
report from Caritas (a Spanish Non-governmental organization
linked to the Catholic Church) documented an
increase in the number of requests for social aid from
900,000 in 2007 up to 1,800,000 in 2010. The most frequent
demands were for food, housing, employment, legal
advice, and psychological support [15].
The impact of the economic crisis and the impoverishment
of the population have had a substantial effect on
children. According to UNICEF [18], the number of children
who reside in households living in poverty has
increased from 23.7 % in 2009 to 26.2 % in 2010. The
number of children who live in households with a high
level of poverty has risen four percentage points from
2008, reaching 13.7 % in 2010. Chronic poverty affecting
children has grown by 53 % from 2007 to 2010, reaching
16.7 %. In the total population, chronic poverty has
increased by 22 %, reaching 11 % during these 3 year
period. This impoverishment of families with children has
paralleled a general decrease in economic support to children
and their families [18].
The increase in child poverty will impact other aspects
of living, such as food, housing conditions (overcrowding,
reduction in energy expenditure), educational expenses,
leisure and free time, and activities geared towards educational
development. The high rate of early school dropout,
more than 28 % in Spain, has joined the growing
effects of poverty [18]. The long-term effects of reduced
training include reduced employability and the encouragement
of future poverty.
An unemployment rate of 57.2 % in young people under
the age of 25 is another consequence of the crisis [9].
Consequently, there is an emigration movement of young
adults with university qualifications in search of work to
other EU countries. The long-term impact may include a
loss of overall professional competitiveness of Spanish
society. Between January and June 2011, 2,400 Spanish
people found employment opportunities in Germany; the
demographics mostly included highly qualified men 
between 25 and 35 years of age and represented a 49 %
increase from the previous year [3].
 
Impact of the economic crisis on health
The Spanish health system has been decentralized to the 17
Autonomous Communities (regional departments). The
system offers nearly universal coverage, and its funding
originates from general tax revenues. A health department
in each community is responsible for key areas, such as
healthcare planning, public health and management of
health services [4, 11].
In 2010, national and regional governments in Spain
proposed major social spending cuts in response to a dramatic
rise in debt-related interest rates [4, 11].
The central parliament in Madrid approved a 5–7 %
salary reduction for all Spanish civil servants in 2010.
Decrees on drug prices were passed in 2010 and 2011,
which reduced drug expenditures [4]. In April 2012, more
health reform measures were approved by the government,
including a reduction in the co-payment for pharmaceuticals
and certain health products, a reduction in the overall
health budget of 7 billion, and other cost-containment
measures [17]. This combination of health reform measures
has generated an important reduction in clinical activity,
personnel redundancies, salary reductions, delay in payments
to providers and a stop for major investments [4].
Another consequence of the economic crisis is the
movement toward the privatization of the public healthcare
system and a return to past organizational models in several
Autonomous Communities. Health professionals, including
mental health specialists [16], have expressed their opposition
to the transfer of public institutions to private corporations
and to a reduction in resources and services.
Economic recession periods in developed, industrial
countries are typically related to increases or decreases in
mortality. The higher mortality related to medical reasons
is due to an increase in cardiovascular pathologies, respiratory
infections and chronic liver disease [19]. The decline
in mortality is thought to be the result of lower mortality in
workplace and traffic-related accidents, as well as increases
in leisure time, stress reduction and the ability to devote
more time to self-care [1, 2].
To date, the impact of the economic crisis in Spain on
citizen health has not been clearly quantified by health
indicators [4]. In addition, the data concerning child and
adolescent populations are less available.
In our view, some factors perform a protective role
against crisis and its health and social consequences.
Among these factors, the amount of existing savings, the
support of the nuclear and extended family, the social
welfare benefits and the informal economy play a critical
protective role. The existence of these positive factors may
delay the influence of economic changes in the health of
the population [6].
 
Impact of the economic crisis on mental health
Poverty, unemployment and mental health share a strong
link. First, poverty itself is associated with psychological
distress. Second, certain economic stressors, such as
unemployment, generate poverty; these stressors often
precede mental health difficulties, such as anxiety and
depression. Thus, poverty is an important risk factor for
mental illness. Finally, people with a serious and/or chronic
mental disorder (e.g., schizophrenia) experience high levels
of unemployment. Many of these individuals are dependent
on welfare coverage and are therefore at risk for poverty
[12].
Few studies have analyzed the impact of the economic crisis
on mental health in Spain. A survey of primary care centers
indicated that, comparedwith the pre-crisis period of 2006, the
2010 survey revealed significant increases in the proportion of
patients with mood (19.4 percentage points increase in major
depression and 10.8 percentage points increase in dysthymia),
anxiety (8.4 percentage points increase in generalized anxiety
disorder), somatoform (7.3 percentage points increase) and
alcohol-related disorders (4.6 percentage points increase in
alcohol dependence). Approximately one-third of the overall
risk of major depression could be attributed to the combined
risks of individual unemployment, family unemployment and
mortgage payment difficulties [5].
In general, there is an association between a rise in
unemployment and an increase in suicide rates [1, 10, 20].
Nevertheless, the available data in Spain show a reduction
in the suicide rate between 2007 and 2010. This reduction
is in contrast to the increasing suicide rate reported from
other European countries, which may be related to the
financial crisis [17]. The rate of suicide in Spain in 2009
was 6.3 per 100,000 and has been slightly reduced in
successive years. The number of deaths by suicide remains
stable: 3,421 in 2008, 3,145 in 2010 and 3,180 in 2011 [8].
Economic adversity or poverty is strongly associated
with mental health problems in childhood. An important
survey performed in Ireland (over 12,000 participants
between the ages of 5 and 16 years) indicated that 16 % of
children from families with a weekly household income of
under £100 had mental health problems; this was compared
to 5 % of children from families with a weekly household
income of more than £600. This study also found that
children in Local Authority Care and refugee and asylum
seeker children were at high risk of mental health problems
[12].
Risk for depression, substance use, early sexual activity
and criminal activity during adolescence are clearly
increased by chronic exposure to poverty. The awareness
584 Eur Child Adolesc Psychiatry (2013) 22:583–586
123
of financial difficulties within the family negatively
impacts an adolescent’s mental health. Specifically, this
awareness is associated with depression in adolescent girls
and drinking to the point of intoxication in boys. A sense of
helplessness and feelings of shame and inferiority are also
associated with the awareness of familial economic difficulties
in adolescents [12].
Currently, there are insufficient data on the consequences
of the economic crisis in Spain on children and
adolescents. We know, however, that child poverty is
increasing at an alarming rate, with the risk of generating
deficits in cognitive, emotional and physical development
in minors, and lifelong consequences on health and wellbeing
[20].
To conclude, the impact of the economic crisis on three
areas of critical importance to the mental health of children
and adolescents includes the following: education, professional
training and research.
Education in Spain has suffered cuts to its funding. The
latest data published (2010) demonstrate an overall
decrease in funding by 0.7 % compared to 2009. The cost
associated with non-university education decreased by
2.4 %, while the cost of college education increased by
0.8 %. In terms of the 2010 GDP, funding for education
amounted to 5.03 % [13].
Spain is one of the few EU countries that have not yet
officially recognized the specialty of Child and Adolescent
Psychiatry. Progress has been made in recent years with the
endorsement of Child and Adolescent Psychiatry by the
Ministry of Health [14] as a fundamental component in the
development of psychiatric care to minors. However, the
legal and administrative steps required are still pending.
Significant spending cuts have facilitated the current
impasse and have slowed the implementation of this
specialty.
Mental and neurological diseases receive the most
number of research grant projects and funding from the
Instituto de Salud Carlos III (ISCIII), one of the key
funders of health research in Spain. The number of people
engaged in research and development (R and D) activities
in Spain decreased by 3.1 % in 2011 over the previous
year. Overall spending for public and private R and D
decreased by 2.8 % in 2011 compared to 2010. That
expenditure represented 1.33 % of the GDP. Government
spending has decreased by 33.9 % since 2009. The total
public budget for R&D and Innovation in respect to the
GDP has gone from 0.92 % in 2009 to 0.60 % in 2012.
This change represents a return to the budget level of 1985,
when the current science and technology system was
implemented in Spain [7].
In the absence of data on the effect of the economic
crisis on general mental health and, in particular, on child
and adolescent health, as well as the existence of data that
differentiate Spain from other countries (i.e., suicide), it is
difficult to assess what the future holds. With some degree
of caution, national experts predict a wide range of negative
consequences resulting from unemployment, poverty,
inequality and changes in the organization of health and
mental health care [6].
 
Conclusions
The economic crisis has affected the Spanish society with
great intensity. Increases in unemployment, poverty and
inequality have paralleled the growth of debt and major
cuts in social services, health, education and research. The
data on the effects of this crisis on the health of the Spanish
population are inadequate, particularly in the field of child
and adolescent mental health. The available data indicate
that there are no immediate health effects, although it is
assumed that the combination of multiple factors will
generate negative effects in the intermediate and long-term
future.
 
Aranzazu Fernández-Rivas
Division of Child and Adolescent Psychiatry
Department of Psychiatry
Basurto University Hospital, Bilbao, Spain
e-mail: aranzazu.fernandezrivas@osakidetza.net
 
Aranzazu Fernández-Rivas, Miguel Angel González-Torres
Department of Neuroscience
University of the Basque Country, Bilbao, Spain
 
Miguel Angel González-Torres
Department of Psychiatry
Basurto University Hospital, Bilbao, Spain
 
 
References
1. Cooper B (2011) Economic recession and mental health: an
overview. Neuropsychiatrie 25(3):113–117
2. Dávila Quintana CD, González Lo´pez-Valca´rcel B (2009) Crisis
económica y salud. (Economic crisis and health). Gac Sanit
23(4):261–265
3. El País (2011) El número de espanoles que emigran a Alemania
se dispara por la crisis. http://economia.elpais.com/economia/
2011/12/22/actualidad/1324542779_850215.html
4. Gené-Badia J, Gallo P, Herna´ndez-Quevedo C, Garc?á-Armesto S
(2012) Spanish health care cuts: penny wise and pound foolish?
Heal Pol 106:23–28
5. Gili M, Roca M, Basu S, McKee M, Stucker D (2012) The mental
health risks of economic crisis in Spain: evidence from primary
care centres, 2006 and 2010. Eur J Pub Health 23(1):103–108
6. Gomez-Beneyto M (2013) Salud Mental, Crisis Econo´mica y
otras Crisis. Claustre Obert Universidad de Valencia. http://
mediauni.uv.es/2714va#.UasY_-BoGrN
7. Instituto Nacional de Estadística INE (2012) Investigación y
desarrollo tecnológico. Estad?´stica sobre actividades I + D http://
www.ine.es/prensa/np747.pdf
Eur Child Adolesc Psychiatry (2013) 22:583–586 585
123
8. Instituto Nacional de Estadística INE (2013) Defunciones según
la causa de muerte en 2011. http://www.ine.es/jaxi/menu.
do?type=pcaxis&path=/t15/p417/a2011/&file=pcaxis
9. Instituto Nacional de Estad?´stica INE (2013) Encuesta de Población
Activa. Primer trimestre de 2013. http://www.ine.es/daco/
daco42/daco4211/epa0113.pdf
10. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S,
Stucker D, Mackenbach J, McKee M (2013) Financial crisis,
austerity, and health in Europe. www.thelancet.com. Published
online March 27. http://dx.doi.org/10.1016/S0140-6736(13)
60102-6
11. Martin-Moreno JM, Alonso P, Claveria A, Gorgojo L, Peiró S
(2009) Spain: a decentralised health system in constant flux.
BMJ. doi:10.1136/bmj.b1170
12. Mental Health Commission (2011) The human cost: an overview
of the evidence on economic adversity and mental health and
recommendations for action. Mental Health Commission, Dublin.
www.mhcirl.ie/File/HCPaper.pdf
13. Ministerio de Educación, Cultura y Deporte (2012) Gobierno de
Espana. Estadística del Gasto Público en Educación Ano 2010.
http://www.mecd.gob.es/horizontales/estadisticas/recursoseconomicos/
gasto-publico/2010.html
14. Ministerio de Sanidad, Servicios Sociales e Igualdad (2012)
Proyecto de Real Decreto por el que se regula la troncalidad y
otros aspectos del sistema de Formación Sanitaria Especializada
en Ciencias de la Salud. http://www.msc.es/normativa/docs/
Rdecretotroncalidad.pdf
15. Rajmil L, Fernández de Sanmamed MJ (2012) Destruction of a
less developed welfare state and impact on the weakest, the
youths (rapid response to McKee M, Stuckler D: The assault on
universalism: how to destroy the welfare state) http://www.bmj.
com/content/343/bmj.d7973?tab=responses
16. Rodríguez Pulido F (2013) Comunicado de Prensa: La Consejería
de Salud del Gobierno de la Comunidad de Madrid y el Gobierno
de Espana con sus acciones desmantelan el Sistema Público de
Salud. Asociación Espanola de Neuropsiquiatr?´a. https://www.
aen.es/index.php?option=com_content&view=article&id=626:
comunicado-de-prensa-la-consejeria-de-salud-del-gobierno-dela-
comunidad-de-madrid-y-el-gobierno-de-espana-con-susacciones-
desmantelan-el-sistema-publico-de-salud&catid=366:
noticias-breves&Itemid=138
17. Salvador-Carulla L, Roca M (2013) Mental health impact of the
economic crisis in Spain. Intern Psychia 10(1):8–10
18. UNICEF Espana (2012) La infancia en Espana 2012–2013. El
impacto de la crisis en los ninos. http://www.unicef.es/va/content/
la-infancia-en-espana-2012-2013-el-impacto-de-la-crisis-en-losninos
19. Uutela A (2010) Economic crisis and mental health. Curr Opin
Psychia 23:127–130
20. WHO Report (2011) Impact of economic crises on mental health.
World Health Organization, Regional Office for Europe. http://
www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.
pdf