Reimbursed Medicines for Severe Mental and Behavioural Disorders in Bulgaria, 2021–2025: A Contracting Treatment Footprint and the Concentration of Public Expenditure in Second-Generation Long-Acting Injectable Antipsychotics
Between 2021 and 2025, Bulgaria's publicly reimbursed treatment for severe mental disorders declined in volume while public expenditure became increasingly concentrated on a small number of high-cost second-generation long-acting injectable antipsychotics, raising concerns about reduced access to care and budget sustainability.
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Mental health care relies heavily on medicines to help people manage severe conditions like schizophrenia, bipolar disorder, and major depression. In many countries, the government helps pay for these drugs through a national insurance system, ensuring that patients can afford the treatment they need. However, the way these funds are spent is not always straightforward. The cost of a medicine depends heavily on how it is delivered: a simple pill taken at home costs far less than a long-acting injection given by a doctor every few weeks. When a country's health budget is tight, the choices made about which medicines to fund can determine whether thousands of people receive care or are left without support. Understanding these spending patterns is crucial, because it reveals whether the system is reaching the people who need it most or if the money is being concentrated on a small number of expensive treatments while others fall through the cracks.
Researchers in Bulgaria recently examined five years of data, from 2021 to 2025, to see exactly how the country's public health insurance fund spent its money on medicines for severe mental and behavioral disorders. They looked at every single claim for drugs reimbursed for four specific conditions: schizophrenia, manic episodes, bipolar disorder, and recurrent depression. Their goal was to track not just how many people were treated, but how the total cost was distributed across different types of medicines and different regions of the country. What they found was a system that was shrinking in size while simultaneously becoming dominated by a very small group of high-priced injections.
Over the five-year period, the total number of times patients received reimbursed medication dropped by nearly nine percent. At the same time, the total amount of money spent on these drugs fell by almost twenty percent. This means that the average cost per treatment episode actually went down, but the overall volume of care provided by the public system was contracting. The researchers observed that this decline was not uniform across all types of medicine. The use of common antidepressants and anxiety medications fell sharply, while the use of older, cheaper injectable antipsychotics remained steady. In contrast, the use of newer, second-generation long-acting injectable antipsychotics also declined slightly, but these expensive drugs still absorbed the vast majority of the budget.
The most striking discovery was how unevenly the money was spent. Although these newer long-acting injections made up less than four percent of all the treatment episodes recorded, they accounted for more than half of the total money spent. To put this in perspective, a single episode of treatment with one of these expensive injections cost the insurance fund roughly three hundred euros, whereas a standard oral antipsychotic pill cost about fifteen euros. The older, first-generation injectable depots, which serve a similar function of ensuring patients take their medication, cost less than four euros per episode. Despite being so much cheaper, these older injections were the only type of medicine whose usage did not decline during the study period.
This financial concentration was driven by just four specific products, all of which were the newer long-acting injections. Together, these four medicines consumed more than half of the entire national budget for mental health drugs. The researchers noted that this spending pattern was not simply a reflection of having more patients with schizophrenia, who were the primary users of these drugs. Instead, the data showed that the regions spending the most money per patient were simply the ones where doctors prescribed these expensive injections more frequently. In some areas, the share of the budget going to these injections was nearly seventy percent, while in others it was less than fifty percent, yet the number of patients treated in those areas was similar.
The study suggests that the shrinking number of reimbursed treatments does not mean that fewer people need help. Bulgaria already has one of the lowest rates of mental health treatment coverage in Europe, and the steepest drops in medication use occurred for conditions that are less severe or harder to qualify for under the current rules. The researchers propose that as the public system becomes more expensive and complex to navigate, patients and doctors may be shifting toward paying for cheaper medicines out of their own pockets, or simply going without treatment. The data indicates that the public budget is increasingly focused on a narrow slice of high-cost care, leaving very little room for the broader range of treatments needed for depression, anxiety, and mood stabilization.
Ultimately, the findings point to a critical decision facing the health system. The current path sees the majority of funds flowing toward a small number of expensive injections, while the volume of overall care shrinks and the use of affordable, effective alternatives declines. The researchers argue that if the goal is to provide equitable access to mental health care, the focus must shift from simply tracking how many people are treated to understanding how the money is spent. They suggest that the system needs to re-evaluate the balance between these costly new formulations and the older, much cheaper options that have remained in use, ensuring that the budget supports a wide range of patients rather than just a few. Without such changes, the public system risks becoming a mechanism that funds a high-cost specialty for a few, while the broader population of people with mental health needs is left to manage their care without support.
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